Surveypoint

Q01

Name of the investigator

Q02

Name of the supervisor

Q03

State

Assam

Madhya Pradesh

Rajasthan

Q04

District code

Q04_1

Assam

Goalpara

Dibrugarh

Q04_2

Madhya Pradesh

Chhatarpur

Shivpuri

Panna

Rewa

Tikamgarh

Raisen

Q04_3

Rajasthan

Pali

Chittorgarh

Karauli

Banswara

Jaisalmer

Sikar

Q05

Block code

Q06

PSU code

Q07

Latitude

Q08

Longitude

Q09

Type of location

Urban

Rural

Q10

Type of facility

Primary Health Centre

PHC- Health and wellness Centre

Sub-Centre

SC - Health and Wellness Centre

Q11

Facility

Q12

Name of facility

Q13

Has someone visited this facility from Sambodhi for facility readiness in last

Yes

No

Q14

Result of the interview

Respondent is available for interview

Interview interrupted/incomplete

Facility was temporarily closed at the time of back check

No respondent was available (on duty) at the time of backcheck

Other (specify)

Q15

Designation of the Respondent

ANM

Community Health Officer (CHO)

Medical Officer In-charge

Medical Officer

Staff Nurse

Family Planning Counsellor

RMNCH+A counsellor

Pharmacist

Other (Specify)

Q16

Do you consent to participate in the Back check?

Yes

No

Q17

What is the year of establishment of the facility? (YYYY)

Q18

Was the facility upgraded to Health and Wellness center?

Yes

No

Q19

What are the working hours of the facility?

24x7

Non 24x7

Q20

How many days of a week is the facility functional?

Q21

On which days of the week is it non- functional?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Q22

Now, I would like to question about the manpower availability at the facility.

Q22A

Enter Number of Total Position sanctioned.

Q22A_1

ANMs

Q22A_2

Community Health Officer (CHO)

Q22A_3

Medical officer (MO)

Q22A_4

Staff Nurse

Q22A_5

Pharmacists

Q22A_6

Laboratory technicians (pathology)

Q22A_7

Multipurpose worker – Male

Q22A_8

Family planning counselors/RMNCH+A counselor/Health educator

Q22B

Enter Number of Permanent staff present.

Q22B_1

ANMs

Q22B_2

Community Health Officer (CHO)

Q22B_3

Medical officer (MO)

Q22B_4

Staff Nurse

Q22B_5

Pharmacists

Q22B_6

Laboratory technicians (pathology)

Q22B_7

Multipurpose worker – Male

Q22B_8

Family planning counselors/RMNCH+A counselor/Health educator

Q22C

Enter Number of Contractual staff present.

Q22C_1

ANMs

Q22C_2

Community Health Officer (CHO)

Q22C_3

Medical officer (MO)

Q22C_4

Staff Nurse

Q22C_5

Pharmacists

Q22C_6

Laboratory technicians (pathology)

Q22C_7

Multipurpose worker – Male

Q22C_8

Family planning counselors/RMNCH+A counselor/Health educator

Q23

Does this facility provide or prescribe any of the following modern methods of family planning

Yes

No

Q24

For each of the following items, please check in the facility records if there has been a stock-out in the past 6 months:

Q24_1

Combined estrogen progesterone oral contraceptive pills /Mala-N

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_2

Chhaya / Centchroman

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_3

Progestin-only contraceptive pills

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_4

Male condoms

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_5

Female condoms

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_6

Progestin-only injectable contraceptives (DMPA-IM)

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_7

Progestin-only injectable contraceptives (DMPA-SC)

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_8

Implant (e.g., levonorgestrel, etonogestrel)

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_9

Emergency contraceptive pills / Ezy Pills

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_10

Intrauterine contraceptive device (IUCD) -375

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_11

Intrauterine contraceptive device (IUCD) -380A

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q24_12

Pregnancy Test Kits

Stock-out in the last 6 months

No stockout in past 6 months

Not indicated

Product not offered

Facility records not available

Q25

Is there a dedicated area available for family planning counselling?

Yes

No

Q26

What is the number of patients/ clients counselled in last 3 months?

Q27

Does this facility maintain client/ patient registration record?

Yes

No

Q28

Does this health facility have helpline number for family planning services provided by IPAS?

Yes

No

Q29

Does this facility have wall paintings / board displaying availability of free and paid family planning services?

Yes

No

Facility Readiness Assessment Back Check Template -Form Fill

Name of the investigator

Name of the supervisor

State

District code var statement=document.write(localStorage.getItem('total'));

Assam

Madhya Pradesh

Rajasthan

Block code

PSU code

Latitude

Longitude

Type of location

Type of facility

Facility

Name of facility

Has someone visited this facility from Sambodhi for facility readiness in last

Result of the interview

Designation of the Respondent

Do you consent to participate in the Back check?

What is the year of establishment of the facility? (YYYY)

Was the facility upgraded to Health and Wellness center?

What are the working hours of the facility?

How many days of a week is the facility functional?

On which days of the week is it non- functional?

Now, I would like to question about the manpower availability at the facility. var statement=document.write(localStorage.getItem('total'));

Enter Number of Total Position sanctioned. var statement=document.write(localStorage.getItem('total'));

ANMs

Community Health Officer (CHO)

Medical officer (MO)

Staff Nurse

Pharmacists

Laboratory technicians (pathology)

Multipurpose worker – Male

Family planning counselors/RMNCH+A counselor/Health educator

Enter Number of Permanent staff present. var statement=document.write(localStorage.getItem('total'));

ANMs

Community Health Officer (CHO)

Medical officer (MO)

Staff Nurse

Pharmacists

Laboratory technicians (pathology)

Multipurpose worker – Male

Family planning counselors/RMNCH+A counselor/Health educator

Enter Number of Contractual staff present. var statement=document.write(localStorage.getItem('total'));

ANMs

Community Health Officer (CHO)

Medical officer (MO)

Staff Nurse

Pharmacists

Laboratory technicians (pathology)

Multipurpose worker – Male

Family planning counselors/RMNCH+A counselor/Health educator

Does this facility provide or prescribe any of the following modern methods of family planning

For each of the following items, please check in the facility records if there has been a stock-out in the past 6 months: var statement=document.write(localStorage.getItem('total'));

Combined estrogen progesterone oral contraceptive pills /Mala-N

Chhaya / Centchroman

Progestin-only contraceptive pills

Male condoms

Female condoms

Progestin-only injectable contraceptives (DMPA-IM)

Progestin-only injectable contraceptives (DMPA-SC)

Implant (e.g., levonorgestrel, etonogestrel)

Emergency contraceptive pills / Ezy Pills

Intrauterine contraceptive device (IUCD) -375

Intrauterine contraceptive device (IUCD) -380A

Pregnancy Test Kits

Is there a dedicated area available for family planning counselling?

What is the number of patients/ clients counselled in last 3 months?

Does this facility maintain client/ patient registration record?

Does this health facility have helpline number for family planning services provided by IPAS?

Does this facility have wall paintings / board displaying availability of free and paid family planning services?

District code

Now, I would like to question about the manpower availability at the facility.

Enter Number of Total Position sanctioned.

Enter Number of Permanent staff present.

Enter Number of Contractual staff present.

For each of the following items, please check in the facility records if there has been a stock-out in the past 6 months: