Surveypoint

Q01

Date

Q02

State code

Q03

District Code

Q04

Block Code

Q05

Doctor unique id

Q06

Doctor type

Allopathic

Homeopathic

Ayurvedic

Unani

Siddha

Others (specify)

Q07

What level of facility does the Doctor work at?

District

Sub district

Q08

Facility code

Q09

Name of the Respondents

Q10

Sex of the respondent

Male

Female

Q11

Number of years of experience

Q12

How long have you been working with the clinic?

Q13

Do you have a renewed practice license?

Yes

no

A01

When is the first time you heard about this franchise? What attracted you to become a franchise member?

A02

Do you have a contract, MOU or any written agreement with the franchise? What are the roles of franchise and the role of project Ujjwal?

A03

Would you consider yourself committed to the franchise ? Is there anything that would make you feel more “included” or committed to the franchise?

A04

What marketing/advertising of products and services are you offered as part of the franchise? Do you advertise on your own or does the franchise do all of the advertising for you?

A05

How do these promotions work? Are some more successful for your specific outlet? If so, why?

A06

What is the average client profile for each service you offer? What types of services did you offer before you were part of this franchise? Were the services primarily the same services but clients underutilized them, or are they all new?

A07

What is the target population for your practice? What is the total annual number of clients served by your franchised services (ex: IUCD cases, Sterilization cases, OCP, Injectables etc) Total clients otherwise? Average per month?

A08

Has the number of clients increased since joining the franchise? If so, why? If yes, then for which cases has the number increased?

A09

What services do you currently offer exclusively because you are part of this franchise? How have your services changed since you became a member of the franchise? What’s the difference between your clinic before and after? Do you plan to reduce or expand your services?

A10

Do you keep track of the number and type of commodities and services you provide? What additional metrics do you use? May we have these figures.

A11

How do you procure and receive franchise commodities? What inventory management and sales tracking systems are in place in your outlet? How are records kept and used (e.g., manually, email)?

A12

How easily could you introduce a new service or commodity into your existing practice? How might introducing a new component work and what would the main challenges be?

A13

Are there any mechanisms or benefits specifically from the franchise that support you to provide higher-quality care than you otherwise would? How is quality defined under the franchise model? What metrics are used? Was Medical Audit done?

A14

What penalties exist for poor quality and are they imposed? What bonuses exist for exceptional quality and are they used/valued by member providers? Before/after franchise stats on quality?

A15

What are the internal challenge (for example in terms of capacity, equipment and infrastructure faced by the franchise and what has the franchise done to overcome the challenges? What else is the franchise planning to do to improve the situation?

A16

What are the external challenges (for example demand for the service and awareness generation…..)faced by the franchise and what has the franchise done to overcome the challenges? What else is the franchise planning to do to improve the situation?

A17

What would you change about the franchise if you could? Are there other services you would like to see added? How could your job be improved?

B01

What all job aids do you use while counseling your customers about FP? Do you use any screening checklist? Do you find the job aids issued under project Ujjawal helpful?

B02

What all situations and opportunities do you use to discuss the family planning needs with women?

B03

Do you feel the need of creating an enabling environment when discussing family planning need with women or couples? If yes, how do you ensure the same?

B04

How do you ensure that you offer the appropriate FP methods for each category of customers including pill, injectable, IUD, condom, emergency contraception, or female or male sterilization? After screening, do you provide the method and explain how to use, what to expect, and when to return and do you explain the side effects/complications/danger signs of the method selected and what to do?

C01

According to you what are the side effects of IUD? Can you name the complications of the same?

C02

What are the warming signs of possible complications?

D01

What kind of MTP procedures do you practice or prescribe?

D02

Do you know about MTP act? If yes, what in your knowledge are the compliance norms under MTP act?

D03

How many MTPs would you have conducted? What has been the major method of MTP followed by you?

D04

Do you know about PC&PNDT act? If yes, what according to you are the compliance norms for your facility under PC&PNDT act?

D05

Under what circumstances can pre-natal diagnostics technique be offered to pregnant women?

D06

How many ultrasonography have you conducted for pregnant women?

E01

Since when have been married

E02

Have you been sexually Active

Yes

no

E03

Have you used a contraception method

Yes

no

E04

Have you checked for being pregnant

Yes

no

E05

How long do you want to avoid pregnancy

E06

Does the female partner have a history of hypertension, heart disease, impaired liver function, breast cancer

Yes

no

E07

Does the female partner have a history of thrombosis/clotting.

Yes

no

E08

Does the female partner smoke?

Yes

no

E09

Does the male partner smoke

Yes

no

F01

Weight of the female

F02

Blood Pressure (Female)

F03

Pelvic Examination of the female

G01

Since when have been married

G02

Have you used any other contraception method before

Yes

no

G03

Have you checked for being pregnant

Yes

no

G04

Do you have a history of hypertension

Yes

no

G05

Do you have a history of thrombosis/clotting.

Yes

no

G06

Do you smoke?

Yes

no

H01

Weight of the female

H02

Blood Pressure (Female)

H03

Pelvic Examination of the female

I01

What did you recommend?

Briefed about this being normal with OCPs initially

Counselled her that this will subsequently subside

Advised to continue with pills

Briefed about alternative options in contraceptive

Advised to come for a revisit

Eye Doctor Appointment -Form Fill

Date

State code

District Code

Block Code

Doctor unique id

Doctor type

What level of facility does the Doctor work at?

Facility code

Name of the Respondents

Sex of the respondent

Number of years of experience

How long have you been working with the clinic?

Do you have a renewed practice license?

When is the first time you heard about this franchise? What attracted you to become a franchise member?

Do you have a contract, MOU or any written agreement with the franchise? What are the roles of franchise and the role of project Ujjwal?

Would you consider yourself committed to the franchise ? Is there anything that would make you feel more “included” or committed to the franchise?

What marketing/advertising of products and services are you offered as part of the franchise? Do you advertise on your own or does the franchise do all of the advertising for you?

How do these promotions work? Are some more successful for your specific outlet? If so, why?

What is the average client profile for each service you offer? What types of services did you offer before you were part of this franchise? Were the services primarily the same services but clients underutilized them, or are they all new?

What is the target population for your practice? What is the total annual number of clients served by your franchised services (ex: IUCD cases, Sterilization cases, OCP, Injectables etc) Total clients otherwise? Average per month?

Has the number of clients increased since joining the franchise? If so, why? If yes, then for which cases has the number increased?

What services do you currently offer exclusively because you are part of this franchise? How have your services changed since you became a member of the franchise? What’s the difference between your clinic before and after? Do you plan to reduce or expand your services?

Do you keep track of the number and type of commodities and services you provide? What additional metrics do you use? May we have these figures.

How do you procure and receive franchise commodities? What inventory management and sales tracking systems are in place in your outlet? How are records kept and used (e.g., manually, email)?

How easily could you introduce a new service or commodity into your existing practice? How might introducing a new component work and what would the main challenges be?

Are there any mechanisms or benefits specifically from the franchise that support you to provide higher-quality care than you otherwise would? How is quality defined under the franchise model? What metrics are used? Was Medical Audit done?

What penalties exist for poor quality and are they imposed? What bonuses exist for exceptional quality and are they used/valued by member providers? Before/after franchise stats on quality?

What are the internal challenge (for example in terms of capacity, equipment and infrastructure faced by the franchise and what has the franchise done to overcome the challenges? What else is the franchise planning to do to improve the situation?

What are the external challenges (for example demand for the service and awareness generation…..)faced by the franchise and what has the franchise done to overcome the challenges? What else is the franchise planning to do to improve the situation?

What would you change about the franchise if you could? Are there other services you would like to see added? How could your job be improved?

What all job aids do you use while counseling your customers about FP? Do you use any screening checklist? Do you find the job aids issued under project Ujjawal helpful?

What all situations and opportunities do you use to discuss the family planning needs with women?

Do you feel the need of creating an enabling environment when discussing family planning need with women or couples? If yes, how do you ensure the same?

According to you what are the side effects of IUD? Can you name the complications of the same?

What are the warming signs of possible complications?

What kind of MTP procedures do you practice or prescribe?

Do you know about MTP act? If yes, what in your knowledge are the compliance norms under MTP act?

How many MTPs would you have conducted? What has been the major method of MTP followed by you?

Do you know about PC&PNDT act? If yes, what according to you are the compliance norms for your facility under PC&PNDT act?

Under what circumstances can pre-natal diagnostics technique be offered to pregnant women?

How many ultrasonography have you conducted for pregnant women?

Since when have been married

Have you been sexually Active

Have you used a contraception method

Have you checked for being pregnant

How long do you want to avoid pregnancy

Does the female partner have a history of hypertension, heart disease, impaired liver function, breast cancer

Does the female partner have a history of thrombosis/clotting.

Does the female partner smoke?

Does the male partner smoke

Weight of the female

Blood Pressure (Female)

Pelvic Examination of the female

Since when have been married

Have you used any other contraception method before

Have you checked for being pregnant

Do you have a history of hypertension

Do you have a history of thrombosis/clotting.

Do you smoke?

Weight of the female

Blood Pressure (Female)

Pelvic Examination of the female

What did you recommend?