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Anm Template 3 -Form Fill
Ministry of Health and Family welfare
Q01
Name of respondent
Q02
Designation of respondent
ANM
CHO
Q03
Contact number
Q04
GP Code
Q05
Associated Subcentre Name
Q06
Population Covered under that facility
Q07
Gender
Male
Female
Others
Q08
Age
Q09
Educational qualification
Upto class 8th
Upto class 10th
Upto class 12th
Graduation
Post-graduation and above
Q10
Training received
SBA training
Dakshata
Interviewer Information (for creation of a file)
A01
Code of the Interviewer
A02
Name of the Interviewer
A03
Date
A04
Start Time
Validation section
B01
How many OPD visits were recorded in your sub centre in the last 3 months ?
B01_1
44348
B01_2
44378
B01_3
44409
B02
How many health worker (staff) are there in the sub centre
B03
Does the subcentre have functional toilet separate for men & women
Yes
No
B04
What was/is the number of TB patients under the following categories in your sub-centre/HWC, in the last 3 months?
B04A
Total TB patients identified
B04A_1
44348
B04A_2
44378
B04A_3
44409
B04B
TB patients identified through ACF
B04B_1
44348
B04B_2
44378
B04B_3
44409
B04C
TB patients started on treatment
B04C_1
44348
B04C_2
44378
B04C_3
44409
B04D
TB patients continuing treatment and follow up
B04D_1
44348
B04D_2
44378
B04D_3
44409
B05
How many pregnant women were identified in your area in the following months
B05_1
June
B05_2
July
B05_3
August
B05_4
September
B05_5
October
B05_6
November
B05_7
December
B05_8
January
B05_9
February
B05_10
March
B05_11
April
B05_12
May
B05_13
June
B05_14
July
B05_15
August
B06
How many deliveries were identified in your area in the following months
B06_1
June
B06_2
July
B06_3
August
B06_4
September
B06_5
October
B06_6
November
B06_7
December
B06_8
January
B06_9
February
B06_10
March
B06_11
April
B06_12
May
B06_13
June
B06_14
July
B06_15
August
B07
Does this subcentre have delivery facility
Yes
No
B08
What is the average delivery per months at this Sub center
B09
How many pregnant women were identified in your area under the following categories, in the last 3 months?
B09A
pregnant women registered for ANC
B09A_1
June
B09A_2
July
B09A_3
August
B09B
pregnant women received 4 or more ANC
B09B_1
June
B09B_2
July
B09B_3
August
B09C
1st ANC within the first trimester
B09C_1
June
B09C_2
July
B09C_3
August
B09D
Pregnant women getting their Hb tested
B09D_1
June
B09D_2
July
B09D_3
August
B09E
pregnant women identified as HRPs
B09E_1
June
B09E_2
July
B09E_3
August
B09F
Pregnant women identified as anaemic
B09F_1
June
B09F_2
July
B09F_3
August
B09G
HRPs treated in the HWC
B09G_1
June
B09G_2
July
B09G_3
August
B10
How many pregnant women were identified in your area under the following categories, in the last 3 months?
B10A
pregnant women registered for PNC
B10A_1
June
B10A_2
July
B10A_3
August
B10B
pregnant women received 4 or more PNC
B10B_1
June
B10B_2
July
B10B_3
August
B11
How many institutional deliveries were recorded at this sub-centre under the following categories, in the last 3 months
B11A
Number of deliveries recorded at this sub-center
B11A_1
June
B11A_2
July
B11A_3
August
B11B
Deliveries receiving benefits under JSY
B11B_1
June
B11B_2
July
B11B_3
August
B11C
Deliveries receiving benefits under JSSY
B11C_1
June
B11C_2
July
B11C_3
August
B12
What was the number of women identified in your area, under each of the following categories, in the last 3 months?
B12A
Number of lactating women
B12A_1
June
B12A_2
July
B12A_3
August
B12B
Number of non-school going girls
B12B_1
June
B12B_2
July
B12B_3
August
B13
How many VHSND sessions were conducted via this HWC/sub-centre in the last 2 months
B13_1
June
B13_2
July
B13_3
August
B14
What all testing facilities are available during VHSND session
Urine testing kit/uristix
Nischay/Pregnancy testing kits
Digital hemoglobinometer
No testing facility available
Others (specify)
B15
What all infrastructure facilities are available during VHSND session
Drinking water available
Toilet available
Provision for Hand washing
Provision of curtain for Privacy
Others (specify)
B16
How many adolescent girls were screened under the following categories in the VHSND sessions in last 2 months?
B16A
Non-school going girls getting their Hb tested
B16A_1
June
B16A_2
July
B16A_3
August
B16B
Non-school going girls identified as anaemic
B16B_1
June
B16B_2
July
B16B_3
August
B17
How many infants received the following vaccinations at birth in the last 3 months?
B17A
BCG
B17A_1
June
B17A_2
July
B17A_3
August
B17B
OPV-0
B17B_1
June
B17B_2
July
B17B_3
August
B17C
Hepatitis B birth dose
B17C_1
June
B17C_2
July
B17C_3
August
B18
What all medical facilities/treatment are currently available in the HWC?
B18_1
Care in pregnancy and childbirth
Yes
No
B18_2
Neonatal and infant health care services
Yes
No
B18_3
Family planning
Yes
No
B18_4
other Reproductive Health Care services
Yes
No
B18_5
Communicable diseases (Vector borne diseases, leprosy, TB)
Yes
No
B18_6
Outpatient care for simple illnesses and minor ailments (Fever, cold, first aid etc.)
Yes
No
B18_7
Non-Communicable diseases (Diabetes, hypertension, Cancer )
Yes
No
B18_8
Common Ophthalmic and ENT problems
Yes
No
B18_9
Basic Oral health care
Yes
No
B18_10
Elderly and Palliative health care services (Cataract Operations)
Yes
No
B18_11
Emergency Medical Services
Yes
No
B18_12
Mental health ailments
Yes
No
B19
Out of the total number of women delivering at your sub-centre/HWC, how many women received the following benefits under JSSK, in the last 2 months ?
B19A
Drugs and consumables
B19A_1
June
B19A_2
July
B19A_3
August
B19B
Diagnostics and tests
B19B_1
June
B19B_2
July
B19B_3
August
B19C
Blood wherever required
B19C_1
June
B19C_2
July
B19C_3
August
B19D
Diet for 3-7 days
B19D_1
June
B19D_2
July
B19D_3
August
B19E
Transport from home to institution and back home
B19E_1
June
B19E_2
July
B19E_3
August
B20
What percent of the TB patients identified in your area in the last 2 months, have been following the treatment process and follow up?
None
Less than 10%
10-24%
25-49%
50-74%
75-99%
All TB patients (100%)
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