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Facility Readiness Assessment Template -Form Fill
Identification of the facility
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
Sehore
Shivpuri
Rewa
Satna
Tikamgarh
Raisen
Q04_3
Rajasthan
Pali
Chittorgarh
Karauli
Banswara
Jaisalmer
Sikar
Q05
Block code
Q06
Latitude
Q07
Longitude
Q08
Type of location
Urban
Rural
Q09
Type of facility
Primary Health Centre
Health and wellness Centre
Sub-Centre
Q10
Facility code
Q11
Name of facility
Q12
Does this facility offer family planning services?
Yes
No
Q13
Result of the interview
Respondent is available for interview.
Interview interrupted/incomplete
Facility was temporarily closed
No respondent available (on duty)
Other (specify)
Q14
Assessment start date
Q15
Assessment completion date
Q16
Number of visits made to the facility for completing the assessment
Q17
Designation of facility in-charge
ANM
Community Health Officer (CHO)
Medical Officer In-charge
Medical Officer
Other (Specify)
Q18
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)
Q19
Do you consent to participate in the research?
Yes
No
Q20
Do you consent to spot checks?
Yes
No
Basic Details of the Facility
A01
What is the year of establishment of the facility? (YYYY)
A02
Was the facility upgraded to Health and Wellness center?
Yes
No
A03
In which year, the facility was upgraded to Health and Wellness center?
A04
What are the working hours of the facility?
A05
Mention the timings in which the facility is functional
A06
How many days of a week is the facility functional?
A07
On which days of the week is it non- functional?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
A08
Is any doctor/staff nurse/ LHV/ ANM available 24X7 at the facility?
Yes
No
A09
What is the average number of out-patient visits per day in your facility at present?
A10
What is the total number of deliveries conducted at the facility in the last 6 months?
Staffing/Human Resources
B01A
Enter Number of Total Position sanctioned.
B01A_1
ANMs
B01A_2
Community Health Officer (CHO)
B01A_3
Medical officer (MO)
B01A_4
Staff Nurse
B01A_5
Pharmacists
B01A_6
Laboratory technicians (pathology)
B01A_7
Multipurpose worker – Male
B01A_8
Family planning counselors/RMNCH+A counselor/Health educator
B01B
Enter Number of Permanent staff present.
B01B_1
ANMs
B01B_2
Community Health Officer (CHO)
B01B_3
Medical officer (MO)
B01B_4
Staff Nurse
B01B_5
Pharmacists
B01B_6
Laboratory technicians (pathology)
B01B_7
Multipurpose worker – Male
B01B_8
Family planning counselors/RMNCH+A counselor/Health educator
B01C
Enter Number of Contractual staff present.
B01C_1
ANMs
B01C_2
Community Health Officer (CHO)
B01C_3
Medical officer (MO)
B01C_4
Staff Nurse
B01C_5
Pharmacists
B01C_6
Laboratory technicians (pathology)
B01C_7
Multipurpose worker – Male
B01C_8
Family planning counselors/RMNCH+A counselor/Health educator
Service Availability
C01
Does this facility provide or prescribe any of the following modern methods of family planning
C01_1
Oral contraceptive pills
Yes
No
C01_2
Types of Oral Contraceptive pills available
Combined estrogen progesterone oral contraceptive pills / Mala-N
Progestin only contraceptive pills
Emergency contraceptive pills/ Ezy Pills
Chhaya / Centchroman
Others (specify)
C01_3
Injectable contraceptives
Yes
No
C01_4
Types of Injectable contraceptives
Antara IM/ Depot Medroxy Progesterone Acetate through intramuscular route (DMPA-IM)
Antara – SC/ Depot Medroxy Progesterone Acetate through subcutaneous route (DMPA-SC)
Combined estrogen progesterone injectable Contraceptives
Others (specify)
C01_5
Condoms
Yes
No
C01_6
Types of Condoms
Male condoms
Female condoms
C01_7
Intrauterine contraceptive devices (IUCD)
Yes
No
C01_8
What are the types of IUCD services provided by the facility?
Interval IUCD
PP-IUCD
PA-IUCD
C01_9
Implants
Yes
No
C01_10
Sterilization Services
Yes
No
C01_11
Type of Sterilization Services
Conventional vasectomy
No-scalpel vasectomy (NSV)
Conventional tubectomy
Minilap sterilization
Laparoscopic sterilization
C02
Does the facility involve in outreach activities for family planning services?
Yes
No
C03
Type of outreach activities provided
Awareness / Information on use of contraceptives.
Distribution - provision of non-clinic contraceptives such as condoms and OCPs.
Distribution - provision of Pregnancy test kits
Information on compensation for loss of wage resulting from sterilization and insurance scheme for family planning.
Counselling of eligible couples to take up family planning.
Organize family planning Pakhwara.
Organize Saas Bahu Sammelan
Distribution of Nayi Pehel kits
Raising awareness through Sarthi Van
Organize Fixed day static Sterilization Services / Sterilization Camps (FDSS)
Others (specify)
Family Planning Documents & Checklist
D01
Please tell me if the printed copies (hardcopy) of the following guideline/documents are available in the facility today
D01_1
National family planning guidelines
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D01_2
Reference Manual for Integrated RMNCAH+N Counseling
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D01_3
Reference Manual on Oral Contraceptives
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D01_4
Reference Manual for IUCD
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D01_5
Reference Manual for Injectable Contraceptive (DMPA)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02
Please tell me if the following family planning checklists and/or job aids are available in the facility today.
D02_1
Checklist: Family Planning Counselling
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_2
Pregnancy Screening Checklist
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_3
Medical Eligibility Criteria (MEC) and Client’s Assessment
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_4
Checklist: Method Specific Counselling on Combined Oral Contraceptives (COCs)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_5
Checklist: Method Specific Counselling on Progestin-Only-Pills (POPs)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_6
Checklist: Method Specific Counselling on Centchroman (Ormeloxifene)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_7
MPA Client Card and Instructions for Clients
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_8
Checklist on Insertion of Interval IUCD
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_9
Checklist on Insertion of PPIUCD after Normal Delivery (Post placental and within 48 Hours of Delivery)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_10
Checklist on Insertion of Intra-cesarean IUCD
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_11
Checklist on Concurrent PAIUCD Insertion (Uterine Size less than 12 weeks after abortion)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_12
Checklist on Concurrent PAIUCD Insertion (Uterine Size more than 12 weeks after abortion)
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_13
Checklist on IUCD Removal
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D02_14
IUCD Card
YES, OBSERVED
YES, REPORTED NOT SEEN
NO
D03
Have you or any provider(s) received the following family planning services
D03_1
Received any family planning training in the last two years?
Yes
No
D03_2
Received any training in adolescent sexual and reproductive health in the last two years?
Yes
No
D03_3
Is any provider in the facility trained on administering injectable Contraceptives?
Yes
No
D03_4
Is any provider in the facility trained on IUCD insertion?
Yes
No
D03A
If yes, ask number of manpower trained
D03A_1
Received any family planning training in the last two years?
D03A_2
Received any training in adolescent sexual and reproductive health in the last two years?
D03A_3
Is any provider in the facility trained on administering injectable Contraceptives?
D03A_4
Is any provider in the facility trained on IUCD insertion?
D03B
If yes, ask type of manpower trained.
D03B_1
Received any family planning training in the last two years?
ANMs
Community Health Officer (CHO)
Medical officer (MO)
Staff Nurse
Family planning counselors/RMNCH+A counselor/Health educator
D03B_2
Received any training in adolescent sexual and reproductive health in the last two years?
ANMs
Community Health Officer (CHO)
Medical officer (MO)
Staff Nurse
Family planning counselors/RMNCH+A counselor/Health educator
D03B_3
Is any provider in the facility trained on administering injectable Contraceptives?
ANMs
Community Health Officer (CHO)
Medical officer (MO)
Staff Nurse
Family planning counselors/RMNCH+A counselor/Health educator
D03B_4
Is any provider in the facility trained on IUCD insertion?
ANMs
Community Health Officer (CHO)
Medical officer (MO)
Staff Nurse
Family planning counselors/RMNCH+A counselor/Health educator
Contraceptive supplies and commodities
E01
Does this facility stock contraceptive commodities at this service site?
Yes
No
E02
Are any of the following reproductive health medicines and commodities available in this service site today?
E02_1
Combined estrogen progesterone oral contraceptive pills /Mala-N
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_2
Progestin-only contraceptive pills
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_3
Chhaya / Centchroman
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_4
Combined estrogen progesterone injectable contraceptive
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_5
Progestin-only injectable contraceptives (DMPA-IM)
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_6
Progestin-only injectable contraceptives (DMPA-SC)
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_7
Male condoms
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_8
Female condoms
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_9
Implant (e.g., levonorgestrel, etonogestrel)
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_10
Emergency contraceptive pills (e.g.levonorgestrel tablet, ulipristal acetate tablet, mifepristone tablet 10-25 mg) / Ezy Pills
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_11
Intrauterine contraceptive device (IUCD) -375
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_12
Intrauterine contraceptive device (IUCD) -380A
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E02_13
Pregnancy Test Kits
At least One Valid
Available not valid
Reported available but not seen
Not available currently but was available once in last 3months
Not available in last 3 months
Never available
E03
For each of the following items, please check in the facility records if there has been a stock-out in the past 6 months
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
E03_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
Equipment and Kits required for Family Planning Services
F01
Please tell me if the following basic equipment and supplies used in the provision of client services are available and functional in this facility today.
F01_1
Adult weighing scale
AVAILABLE
FUNCTIONING
F01_2
Measuring tape-height board/stadiometer
AVAILABLE
FUNCTIONING
F01_3
Thermometer
AVAILABLE
FUNCTIONING
F01_4
Stethoscope
AVAILABLE
FUNCTIONING
F01_5
Blood pressure apparatus (may be digital or manual sphygmomanometer with stethoscope)
AVAILABLE
FUNCTIONING
F01_6
Examination table
AVAILABLE
FUNCTIONING
F01_7
Light source (flashlight acceptable)
AVAILABLE
FUNCTIONING
F01_8
Intravenous infusion kits
AVAILABLE
FUNCTIONING
F01_9
Oxygen concentrators
AVAILABLE
FUNCTIONING
F01_10
Oxygen cylinders
AVAILABLE
FUNCTIONING
F01_11
Central oxygen supply
AVAILABLE
FUNCTIONING
F01_12
Flowmeter for oxygen therapy (with humidification)
AVAILABLE
FUNCTIONING
F01_13
Oxygen delivery apparatus (key connecting tubes and mask /nasal prongs)
AVAILABLE
FUNCTIONING
F01_14
Syringe with needles
AVAILABLE
FUNCTIONING
F01_15
Operating table capable of Trendelenburg position
AVAILABLE
FUNCTIONING
F01_16
Instrument trolley
AVAILABLE
FUNCTIONING
F01_17
Puncture-proof box for needles
AVAILABLE
FUNCTIONING
F01_18
Oral airways Guedel size 3, 4, 5
AVAILABLE
FUNCTIONING
F01_19
Nasopharyngeal airways size 6, 6.5 ,7.0
AVAILABLE
FUNCTIONING
F01_20
Suction machine with tubing and two straps
AVAILABLE
FUNCTIONING
F01_21
Ambu bag with mask size 3, 4, 5
AVAILABLE
FUNCTIONING
F01_22
Tubing and oxygen nipple
AVAILABLE
FUNCTIONING
F01_23
Intravenous infusion sets and fluids
AVAILABLE
FUNCTIONING
F01_24
Sterile laparotomy instruments
AVAILABLE
FUNCTIONING
F01_25
Endotrachael tube size 6, 6.5 , 7, 7.5, 8.0
AVAILABLE
FUNCTIONING
F01_26
Laryngeal mask airway size 3, 4, 5
AVAILABLE
FUNCTIONING
F01_27
Combitube
AVAILABLE
FUNCTIONING
F01_28
Cricothyroidectomy set
AVAILABLE
FUNCTIONING
F02
Please tell me if the following IUCD set is available and observed in this facility today.
F02_1
Instrument tray with cover (HLD or sterile)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_2
Tenaculum/ Volsellum
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_3
Uterine Sound
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_4
Vaginal Cusco's/Sim’s Speculum (Large, Medium, Small)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_5
Anterior Vaginal Wall retractor
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_6
Scissors (Mayo’s scissors)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_7
Long Artery forceps
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_8
Sponge-holding Forceps
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_9
Kidney Tray (Large)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_10
Small bowl for betadine
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_11
Cheattle forceps
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F02_12
Kelly’s Forceps/ Long Placental forceps
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03
Please tell me if the following resources/ supplies used for infection control are available in the general outpatient area of this facility today.
F03_1
Clean running water (piped, bucket with tap, or pour pitcher)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_2
Hand-washing soap/liquid soap
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_3
Alcohol based hand rub
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_4
Disposable latex gloves
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_5
Waste receptacle (pedal bin) with lid and plastic bin liner
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_6
Sharps container ("safety box")
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_7
Environmental disinfectant (e.g., chlorine, alcohol)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_8
Disposable syringes with disposable needles
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_9
Auto-disable syringes
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_10
Bucket/ Tub for decontamination (for preparing bleaching solution to soak the instruments
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_11
Brush for cleaning hinges/ joints of instruments
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_12
Autoclave/ Boiler functional/ Large utensils with lid + gas stove
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_13
Waste disposal containers with colored plastic bags (as per guidelines)
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
F03_14
Clean sheet/mackintosh
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
Counselling services
G01
For what family planning services, counseling is provided?
Counseling Couples on Contraceptive Choices during Pregnancy
Counseling Couples on Contraceptive Choices in Interval
Counseling Couples on Contraceptive Choices in Post Pregnancy Period
Counseling Couples on delay first child
Counseling for Sexually Active Adolescents
Others (Specify)
G02
Is there a dedicated area available for family planning counselling?
Yes
No
G03
Does the counselling service room or area have auditory and visual privacy?
Auditory Privacy only
Visual Privacy only
Both Auditory and Visual Privacy
No Privacy
G04
Does this counselling area have Flip Charts/ Posters/Models/Job-aids for family planning?
G04_1
Flipchart
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
G04_2
Posters / Brochures
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
G04_3
Models
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
G04_4
Family planning – basket of choices
OBSERVED
REPORTED NOT SEEN
NOT AVAILABLE
G05
What is the number of trained Family planning counsellors available at this facility?
G06
What is the number of patients/ women /Men counselled in last 3 months?
G07
Does this facility provide family planning counselling through tele-consultation / E- sanjeevani?
Yes
No
G08
Who provides family planning counselling through tele-consultation/ E- sanjeevani?
ANMs
Community Health Officer (CHO)
Medical officer (MO)
Staff Nurse
Family planning counselors/RMNCH+A counselor/Health educator
G09
What devices are used for tele-consultation?
Desktop
Laptop
Tablet
Mobile phone
Others (Specify)
G10
How frequently the teleconsultation/ E-sanjeevani sessions for Family planning are done in a month?
Every day
Once a week
Twice a month
Once a month
More than once a week but not every day
When the client is available
Other (Specify)
Referral System
H01
Does this facility refer Women /Men to higher facilities for family planning services?
Yes
No
H02
Where are the Women/Men referred for family planning services?
Community Health Center
Sub-district hospital
District hospital
Medical college
Private Facility
Others (Specify)
H03
For what family planning services are they usually referred to?
Conventional tubectomy
Conventional vasectomy
Mini lap
Laparoscopic sterilization
No Scalpel Vasectomy
IUCD insertion
For administration of injectables
For removal of IUCDs
For availing OCPs
For further examination
For side-effect / complication management
For Abortion Services in case of failure
For following up for incentives
Others (specify)
H04
Does this facility provide written communication/ referral slip at the time of referral?
Yes
No
H05
Is this facility providing vehicle / arranges a vehicle for referral services for FP?
Yes
No
H06
Is there a provision to provide ambulatory services to a client who has come for FP services before referral?
Yes
No
H07
Are referral records for FP maintained and regularly updated?
Yes
No
Record Keeping
I01
Does this facility maintain client/ patient registration record?
Yes
No
I02
How does this facility maintain client/patient records?
Manually
Digitally
Both
I03
Can staff retrieve their records easily if the FP client/patient return for follow up services?
Yes
No
I04
Please tell me whether this facility has the record maintenance/ updated register for the following services.
I04A
Maintenance (verify through observation if a particular register is present)
I04A_1
Eligible couple register (TCR register)
Yes
No
I04A_2
MCH register /Delivery Register
Yes
No
I04A_3
Referral register
Yes
No
I04A_4
FP register
Yes
No
I04B
Last updation date (DD/MM/YYYY)
I04B_1
Eligible couple register (TCR register)
I04B_2
MCH register /Delivery Register
I04B_3
Referral register
I04B_4
FP register
I05
Please provide me the details on the following services
I05A
45292
I05A_1
# of deliveries conducted at this facility (DELIVERY REGISTER)
I05A_2
# of DMPA – IM administered
I05A_3
# of DMPA – SC administered
I05A_4
# of Implants inserted
I05A_5
# of PPIUCD insertions
I05A_6
# IUCD insertions
I05A_7
# PAIUCD insertions
I05A_8
# Female Sterilizations
I05A_9
# Male Sterilizations
I05B
45323
I05B_1
# of deliveries conducted at this facility (DELIVERY REGISTER)
I05B_2
# of DMPA – IM administered
I05B_3
# of DMPA – SC administered
I05B_4
# of Implants inserted
I05B_5
# of PPIUCD insertions
I05B_6
# IUCD insertions
I05B_7
# PAIUCD insertions
I05B_8
# Female Sterilizations
I05B_9
# Male Sterilizations
I05C
45352
I05C_1
# of deliveries conducted at this facility (DELIVERY REGISTER)
I05C_2
# of DMPA – IM administered
I05C_3
# of DMPA – SC administered
I05C_4
# of Implants inserted
I05C_5
# of PPIUCD insertions
I05C_6
# IUCD insertions
I05C_7
# PAIUCD insertions
I05C_8
# Female Sterilizations
I05C_9
# Male Sterilizations
Infrastructure of the facility
J01
What is the type of Building in which facility is located?
Rented
Owned
Other Govt. Structure
J02
Does this facility have overnight observations/ inpatients beds?
Yes
No
J03
How many beds are sanctioned for this facility?
J04
In total, how many beds are available at this facility?
J05
How many rooms are there in this facility?
J06
Does this facility have a drug shop/ pharmacy in this facility?
Yes
No
J07
How does this facility track stock of drug?
Manual tracking
Digital tracking
No formal system
Others
J08
Is there a functioning lab attached to this facility?
Yes
No
J09
Does this facility have a minor OT?
Yes
No
J10
Does this facility have helpline number for family planning services?
Yes, available and functional
Yes, available but not functional
No, not available
J11
Does this health facility have helpline number for family planning services provided by IPAS?
Yes
No
J12
On an average how many calls are received on this helpline number in a week?
J13
How long has been the helpline number not functional?
Less than a week
More than a week but less than a month
More than a month but less than a quarter
More than a quarter
J14
Does this facility have a board displaying FP service timings?
Yes
No
J15
Does this facility have wall paintings / board displaying availability of free and paid family planning services?
Yes
No
J16
What are the paintings displaying?
Oral contraceptives
Antara
Any other reversible method
Others (Specify)
J17
Does this facility have a signboard indicating the direction for Family planning service?
Yes
No
J18
Does this facility have IEC materials such as posters, banners, and handbills related to family planning available at the site and displayed?
Yes
No
J19
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