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Institution Template 3 -Form Fill

Information
Q01

Date of Assessment
Q02

Name of the State
Q03

Name/Type of the Institution
Q04

GPS
Q05

Name of Investigator
Q06

Code of Investigator
WORKING WOMEN HOSTEL
A01

Whether it is on a public land?
A02

Whether it is suitable and convenient for working women to access
A03

Whether the hostel can be easily accessed by the PWD?
A04

Does the working women hostels have a day care creche facilities available?
A05

Does the working women hostels fulfill the following basic conditions in terms of basic amenities?

A05_1

Living rooms (Single, double)
A05_2

Dormitory

A05_3

Common Room
A05_4

Dining Room
A05_5

Kitchen and store
A05_6

Bathroom
A05_7

Toilet
A05_8

Washbasin
A05_9

Warden room
A05_10

Sick room
A05_11

Floor height
A05_12

Total built up area
A05_13

Washing machine
A05_14

Geyser/ solar heating
A05_15

Computers , Internet
A06

Is there a CCTV installed at entrance and other security measures available?
A07

Is the day care centres are safe and well ventilated with adequate reading and playing materials for children?
A08

Does the working women hostel have medical first aid available?
A09

Does the working women hostel maintain attendance registers and contact details of the beneficiaries as well as mothers of the children available?
A10

Does the working women hostel have the following staff available in the facility?
A11

Is there a hostel management committee?
National Creche Scheme
B01

Whether it is suitable and convenient for working women to access the creche,incase of any emergency.
B02

What is the opening and closing hours of the creche?
B03

Can the creche facilities be accessed by non-working women also?
B04

Can children with special needs also access the creche?

B05

Is the Centre clean, well-lighted with adequate ventilation.
B06

Is there a provision for safe and regular drinking water facility
B07

Is the food provided to the children having the adequate  nutritional value

B08

Is the food provided in the creche age appropriate?
B09

Does the creche maintain the records and registers which include all the required information about the mothers
B10

Does the creche also maintain specific entry in the registers and records for severely underweight children
B11

Is the user charges collected according to the following table

B11A

BPL families

B11A1

Rs.20 per child per month
B11B

Families with Income (Both Parents) of up to Rs. 12,000/- per month

B11B1

Rs.100 per child per month
B11C

Families with Income (Both Parents) of above Rs.12,000/-

B11C1

Rs.200 per child per month
B12

Is there an admission/ enrolment register for recording profile of children and parents including profession/income of both parents
B13

Is there an attendance register of children
B14

Is there an attendance registers of functionaries
B15

Is there health checkups records maintained which need to be shared with doctors
B16

Is there a supplementary nutrition register for recording the food provided to the children.
B17

Does the creche maintain (a)Mother’s meeting register (b) Visitors register (c) Register for user fee?
B18

Are there required number of creche helpers and workers available in the creche?
B19

Is there a first-aid kit
B20

Did you ever face drinking water issues in the past? 
B21

Did you face network connectivity issues in the past? 
B22

Did you face supply crunch of essentials in the past? 
B23

Is there a NGO/CBO involved in the functioning of this institute? 
B24

Is there a feedback mechanism in place? 
B25

Is internet available to all now? 
B26

Are records maintained digitally? 
B27

Is data about the institute relayed to state/district HQ ?
B28

If 27 is yes , how is the data relayed to the HQ  
B29

Were you given any specific skills training given on or off the job? 
B30

Are you satisfied with the training that your were provided? 
B31

Do you think there should be more training given to improve your performance? 
Anganwadi Services (Erstwhile Core ICDS)
C01

Model of anganwadi
C02

Does the AWCs have the following amenities (tick all the applicable options)
C02A

Please tick (whichever applicable) based on the reliability/regularity of the services provided. 

C02A1

Availability (Y/N)

C02A1_1

Water Supply
C02A1_2

Electricity
C02A2

Reliability/Regularity

C02A2_1

Water Supply
C02A2_2

Electricity
C02A3

Average hrs of supply in 24 hrs (mention hrs of supply)

C02A3_1

Water Supply
C02A3_2

Electricity
C02B

Is there THR packages available in the AWC?
C03

Are the AWW educated till Metric and Above?
C04

Have the AWWs received Job Training?
C05

Whether ICDS-CAS implemented in the AWC?
C06

Has the AWW attended ICDS-CAS training?
C07

Has the devises provides under ICDS-CAS functional?
C08

Has the AWW started updating the records using cellphones/tablets?
C09

Do the AWW belong to the Local Area?
C10

Are the AWCs having adequate availability of Educational Material for Nutrition and Health Education (NHED)?
C11

Does the AWC’s have the following growth monitoring devices?

C11A

Available in the AWC

C11A_1

Infantometer
C11A_2

Stadiometer
C11A_3

Infant Weighing Scale
C11A_4

Mother & Child Weighing Scale
C11B

Device is functional/not functional

C11B_1

Infantometer
C11B_2

Stadiometer
C11B_3

Infant Weighing Scale
C11B_4

Mother & Child Weighing Scale
C12

Are the AWCs maintaining Health Cards?
C13

Are the AWW’s filling the MCP card efficiently?
C14

Which of the following registers & records are being maintained by Anganwadi worker?
C15

On which of the following is the food cooked?
C16

Tick whatever materials children have received from Anganwadi Centre?

C16A

Received

C16A_1

School bag
C16A_2

Tiffin box
C16A_3

water bottle
C16B

Items (no) received by AWC from 1st April 2019 - 31st Oct, 2019

C16B_1

School bag
C16B_2

Tiffin box
C16B_3

water bottle
C16C

Items (no) disbursed from 

C16C_1

School bag
C16C_2

Tiffin box
C16C_3

water bottle
C17

What are the materials (PSE) you have received for providing pre – school education service? (tick whichever applicable)

C17_1

Building block set (basic shapes that vary in color, size and thickness) 
C17_2

Colourful beads and wires 
C17_3

Balls of varying sizes 
C17_4

Simple puzzles (e.g jigsaw puzzle, colour puzzle, shape puzzle) 
C17_5

Balls of varying sizes 
C17_6

Alphabet and number cards 
C17_7

Picture books with one or two text lines
C17_8

Toys (e.g dolls, maze etc) 
C17_9

Plastic fruits and vegetables 
C17_10

Variety of tools (e.g.,spoon, measuring cups, paint brushes, etc.) 
C17_11

Crayons, markers, coloured pencils, coloured chalk
C17_12

Tape/Glue
C17A

Are there any provisions for replacing and replenishing the material provided for PSE? 
C18

Are there provisions for adequate drinking water available in the facility?  
C18_1

If no, have they ever requested the higher authorities for the same? 
C18_2

Did the higher authorities respond? 
C18_3

How many days did they take to respond? _________(days) 
C18_4

Was the response of the higher authorities satisfactory? 
C18_5

Are there provisions for adequate sanitation facilities available in the facility?  
C18_6

If no, have they ever requested  the higher authorities for the same? 
C18_7

Did the higher authorities respond? 
C18_8

How many days did they take to respond? _________(days) 
C18_9

Was the response of the higher authorities satisfactory? 
C18_10

Are there provisions for adequate cooking facilities available in the facility?  
C18_11

If no, have they ever requested  the higher authorities for the same? 
C18_12

Did the higher authorities respond? 
C18_13

How many days did they take to respond? _________(days) 
C18_14

Was the response of the higher authorities satisfactory? 
C19

Did you face network connectivity issues in the past? 
C20

Did you face supply crunch of essentials in the past? 
C21

Is there a NGO/CBO involved in the functioning of this institute? 
C22

Is there a feedback mechanism in place? 
C23

Is internet available to all now? 

C24

Are records maintained digitally? 
C25_1

Is data about the institute relayed to state/district HQ 
C25_2

If yes , how is the data relayed to the HQ  
Institutional Study for Ujjawala
D01

Is the location of the Protective and Rehabilitative Homes (P&R) and Half-way Homes suitable and convenient
D02

Do the protection homes have the following staff
D03

Do the protection homes have the required facilities such as furniture, utensils, linen beds, locker etc.

D04

Do the homes have sufficient Electricity and Water supply
D05

Are the following services provided by the homes
D06

Is CCTV camera and security guard available within the premise?
Institutional Study for SwadarGreh
E01

Is the location of the SwadarGreh suitable and convenient
E02

Does the SwadarGreh has the following staff:(tick all the applicable options)
E03

Do the protection homes have the required facilities such as furniture, utensils, linen beds, locker etc.

E04

Do the homes have sufficient Electricity and Water supply
E05

Are the following services provided by the homes
E06

Is CCTV camera and security guard available within the premise?
Institutional Study for One-Stop Centre
F01

Is the location of OSC suitable and convenient.
F02

Is there a hospital/medical facillity which is prominently visible andd accessible near the OSC?
F03

Is there the provision of the following in the OSC
F04

Does the OSC have the following staff?
F05

Are the following facilities provided to the beneficiaries by the OSC
F06

Is there a video conferencing facility available in the OSC?
F07

Is there adequate number of basic kits  avialable in the OSC?