PHC Supportive Supervision Format - Nrhmharyana.org

MONITORING CHECKLIST OF MCH ACTIVITIES OF PHCName of District…………………Name of the CHC:..................................Type of Health facility: PHC/Urban RCH/Civil DispensaryName of PHC/Urban RCH/ Civil Dispensary…… ………………………………………………Official Email id of PHC: …………………Landline no: ………………………………Population under PHC….........................No of Sub centers under the PHC………..Name of Supervisory Officer…………….. Date of visit: ...............................................Designation:…………………………..Organization:……………………………….Sr.Activity Observation RemarksNo.A. Infrastructure and General Overview1. No. of Staff Nurses in PHCRegularContractual0/1/2/3/4/50/1/2/3/4/52. Whether the location of the PHC Yes/Noappropriate for providing goodservices3. Whether this PHC is 24x7 Yes/No4. No of Medical Officer posted andavailable in PHC0/1/2/3/4 Name of Medical Officers and contact no:1.2.3.4.5. No of Dental Surgeon posted 0/1/2/3 Name of Dental Surgeon and contact no:1.2.6. No of Lady Medical Officer in PHC 0/1/2/3 Name of LMO and contact no:1.2.3.7. No of Ayush doctor posted in PHC 0/1/2 Name of Ayush Doctor and contact no:1.2.8. No. of LHV/MPHS (Female) posted 0/1/2/3in the PHC9. No of HI/MPHS(Male) posted in 0/1/2/3PHC10. No of Lab Technician posted in 0/1/2/3PHC11. No of Pharmacists posted in PHC 0/1/2/312. No. of rooms in the PHC (includinglabour room & emergency room)0/1/2/3/4/5/6/7/8/9/10/11/12/13/14/1513. Type of building Govt./Private14. No of rooms actually used for 0/1/2/3/4/5/6/1

providing services 7/8/9/10/11/12/13/14/1515. Metered Electricity supply Yes/No16. Is Inverter available and functional Yes/No17. Is Generator available and functional Yes/No18. Computer available and functional Yes/No19. Internet connectivity Yes/No20. Printer Yes/No21. Photocopier available Yes/No22. Telephone facility (landline) Yes/No23. Filtered Drinking water facility Yes/No24. Laundry facility available Yes/No25. Waste disposal facility available Yes/No26. Is the waste disposal outsourced to Yes/Noany agency27. Disposal pitasYes/NoperCPCBrecommendationsavailable28. ImmunizationwasteYes/Nochemicallydisinfected29. Disposal pit usedfor disposal Yes/Noofdisinfectedsharps(cutneedles,brokenvials &ampoules)B. Ambulance30. Is the ambulance available at PHC Yes/No31. If available, is it functional at the Yes/Notime of visit32. Is the Log book of ambulance Yes/Noproperly maintained33. x IEC for Referral Transport Yes/No34. No of patients transported inprevious monthC. OPD Available Functional35. Wall clock with seconds arm Yes/No Yes/No36. BP apparatus Yes/No Yes/No37. Stethoscope Yes/No Yes/No38. Weight machine Yes/No Yes/No39. Height measuring scale/markings on Yes/No Yes/Nothe wall40. Digital thermometer Yes/No Yes/No41. OPD register Yes/No42. No of OPD patients Previous seven workingdays _______________43. Adequate space for services for OPD Yes/No44. Is there is waiting area with sitting Yes/Noarrangement for patients45. Is toilet available in OPD Yes/No2

46. Cleanliness and hygiene in:1.OPD2.ToiletYes/NoYes/No47. Chart of PHC at a glance available Yes/No48. Poster of reporting of AFP cases Yes/No49. Is there a complaint box Yes/No50. Is there a Grievance redreesalmechanism for JSSK etc.Yes/NoD. Labour Room51. Is there separate labour room Yes /no52. Is there a separate post-partum room Yes/No53. If yes, No of beds in Post-partumroom54. Curtains/privacy in labor room Yes/No55. Cleanliness and hygiene inlabor room Yes/No56. Is toilet available in labor room Yes/No57. Water supply (24 hours by overhead Yes/Notanks etc.) in labor room58. Is newborn care corner available inLabour room.Labour Room Equipment Available Functional59. Examination table Yes/No Yes/No60. Labor table Yes/No Yes/No61. Instruments for delivery Yes/No Yes/No62. Macintosh with Kally’s pad Yes/No63. Radiant warmer Yes/No Yes/No64. Resuscitation kitYes/No Yes/No(Ambu bag, Laryngoscope, Mask (0& 1), Mucus Extractor)65. Suction machine (footYes/No Yes/Nooperated/Electrical)66. Baby weighing machine Yes/No Yes/No67. Oxygen cylinder Yes/No Yes/No68. Room thermometer Yes/No Yes/No69. Equipment for sterilization (Sterilizer, Yes/No Yes/NoAutoclave, Boiler)70. Equipment for IUD insertionSpeculum :- a. Sim’s, b. Cusco’s, Yes/No Yes/NoUterine sound, Volsellum, Ant.Vaginal wall Retractor, Scissors,Torch, Chittel forceps)71. OT lights with battery backup Yes/No Yes/No72. Foley’s catheter/ Catheter K90 Yes/No Yes/No73. FHS Doppler Yes/No Yes/No74. Infant feeding tube Yes/No Yes/No75. I.V. Canulas and intercath Yes/No Yes/No76. Scalp vein set Yes/No Yes/No77. Wall clock with second arm Yes/No Yes/No78. Naso gastric tube Yes/No Yes/No79. Thermometer Yes/No Yes/No3

80. Stretcher Yes/No Yes/No81. Colour coded buckets Yes/No Yes/No82. Bleaching powder Yes/No Yes/No83. Twin (Sieve) bucket for disinfection Yes/No Yes/No84. Segregation of Biomedical wastes Yes/No Yes/No85. Whether surface cleaning of labour Yes/Noroom done with carbolic acid/formalinin last two months86. BP apparatus Yes/No Yes/No87. Stethoscope Yes/No Yes/No88. Weight machine Yes/No Yes/No89. NSSK resuscitation protocol poster Yes/No90. Family Planning chart/poster etc. Yes/No91. MTPs chart/poster etc. Yes/No92. PPH Management protocol poster Yes/No93. JSSK IEC Yes/No94. JSY IEC Yes/No95. Newborn corner register Yes/No96. Labour room register Yes/No97. Partograph Yes/No98. Duty roster of staff Yes/No99. Maintenance of Maternal deaths Yes/Norecords100. Maintenance of Infant death and Still Yes/Nobirth records101. Whether the Maternal Death, Infant Yes/NoDeath and Still Birth reported byANMs by Surveillance formatsentered in Online SurveillanceSoftware?102. No of deliveries Previous month______________103. No of Woman who stayed Previous monthfor 48 hrs after delivery at ______________PHC104. Free diet given to Pregnant Previous monthwomen______________105. No of pregnant women Previous monthreferred______________106. No of Male babies born in Previous monthprevious month______________107. No of Female babies born in Previous monthprevious month______________108. No of infants referred Previous month______________109. No. of babies whose weight Previous monthwas done at birth______________110. No of Low birth weight Previous monthbabies______________111. No of Still births Previous month______________4Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________Previous 3 months_________________

112. No of Infant deaths Previous month______________113. No of MTPs performed Previous One YearSurgical______________Medical______________114. IUDs Previous month______________ComponentNo. of Staff Nursetrained115. SBA trained 0/1/2/3/4/5/6 0/1/2/3116. F-IMNCI trained 0/1/2/3/4/5/6 0/1/2/3117. NSSK trained 0/1/2/3/4/5/6 0/1/2/3118. IUD and alternate IUD 0/1/2/3/4/5/6 0/1/2/3trained119. MTP trained 0/1/2/3/4/5/6 0/1/2/3120. RTI/STI trained 0/1/2/3/4/5/6 0/1/2/3121. Is the Staff Nurse able tocorrectly measure BloodPressure with BP apparatus?(Ask her to check your BP)0/1/2/3/4/5/6122. Can SN do Abdominalexamination of PW123. Can Staff Nurse do Bag andMask usage or resuscitation124. Does Staff Nurse knows PPHmanagement125. Does Staff Nurse knowsMucus extractor usage126. Does Staff Nurse knowWarmer usage (Settingtemperature etc.)0/1/2/3/4/5/60/1/2/3/4/5/60/1/2/3/4/5/60/1/2/3/4/5/60/1/2/3/4/5/6127. FHS hearing ability 0/1/2/3/4/5/6128. Does the Staff Nurse know 0/1/2/3/4/5/6how to maintain asepticconditions for delivery?(Cord cutting)129. Does the Staff Nurse knowhow to identify high riskpregnancy? (on the basis ofBP, weight and previousoutcome of pregnancies)130. Does the Staff Nurse knowshow to fill the partographs131. Does the Staff Nurse knowsthe danger sign in Newbornbaby132. Percentage of marks of StaffNurse as per theQuestionnaire:0/1/2/3/4/5/60/1/2/3/4/5/60/1/2/3/4/5/6SN1___________SN2___________SN3___________SN4___________SN5___________SN6___________Previous 3 months_________________Previous 3 months_________________No of MO TrainedRemarks5

E. LaboratoryLaboratory Equipment andReagents133. Is the laboratory facilities availablein PHC 24x7134. Is PHC a designated Microscopiccenter135. Slide preparation facility formalaria parasite136. No of slides prepared in last 7working days137. No of malaria cases detected inlast 1 month138. Sputum examination facility forZN stainingAvailable&functionalYes/NoYes/No139. No of sputum examination in last1 month140. Laboratory testing facility available Yes/NoforHbYes/NoABoRHYes/NoVDRLYes/NoUrine Albumin/SugarYes/NoHIVYes/NoBlood glucoseYes/NoBlood groupingYes/NoTLC & DLCYes/No141. Glucometer Yes/No142. Haemoglobinometer Yes/No143. Urostix Yes/No144. Gloves Yes/No145. Disposable syringes Yes/No146. Gloves disposable Yes/No147. Microscope Yes/No148. Centrifuge Yes/No149. Refrigerator Yes/No150. Pippettes Yes/No151. Tubes Yes/No152. ZN Stain Yes/No153. Leishman stain Yes/No154. N/10 HCL Yes/No155. Sodium citrate Yes/No156. Carbolfuchsin Yes/No157. Methylene blue Yes/No158. Sulphuric acid Yes/No159. Benedict solution Yes/No160. Acetone Yes/No161. Immersion oil Yes/No162. Xylene Yes/No163. Spirit Yes/No6RemarksAvailable Functional RemarksYes/No Yes/NoAvailable Functional RemarksYes/No Yes/NoNo. of Laboratory tests done for thefollowing in previous seven days

164. Urine Pregnancy Test Kit available Yes/No165. Is Chart for Waste disposal Yes/Noavailable166. Chart for AFB grading Yes/No167. Chart for ZN staining Yes/NoF. Cold Storage room Available Functional168. Is PHC a Cold Chain Point? Yes/ No169. No. of Small Deep freezers 0/1/2 0/1/2170. No of Small ILRs 0/1/2 0/1/2171. No of large Deep freezers 0/1/2 0/1/2172. No of Large ILRs 0/1/2 0/1/2173. Sufficient no. of Vaccine carriers Yes/ No Yes/ Noavailable (No. of polio booths x2)174. Sufficient no. of Ice packs Yes/ No Yes/ Noavailable (No. of polio booths x 2x 4)175. Biomedical waste disposala) Red Bagsb) Black BagsYes/No Yes/NoYes/No176. Hub Cutter Manual Yes/No Yes/No177. Hub cutter Electrical Yes/No Yes/No178. Documented emergency plan in Yes/Nocase of breakdown of cold chain179. Chart on four messages to be Yes/Nogiven at the time of immunizationof child180. Chart on vaccine sensitivities Yes/No181. Vaccine protocol charts (Freeze Yes/Noand heat sensitivities)182. Documented visits of Refrigerator Yes/NoMechanic in last 2 months183. Documented PHC plan for Yes/NoAlternate Vaccine delivery184. Computerized micro plan forRoutine immunizationa) Estimation of beneficiariesb)Estimation of logisticsYes/NoYes/NoYes/No185. Handwritten micro plan for Yes/NoRoutine immunization186. Routine ImmunizationAvailableMapYes/NoANM RosterYes/NoSupervisory planYes/NoAVD planYes/NoCoverage Monitoring Chart Yes/NoBlock Meeting Conducted Yes/Noregarding RIYes/NoSupervisory visitYes/No187. Routine immunization IEC Yes/No188. Documentation of ASHA payment Yes/ No7

in RI sessions189. Alternate Vaccine Delivery Yes/Nopayment register190. Routine Immunization trained Staff Nurses:0/1/2/3/4/5/6191. Does the PHC has designated cold Yes/ Nochain handler192. No. of people trained in Cold 0/1/2/3/4/5/6/7/Chain training8193. Does the cold chain handler knows Yes/Noabout conditioning of ice packsSupplies and stocks8MO:0/1/2/30/1/2/3Actual count Record Remarks194. DPT vaccine (in vials)195. TT vaccine (in vials)196. OPV vaccine (in vials)197. Measles vaccine (in vials)198. BCG vaccine (in vials)199. Hepatitis B vaccine (in vials)200. JE vaccine(in vials)201. BCG Diluent (ampoules)202. Measles Diluent (ampoules)203. JE diluents (ampoules)204. Pentavalent vaccine (in vials)Placement of Ice Lined Refrigerator (ILR)& Deep Freezer (DF)205. Are allILRs &DFs placed Yes/Noonblocks (e.g.wooden/plastic)206. Are allILRs &DFsatleastYes/No10cmawayfromwallsandsurrounding equipment207. Are allILRsYes/No&DFsawayfromdirectexposuretosunlight,moisture andrain208. Are allILRsYes/No&DFsconnectedthroughseparatefunctional Voltage StabilizersTemperature log book209. Temperature LogBooks available Yes/NoforeveryILR andDF210. Twicedailymonitoringoftemperatu Yes/Nore inrespective log books211. Record ofpowerfailures/cuts Yes/No(ifany)212. Record ofDefrostingILRs & DFs Yes/No213. Periodic checks of Temperature Yes/NoLogBooksbyFacilityin-charge (seeevidence ofsignatures)Ice Lined Refrigerator (ILR)214. Is Functionalthermometer Yes/Noplacedinside everyILR215. Is the CabinetTemperature ofILRs Yes/Nobetween+2 to+8 CRemarksRemarksRemarks

216. Is there any frost present oninsidewalls ofILR217. Are allvaccine vialscorrectlyarrangedinsidelabeledcartons (expirydate, batch)218. Is there any T-series orHepatitisBvaccine vials placedinthebottomofILR219. Is there anyitemotherthanRIvaccines placedinside ILR220. Are vaccines inILRwithinexpirydates(checkafewvials)221. All Vaccinevials within usablestage ofVVM(checka fewvials)222. Are all vaccine vials inILRwithlabels(checkafewvials)223. Is thereanyreconstitutedBCG&Measlesvials placed inside the ILR224. Are DiluentsplacedinILR,atleast24hoursbeforedistribution(observeand/orconsult)Deep Freezer (DF)225. Is Functionalthermometerplacedinside everyDF226. Is CabinetTemperature ofDFsbetween-15to-25 C227. Is there any frost more than5mmpresent oninside walls ofILR228. Are the icepacks correctly placedinside DF(incrisscrossmanner,while freezingand in stacks when frozen )229. Is there any RI vaccinesstoredinsideDFs(includingreconstitutedvaccines)Immunization sessions230. Immunization sessions (for lastcalendar month)Yes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoPlanned (p)(consultmicroplan)Conducted (c)(consult vaccineissue register)Remarks% conducted(c/p x100)231. Doses administered(Cumulative for last3reportingmonths)*MPR= Monthly ProgressiveReportDPT1(D1)(ConsultMPR*inUIPformat)DPT3(D3)(ConsultMPR*inUIPformat)%Dropout([D1-D3]/D1X 100)232. AnyAEFIreportedorZeroReportinlast3calendarmonths Yes/No9

233. AnyVPD reportedorZeroReportinlast3calendarmonths Yes/NoG.Ward& Nursing Station Available Functional234. Wall clock with seconds arm Yes/No Yes/No235. BP apparatus Yes/No Yes/No236. Stethoscope Yes/No Yes/No237. Weight machine Yes/No Yes/No238. Digital thermometer Yes/No Yes/No239. Indoor register properly maintained Yes/No240. Stretcher Yes/No Yes/No241. Wheel chair Yes/No Yes/No242. No of Beds in ward243. No of Indoor patients in ward At the time of visit_______________244. Is there waiting area with sitting Yes/Noarrangement for attendants?245. Is functional toilet available in Yes/NoWard?246. Linen in sufficient quantity Yes/No247. Cleanliness and hygiene in:1.WardYes/No2.ToiletYes/NoLast 7 working days_______________H. Drugs and Drug StoreName of the drug/ointment/contraceptive/Vaccine248. LignocaineHydrochloride +AdrenalineAvailable inStoreYes/NoAny expiredtablets/ointments/contraceptivesYes/No249. Atropine Yes/No Yes/No250. DiazepamInjectionTabletYes/NoYes/NoYes/NoYes/No251. PromethazineSyrupInjection252. Acetylsalicylic acidtablet253. DiclofenacTabletYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoInjectionYes/NoYes/NoYes/NoYes/No254. Ibuprofen tablet Yes/No Yes/No255. ParacetamolSyrupTabletInjectionYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoRemarks (Availability inOPD/Labour Room/Emergencyward/ OT etc)10

256. CetrizineTabletSuspensionYes/NoYes/NoYes/NoYes/No257. Dexamethasone injection Yes/No Yes/No258. Chlorpheniramine tablet Yes/No Yes/No259. Prednisolone tablet Yes/No Yes/No260. Pheniramine maleate inj. Yes/No Yes/No261. Antisnake venominj. Yes/No Yes/No262. CarbamazepineTabletSyrupYes/NoYes/NoYes/NoYes/No263. Diazepam inj. Yes/No Yes/No264. PhenobarbitoneTabletInjectionYes/NoYes/NoYes/NoYes/No265. PhenytoinTablet/CapsuleInjection266. AlbendazoleTabletYes/NoYes/NoYes/NoYes/NoSuspensionYes/NoYes/NoYes/NoYes/No267. Amoxicillin + clavulanic Yes/No Yes/Noacid tablet268. Ampicillininj. Yes/No Yes/No269. AmoxicillinTablet/CapsSuspensionYes/NoYes/NoYes/NoYes/No270. Ceftriaxone inj. Yes/No Yes/No271. Amikacin inj. Yes/No Yes/No272. Azithromycin caps. Yes/No Yes/No273. CefadroxilTabletSyrup274. CiprofloxacinYes/NoYes/NoYes/NoYes/NoYes/No Yes/NoTabletYes/No Yes/NoInjectionYes/No Yes/NoEye drops275. Doxycycline tabs./caps. Yes/No Yes/No276. Gentamicin inj. Yes/No Yes/No277. MetronidazoleYes/No Yes/NoTabletInjectionSuspension278. Norfloxacintabs. Yes/No Yes/No279. CotrimoxazoleYes/No Yes/NoTabletSuspension280. ClotrimazoleYes/No Yes/NoGelPessaries281. Fluconazole tab. Yes/No Yes/No282. Cyanocobalamininj. Yes/No Yes/No11

283. IFA tablets large Yes/No Yes/No284. IFA tablets small Yes/No Yes/No285. IFA syrup Yes/No Yes/No286. Folic acid tab. Yes/No Yes/No287. Atenolol tab Yes/No Yes/No288. Isosorbide 5Yes/No Yes/Nomononitrate/dinitrate tab289. Adrenaline inj. Yes/No Yes/No290. Amlodipine tab. Yes/No Yes/No291. Methyldopa tab. Yes/No Yes/No292. Miconazole cream Yes/No Yes/No293. PovidoneIodineointment/ Yes/No Yes/Nosolution294. Silver sulfadiazine cream Yes/No Yes/No295. Benzyl-Benzoate Yes/No Yes/No296. Cetrimide solution Yes/No Yes/No297. FurosemideYes/No Yes/NoTabletInjection298. Aluminium hydroxide + Yes/No Yes/Nomagnesiumhydroxidesuspension299. Ranitidine tab. Yes/No Yes/No300. DomperidoneYes/No Yes/NoTabletSyrup301. Metoclopramide Yes/No Yes/NoTabletInjection302. DicyclomineYes/No Yes/NoTabletInjection303. Bisacodyl tab. Yes/No Yes/No304. Glibenclamidetab. Yes/No Yes/No305. Metformin tab. Yes/No Yes/No306. Rabies vaccine inj. Yes/No Yes/No307. Gum Paint Yes/No Yes/No308. ClorehexidineYes/No Yes/Nomouthwash309. IsoxsuprineTabletYes/No Yes/NoInjection310. HaloperidolYes/No Yes/NoTabletInjection311. Fluoxetine cap. Yes/No Yes/No312. Alprazolam tab Yes/No Yes/No313. Budesonide inhalationaerosolYes/No Yes/No314. Salbutamol nebulizersolutionYes/NoYes/No12

315. Theophylline compound Yes/No Yes/No316. Etophylline +TheophyllineTabletInjection317. Glucose/dextrose IVsolution318. Isolyte – P (Forpaediatric use) IVYes/NoYes/NoYes/NoYes/NoYes/NoYes/No319. Ringer lactate IV Yes/No Yes/No320. Sodium chloride/normalsaline IVYes/NoYes/No321. Calcium tablets Yes/No Yes/No322. B-complex tablets Yes/No Yes/No323. Hydrocortisone Injection Yes/No Yes/No324. Ondansetrone Injection Yes/No Yes/No325. Oxytocin inj. Yes/No Yes/No326. Magsulf injection Yes/No Yes/No327. MetherginYes/No Yes/NoTabletInjection328. Mesoprost tablets Yes/No Yes/No329. Cotrimoxazole tablets Yes/No Yes/No330. Vitamin A Yes/No Yes/No331. Paracetamol tablets Yes/No Yes/No332. ORS packets Yes/No Yes/No333. Zinc tablets Yes/No Yes/No334. GV paint Yes/No Yes/No335. Betadine ointment Yes/No Yes/No336. Oral Pills Yes/No Yes/No337. Condoms Yes/No Yes/No338. IUD Yes/No Yes/No339. Catgut sutures Yes/No Yes/No340. Drug stock registerproperly maintainedI. Other Equipment Available Functional341. Washing machine Yes/No Yes/NoJ. Dental EquipmentAvailableFunctional342. Dental chair Yes/No Yes/No343. Dental X-ray films Yes/No Yes/NoRemarks (No of patient treated/ Xrays done in last 7 working days)K. Record KeepingName of the Register/Record(Are all required columns duly filled?)Maintainingregister/recordRemarks& Action Taken13

344. JSY Payment registerGoIYes/NoStateYes/No345. ASHA payment register Yes/No346. Equipment register Yes/No347. Movement register Yes/No348. Whether all delivery patient data Yes/Noentered in Anemia TrackingSoftware or not?349. Birth and Death Registers Yes/No350. Adolescent health clinicregister Yes/No351. SKS meetings register Yes/No352. Family planning register Yes/No353. Maintenance of IMNCI supervisory Yes/Novisit records354. Whether Single reporting data of all Yes/Nosubcenters and PHC entered onlineor not?355. MCTS reports Yes/No356. Last month report provided to Yes/NoCHC/District357. Cash Book for:SKSYes/NoAnnual Maintenance Grant Yes/NoUntied FundsYes/NoUser FeeYes/NoL. IEC Activity (Boards/Posters)Component Displayed Remarks358. PNDT Yes/No359. Leprosy Yes/No360. Tuberculosis (DOTS) Yes/No361. AIDS Yes/No362. Blindness prevention Yes/No363. Childhood illnesses Yes/No364. Citizen charter Yes/No365. Birth and Death registration Yes/No366. SKS meeting boards Yes/No367. Is Color coded kits for Syndrome Yes/Nomanagement of RTI/STI available368. No of cases Managed/treated for Previous monthRTI/STI______________369. Is PHC working as DOTS centre Yes/No370. No of clients on DOTS treatmentCat-ICat-IICat IVTotal14

371. Is this PHC an IntegratedCounseling and Testing Center372. No of Client Counseled forHIV/AIDS in last 1 monthYes/NoM. Exit interview Patient 1 Patient 2 Patient 3 Patient 4373. Have you been provided free Yes/No Yes/No Yes/No Yes/Nomedicines from the hospital?374. Have you been asked to conduct any Yes/No Yes/No Yes/No Yes/Notests from outside?375. Have you been asked to buy any Yes/No Yes/No Yes/No Yes/Nomedicines from outside?376. Have you been asked to go to any Yes/No Yes/No Yes/No Yes/Nooutside doctor (Private)?377. How long did you have to wait forthe doctor to see you?30 mins30 mins30 mins30 mins378. If the patient had undergone delivery Yes/No/NA Yes/No/NA Yes/No/NA Yes/No/NArecently at public health facility, didshe had any out of pocket expense?379. Good/ Good/ Good/ Good/How did the doctor behave withSatisfactory/ Satisfactory/ Satisfactory Satisfactoryyou?Bad Bad /Bad /Bad380. How did the nurse and other staffbehave with you?N. Monitoring and Supervision381. No. of documented visits byCivil Surgeon in last one year382. No. of documented visits byDeputy CMO from district in last3 months383. No. of documented visits bySMO to this PHC in last onemonths384. No of Visits by officers/officialsfrom State HQs in last one yearGood/Satisfactory/BadGood/Satisfactory/BadGood/Satisfactory/BadGood/Satisfactory/Bad15

O. HBPNC Yes/NO Remarks385 Monthly review meeting for HBPNC planned in last 3 month?386 Monthly review meeting for HBPNC held in last 3 month?Supervision/monitoring plan for HBPNC developed for the current month?387 Check form 'C"Yes/NO388No. of supervisory visits planned by PHC team (MO, LHV) during previousmonth (Check form C)No. of supervisory visits conducted by PHC team (MO, LHV) during previous389 month (Check form B)390 MO & LHV received HBPNC supervisory training Yes/NONo. of cards submitted by ASHA in previous month (Check Self appraisal391 form)392No of beneficiary (cards) for which payment made to ASHA (out of submittedin previous month) during previous monthNo. of cards entered (out of submitted in previous month) in software by393 information assistant during previous month?394 Do all ANMs submit DHIS-2 (single reporting) report of HBPNC regularly Yes/NO395Are PNC cards countersigned by MO after submission by ANMs- check fewPNC cards for confirmationYes/NO396 ASHA drug kit replenishment guidelines are available with PHC Yes/NORecommendations of the Monitoring Official /officer :16

Suggestions from the district :Compliance report timeline :-Signature of the monitoring OfficialName of the Monitoring Official: ________________Designation: ________________________Date of Visit: _______________17