Standards for Female and Male Sterilization Services - STATE ...
Standards for Female and Male Sterilization Services - STATE ...
Standards for Female and Male Sterilization Services - STATE ...
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54<strong>St<strong>and</strong>ards</strong> <strong>for</strong> female <strong>and</strong> male <strong>Sterilization</strong> servicesAnnexure 3Medical Record <strong>and</strong> Checklist <strong>for</strong> <strong>Female</strong>/<strong>Male</strong> <strong>Sterilization</strong>Reg. No................................................................................Date................/............................/....................................(D/M/Y)OT No.....................................................................................Date of operationDate................/.............................. /.....................................(D/M/Y)Name of the state ..................................................................................................Name of the district ..................................................................................................Name <strong>and</strong> type of the hospital/facility ..................................................................................................Camp.......................................................................................PP centre.................................................................................PHC/CHC.............................................................................District hospital.....................................................................Medical college hospital........................................................Other (specify.........................................................................Name of the acceptor ..................................................................................................Name of father ..................................................................................................Name of husb<strong>and</strong>/wife ..................................................................................................Address....................................................................................................................................................................................................Contact number (if available)....................................................................................................................................................................................................
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