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1

,e Supervision Checklist

C9: Designation of In-charge-CS: Name of Facility in-charge/nodal officer - l\ R. r E::.. 'f ,Arv M. 0'

Data of previous month from facility I \ (o E Drugs/supplies availability (If possible, verify physically}1

El: Reproductive Health E3: New Born Health E7. Antibiotics D1 Number of deliveries in facility ,, "---"(),/\...­

Female interva l sterilization

Female postpartum steri lization

Male ster ilization

I I

I ..g..--­centres and with ASHAs) t ablets 9 E2.8: Pregnancy Test Kit (oniv at sub- ES.2: Weekly Iron folic acid su~nta~ D E8.13: Soap SJ_,/

/ I E2.9: Functional Blood Bank/blood E 5.3 Tablet Albendazole µJ- E8.14: Color coded bins and bags '-G-"'

08 No of women received IFA tab L storage units "

l.f}---'E2.6: Sterile pads _g__ E8.11: Autoclave/Boiler "' E.5: 1'.\dolescent Healthr E2.7: IFA Tablet l~=r ·1 10' ES.l: Dicyclomine 0,/ E8.12: Running water ~

Cl: Name of the supervisor~/'::-.,... 1?::., ·. ~ :~ g~.ti9.~

C4: Facilit y Name - 10 1\ T A W f. i/-:L , Block 1<::,L\.L--r 1' t>.J.. District l::. . ~ . 1-\-- .

El.1: IUCD 375, 380A 'ff E3.1: lnj. Vit Kl(l mg/ml) lt!Y"" E. 7 .1 Ant ibiotics as per RMNCH+A SXS Matrix ( Amoxyclillin, Ampicillin,

Ampicilli n, Gentamicin, Metronidazole, Tri methoprim &Sulpha methoxazole, Cef rtiaxone (oral/lM/IV as applicable)

,v­::v ,-­------_,,----,,------,­--'rJ...,1!.­

Total Deliveries

Normal

Assisted Vagi nal Delivery

(-section

Referred out cases

Live births I .

) D2 Number of new-borns

immunized before discharge

D3 IPD load

D4 OPD load

OS IUCD inserted in facility

Interval ~ Postpartum (')

Post Abort ion () D6 Sterilization done

E2.S: lnj. Tetanus Toxoid \!J/ E4.4: Tablet Albendazole '8---- E8.10: Fetoscope/ Doppler 'Er'

~~ - ~ 3: Level of supervisor - Block/ District/ State/Nat ion a I/ Other

i,----­ICS: Facility Type - SC/ Non""24 * 7 PHC /24*7 PHC/Non- FRU CHC/FRU (6: Fac ility Level - Ll/ L2/ L3

CHC/SDH/DH/AREA HOSP/other

_..g--­

D I I I

lyqs-l

El.2: OCP 1--Er E3.2 : Mucus Extractor 1._[1..,-- ES: Other essential supplies

&equipments(check _functionality & utilization)

El.3: ECP ~ E3.3: Bag and mask '-ff E8.1 Weighing Machine Ll (240 ml) with both pre & t erm mask ( size 0,1) .,,. ......

El.4: Condoms [)/ E3.4: Clea n linen/towels for receiving new born lfJ E8.2: Hub cutter with needle destroyer g----­El.S: M ifepristone + Misoprostol (MMA) \Q/ E3.S: Ster ile cord cutting equipment \Q/ E8.3: Refrigerator a­El.6: MVA Kit/EVA "0---.....E3.6: Designated Newborn Care Corner ~ E8.4: RTI/STI Kit s- ­E2: Maternal Health E3.7: Functional Radiant Warmer '1J E8.S: Bleaching Powder @-/

E2.1: lnj . Oxytocin (check whether stored '&- E4: Child Health E8.6: Oxygen Cylinder functional fi1_ in cold box/refrigerator) E2.2: Tab Misoprostol g-­ E4. l ORS 'W' E8.7: BP apparatus with stethoscope 'Er E2.3: Antihypertensive (a lpha \0......­ E4.2: Zinc (10mg & 20 mg) ~ E8.8: Thermometer -a­methyldopa/Labetalol or Nifedipine)

E2.4: lnj. Magnesium Sulfate ~ E4.3: Syp Sa lbutamol/Sa lbutamol Nebulizing \JI-"" E8.9: PPIUCD Forceps ~Solut ion

09 No. of ANC clients with high E2.10: Haemoglobinometer E8.15: Electricity back-up u:YI \CJ/"' E6: Vaccines risk condit ions

E2.11: Urine albumin kit ,__g----- E6.1: BCG I D E8.16: Toilet near LR 0. ­D10 HR deployed/posted in Labor Room

E 2.12 : Blood grouping typing 1-S-- E6.2: OPV I D Post Trained in

E 2.13:HIV screening :s. E6.3: Hep B 1/ D ed NSSKSBA/ PPIUCD

E 2.14: Hepatitis B screening [X E6.4: DPT D ES.17: Cold box, ILR, Deep freezer ~BEmOC I c,.J­MO I -

ANM/Sta -- lP/VIM.- ' ff nu rse . ~ -

E2.15: Partograph 0 E.6.5: Measles D present for vaccine storage as perc.. ' requirement E2.16: Protocols displayed in LR D E.6.6: Syrup Vit. A {] ,, E2.17: IV Fluids \.Q---::: E.6.7: Pentavalent vaccine (in relevant statesI J;Y' E 8.18 MCP cards O ("­E 2.18 lni Dexamethasone I.{'.! E.6.8 JE v.1ccine /where! ~elevantl D

0

( Fl. Ante Response

· Nata l Care · "';. · ·- ' Fl.l Blood Pressure Measured during ANC visits s--Tes D No D NA

.. ,., - Fl.2 Haemoglobin measu red du ring ANC visits 0----Ves D No O NA0..... :..ii'~ -:~~~ ~ Fl.3 Bl~od Glucose measured duri.ng ANC v'.s'.ts 8-Yes O No O NA

•'/1' ~f Fl.4 Urine Albumin measured du ring ANC v1s1ts 'fr"' Yes O No O NA

j,;:_;/l] Fl.S Appropriate hianagement/referral of high risk clients (identified on the basis of High BP/ Blood sugar/Haemoglobin) -Er Yes O No O NA

• .• , ·-· - F1.6 Family Planning Counselling happening during ANC visits Er" Yes O No O NA

F2. Intra- • F2.1 Fetal Heart Rate (FHR) recorded at the time of admission S- Yes D No

partum and ' F2.2 Mother's temperature and BP recorded at t he t ime of admission Er Yes D No

Im m ed iat e F2.3 Partograph used to monitor progress of labor g--- Yes D No post~p artum

.'' ' F2.4 Antenata l corticosteroids used for preterm labour O Yes @--No O NA practi ces

, F2.S Magnesium Su lphate used to manage severe Pre-eclampsia and Eclampsia cases D Yes S- No

~- : '_; · J F2.6 Uterotonic (Oxytocin or Misoprostol) given to mother immediately after birth of baby g--- Yes O No

F3. E_ssential F3.l Newborn care corner adequately equipped {bag-a nd-mask, radia nt warmer, mucous extractor, shoulder roll, thermometer, clock, Oxygen source) B- Yes D No1

-n~w)5'orn• "'· F3.2 Early initiation of breastfeeding practices e---Yes D No

. care (ENBC) , ~ F3.3 Practice of skin to skin contact being promoted a------Yes D .No

and New- i F3.4 Babies dr ied with clean and sterile sheets/ towels just after delivery g---yes D No b orn• · · - .,t---r--------------------------- ----------- - - - - ------------ --t------- -----1 Resuscitation ., F3.s Provider aware about the steps of new-born resuscitation {Posit ioning, suctioning, stimulation, repositioning, PPV using Ambu bag) 0-----Yes O No

' (NBR) F3.5 New-borns given BCG,OPV, Hep-B within 24 hours of birth 8-" Yes D No

F4. Family F41 Family planning counselling being done -a-Yes EJ No

Plan 11_ing ,· · · F4.2 Postpartum !UCO insertions being done D Yes B-'No

r' J~,.;-~ ~ F4.3 Interval IUCD insertions being done O Yes No O NA 'b)( ts,··,~<rt.~ ,~; F4.4 Steril ization procedures being done {Fixed Day Services or Fixed day Camps) 0 Yes [3- No 'I".-.of" ..__ • , F4.S Postpartum sterilization being done D Yes s--lifo ~ n

FS: Glien£' ·.; F.s.1 Privacy during delivery? 19-Yes O No \ ()t, ' .

Satisfaction ~ F.s.2 Is transport being provided for drop back? ~es D No

·.,t:.~ !\l5: F.S.3 Staff was well behaved with you during your stay? i;;J--yes D No

·}t.\·< F. S.4 Were you informed about the procedures before they were undertaken Q--r'es D No : -~- .--:.1·<

~- • -· 1;,, ~,~: F.s.s Free diet provided? -a-- Yes D No

.(~' ;::, ' " F.S.6 Would you suggest visiting this facil ity to your re latives/friends? ~ Yes D No V

, 1 F6. Facility F6.1 Is utilization of untied fund adequate? (51../Yes D No

mechanisms F6.2 Awareness generat ion (use of IEC/BCC)- Posters, audio visual aids, display of citizen charter? D Yes D No

and others F6.3 Is grievance redressa l mechanism in place? D Yes ·Q---No

. F7 F 7.1 xclusive breastfeeding practised upto six months (no water) UV--Ves D NoIFunctionality F.7.2 Complementary feeding practised D Yes D No of programs

( F.7.3 ORS and Zinc available with ASHAs and distributed in community ID--Yes D No at community

F.7.4 Growth monitoring at AWW centers and VHNDs D Yes D No

F.7.5 Malnourished children referred to Nutritional Rehabilitation Centres liJ.--Yes D No

F. 7.6 Incentives to ASHAs for delaying and spacing of births D Yes ~No

F. 7.7 Incentives to ASHAs for accompanying clients for PPIUCD insertions D Yes [lJ---No

F.7.8 Weekly IFA supplementation (WIFS) ~ )es D No

F.7.9 Community based dist ribution of Misoprostol for PPH prevention 0 Yes ~O NA

F7.10 Home-based new born care by ASHA D Yes fil---1fo F.7.11 HBNC kits available with ASHA 0 Yes (9---"Wo

J F7.12 Referrals of sick newborns or newborns with danger signs being undertaken ~ 0 No

F.7.13 Home delivery of contraceptives by ASHAs g.---ves D No 0 NA

F.7.14 Menstrual hygiene practices being promoted ~ D No 0 NA

F. 7.15 VHNDs being conducted on a monthly basis (Services include ANC, Growth Moni toring, Immunization, Health Messages etc) 0 Yes 0 No

F7.16 JSSK (JSSK entitlements being given?) liY'Yes D No

F7.17 JSY (JSY entitlements being given?) , tv'ves O No• "F7.18 Rashtriya Bal Swasthya Karyakram operational JJ rl-, /_ D c_ /c ~ ) 0 Yes O No r " V- I

Major findings from last visit Action taken on interventions/

activities identified from last visit

Plan of Action

Major findings from this visit Intervention/ Activities identified Level of intervention Responsibility Timeline

Reproductive

Health/Family Planning

M aternal Health

Newborn Health

Child Health

Adolescent Health n\\'c,e~ . / )

~ VI ~ Facility In-charge i,ig~~\GI~ ,

" -~