Format for listing empaneled providers for uploading in State/UT website

State Haryana/Panipat

Year 2016-17

Empanelment List for (Prepare separate list for

Minilap, Lap and Vasectomy and indicate the same)

SNo.

Name

of

District

Name of

Empanelled

Sterilization

Provider

Qualification

(MBBS/MS-

Gynae/DGO/DNB/MS-

Surgery/Other Specialty Designation

Type of

Facility

Posted

(PHC/CHC/

SDH/DH)

Postal address

of facility

where

empaneled

provider is

posted Contact

number

1 Panipat Dr. Shashi M.S Gynae M.O DH ` 9416077819

2 Dr. Suman M.S Gynae M.O DH

9896077704

3 Dr. Lipika M.S Gynae M.O DH

9466688482

4 Dr. Mani M.S Gynae M.O DH

8221056742

5 Dr. Sanjiv

Gupta M.S Plastic Surgery MO DH

9467361588

6

Dr. Vijay

Malik M.S Gen. Surgery SMO DH

9996996184

7

Dr. Sanjeev

Goel M.S Gen Surgery SMO DH

946131888

8 Dr. Ajay

Kapoor M.S Plastic Surgery SMO DH

941633304

Line Listing Of Sterilization Trained/Empaneled Providers S

.No

Na

me

of

Dis

tric

t

Na

me

of

tra

ined

/ E

mp

an

elle

d

pro

vid

er

Qu

ali

fica

tio

n

Pla

ce

of

Post

ing

(N

am

e of

Fa

cili

ty a

nd

Lev

el)

Co

nta

ct

Nu

mb

er

Trained/

Empaneled for Services provided in last one year

Rem

ark

s

Min

ila

p

La

pa

rosc

op

ic S

teri

liza

tion

NS

V

Nu

mb

er o

f M

inil

ap

per

form

ed

If n

ot

per

form

ed s

urg

ery

,

ple

ase

qu

ote

th

e re

aso

n

for

no

n-p

erfo

rma

nce

Nu

mb

er o

f L

ap

aro

sco

pic

Ste

rili

zati

on

per

form

ed

If n

ot

per

form

ed s

urg

ery

,

ple

ase

qu

ote

th

e re

aso

n

for

no

n-p

erfo

rma

nce

Nu

mb

er o

f N

SV

per

form

ed

If n

ot

per

form

ed s

urg

ery

,

ple

ase

qu

ote

th

e re

aso

n

for

no

n-p

erfo

rma

nce

P

an

ip

at

Dr.

Shas

hi

M

.

O DH

9

41

60

77

81

9 Y

es No

N

o

108

No No No No No

Dr.

Sum

an

M

.

O

DH 9

89

60

77

70

4

Ye

s No N

o

70

No No No No No

Dr.

Lipi

ka

M

.

O

DH 9

46

66

88

48

2

Ye

s

No N

o

123

No No No No No

Dr.

Man

i

M

.

O

DH 8

22

10

56

74

2

Ye

s

No N

o

123

No No No No No

Dr.

Sanj

iv

Gupt

a

M

O

DH 9

46

73

61

58

8

Ye

s

No Ye

s

39

No No No No No

Dr.

Vija

y

Mali

k

S

M

O

DH 99

96

99

61

84

Ye

s

No Ye

s

396

No No No No No

Dr.

Sanj

eev

Goel

S

M

O

DH 94

61

31

88

8 Ye

s

No Ye

s

12

No No No No No

Dr.

Ajay

Kap

oor

S

M

O

DH 9

41

63

33

04 Ye

s

No Ye

s

80

No No No No No

Format for listing SQAC/SISC/DQAC and DISC members in State/UT website

State/District Haryana/Panipat

Year 2016-17

Type of Committee (DQAC )

SNo. Name of

Member

Designation in the

Committee

(Chairperson/Vice

Chairperson/

Convener/Member

Secretary/

Member)

Designation in the state

(Secretary/MD/Director/

Joint Director/Deputy

Director/Empaneled

Gynaecologist/Surgeon

etc) Member Since

(Month/year) Address Contact

number

1

Dr. Inderjeet

Singh Dhankhar C.M.O.

15.12.2014 C.M.O. Panipat 7027826976

2

Dr. Sudhir

Batra Dy. C.M.O.

15.12.2014 Dy. C.M.O. Panipat 9812233320

3 Dr. Shashi Lata Gyaneologist

15.12.2014 G.H.Panipat 9416077819

4 Dr. Vijay Malik S.M.O.

15.12.2014 G.H.Panipat 9996996184

5 Dr. Kavita M.O.

15.12.2014 G.H.Panipat 9416389742

6 Sarla P.O.

15.12.2014 W.C.D. Panipat 9896386599

7 Anil Lathwal Advocate

15.12.2014 Panipat 9813084006

8 Kailasho L.H.V.

15.12.2014 O/o C.M.O. Panipat 9050207810

Annual /Biannual Report Format

State

Report Type: (Annual /Biannual)

Reporting period

I. Family Planning performance

Services Q1 Q2 Q3 Q4 Total

Interval Minilap 659 300 359 541 1859

Laparoscopy 0 0 0 0 0

PPS 21 9 13 16 59

Female Sterilization 680 309 372 557 1918

Male sterilization 29 12 21 22 84

IUCD 1491 1344 1352 1450 5637

PPIUCD 2498 3149 2066 1885 9598

PPIUCD Acceptance

(Out of total public

health institutional

deliveries)

2927 4221 3888 3270 14306

ASHA Scheme Performance:

Services Q1 Q2 Q3 Q4 Total

HDC (percentage

distribution of

condoms, OCP and

ECP)

110 111 123 127 127

ESB Schemes (To be

filled by states where

scheme is implemented)

207 207 209 189 189

PTK Utilization

Status of Functionality of QAC

Number of meetings held 1

Frequency of meetings held(Quarterly/half yearly): Yearly

Minutes of the meeting prepared (Yes/No) Yes

Number of deaths ,complication and failure reported – Failure Reported

Number of Enquiries conducted for each category

Remedial steps taken

Status of FPIS Claims

S.N

o

STA

TE

FRESH/NEW CLAIMS

SUBMITTED IN 2016-17

( April 2016 to March 2017)

OUTSTANDING CLAIMS

from previous years (before

April 2016)

CLAIMS PAID IN 2016-17 CLAIMS REJECTED

(2016-17) OUTSTANDING CLAIMS TILL 31st MARCH 2017

Co

mp

licat

ion

De

ath

Failu

re

Co

mp

licat

ion

De

ath

Failu

re

Complication Death Failure

COMPLICATION DEATH FAILURE

No

. of

Fre

sh/n

ew

C

om

plic

atio

n C

laim

s su

bm

itte

d in

20

16

-17

pai

d

Tota

l Am

ou

nt

No

. of

ou

tsta

nd

ing

Co

mp

licat

ion

Cla

ims

fro

m p

revi

ou

s ye

ars

pai

d in

20

16

-17

Tota

l Am

ou

nt

No

. of

Fre

sh/n

ew

de

ath

Cla

ims

sub

mit

ted

in 2

01

6-1

7 p

aid

Tota

l Am

ou

nt

No

. of

ou

tsta

nd

ing

de

ath

Cla

ims

fro

m

pre

vio

us

year

s p

aid

in 2

01

6-1

7

Tota

l Am

ou

nt

No

. of

Fre

sh/n

ew

fai

lure

Cla

ims

sub

mit

ted

in 2

01

6-1

7 p

aid

Tota

l Am

ou

nt

No

. of

ou

tsta

nd

ing

fai

lure

Cla

ims

fro

m

pre

vio

us

year

s p

aid

in 2

01

6-1

7

Tota

l Am

ou

nt

Co

mp

licat

ion

Am

ou

nt

De

ath

Am

ou

nt

Failu

re

Am

ou

nt

No

. of

co

mp

licat

ion

Cla

ims

(su

bm

itte

d in

year

20

16

-17

) n

ot

pai

d

Am

ou

nt

No

of

old

pe

nd

ing

co

mp

licat

ion

cla

ims

fro

m p

revi

ou

s ye

ars

no

t p

aid

Am

ou

nt

No

. of

de

ath

Cla

ims

(su

bm

itte

d in

ye

ar

20

16

-17

) n

ot

pa

id

Am

ou

nt

No

of

old

pe

nd

ing

de

ath

cla

ims

fro

m

pre

vio

us

year

s n

ot

pai

d

Am

ou

nt

No

. of

fai

lure

Cla

ims

(su

bm

itte

d in

ye

ar

20

16

-17

) n

ot

pa

id

Am

ou

nt

No

of

old

pe

nd

ing

fai

lure

cla

ims

fro

m

pre

vio

us

year

s n

ot

pai

d

Am

ou

nt

1 0 0 4 0 0 3 0 0 0 0 0 0 0 0 0

120000 3

90000 0 0 0

00 0 0 0 0 00

3

90000 0 0

Specify reasons for claim rejection (Death/complication/failure)

Status of Death Audit

Name of State Number of Death

reported

Number of death audits

conducted

Number of deaths

attributed to sterilization

Reason of death Action taken

Haryana 0 0 0 0 0