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III Feedback of Trained PersonnelName of Trained Personnel :-Name & Date of the last training received :-

Questions Yes/No Remarks1 Was the purpose/objective of taking the training fulfilled?

2 Was the duration of the training was sufficient?

3 Was the course content sufficient?

4What did you like most about the training that you received?(put mark)

Content

Training Methodology Used

Training skills

Practical demonstration

Training Environment

Field Visits

Accommodation & Food

5Any component (from the options above) of training that youare not satisfied with?

Kindly state in detail

6 Any training materials given to you?

7 Are those materials available in the 24 X 7 PHC?

8Do you feel the training that you received is beneficial to youin service delivery?

9 If No, Give the Reason (List out the problems)

10Are you unable to utilize the skills learnt during the training at

work place

11 If Yes, Give the Reasons (put mark)

12 Inadequate training

Lack of Infrastructure

Lack of Drugs and Equipments

Lack of supporting staff

Administrative Problems

13 Any other training that you feel will be beneficial for yourwork? ( List the name of the trainings)

14 Any suggestions regarding training

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IV Facility Monitoring for PHC

A Infrastructure

Questions

Yes/No/Functional (mark F)/

Non-Functional(mark NF)

Remarks

1Is a designated Government building available for thePHC?

2 Where is this PHC located? Within village locality

Far from village locality

If far from locality (specify in km)

3 Is pharmacy available?

4 Are OPD rooms/cubicles available?

5 Is family Welfare Clinic available?

6 Waiting room for patients available?

7 Emergency Room/Casualty available?

8 Separate wards for males and females available?

9Fully furnished & equipped Labour room available?(as per Annexure 1 enclosed)

10If Labour room is present, are deliveries carried out in the

Labour room 24x7 PHC?

11 If Yes, Availability of New born care facilities

New Born table

Pediatrics Ambu Bag & Mask

Radiant warmer/200 watt lamp

Mucus sucker/Suction machine

Oxygen hood & Cylinder

12If deliveries not being conducted 24x7, then what are the

reasons for the same?

Shortage of staff

Staff not staying at PHC

Poor condition of the Labour room

No power supply in the Labour room

Any other specify

13Are separate areas for septic and aseptic deliveries

available?

14 Is operation theatre available?

15If operation theatre is present, are surgeries carried out in

the operation theatre?

16Is Operation Theatre used for obstetric/gynecological

purpose?

17

If operation theatre is present, but surgeries are not being

conducted there, then what are the reasons for the same?

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Non-availability of doctors /staff

Lack of equipment /poor physical state of theoperation theatre

No power supply in the operation theatre

Any other reason (specify)

18 Ancillary Rooms - Nurses rest room available?

19 Are laboratory facilities available?

20 Is proper water supply available?

21 Is regular power supply available?

22 Is power back up available?

23Are separate toilets for males and females available and

functional?

24 Is Store room available?

25 Is Kitchen available in the PHC?

26 Does the PHC provide diet to the patient?

27 Are colour coded containers for waste disposal available?28 Is bio-medical waste pit available?

29 Laundry facility available?

30 Is Telephone facility available and functional?

31 Computer available?

32Is transport facility for movement of staff available and

functional?

33Is residential facility for the staff available with allamenities available?

Medical Officer

Pharmacist

Nurses

Other staff

34Are essential drugs available?

(as per Annexure II enclosed)

35Is transport (Ambulance) for referral available andfunctional?

36 Name of the nearest referral centre (Mention the distance)

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V Health Services Yes / No Remarks

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A Assured Services available

OPD Services

Emergency services (24 x7)

Referral Services

In-patient Services

B Maternal Health Services

1 Ante-natal Care

Are antenatal clinics organized by the PHC regularly?

Is the Antenatal care provided?(Inj. T.T, IFA tablets, weight and BP checkup and Hb estimation)

2 Intra-natal Care

Is the facility for normal delivery available 24X7 in the PHC?If Yes

Hand Washing facility available and utilized

Sterilized gloves used

Is the facility for assisted deliveries available in the PHC for

24 hours?

Managing Labour using Partograph(Ask to show for last delivery conducted)

Identification & Management of danger signs during Labour

Pre-referral treatment for PPH, Eclampsia & Sepsis

Minimum 48 hours of stay post delivery

Is the facility for referral of complicated cases of

pregnancy/delivery available 24X7 at PHC?

Are the facilities under Janani Suraksha Yojana provided?

3 Post-natal care (Essential)

Breast Feeding (within 1 Hour of Birth)

Advise Mother on Exclusive Breast feeding

4Is treatment for anemia given to both pregnant as well as non-

pregnant women?

5 Syndromic management of RTI/STI done

6Is the facility for internal examination for gynecological conditions

available at the PHC?

7Is the treatment for gynecological disorders like leucorrhoea,

menstrual disorders available at the PHC?

8 Is the facility for MTP (Abortion)available at the PHC?

C Family Planning Services Is IUCD inserted?

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Are the OCP, emergency pills and condoms distributed?

Is the facility for Tubectomy and Vasectomy available at thePHC?

D Child Health Services

Essential New Born Care

Prevention of Hypothermia (KMC)

Maintain airway & breathing Cord Care

Eye Care

Immunization services ( If Yes )

Are the Immunization services as per Government schedule

Hub cutter used

Proper disposal of sharps

Care of Sick Children Is the management of children suffering from diarrhea with

severe dehydration done at the PHC?

Is the treatment of minor illness like fever, cough, cold, worm

disinfestation etc. available

Is the treatment of children with pneumonia available at the

PHC?

Is VHND organized every month?( If Yes )

Is the growth of infants and children monitored

Nutrition Counselling provided

E Adolescent Health

TT Immunization

IFA Tablets

Nutrition Counselling

Counselling for menstrual hygiene and menstrual disorders

Counselling for RTI/STI

F Disease Control Is the facility for taking peripheral blood smear in case of

fever available?

Is it a DOT centre?

IV Investigation Services

Laboratory ServicesName of the Tests Yes/No Remarks

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1 Hb

Preparing blood smear for -

Malaria Parasite

Others (Rapid test for Malaria etc)

2 Urine

Albumin

Sugar

Pregnancy test3 BT/CT

4 Blood Sugar

5 Blood Grouping (Rh typing)

6 Blood Cross Matching

7 Diagnosis of RTI/STDs with wet mounting, grams stain, etc.

8 Sputum testing for TB

9 VDRL

10 RPR test for Syphills / YAWS surveillance

11 Rapid tests for HIV

Radiology Services

1 X Ray

Annexure I

PHC 24 x 7

List of Furnitures in Labour Room

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Sr.No. Item Yes/No Remarks1 Examination Table

2 Delivery Table

3 Footstep

4 Bed Side Screen

5 Stool for patients

6 Arm board for adult & child

7 Saline stand

8 Wheel chair 9 Stretcher on trolley

10 Oxygen trolley

11 Height measuring stand

12 Iron bed

13 Bed side locker

14 Dressing trolley

15 Mayo trolley

16 Instrument cabinet

17 Instrument trolley

18 Bucket

19 Attendant stool

20 Instrument tray

21 Chair

22 Wooden table

23 Almirah

24 Swab rack

25 Mattress

26 Pilow

27 Waiting bench for patients / attendants

28 Medicine cabinet

29 Side rail30 Rack

31 Bed side attendant chair

List of Equipments and consumables

S.No. Item Yes/No Remarks1 Basin 825 ml., (Stainless Steel)

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2 Basin deep (capacity 6litre)

3 Tray instrument/Dressing with cover

4 Flashlight

5 Torch (ordinary6 Dressing Drum. with cover7 Hemoglobinometer set Sahli type

8 Weighing Scale, Adult

9 Weighing Scale, Infant

10 Weighing Scale, (baby)

11 Tissue Forceps12 Sterilizer13 Surgical Scissors straight14 Sims Uterine Depressor/Retractor

15 Measuring Jug

16 Surgeons Scrubbing Brush with whiteNylonBristles

17 Sphygmomanometer

18 Kellys hemostat Forceps straight

19 Vulsellum Uterine Forceps curved20 Cuscos/Graves Speculum vaginal bi-valve

21 Sims Speculum vaginal double ended

22 Uterine Sound23 Cheatles Forcep24 Vaccine Carrier

25 Ice pack box

26 Sponge holder

27 Plain Forceps

28 Suture needle straight & curved

29 Clinical Thermometer oral & rectal30 Room Heater/Cooler for immunization

clinic withelectrical fittings

31 Foetoscope32 Dressing Forceps (spring type33 Artery Forceps, straight,34 Cord cutting Scissors

35 Stethoscope

36 HUB Cutter

37 Ambu Bag38 Measuring Tape39 I/V Stand40 Tracking Bag and Tickler Box

(Immunization)

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Annexure II

Essential Obstetric Care Drugs Kit for PHC

Sr.No. Item Yes/No Remarks1 Diazepam Injection

2 Lignocaine Injection

3 Pentazocine Injection

4 Dexamethasone Injection

5 Promethazine Injection6 Methylergometrine Injection7 Paracetamol Tablets

8 Theophylline Inj

9 Tab Co-trimoxazole

10 Adrenaline Injection

11 Amoxycillin Capsules12 Metronidazole Tablets13 Atropine Injection

14 Fluconazole Tablets

15 Methyldopa Tablets

16 Oxytocin Injection

17 Phenytoin Injection

18 Dextrose Injection

Drug for RTI/STI-

Sr.No. Item Yes/No Remarks1 Ciprofloxacin Hydrochloride Tablets

2 Doxycycline Hydrochloride Capsules

3 Erythromycin Estolate Tablets

4 Benzathine Penicillin Injection5 Tinidazole Tablets6 Clotrimazole Cream & pessary

7 Clotrimazole Cream 2%8 Gramma Benzene Hexachloride

Ointment

9 Distilled Water Ampoules

Drugs and Consumables for MVA:

Sr.No. Item Yes/No Remarks1 Chlorine solution2 Antiseptic solution (savlon)3 Local Anaesthetic agent

(injection1%Lignocaine)4 Sterile saline/sterile water

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