Check List with example
This form is used for facility identification and other related information. Click to view.
Form A : Provider’s Availability & Practices
The purpose of questions in this section is to assess the availability of Medical, nursing, paramedical and support staff for providing different types of services and to assess their training needs. On the day of visit ask the MO In-charge or other staff, as identified by him/her, to answer the questions. Click to view details .
Form B : Infrastructure
Checklists are prepared on the following issues.
- Cleanliness of facility
- Facilities and privacy for clients
- Services and facilities
- Information and communication services
The purpose of these questions in this section is to observe cleanliness & maintenance of the facility, proper segregation of waste and others service provide to the clients/patients. Click to view details .
Form C : Infection Prevention Practices
The purpose of these questions in this section is to access the infection prevention measures being participated in the facility. This is not only important for the clients/patients but equally important for providers. Click to view details.
Form D : Equipment, Drugs & Other supplies
The purpose in this section is to assess the availability of equipment and other supplies, the working status of the equipment and adequacy of the available medicines. Click to view details.
Form E : Output Indicators for service quality assessment
This section deals with review records & calculate the data as required in the questions. Also write the total number of the information data required for the corresponding period in the last year. Compare the current data with that of the last year for the corresponding months by subtracting last year’s data from the current data. Also calculate the change of percentages. Click to view details.
Form F : Assessment Results of three consecutive visits
This form is use to put marks of different component (form A to form E) and calculate the total marks and percentage. Based on that percentage put the “Grade” (“A”, “B”,”C” & “D”) of any particular facility. Click to view details.
Form G : Action plan prepared at facility level at the end of the facility visit
The purpose of this form is to identify the problems/gaps of different components (form A to E), solutions and suggest interventions level wise i.e. at the facility, district or state. Click to view details.
Form H : Actions to be taken at facility level (consolidated) prepared by DNO
(Monthly summary report)
This report is to be consolidated from Facility visit reports (Form-G) at District level by the DNO. It refers to the actions to be taken up at the facility level. The report is to be shared with the facility heads and to be discussed during the monthly MIES meetings. Click to view details.
Form I : Actions to be taken at district level (consolidated) prepared by DNO
(Monthly summary report)
This report to be prepared from the facility visit reports (Form-G) taking into consideration the follow up actions to be taken up at the District level. It will be prepared by the DNO. Click to view details.
Form J : Actions to be taken at state level prepared by SNO (Monthly summary report)
This report is to be prepared from the facility visit reports (Form-G) by the SNO. He/She will enlist the follow up actions to be taken up at the State level. Click to view details.
This is a questionnaire applied by the monitoring officer/assessor to ten OPD and five indoor (where applicable) clients. The assessor fills up the form basing on the response offered by the clients. Filled up exit interview forms are handed over to the DNO for data entry, compilation and interpretation. Click to view details.
Click to view Calculation based on the repots of the facility visits (Example form wise).
Few example of achievement during STG (July 2009-December 2009).
Click to view details.