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Revised CSSM Monthly Reporting Format For ANMs

This document is an ANM's monthly reporting form summarizing key health indicators for a Sachivalyam (administrative division) in a given month and year. It includes data on antenatal care, deliveries, immunizations, family planning services, and vital events like infant, child and maternal deaths. The indicators are reported by the ANM for home/subcenter visits as well as services provided at other government and private facilities.

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27K views

Revised CSSM Monthly Reporting Format For ANMs

This document is an ANM's monthly reporting form summarizing key health indicators for a Sachivalyam (administrative division) in a given month and year. It includes data on antenatal care, deliveries, immunizations, family planning services, and vital events like infant, child and maternal deaths. The indicators are reported by the ANM for home/subcenter visits as well as services provided at other government and private facilities.

Uploaded by

phc kallumarri
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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CSSM MONTHLY REPORTING FORM

Sachivalyam Name:: Name of ANM: Month:            Year:2021 

During the Month


Sl. By ANM at
No.
Indicators At Other Govt. At Private
Home/ Total
Facilities Facilities
Subcentre

1 2 3 4 5 6
1 Maternal Health
a).Total No. of ANCs Registered:
b).No. of ANC's with 1st Pregnancy:
c).No. of ANC's with 2nd & above Pregnancy:
d).No. of ANCs registered within 1st Trimister:
e).No. of ANCs with Age below 19yrs (Teenage Pregnancies):
f).No. of High Risk ANCs(Identified):
g).No. of ANCs received 4 check-ups:
h).No. of PW given 180 IFA Tablets
i).No. of PW given 360 Calcium Tablets:
j).No. of PW Identified with Anemia <11 grms:
k).No. of PW Identified with Severe Anemia <7 grms:

l).No.of Pregnant Women with Hiper tension(BP>140/90) detected

m).Pregnant Women tested Postive for Gestational Diabetes


Mellitus(GDM)

n).No.of Pregnant Women tested for HIV(First Time):

o).No.of Pregnant Women tested HIV Positive(First Time):

p).No.of Pregnant Women tested for Syphilis(First Time):

q).No.of Pregnant Women tested Positive for Syphilis(First Time):

r) No. of Pregnant Women tested for HBsAg (First Time):

s) No. of Pregnant Women tested Positive for HBsAg (First Time):

t) Out of positive PW for HBsAg, number reffered for Institutional


Delivery
2 Deliveries
a).Total Deliveries:
b).C-Section Deliveries:
c).Home Deliveries by Trained SBA(Doctor/Nurse/ANM):
d).Home Deliveries by Un-Trained SBA(trained birth
attendant/relatives/etc.):
3 Births
a).No.of  Live Births:
b).Male:
c).Female:
d).No.of Still Births:
4 Home Based New Born Care
a).No.of Newborns received 6 HBNC visits after institutional Delivery:

b).No.of Newborns received 7 HBNC visits in case of home delivery:

5 Newborn Low Birth Weight


No.of Newborn Low Birth Weight <2.5 Kgs:
a).No.of LBW children refered by ASHAto NRC:
b).No.of sick Children refered by ASHA to SNCU:

c). NO. of SNCU discharged babies provided Followup visit of by


ASHA(below 1year):

6 Breast Feeding

Breast Feeding with in 1 hour after delivery:


During the Month
Sl. By ANM at
No. Indicators At Other Govt. At Private
Home/ Total
Facilities Facilities
Subcentre

7 Postnatal checkups

a).Mothers recieved 1st Postnatal Checkups by ANM with in 48 hours


after delivery:

b).Mothers received 1st Postnatal Checkup by ANM between 48 hours to


14 days after delivery:

c) No. of Lactating Mothers tested for Anemia


d) Out of above tested Lactating Mothers, number identified with
Anemia <11 Grms.
e) Number of Anemic Lactating mothers provided IFA tablets.
Anemia in "Women in Reproductive Age Group" (WRA) (Women
8
excluding Pregnant Women & Lactating Mothers)
a) No. of Women in Reproductive Age Group (WRA) tested for
Anemia
b) Out of above tested Women in Reproductive Age Group (WRA),
number identified with Anemia (<11 Grms)

c)Number of Anemic women in WRA age group provided IFA tablets.

9 Immunization

A Pregnant Women: 

a).TT(2nd dose + Booster):

B Infants 

a).Vitamin K1(Birth Dose):

b).BCG:

c).OPV Birth dose (0 dose):

d).Hep-B Birth dose (0 dose):

e).Polio (1st dose):

f).Polio (2nd dose):

g).Polio (3rd dose):

h).Pentavalent (1st dose):

i).Pentavalent (2nd dose):

j).Pentavalent (3rd dose):

k).Rota Virus Vaccine (1st Dose):

l).Rota Virus Vaccine (2nd Dose):


m).Rota Virus Vaccine (3rd Dose):
n).Inactivated Polio Vaccine (1st Dose):
o).Inactivated Polio Vaccine (2nd Dose):
p).Measles & Rubella 1st:
q).Full Immunisation (Infants):
r).JE (1st dose):

s).Measles & Rubella 2nd:

t).OPV Booster:
u).DPT Booster:

v).JE (2nd Dose):

w).Vitamin-A (1st dose):


x).Vitamin-A (5th dose):

y).Vitamin-A (9th dose):

z).Child Immunization-Typhoid:

aa).DPT(5 years):

ab).TT(10 Years) :

ac).TT(16 Years):
During the Month
Sl. By ANM at
No. Indicators At Other Govt. At Private
Home/ Total
Facilities Facilities
Subcentre

10 Family Planning Beneficiaries


A Vasectomy
a).Conventional :
b).NSV:
B Tubectomy
a).Traditional:
b).D.P.L:
Total: (Vas+Tub)
C IUCD (CUT) Insertions:

a).Number of Interval IUCD Insertions (excluding PPIUCD and PAIUCD):


b).Number of Postpartum (within 48 hours of delivery) IUCD insertions
(PPIUCD):
c).Number of Post Abortion (within 12 days of spontaneous or surgical
abortion) IUCD insertions (PAIUCD):
Total IUCD (Interval IUCD+PP IUCD+PA IUCD)
D Nirodh Pieces
a).Total Nirodh Pieces distributed:
b).Nirodh Pieces Distributed to Vasectomised Persons:
c).Regular Nirodh Users:
E Oral Pills Cycles
a).Oral Pills Cycles distributed:
b).Oral Pills Users:
11 No. of MTP/Abortions Cases done:
12 Vital Events
A Total No. of Infant Deaths:
B Infant Deaths Age Wise:
a). 0-1 Day:
b). 1-7 Days:
c). 7 days to 4 weeks:
d). 4 weeks to 12 Months:
C Infant Deaths Cause Wise:
a).Sepsis:
b).Asphyxia:
c).Pneumonia:
d).Diarrhoea:
e).Fever Related:
f).Measles:
g).Other causes:
D Total No. of child deaths(1-5years):
E Child Deaths Cause Wise
a).Pneumonia:
b).Diarrhoea:
c).Fever Related:
d).Measles:
e).Other causes:
F Total No of Maternal Deaths:
G Maternal Deaths Cause Wise
a).Bleeding:
b).High Fever:
c).Abortion:
d).Obstructed / Prolonged labour:
e).Severe Hypertension / Fits:
f).Other caused (including causes notknown):
Other Adult Deaths (except Infant deaths, child deaths & Maternal
H
Deaths):

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