National Health Mission

District Level
Comprehensive Reporting Formats
Under National Health Mission (Version 1.0)

Month / Year :
District :
Softcopy (in excel) and scanned signed copy to be submitted by 15th of every month. (No need of hardcopy)
Please do not modify/delete the format
 Janani Suraksha Yojana (JSY)

Name of the District:

Number of Blocks :
Total Population of Distt. : Annual expected number of deliveries :________________
Percentage of ST Population in the District: __________________ Annual expected number of deliveries of SC/ST & BPL population
Percentage of SC Population in the District: __________________ Institutional Home

Percentage of BPL Population in the District: _________________ Rural Urban Total Rural Urban Total

New women registered under JSY Home Deliveries Institutional Deliveries Total

Inst. Deliveries in Private Health Institution among JSY beneficiaries

Inst. Deliveries in Public Health Institution among JSY beneficiaries (c) Total JSY Beneficiaries (a+d)

No. of Total No. of

Block Home mothers mothers paid
No. of mother No. of mother JSY incentives
Deliveries paid JSY paid JSY paid JSY
among JSY incentives for Institutional
incentive for incentive for delivery (d=b+c)
Rural Urban beneficiaries for Home Rural Urban Institutional Rural Urban Institutional Home (a) Instt.(d) Total
delivery (a) deliveries in deliveries in
Public Private
Institutions(b) Institutions(c)

ST SC BPL Total ST SC BPL Total ST SC BPL Total ST SC BPL Total ST SC BPL Total ST SC BPL Total

Total

Financial Progress (Rs. In Lakhs)

Incentive for Incentive

Incentive for Institutional Incentive for Institutional for ASHAs Administra
Block Home Delivery delivery (Govt. delivery (Pvt. Instt.) (Only for tive Total
instt.) FMR Code Expenses
A.1.3.4)

Total

Signature of Chief Medical officer Signature of DPO Name of Dealing Assistant

email Id: email ID: Mobile Number:
 Janani Shishu Suraksha Karyakaram (JSSK)

IMPLEMENTATION :CASHLESS SERVICES Status

S. No. Provision for Cashless deleiveries for all pregnant women and sick newborns at all Govt. health facilities
1 No. of blocks where free entitlements are displayed at all health facilities
2 No. of blocks where free diet is available to PW (at all facilities 24*7 PHC and above level)
3 No. of blocks where lab is functional for basic tests for PW (at all facilities 24*7 PHC and above level)
3a No. of blocks where any facility has stock outs of lab reagents / equipment not working
4 No. of blocks where any facility has stock outs of essential drugs / supplies for Pw and sick newborns
5 No. of blocks where any facility has user charge for PW / Sick newborns for : i. OPD
ii. Admission / delivery / C-section
iii. Lab tests / diagnostics
iv. Blood

SERVICE UTILISATION : REFERRAL TRANSPORT (RT)

S.No. Referral transport service NAS 102/108 State Vehicle PPP Vehicles Others
1 No. of PW who used RT Service for :
i. Home to health institution
ii. Transfer to higher level facility for complications
iii. Drop back home
2 No. of sick newborn who used RT Services for :
i. Home to health institution
ii. Transfer to higher level facility for complications
iii. Drop back home

JSSK - Pregnant Women

Total No. of Normal Total No. of C-
Total Total Total Financial Expenditure on transportation
Deliveries Section
expendit expendit
ure on ure on
Name of Total expenditure on
S.No. Ante Post Diet Free Blood
Block Home to Health Diagnostics
Natal Physical Financial Physical Financial Natal IFT Drop Back
period period Instt.
treament treament

Physical Financial Physical Financial Physical Financial Physical Financial Physical Financial Physical Financial

Total
 JSSK-Infants
S.No. Name of Total Number of Infants treated Total Total Financial Expenditure on transportation Total expenditure
Block OPD IPD Surgical Total Financial Home to Health IFT Drop Back on Diagnostics
Interventi Expenditu Instt.
re on Physical Financial Physical Financial Physical Financial Physical Financial
on

Total

Signature of Chief Medical officer Signature of DPO Name of Dealing Assistant :

Email ID : Email ID : Mobile Number :
 Comprehensive Abortion Care (CAC)

Name of the District: ________________ Month & Year of Reporting: ___________________________

Name of CAC Nodal Officer:____________________________ Contact No.:_____________________

Email Id:____________________________________________

1) District level indicators:

DLC established (Yes/No). 2) Capacity building:
District Level Regular DLC meeting held in the reporting
a Committees period (at least one meeting/ quarter) (Yes/No).
(DLCs)* Name of the Nodal agency/any agency under PPP for training:...............

Approved NGO & Approved by DLC to provide safe abortion S. No Indicator Numbers
b Private clinics and services in current month.
hospitals Total MOs in District

Approved NGO & Approved by DLC to provide safe abortion

c Private clinics and services in till date in the district. Training on Target training MOs for current year
a CAC
hospitals
MOs trained for CAC in Quarter
2) Block level indicators: MOs trained (Cumulative for the year)
S.No Indicator Numbers b Total MOs reoriented on MMA
Total ANMs and Staff Nurses trained to provide
a Total Number of Blocks in the district. c confidential counselling for MTP and post-abortion
care.
Blocks in which Comprehensive Abortion Care (CAC)–Training and Total ASHAs and other field functionaries trained to
Service Delivery Guidelines, CAC training package and MMA provide confidential counselling for MTP and post-
b handbook is available. d abortion care.

Total Health DPs Total Health Providing Providing Providing Number of MTPs performed in the
facilities in the Total no. of DPs offering Facilities offering MTPs up MTPs up to CAC services reporting quarter................ Post abortion Contraception
Facility in District CAC CAC services(DPs to 8 weeks 12 weeks up to 20
District 12-20 OCP/ Inj.
services + non DPs only only weeks Up to 12 weeks weeks contrace IUCD Sterilizat others
ptive ion
MVA MMA EVA others

Medical colleges

District Hospital

Sub Divisional
Hospitals/Civil
Hospital-FRU
SDH/CH- Non
FRU's
CHC-FRU

24×7 PHC+CHC
NonFRU
PHC

Total (Public) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Approved NGO
& Private clinics
and hospitals
Total(Pvt+
Public) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Signature of Chief Medical Officer Signature of CAC Nodal Officer Name of Dealing Assistant:
Email ID : Mobile Number :

1) District level indicators: 2) Capacity building:

S.No Indicator Numbers Name of the Nodal agency/any agency under PPP for training:...............
a Total Number of Blocks in the district S. No Indicator Numbers
b Block in which Comprehensive Abortion Care (CAC)–Training and a
Service Delivery Guidelines, CAC training package and MMA
handbook is available Total MOs in District

1) District level indicators: Training on Target training MOs for current year
CAC
 Training on
a District Level DLC established (Yes/No). CAC
MOs trained for CAC in Quarter
Committees
(DLCs)* Regular DLC meeting held in the reporting
period (at least one meeting/ quarter) (Yes/No). MOs trained (Cumulative for the year)

b Approved NGO & Approved by DLC to provide safe abortion b Total MOs reoriented on MMA
Private clinics and services in current month
hospitals c Total ANMs and Staff Nurses trained to provide
confidential counselling for MTP and post-abortion
care.
c Approved NGO & Approved by DLC to provide safe abortion d Total ASHAs and other field functionaries trained to
Private clinics and services in till date in the m provide confidential counselling for MTP and post-
hospitals abortion care.
 Maternal Death Review (MDR)

District ________________

Total primary informer reports received :___________

(Total of reports received Through Annexure 6 &through comprehensive call centre 104)

Out of total pruimary informer reports number of maternal death comprehensive : ______________________

Sr. No. Date of Death Name of Deceased Place of Death When did the death occur Probable Cause Status of Newborn CBMDR FBMDR
of Death (Delivery Outcome)
During abortions Conducted Yes/No Name of the Name of Investigator/ Annexure 2+3 Conducted Yes/No Annexure 1+3
Health On the During During or within 6 respondent who was Date of interview Submitted Yes/No
Home weeks after the interviewed
Facility Road Pregnancy Delivery
abortion

Signature of Chief Medical Officer : District Nodal Officer : Name of Dealing Assistant :
Email ID : Email ID : Mobile Number :
 Outreach Camps (ORC)

Total No. of camps in the Month :____________ Cumulative camps in 2016-17 :______________

Camp Detail
No. of Camps Place Where camps are organised Block

Status of Human resource

Camp1 Camp2 Camp3 camp4 Camp5 camp6 Camp7
Category
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Medical Officer
AYUSH Doctor
Laboratory
Technician
Refractionist
Dental Surgeon

FHS
MHS
Health Educator

Health Worker
ASHA

No of participants

Male Female Children Total

Place where camp
are organized
Camp1
Camp2
Camp3
Camp4
Camp5

a) Diagnostics

Camp1 Camp2 Camp3 Camp4

Tests Male Female Children Male Female Children Male Female Children Male Female Children

Blood Sugar.
Blood Pressure
Height
Weight
Urine test

Urine for
pregnancy test
Hb

NCDs
Camp1 Camp2 Camp3 Camp4
Tests Male Female Children Male Female Children Male Female Children Male Female Children
No. of New
Hypertension
cases diagnosed
No. of new
Diabetes Mellitus
cases diagnosed

b) Immunization
Camp1 Camp2 Camp3 Camp4
Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total
BCG
Penta
OPV
Hepatitis
Measles (1)
Measles (2)
DPT Booster
OPV Booster
Vitamin A
Rota Virus
Vaccine
Injectable Polio
vaccine

c) ANC Checkup (PW)

1st ANC 2nd ANC 3rd ANC High High Risk referred IFA Calcium
risk Pregnanc to higher supplem supple
pregnan ies institutio entation mentati
cies treated ns on
identifi
ed

Camp1

Camp2

Camp3
Camp4

Camp5

Treated Place Referrals

where
Place where camp Male Female Children Total camp are Male Female Children Total
are organized organized
Camp1 Camp1
Camp2 Camp2
Camp3 Camp3
Camp4 Camp4
Camp5 Camp5

IEC
Talks Male Female Children Total
1
2
3
4
5

Financial Reporting format

S.No Expenditure
Particulars
Camp1 Camp2 Camp3 camp4 Camp5
1 Transportation
2 Working Lunch
3 Lab Consumables
4 Drugs
Total Expenditure
Balance

Note: More Columns and rows can be added if required

Signature of Chief Medical Officer Signature of District Nodal Officer Name of Dealing Assistant
Mobile No.
 High Risk Pregnancy

1. District :_______________________ 4. For the month of : ________________________

2. Block : ________________________ 5. Date: _____________________
3. Name of the Sub-centre : ___________________
Indicator Number
Pregnant woman registered within 12 weeks
Total No. of 1st ANC done at the time of registration
Total No. of 2nd ANC
Total No. of 3rd ANC
Total No. of 4th ANC
Total No. of cases identified as “high risk”

Signature of Chief Medical Officer : Name of Dealing Assistant:

Mobile No.
Dated:
 Folic Acid

District: __________________
Month/Year :_____________________

Early Ante
Natal
No. of beneficiaries No. of beneficiaries Ante Natal registration No. of pregnant women Total Number
identified in Pre- administered Folic No. of tablets Registeration during during the given Folic Acid in the first No. of tablets of tablets
conceptional period Acid tablets consumed (a) the month month 12 weeks consumed (b) consumed (a+b)

Signature of Chief Medical Officer Signature of the Nodal Officer Name of Dealing Assistant :
Dated: Mobile No.
 Gestational Diabetes Mellitus (GDM)

In Number
Total No. of ANC conducted in reporting month:
No. of new GDM cases diagnosed in the reporting month:
No. of GDM cases diagnosed in 1 st trimester in reporting month:
No. of new GDM cases on treatment in the reporting month:
No. of new GDM cases started on Insulin therapy in the reporting month:
Cumulative No. of GDM cases on Insulin therapy in the reporting month:
Supplies (Insulin & Glucometer) available in all blocks – Yes/No
If No, reflect requirement in PIP/ to State HQs

Signature of Chief Medical Officer Signature of the Nodal Officer Name of Dealing Assistant:
Mobile No.
 Monthly Reporting Format – Pradhan MantriSurakshitMatritvaAbhiyan

Name of District: Month & Year:

Date of Reporting: Reported By:

Reporting under PMSMA for Pregnant women (2nd & 3rd Trimester)
S.No. Data element Number of P.W who received Remarks
care at the PMSMA Clinics
(Number of Pregnant Women )

Total number of pregnant women

1. Received Antenatal care under
PMSMA in the current month
Received Antenatal care under
2. PMSMA in 2ndor 3rdtrimester for 1st
time
Total No. of PW who have already
3. been registered on MCTS
No of Pregnant women tested for
4. Haemoglobin
No of pregnant women whose
5. Ultrasound was conducted
No of pregnant women screened for
6. HIV
No of pregnant women tested for
7. Syphilis
No of pregnant women screened for
8. GDM
Identification of High Risk Pregnancies
9.
No. of Pregnant women Identified
a) with severe anaemia
No. of Pregnant women identified
b) with pregnancy induced
hypertension
No. of Pregnant women identified
c) with diabetes
No. of Pregnant women found
d) reactive for HIV
 No. of Pregnant women Identified
e) with syphilis
No. Of required women with other
High Risk Preganancies (other than a-
f)
f)
Total Number of high risk Total of a) to f)
10 pregnancies identified
Total Number of high risk
11 pregnancies referred to higher
facilities

Monthly Performance by Volunteer

12 Name of the Volunteer

13 Total No of pregnant women seen

by Volunteer
14 No of hours spent by the
volunteer

Process Indicators* Format-2

S.No. Data elements Numbers

Number of health facilities where
1) current round of PMSMA was
conducted
b) DH
c) SDH/CH
d) CHC/ UCHC/ Maternity Homes
e) PHC / UPHC
g) Others
* This form must be filled by block followed by district level

Signature of Chief Medical officer: Signature of the Nodal Officer

Dated:
 Weekly Iron Folic Acid
Format 9
District : State: Reporting month and year

Total No. Of Schools(including

Total No. Of Blocks in the district: Govt. /Govt aided/ Residential
schools in the districts): Total No. Of AWCs in
the Districts:
Total No. of blocks submitting reports from Education Deptt.:
Total No. of blocks submitting reports from ICDS Deptt.:

Total No. Districts submitting reports for the month (by both education and ICDS Dept.)
1 IFA Consumption In School In AWC Total
Total no. of adolessents covered under WIFS Programme in the Girls:
Distict Boys: b) c)
Total a ) :

No. of Girls consuming at least 4 IFA tablets in this month

No. of Boys consuming at least 4 IFA tablets in this month
Total No. of adolescents consuming at least4 IFA tablets in this d) e) f)
month

Total No. of staff (Nodal Teachers / AWWs/AWHs) cosuming at

least 4 IFA tablets in this month
COVERAGE % (d)/(a)x100= (e)/(b)x100= (f)/(C )x100=
2 Albendazole Consumption (Februray / August) In School In AWC Total
No. of Girl Cosuming Albendazole tablets
No. of Boys Cosuming Albendazole tablets

Total No. of adolescents consuming Albendazole tablets m) n) p)

COVERAGE % (m)/(a)x100= (n)/(b)x100= (p)/( c)x100=

Girl Boys Total Girls Girls Boys Total
Identifies
3 Adolescents with moderate / servere
anaeia (Based on physical check-up only ) Referred
4 Nutrition and Heatlh Education Sesstion

Total No. Nutrition Health Education sessions planned in the reporting month

Total Nutrition Health Education session conducted in the reporting month

5 Adverse Effects :

No. of adolescents who experience aderse effects following IFA consumption

No. of adolescents who were referred to health facility for management of aderse
effects
6 Supply Details (TO BE SUBMITTED APRIL AND OCTOBER)
Stock
Quantity Date of Utilized (in Balance Stock with
Expiry Date of the Stock
Pocured Procurement the last 6 expiry date
months)

IFA Tablets
Albendazole tablets

Signature of Chief Medical Officer: Signature of Nodal Officer Name of Dealing Assistant:
Dated: Mobile No.
 Adolescent Friendly Health Centres (AFHC)

Name of the State: Himachal Pradesh Name of the concerned Person:

Reporting period and year: Contact No.:

A. Budget for RKSK Amount (in lakhs) Comments/Observations

Allocated Budget for RKSK 2015-16 (in
lakhs)
Expenditure during F.Y. 2015-16 till
31.03.2016 (in lakhs)

Allocated Budget for RKSK 2016-17 (in

lakhs)

Expenditure during F.Y 2016-17 (in lakhs)

B. Establishment of Adolescent Friendly No. of clinics established as on No. of clinics functional as on Target AFHCs for 2016-17 as per
Health Clinics (AFHCs) ……….2016 ……….2016 RoP
Medical College
DH
SDH
CHCs
PHCs
UHC
Sub centres
PPP
Total
C. Training Status of staffs on AFHS No. Trained as on 2016 Untrained as on 2016 Training target for 2016-17
No. of Medical Officers (male) trained on
AFHS
No. of Medical Officers (female) trained on
AFHS

No. of ANMs/LHVs trained on AFHS

No. of MPW (male) trained on AFHS

No. of Counsellors trained on AFHS
Service Provisions
Male Female
Unmarried Married Total Unmarried Married Total
Indicators 10-14 15-19 10-14 15-19 10-14 15-19 10-14 15-19 10-14 15-19 10-14 15-19
Total no. of Clients registered in AFHCs
during reporting period
Clinical Services provided to the Clients out of total no. of registered clients during the reporting period
Total no. of Clients who received clinical
servicesout of total no. of registered
clients in AFHCs during the reporting
period
Menstrual Problems
RTI/STI Management
Skin Problems
ANC
IFA Tablets
Contraceptives
1. Condoms
2. OCP
3. ECP
4. IUD
Immunization
Others
Counselling Services provided to the clients out of total no. of registered clients during the reporting period
Total no. of Clients who received
counselling services in AFHCs out of total
no. of registered clients during the
reporting period
Nutrition
Skin
Pre-marital Counselling
Sexual Problems
Contraceptive
Abortion
RTI/STI
Substance abuse
Learning problems
Stress
Depression
Suicidal Tendency
Violence
Sexual Abuse
Other Mental Health Issues
Others
Referral (to other health facilities) out of total no. of registered clients during the reporting period
Total no. of Clients referred (from AFHCs)
to other facilities out of total no. of
registered clients during the reporting
period
ICTC
Suraksha/RTI/STI Clinic
Skin OPD
Ob/Gyn Department
MTP
Psychatrist
Others
Out-reach Activities
Client participation & mode of out-reach In-school Out-school
activities during the reporting period Male Female Male Female
Total no. of clients participated in the out-
reach sessions during the reporting period
conducted during the reporting
Mode of Out-reach activities period Topics discussed Activities Conducted
Direct in schools
Direct in colleges
VHNDs
School Health Team
Mobile Medical Unit
Teen Clubs
Youth clubs/Gymnasium
SHGs
Vocational Training Centres
Youth Festivals
Health Mela
Others
Peer Educators/other community No. Identified (Total) No.Trained (Total)
mobilisers
Has the state established Adolescent
Health Helpline?
(1: Yes, 2: No)
'If yes,details of the helplines and number of
adolescent male/female provided services

Signature of Chief Medical Officer: Signature of District Nodal Officer Name of Dealing Assistant:
Dated: Mobile No.
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTH/YEAR END (2016-17) REPORTING FORMAT (BLOCK/
DISTRICT/ STATE) - SCREENING
_Select
Name of State/UT: _Select State_ No of ReportedDistricts: Select No of Dist. No of Blocks : Reporting Month Month_ Year

6 weeks to 6 years (MHT) 6-18 years enrolled in Govt and Govt aided schools (MHT) Birth to 6 weeks
Target : No. of No. of Percentage Found Referred Target : No. of No. of Percentage of Found Referred Delivery points ASHA, HBNC
children children of total positive for for this children children total children positive for for this
No. of Found No. of Found
screened screened children selected current Total screened screened screened till selected current
children positive for children positive for
Total in current cumulative screened till health month/year children to in current cumulative this month health month/year
screened selected screened selected
children to month till current this month conditions be month/year till current (Cumulative) conditions
at the health by the health
Male be /Yearby month (Cumulative)
#DIV/0! in current screened by M.H.T. month #DIV/0! in current

Female #DIV/0! #DIV/0!

Total #DIV/0! #DIV/0!
Screening visits organised (Monthly)
Annual Total Total Cumulativ Doctors Pharmacist ANM/ Staff nurse
plan : AWC/Scho AWC/School e gap No of
ol visit visit including Teams
planned in conducted carry Male Female Male Female Male Female
Total visit this month this month forward
Approve
Number Number Number Number
d
Visit 1 In-place
AWC
Visit 2 Trained
Govt and Govt aided Functional in Field
Birth-6 weeks
6 weeks to 6 years 6 years to 18 years Total children
Delivery points ASHA, HBNC
screened in the Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
year ________ 0 0 0 0 0 0
From ________ To
Defects
Sl No at Birth: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total
Neural
1 tube
defect
Down’s
2
Syndrome
Cleft Lip
3
& Palate
 4 Club foot
Developm
ental
5
dysplasia
of the hip
Congenita
6
l cataract

Congenita
7
l deafness
Congenita
8 l heart
diseases
Retinopat
hy of
9
Prematuri
ty
Deficiencies:Tot
al
Severe
10
Anaemia
Vitamin A
deficiency
11
(Bitot
spot)

Vitamin D
Deficienc
12
y,
(Rickets)

A) SAM
B) Severe
13 Thinning
C)
Obesity
14 Goitre
Childhood
Diseases:Total
Skin
15
conditions
Otitis
16
Media
Rheumati
17 c heart
disease
 Reactive
18 airway
disease
Dental
19 Condition
s
Convulsiv
20 e
Delays
disorders
including
Disabilities:Tota
Vision
21 impairme
nt
Hearing
22 Impairme
nt
Neuro
motor
23
impairme
nt
Motor
24
delay
Cognitive
25
delay
Language
26
delay
Behaviour
27 disorder
(Autism)
Learning
28
disorder
Attention
deficit
29 hyperactiv
ity
disorder
30 Others
Adolescent Health:Total
Growing
31 up
concerns
Substanc
32
e abuse
Feel
33 depresse
d
 Delay in
34 menstruat
ion cycles
Irregular
35
periods
Pain or
burning
36 sensation
while
urinating

Discharge
/ foul
smelling
discharge
37
from the
genitor-
urinary
area

Pain
during
38
menstruat
ion
Total Children Referred to0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
CHC
PHC
DH
NRC
SNCU
DEIC
AFHC
(to be filled
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
only at district
ASHA
Health facility/
Delivery points
Mobile health team
Self-referral at DEIC
Private
NGO/CSO
Report prepared by Report verified by Block/ District / State Nodal person
Name
Signature
Designation
Date
 Menstrual Hygiene Programme

Name of District: No. of Blocks:

Funds
generated Funds
from sale recouped
of sanitary to the DHS
napkinsin Expenditure in Rs. Lakhs in the
the reporting
No. of No. of reporting month
packs as packs as month
free free No.of No.of
Total No. of No. of girls No. of girls Total No. distributio distributio Sanitary Sanitary Total
Name of Quantity Packs Total No. reached reached till of ASHAs n to n to packs sold packs sold consumpti Balance
Sr.No. Block received Received of Ags in during the the in selected ASHA/link ASHA/link to AGs in to AGs on till stock
by the During the the Block reporting reporting distt. worker worker till the upto reporting Incentive
Block Month month month during the the reporting reporting month to Rental
reporting reporting month month ASHA/Link Cost for
month month Workers storage of Transport-
in Rs. for holding Sanitary in ation cost in Rs.
AGs the of SN Lakhs
meeting in reporting
the month (if
reporting applicable)
month

Signature of Chief Medical Officer: Signature of the Nodal Officer Name of Dealing Assistant:
Dated: Mobile No.
 De-Addiction

Substances Abused OPD Cases IPD cases

TOBACCO
ALCOHOL
OPIUM+derivatives
MARIJUANA+deriv
SOLVENTS/INHALANTS
MEDICINES MISUSED
MULTIPLE/OTHERS
Total

Signature of Chief Medical Officer Signature of the Nodal Officer

Name of Dealing Assistant:
Dated: Mobile No.
 Family Planning
S.No. 1) Monitoring of RMNCH+A Counselors performance Number
1 Total No. of clients counseled per month
2 No. of counseling visits in maternity ward
3 No. of OPD days in MCH wing and OPD
4 No. of clients who opted for PPIUCD out of total counselled in the reporting month
5 No. of clients who opted for post-partum sterilization out of total counseled in the reporting month.
6 No. of clients who opted for other family planning methods out of total counseled in the reporting month
2) PTK
1 Opening balance at the start of month.
2 Stock received in the month
3 Stock utilized through SC
4 Stock utilized through ASHAs
Balance available at the end of the month
3) PPIUCD report
1 No. of deliveries in the month in delivery point.
2 Total NO. of PPIUCD insertions done in a month.
3 Total no. of doctors/staff nurses trained in PPIUCD insertion
4) Monitoring Status of Family Planning Sterilization camps
1 No. of visits by CMO for monitoring of FP sterilization camp.
2 No. of visits by BMO for monitoring of FP sterilization camp.
3 No. of FP sterilization beneficiaries dropped by 102.

Signature of the Chief Medical Officer Signatuer of the Nodal Programme Officer

Signature of the Dealing Assistant

Mobile Number:
 Annexure 1.3: Reporting format for newborn facility
(All newborn care facility should submit a Monthly report to the Distt. NBCCs will only fill in section A, while section A,B and C will be filled in from all
SNCUs)

Type of Unit : SNCU/NBSU/NBCC (Tick one or more option as applicacble) (e.g. The DH will have all three, while the FRU will have both NBSU and NBCC)

Name and address of the Health Facility:________________________________________________________________

No. Of Beds: ________________ Date of Operationalization :_________________
Section A
Section to be filled from labour room & OT records (as applicable)
Sl. No. Total Number [N]
1 Total Deliveries
2 Caesarean sections
3 Live birth
4 Still Births
4a Fresh
4b Maceerated
5 Term Babies
6 Birth weight of babies
>2500gm
<2500gm
1500-2499g
1000-1499g
<1000g
7 Paterem births (Gestation)
>37weeks
<37 weeks
8 No. Of newborn who required resuscitation at birth
9 Total No. Of newborn deaths
10 No. Of referrals made (to higher facilities)
11 Human resource Sanctioned In Place
MO
SN
Human Recource Trained (NSSK for NBCC, F-IMNCI for
NBSU and SNCU. Please tick applicable column) F-IMNCI
12 NSSK FBNC
 MO
SN
Section B

Section B to be filled from the special newborn care unit/ Newborn Stabilization Unit records
Sl. No. Total Number Inborn [l] Outborn [O]
7 Admission in the unit
7a Male
7b Female

Birth weight/ weight at admission* Inborn -Record the birth weight Outborn- Record
8 birth weight if avilable, if it is not avilable, record and report weight at admission
8a >2500g
8b 1500-2499g
8c 1000-1499
8d <1000g
9 Gestation
9a >37 weeks
9b 34-37 weeks
9c <34 week
10 Morbidity profile
10a Respiratory distress syndrome
10b Meconium aspiration syndrome
10c Other causes of respiratory distress
10d HIE/Moderate-severe birth asphyxia
10e Sepsis / Pneuonia/Meningitis
10f Major congential malformation
10g Jaundice requiring phototherapy
10h Hypothermia
10i Hypoglycemia
10j Others
11 Management (no. Of babies who received)
11a Phototherapy
11b Antibiotics
11c Oxygen
12 Step down care
 No. Of babies managed in the unit from postnatal ward/
12a step-down
12b No of babies managed in the step down from SNCU
13 Outcome
13a Discharge
13b Referral
13c Left againsst medical advice (LAMA)
13d Died
14 Duration of stay
14a <1 day
14b 1-3 days
14c 4-7 days
14d >7 days
Sl. No. Total Number Inborn [l] Outborn [O]
14e Average duration of stay

No. Of non-functional equipment (Non- functional

15 equipment=not working>7 days/month
15a Phototherapy unit
15b Radient warmer
15c Oxygen concentrator
15d Suction machine
15e Generator/Invertor

Section C

Section C to be filled from the special newborn care unit/ Stabilization Unit death records
Sl. No. Total Number Inborn [l] Outborn [O]
16 Mortality profile (Cause of death)
16a Respiratory distress syndrome
16b Memconium aspiration syndrome
16c HIE/Moderate- Severe birth aspixya
16d Sepsis/Pneumonia/Menigitis
16e Major congenital malforamtion
16f Prematurity
16g Others
 16h Cause not established
17 Duration between the time of admission & death
17a <1 day
17b 1-3 days
17c 4-7 days
17d >7 days
18 Age at death
18a <1day
18b 1-6 days
18c _> 7 days
19 Birth weight/weight at the time of death
19a >2500 g
19b 1500-2499 g
19c 1000-1499g
19d <1000g
20 Gestation
20a Term
20b Preterm
20c Post term

Signature of the Chief Mediacl Offier Signature of the Nodal Programme Officer

Name of the Dealing Assistant

Mobile Number:
 State Reporting format for New Born Stabilization Units (NBSUs)
All New Born Stabilization Units (NBSUs) should submit a monthly report to the District. A compiled report from all NBSUs in the district should be forwarded to the State which will be shared with Child Health division by the 5 th of every month in the
prescribed state format in excel only .)
State: Month : Year:
Details
No. of
of NBSU Live birth reported at Admission Profile Duration of stay Outcome (Number of babies)
beds Date of No. of No. of the facility Total In-borm Out-born birth weight
HPD Type of Name & Address (radiant Opertionaliz Designated Designated admission Less than More than Referred Discharged Lama Died
1-3 days
District (Y/N) Sr. No facility of the facility warmers) ation MO Staff Nurse Total Male Female in NBSU Male Female Male Female < 2500gm >2500gm 24hrs 3 days
Bilaspur N 1 CHC Bharari
N 2 CHC Berthin
Hamirpur N 3 CHC Barsar
N 4 CHC Bhoranj
N 5 CHC Sujanpur Tihra
Kangra N 6 DH Dharamshala
N 7 CH Nurpur
N 8 CH Palampur
N 9 CH Baijnath
N 10 CH Dehra
N 11 CH Kangra
N 12 CHC Shahpur
N 13 CHC Jawalamukhi
N 14 CHC Thural
N 15 CHC Jaisinghpur
N 16 CHC Gangath
N 17 CHC Chadhaiar
Kinnaur Y 18 DH Reckong Peo
Y 19 CHC Pooh
Y 20 CHC Sangla
Y 21 CHC Bhawanagar
LS Y 22 DH Keylong
Y 23 CHC Udaipur
Y 24 CHC Kaza
Mandi Y 25 CH Sarkaghat
Y 26 CH Joginder Nagar
Y 27 CH Karsog
Y 28 CH Sandhol
Y 29 CHC Baldwara
Y 30 CHC Ladbharol
Y 31 CHC Ratti
Y 32 CHC Gohar
Y 33 CHC Padahar
Shimla N 34 DH DDU Shimla
N 35 CH Chopal
N 36 CH Rohru
N 37 CH Nerwa
N 38 CH Jubal
N 39 CHC Kotkhai
N 40 CH Theog
N 41 CHC Kumarsain
Sirmour N 42 CH Nahan
N 43 CH Rajgarh
N 44 CH Dadahu
N 45 CH Sarahan
N 46 CHC Shillai
Solan N 47 CHC Nalagarh
N 48 ESI Parwanoo
Una N 49 CHC Daulatpur
Signature of State Child Health Nodal Officer
 Newborn Care Corner (NBCC) Monthly Reporting

District: Number
Report received from
Total Deliveries
1 Caesarean sections
2 Live-Births
3 Male
Female
Still Births
4 4a. Fresh
4b.Macerated
Birth weight of babies
>2500gm
<2500gm
1500-2499g
5
1000-1499g
<1000g
How many LBW provided KMC
6a Term births (Gestation)>37 weeks
6b Preterm Births (Gestation)< 37 weeks
7 No of Preterm mothers received Antenatal CS
8 No of Newborns who required resuscitation at birth
9 No of Newborns breast fed within one hour
a No of New borns who received
b Vit K inj. At birth
c OPV (zero dose) at birth
d BCG
10 Hep B (zero dose ) at Birth
11 Total no. of newborn deaths
12 No.of newborns with conginital malformations
13 No of newborns admitted to SNCU/NBSU
 14 Cause of admission to SNCU/NBSU
15 No of referrals made (to higher facilities)
16 Human Resource Trained (NSSK for NBCC, F-IMNCI) for
MO
SN

Signature of Chief Medical Officer Signature of the Nodal Programme Officer Name of the dealing Assisstant
Dated Mobile Number
 Monthly reporting format : Nutrition rehabilitation centres

District Sirmour Kangra Shimla Una Mandi

Name of Health Facility CH Paonta Sahib Dr. RPGMC Tanda IGMC RH Una ZH Mandi
Number of Beds
A Admisions
SC/ST
BPL
Total Admisions
A.1 Admission criteria
-3 SD WFH
MUAC<115 mm
Bilateral pitting oedema
A.2 Referral By
Frontline worker
Self
Paediatric ward/emergency
A.3 Duration of Stay
<7 days
7-15 days
>15 days
A.4 Bed occupancy
bed occupancy rate
A.5 Weight Gain
achieved target weight (15% weight gain)
B Monthly output
1 Discharges from NRC
2 Defaulters
3 Non responders
4 Deaths
5 Children due for follow up (in the month)
6 Children followed up during the month
 7 Deaths during follow up period (after discharge
from NRC
8 Relapse

Signature of Chief Medical Officer Signature of the Nodal Programme Officer Name of the dealing Assisstant
Dated Mobile Number
 Report of Vitamin - K

Districts Target as per Zero Dose No. of live births Vit. K Inj. given Month
OPV
Bilaspur
Chamba
Hamirpur
Kangra
Kinnaur
Kullu
L&S
Mandi
Shimla
Sirmour
Solan
Una
Total

Signature of Chief Medical Officer Signature of the Nodal Programme Officer Name of the dealing Assisstant
Dated Mobile Number
 Antenatal Steroid Use Record
Date
S.No. OPD/IPD No. Name of the Patient Date of Time of Gestation in Dexamethasone injection (6mg If referred , Date & Sex of Weight of Clinical condition of Final
admission Admission weeks Intramuscular, 4 doses 12 Hrs. apart, if Institute time of New New Born New Born Outcome
fgestation <34 weeks and no evidence of where delivery born in
infection and labor not imminent) referred Kilogram

1st dose 2nd dose 3rd dose 4th dose Respirat HMD SNCU Survived
(Date & time (Date & time (Date & time (Date & time ory (Y/N) admission /Died/
Distress (Y/N) LAMA
(Y/N)

Signature of Chief Medical Officer Signature of the Nodal Programme Officer Name of the dealing Assisstant
Dated Mobile Number
 Refferals

Name of District :
Maternal Referals Child referrals

Sr. no Patient Name Age (Yrs.) Contact Indication Referred Referred Outcome S.n. Patient Name Age/ Sex Contact Date & Date & Indication Referred Referred
no. of of referral by to which no. of time of time of of referral by to which
Patient/at hospital Patient/at admission referral hospital
tendant tendant

Signature of Chief Medical Officer : Signature of Nodal Programme Officer Name of Dealing Assistant:
Dated: Mobile No.
 Reprot of Gentamycin

Total number of Young

Number among column
Total number of Young Total number of Young infnats (0-2 motnhs) among
Number among coumn Number among column C who C who completed 7 days
Infants from 0-2 nfants (0-2 months) those diagnosed with sepsis
among column C who completed 7 days of antibiotic of antibiotic treatment
months (16 per 1000 diagnosed with sepsis by given pre-referral dose of
refuse referral treatment from PHC/ANM from PHC/ANM and
live births) ANM/ASHA Injection Gentamycin and
survived.
Syrup amoxycillin

A B C D E F

Signature of Chief Signature of Nodal

Medical Officer : Programme Officer Name of Dealing Assistant:
Dated: Mobile No.
 Child Death Reporting format
Name of the Facility:

Cumulative deaths reported Male:

Female:
Total:
Indicators Case1 Case2 Case3 Case 4 Case5 Case6 Case7
MCTS ID
B/Father’s Name
B/Mother’s Name
Address
Sex (M/F)
Category (SC/ST,OBC,Gen)
Age
0-1day
2-7days
8-28days
29days-1year
1-5year
Place of Birth : Home/ Pvt./ Public/transit

Birth Weight (Kg.s)

Current weight (last recorded weight in
MCP card)
Immunization status: Complete as per age
(Y/N)
Date of Admission (DD/MM/YYYY)
Date of death (DD/MM/YYYY)
Place of Death: Home/ Pvt./ Public/transit

Cause assigned at time of death / full and

final diagnosis
Child death review conducted* (Y/N)
Name of the treating doctor

* Delays identified during Child Death Review:

Delay 1 : parents do not recognize the seriousness of illness in child and do not tale medical advice
Delay 2 : No means of trasnposrtation to shift the child to nearest health facility
Delay 3 : Occurs at health facility when treatment is not provided as per protocols

Signature of Chief Medical Officer : Signature of Nodal Programme Officer Name of Dealing Assistant:
Dated: Mobile No.
 RVV Monthly report

Sr. Opening Balance in doses (Also Closing Balnce in

included received during the
no District RVV1 RVV2 RVV3
month) doses

1 Bilaspur
2 Chamba
3 Hamirpur
4 Kinnaur
5 Kullu
6 Lahaul & Spiti
7 Mandi
8 Shimla
9 Sirmour
10 Solan
11 Una

Signature of Chief Medical Officer : Signature of Nodal Programme Officer Name of Dealing Assistant:
Dated: Mobile No.
 IPV Report

Closing stock of IPV by Total Children

Sr. Total IPV doses received by Children immunized
District-Name (for the months immunized for IPV TILL
No. Districts till date for IPV
report) date
1 Bilaspur
2 Chamba
3 Hamirpur
4 Kangra
5 Kinnaur
6 Kullu
7 L&S
8 Mandi ,
9 Shimla
10 Solan
11 Sirmour
12 Una

Signature of the Chief Medical Officer Signature of the Nodal Programme Officer Name of the Dealing Assistant
Mobile Number
 RMNCH+A Counsellors Monthly Reporting Format
Name of Health Facility :
1 Name of RMNCH Counsellor
2 Date of Joining
3 Name of facility where posted
4 Whether received four days training for Counsellors (Y/N). If yes, When
5 Interval IUCD
PPIUCD
Post partum Sterilization
Interval Sterilization
Services Available in the Male Sterilization
facility (Numbers) High Risk Pregnancy identification
Comprehensive Abortion care
Children OPD & Ward
Nutrition Rehabilitation center
Adolescent clinic & deaddiction center
6 Service delivery data
6.1 Total Number of deliveries in the facility
6.2 Number of ANC OPD clients in the facility
6.3 Number of ANC Clients counselled
6.4 Number of High Risk Pregnancy Cases registered in ANC OPD
6.5 Number of High Risk Pregnancy Cases Counselled by RMNCH+A Counsellor

6.6 Number of counselled clients who opted for PPIUCD

6.7 Number of counselled clients who opted for post-partum sterilisation
6.8 Number of counselled clients who opted for other family planning methods (OP,
CC, Interval IUCD, Interval sterilisation and male sterilisation)

6.9 Number of Post Natal Care women counselled on Post Partum and Essential
NewBorn care during their 24/48 hours of stay at health facility
 6.10 Number of newborn received all newborn vaccination (Vit. K, BCG, Hep B birth dose
and, OPV 0 dose) before discharge
6.11 Number of PPIUCD clients due for follow up this month
6.12 Number of PPIUCD clients followed up at 6 weeks
6.13 Number of clients received comprehensive abortion care services at the facility

6.14 Number of Counselled abortion clients who opted for IUCD

6.15 Number of Counselled abortion clients who opted for sterilisation
6.16 Number of children (0-5 years) attending Pediatric OPD
6.17 Number of children below 5 years attending children OPD identified with Moderate
Malnutrition
6.18 Number of children below 5 years attending children OPD identified with SAM
severe malnutrition

6.19 Number of SAM children admitted to Pediatric ward/ NRC by RMNCHA counselor

6.2 Number of clients(Mothers and children) who are counselled for Nutrition and
Childhood illness who visited the Pediatric OPD/ admitted in ward

6.21 Number of counselled children with mild or moderate undernutrition who re-
visited the facility for follow up with RMNCHA counselor

Medical Name of the Dealing

Officer : Signature of the Nodal Programme Officer Assistant
Dated: Mobile Number
 Monthly Reporting Format for NHM/RCH Training

Cumulative
No. of
Name of Training Achievemnet
Category of No. of Batched batches No. of Actual
activity Duration Date of Venue of in the Budget
Sr. No. participants palnned during conducted participan Expenditu Remarks
alongwith FMR of training training training current Allocated
trained the year during the ts trained re
Code Financial
month
year

Signature of Chief Medical Officer : Signature of the Nodal Programme Officer Name of the Dealing Assistant
Dated: Mobile Number
 Sick New Born Care

Indicators Bilaspur Chamba Hamirpur Kangra Kinnaur Kullu L&S Mandi Shimla Sirmour Solan Una
No of delivery points in the district
No. of delivery points with functional NBCC in the district
No. of OTs in Public hospitals
No. of OTs in public hospitals with functional NBCC
No. of staff nurses posted in Labour rooms at delivery points
No. of staff nurses posted in Labour rooms at delivery points
trained in NSSK & SBA
No. of ANMs posted at delivery points
No. of ANMs posted at delivery points trained in NSSK & SBA
No. of SNCU proposed in district
No. of SNCU functional in districts
No. of Doctors managing SNCU and trained in FBNC
trained in F-IMNCI & IMNCI
No. of doctors posted in Civil hospitals & CHCs who are
trained in F-IMNCI & IMNCI
No. of staff nurses who are trained in FBNC & IMNCI
No. of ANMs & HWs who are trained in FBNC & IMNCIin
district

Signature of Chief Medical Officer : Signature of the Nodal Programme Officer Name of the Dealing Assistant
Dated: Mobile Number
 National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)

NPCDCS Register for screening common NCDs in Government Health facilities (To be filled by Sub centre, PHC, CHC and District NCD clinics)
State: Type of Facility: Name of Facility: In-charge of Facility: Total Population:
Date: NPCDCS Code:
Left side of Register Right side of Register
Personal Details Personal History Family History Patient Examination Screening Outcome Other Co-
Tobacco morbidities
Screening
Any Less Blood
Alcohol
known Smokeles Physical BMI Sugar Any Status
consump Oral Visual Screened
Patient NCD s activity High Fasting/ Breast other after
tion in Blood cavity inspectio for TB
ID (DM/ Smoking (Chewing (Sedentar Diabetes Blood CVD Stroke Cancer Height Weight (Wt. in Kg Random Examinat investigat treatmen On ATT
Sl No. last one pressure examinat n of Final Date of t symptom
(NPCDCS HTN/ , y Pressure / Ht. in (To ion ion/
Contact CVD/ Ca) month ion Cervix s
No.) Name / Address Age/ Sex snuffing) lifestyle) m2) mention finding diagnosis starting Initiation
No. FBS/RBS) at NCD treatmen
clinic t

Please Referred/
Normal/ Normal/ Normal/ on FU/ Lost
to FU/ Yes/ No Yes/ No
mention Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No (metre) (kg) (kg/m2) mm/ Hg mg/ dl
Disease Abnormal Abnormal Abnormal
Died/
1
2
3
4
5

Signature of the Chief Medical Officer Signature of the Nodal Programme Officer Name of the dealing Assistant
Dated Mobile Number
 National Programme for Health care for Elderly (NPHCE)

Particular During the month % Up to the month % Cumulative till

30/04/2014
No. of person examined
Suspected for Diabetes
Suspected for
Hypertension (>90)
Suspected for Cancers
Suspected for CVD &
Stroke
Suspected for other NCDs
Aids & Appliances provided

Infrastructure development & capacity building -

Particular Established /complete Expected Remarks

Geriatric clinic on fixed days at - - No Doctors under NCD available

CHC/PHC

Home based care -

Training of MOs/SN/LTs/HW
Procurement of Aids and appliances
for Distt/CH/CHC/PHC /SC level

Signature of the Chief Medical Officer Signature of District Programme Officer Name of Dealing Assistant
Cum- Medical Officer of Health Mobile Number
 National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for Sub Centre

Name of the Sub-centre_______________ PHC _______________ Block/ Mandal ________________

Part A: Hypertension and Diabetes Screening

No. of new persons Suspected No. of new persons Suspected
Total No. of NCD Checkups No. of known cases of DM on No. of known cases of HTN on
Name of Done for DM and refered for for HTN and refered for
Follow-up Follow-up
the Confirmation Confirmation
village Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total

Total

Part B: Screening for Common Cancers

No. of persons suspected with cancer and refered to by the Subcentre last Total No. of known
Name No. of persons screened PHC/ CHC/ GH month who underwent Cancer patients in the
of the for cancers Oral investigations at higher Village
Village Male Female Total Male Female Total Breast Cervical Total Male Female Total Male Female Total
Total

Signature
Name and Designation

Date of reporting_____________________

*The Report should be filled by ANM of Sub centre and sent to MO I/C PHC on last day of the same month.
 National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for Primary Health Centre (PHC)

Name of the PHC_______________ Name of the linked Block PHC/CHC _______________

No. of Sub-centres under the PHCs _________ No. of Sub-centres reported during the month:___________

Part A (Screening for HTN and Diabetes)

Name Of No. of new persons Suspected No. of new persons Suspected
Total NCD Checkups Done No. of known cases of DM on No. of known cases of HTN on
the Sub for DM and refered for for HTN and refered for
Follow-up Follow-up
Centre / Male Female Total Male Confirmation
Female Total Male Confirmation
Female Total Male Female Total Male Female Total
PHC
PHC

SC1
SC2
SC3
SC4
SC5
SC6
Total
Overall Total

Part B: Screening for Common Cancers

Name of No. of persons screened No. of persons suspected and refered to PHC/ CHC/ No. of known Cancer
the Sub GH
for Cancers Oral patients
Centre/ Breast Cervical Total
PHC Male Female Total Male Female Total Male Female Total
Name Of the PHC

SC 1
SC2
SC3
SC4
SC5
SC6
SC7
Sub Centre total

Overa
ll
Total

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated from PHC OPD screening data and also by compiling data of Form 1 of all sub-centres under the PHC.
This report should be verified and signed by Medical Officer I/c PHC and sent to Block PHC/CHC by 5th day of every month
 Form 3A

National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for NCD Clinic at Community Health Centre (CHC)/ Sub District Hospital(SDH)
Name and Address of the SDH / CHC ___________________ Block/ Taluk/ Mandal/ Zone_________________

During the Reporting Month

Indicator
Male Female Total
I. Common NCDS under NPCDCS
1.Total no. of persons attended NCD Clinic (New and Follow up)
A. Diabetes Only
2. No. newly diagnosed with B. Hypertension Only
C. HTN & DM
A. Cardiovascular diseases
B. Stroke
3. No. of persons suspected and C. Oral Cancer
referred for D. Breast cancer
E. Cervical cancer
F. Other cancers
A. Diabetes Only
4. No of newly diagnosed patients
B. Hypertension Only
initiated on treatment
C. HTN & DM
A. Diabetes Only
5. Patients on treatment Follow
B. Hypertension Only
Up
C. HTN & DM
6. Total No. of persons referred to District Hospital/ Higher Centres
7. No. of persons counselled for health promotion & prevention of
II. Comorbid Conditions
A. No. of known TB cases on ATT
8. Among all confirmed Diabetic
patients [New (2A+2C) & Follow B. No. screened for TB Symptoms
up (5A+5C)] C. No. suspected for TB & refered
to DMC/ PI

Signature:
Name and Designation
Date of reporting_____________________

*This report should be generated from CHC OPD screening data.

This report should be verified and signed by Medical Officer I/c CHC.
This report should be sent to District NCD Cell by 7th day of every month.
 Form 3B
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for Community Health Centre (CHC)/Block PHC/ SDH

Name and Address _______________________________________________________________________________________

Total No. of PHC in the District _________ Total No. Of PHCs reported_________________________

Part A : Screening for HTN and Diabetes

No. of new persons No. of new persons
Total NCD Checkups No. of known cases of No. of known cases of
Source Done Suspected for DM and Suspected for HTN and DM on Follow-up HTN on Follow-up
Of Data Male Female Total refered for Confirmation
Male Female Total refered for Confirmation
Male Female Total Male Female Total Male Female Total

Compile
d data
from all
PHCs &
Sub
Centres

PART B: Screening for Common Cancers

No. of persons suspected with Cancer and refered
No. of persons screened to PHC/ CHC/ other GH No. of Known Cancer
Source for Cancers patients
of Data Oral
Breast Cervical Total
Male Female Total Male Female Total Male Female Total
Compile
d data
from all
PHCs &
Sub
Centres

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 2 of all PHCs under the Block/Taluk/Mandal.
This report should be verified and signed by Medical Officer I/c .
This report should be sent to District NCD Cell by 7th day of every month.
 Form 4
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for District NCD Clinic

Name of Health Facility where located :______________________________

All information below are for the reporting month

During the Reporting Month
Indicator
Male Female Total
I. Common NCDS under NPCDCS
1. Total no. of persons attended NCD Clinic in the reporting mont
A.Diabetes Only
B. Hypertension Only
C. HTN & DM (Both)
D. CVDs
2. No. newly diagnosed with E. Stroke
F.Oral Cancer
G. Breast cancer
H.Cervical cancer
I.Other cancers
A CVDs
3. Suspected and referred cases C. Stroke
of CVDs & Cancer (In Resource D. Oral Cancer
limited settings where there are
No capacity to perform E. Breast cancer
confirmatory diagnosis) F. Cervical cancer
G. Other cancers
A.Diabetes Only
B. Hypertension Only
4.No of newly diagnosed C. HTN & DM (Both)
patients initiated on Treatment D. CVDs
E. Stroke
F. Cancer (Including Day Care Centres)
A. CVDs
5. No. of Patients treated at CCU
B. Stroke
 A. Diabetes Only
B. Hypertension Only
C. DM & HTN (Both)
6. No Of patients on follow up
D. CVD (Only OPD data)
E. Stroke (Only OPD data)
F. Cancer (Including Day Care Cen
7.No. of person referred to Terti A.Diabetes
B. Hypertension
C. CVD
D.Stroke
E. Cancer
8. Patients attended Day Care facility for Cancer care
9. No. of persons counselled for health promotion & prevention
of NCDs
11. No. of patients underwent physiotherapy
II. Comorbid Conditions
A. No. of known TB cases on
8. Among all confirmed Diabetic ATT
B. No. screened for TB
patients [New (2A+2C) & Follow Symptoms
up (6A+6C)] C. No. suspected for TB &
refered to DMC/ PI

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated from District NCD Clinic /OPD screening data of District Hospitals.
This report should be verified and signed by Medical Officer I/c .
This report should be sent to District NCD Cell by 7th day of every month.
 Form 5A
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for District NCD Cell
District________________ State____________________

During the Reporting Month Cumulative since April during current Financial year
Indicator
Male Female Total Male Female Total
I. Common NCDS under NPCDCS
1. No. of persons attended NCD Clinics
(New and follow up)
A. Diabetes Only
B.Hypertension Only
C. HTN & DM
D. CVDs
2. No. newly
E. Stroke
diagnosed with
F.Oral Cancer
G. Breast cancer
H. Cervical cancer
I. Other cancers
3. Number of
persons suspected A. CVDs
(Confirmatory B. Stroke
Diagnosis not C.Cancers
available/ Pending)
A. Diabetes Only
B.Hypertension Only
C. HTN & DM
4. No. of newly D. CVDs
diagnosed patients E. Stroke
put on Treatment F.Oral Cancer
G. Breast cancer
H. Cervical cancer
I. Other cancers
A. Diabetes Only
B.Hypertension Only
C. HTN & DM
5. No. of persons
on treatment
follow up
5. No. of persons D. CVDs
on treatment E. Stroke
follow up F.Oral Cancer
G. Breast cancer
H. Cervical cancer
I. Other cancers
A. Diabetes
(Complications)
B. Hypertension
( Complications)
6. No.of person C. CVDs
referred to Tertiary
hospital/TCCC D. Stroke
E. Oral Cancers
F. Breast Cancer
G. Cervical Cancer
H. Other Cancers
7. No. of Patients A. CVDs
treated at CCU B. Stroke
8. No of cancer patients treated in Day
Care
9. No.facility
of persons counselled for health
promotion & prevention of NCDs
10. No. of patients underwent Physiotherap
II. Co-morbidities
A. No. of known TB
cases on ATT
1. Among all
confirmed Diabetic B. No. screened for TB
patients [New Symptoms
(2A+2C) & Follow
up (5A+5C)] C. No. suspected for TB
& refered to DMC/ PI

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 3A (CHC NCD Clinics) and Form 4 (District NCD Clinic) data
This report should be verified and signed by District Nodal Officer.
This report should be sent to State NCD Cell by 10th day of every month.
 Form 5B
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for District NCD Cell
Name and Address of the District NCD Cell ___________________________________________

Total No. of PHC in the District _____________ Total No. Of PHCs reported ____________

Part A : Screening for HTN and Diabetes

No. of new persons No. of new persons
Total NCD Checkups Suspected for DM and Suspected for HTN and No. of known cases of No. of known cases of
Done refered for Confirmation refered for Confirmation DM on Follow-up HTN on Follow-up
Source
Of Data
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total

PART B: Screening for Common Cancers

No. of persons suspected with Cancer and refered
No. of persons screened to PHC/ CHC/ other GH No. of Known Cancer
Source for Cancers patients
of Data Oral
Breast Cervical Total
Male Female Total Male Female Total Male Female Total

Source of Data: Compiled data from all CHCs

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 3B of all
Blocks/Mandals/Taluks under the District
This report should be verified and signed by District Nodal Officer.
 Form 6
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting performa for State NCD Cell
No. of district NCD Cells……………………………. No. Of District NCD Cells reported ………………..

Part A. Programme Data (Compiled data of Form 5A)

During the Reporting Month Cummulative since April (Finanacial
Indicator Year Data)
Male Female Total Male Female Total
i). Common NCDS under NPCDCS
1. Total no. of persons attended NCD Clinics
(New and Follow Up)
A. Diabetes Only
B.Hypertension Only
C. HTN & DM (Both)
2. No. D. CVDs
newly
E. Stroke
diagnosed
with F.Oral Cancer
G. Breast cancer
H. Cervical cancer
I. Other cancers
A. Diabetes Only
B.Hypertension Only
3. No of C. HTN & DM (Both)
new D. CVDs
patients
E. Stroke
initiated
on F.Oral Cancer
treatment G. Breast cancer
H. Cervical cancer
I. Other cancers
A. Diabetes Only
B.Hypertension Only
C. HTN & DM (Both)
4. No of D. CVDs
Patients
on Follow
4. No of
Patients
E. Stroke
on Follow
up F.Oral Cancer
G. Breast cancer
H. Cervical cancer
I. Other cancers
A. Diabetes
5. No. of B. Hypertension
Patients C. CVDs
Referred
to Tertiary D. Stroke
Care/TCCC E. Cancers
6. No of
patients A. CVDs
treated at B. Stroke
CCU
7. No. of persons attended day care centre
8. No. of Persons counselled for health
promotion and prevention of NCDs
9. No. of patients attended physiotherapy

ii). Comorbid Conditions

Among all
confirme A. No. of known TB cases on
d ATT
Diabetic B. No. screened for TB
patients Symptoms
[New
(2A+2C) C. No. suspected for TB &
& Follow refered to DMC/ PI
up
B. Other Programme Markers (Compiled data of Form 5B)
Total No. of NCD check ups done
Diabetes only
Total No. Hypertension Only
Of
Persons
Suspected Oral Cancers
and Breast Cancers
refered
for Cervical Cancers
Other Cancers
patients HTN /Diabetes/ Both HTN and DM
on follow
up in PHC Cancer patients
C. Physical targets and achievements

Achievemen Cumulative Cumulative

Annual Target
t during the achievement achieveme
Name of Facility for the year Remarks
reporting since 1st Apr nt since
2016-17
month 2016 beginning

District NCD Cells

District NCD Clinics
District CCU facilities
District Day Care Centres
CHC NCD Clinics
Others

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 5A & Form 5B of all Districts in the State
This report should be verified and signed by State Nodal Officer.
This report should be sent to National NCD Cell by 15th day of every month.
 Civil Work

Up to date Status of Depoisted works in respect of Health Department

S.N. Division Constitut Name of AA/ES No. Estimated Date of Total funds Depoisted Addl. Fund Physical Land Likely date of Work Remark
ency work Date & Cost Start required Status of Available Completion complete
Amount (Lacs) Work (Y /N) in %

Total funds Total Exp. whether building

Depoisted up to is functional or not
funds date , if not when it will
sanctioned be functional
During
2015-16

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Name of District

Signature of Chief Medical Officer: Signature of the Nodal Programme Officer Name of Dealing Assistant:
Email ID: Mobile No.
Dated:
 Monthly comprehensive NHM reporting format indicators of Family Planning & Quality Assurance

Under Family Planning Number in %

1) Monitoring of RMNCH+A Counselors performance
1 No. of clients counseled per month
1A No. of ANC clients counseled per month
1B No. of PNC clients counseled per month
2 No. of counseling visits in maternity ward
3 No. of OPD days in MCH wing and OPD
4 No. of clients who opted for PPIUCD out of total counselled in the reporting month
5 No. of clients who opted for post-partum sterilization out of total counseled in the reporting month.
6 No. of clients who opted for other family planning methods out of total counseled in the reporting month
2) PTK
1 Opening balance at the start of month.
2 Stock received in the month
3 Stock utilized through SC
4 Stock utilized through ASHAs
Balance available at the end of the month
3) PPIUCD report
1 No. of deliveries in the month in delivery point.
2 Total NO. of PPIUCD insertions done in a month.
2A No. of PPIUCD insertions done in normal delivery cases .
2B No. of PPIUCD insertions done in intra cessarian.
2C No. of PPIUCD insertions doe post abortion.
3 Total no. of doctors/staff nurses trained in PPIUCD insertion
4) Monitoring Status of Family Planning Sterilization camps
1 No. of visits by CMO for monitoring of FP sterilization camp.
2 No. of visits by BMO for monitoring of FP sterilization camp.
3 No. of FP sterilization beneficiaries dropped by 102.
Under Quality Assurance
Key Performance Indicators (KPI) of Quality Assurance of District & Civil Hospitals
Productivity
1 Bed Occupancy Rate
2 Lab test done per thousand patients (indoor & OPD)
3 Percentage of cases of high risk pregnancy/obstetric complications out of total registered
4 pregnancies at the facility
 5 Percentage of surgeries done at night out of total surgeries
6 Percentage of surgeries done during day out of total surgeries
7 Percentage of C- Section out of Total deliveries
Efficiency
1 No. of Deaths in Emergency/Total No. Of emergency attended
2 Percentage of out referrals out of Total Admission
3 No. of major surgeries per surgeon (in a month)
4 OPD per Doctor
5 External Quality score for
6 lab tests (Median value)
7 Percentage of Stock outs of Vital drugs (list of essential commodities under RMNCH+A)
Clinical Care/Safety
1 No. of Maternal Deaths out of total admission during ANC, INC, PNC
2 No. of Neonatal Deaths out of total live births and neonatal admission
3 Percentage of cases for which Maternal Death Review done
4 Average Length of Stay
5 Percentage of Surgical Site Infection out of total surgeries
6 Percentage of Mortality out of total SNCU admissions
7 Number of Sterilization Failures
8 Number of Sterilization Complications
9 No. of Deaths after Sterilization
10 No. of unit issued on replacement X 100/ Total no of unit issued
11 Percentage of delivery having partograph recorded
12 Percentage of IIIrd and IVth generation antibiotics being prescribed (Sampling methods)
Service Quality
1 Percentage of LAMA patients out of total admissions in hospital.
Mean of scores given by each patients in Patient satisfaction survey for Indoor Department done each month on statistically
2 adequate sample (at least 30)
Mean of scores given by each patients in Patient satisfaction survey for Outdoor Department done each month on
3 statistically adequate sample (at least 30)
Average time taken by a patient from entering in queue for OPD registration to finally getting drugs at Pharmacy counter
4 observed in time motion study done at peak hours on sample basis (at least 5 patients) for General OPD
5 Percentage of beneficiaries got payment before discharge to Total no. of JSY beneficiaries registered
6 Percentage of women provided dropback to total no. of deliveries conducted.
 Performance Based Incentives (for HPDs only)

FMR Code S.No. Indicator Physical Achievement Expenditure

A.1.5.1 1 Line listing of Severe anemia
A.8.1.8 2 Line listing of High Risk pregnancy
A.8.1.8 3 Home Delivery attended by SBA
A.8.1.8 4 Institutional Delivery at Sub Centre
A.8.1.8 5 Institutional Delivery at PHC
A.8.1.8 6 Institutional Delivery at CHC (Non-FRU)
A.8.1.8 7 C-Section at CHC/CH (FRU)
A.8.1.8 8 C-Section at District Hospital
A.8.1.8 9 BOR at SNCU
A.8.1.8 10 Composite indicator Sub Centre

Signature of Chief Medical Officer: Signature of the Nodal Programme Officer Name of Dealing Assistant:
Email ID: Mobile No.
 District Status Update of Community Processes Programmes

Total Number of Blocks:- Number of High Priority Blocks-

Process / Activity Details required Numbers
1 No of ASHAs in the District Sanction- Urban: Rural:
Selected- Urban: Rural:
Functional- Urban: Rural:
2 No of VHSNC in the District
VHSNCs to be formed in the district
No. of VHSNCs actually formed in the district
No. of VHSNCs with bank account in the district
No. Of blocks where more than 70% of VHSNC meetings have been held
(as against planned for the month)
3 VHSNC Training status in the District Total no. of members trained in the district
Members trained per VHSNC
Training Status - No. of training days completed and brief information
about the training given
No. of Blocks which have completed VHSNC training
4 Status of VHSNC Fund in the District No. of VHSNC meeting conducted in the month
No. VHSNC meeting attended by BMO/M.O. in the month
Fund released in FY15-16
Fund spent in FY15-16
Fund released in FY16-17
Fund spent in the reporting month
Fund spent in the FY 16-17 till reporting month
5 District training sites (ASHA) Total no of district training sites
6 District trainers (ASHA) Number required
Numbers in place
No. of trainers in place for Round-1 & round-2
No. of trainers in place for Round-3 & round-4
7 ASHA Training
a Induction Module Target (No. Of ASHAs to be trained)
Nos. Trained till the reporting month for current FY
Nos. Trained in the reporting month
c Module 6&7 -Round 1 Target (No. Of ASHAs to be trained)
Nos. Trained till the reporting month for current FY
c Module 6&7 -Round 1

Nos. Trained in the reporting month

d Module 6&7 -Round 2 Target (No. Of ASHAs to be trained)
Nos. Trained till the reporting month for current FY
Nos. Trained in the reporting month
e Module 6&7 -Round 3 Target (No. Of ASHAs to be trained)
Nos. Trained till the reporting month for current FY
Nos. Trained in the reporting month
f Module 6&7 -Round 4 Target (No. Of ASHAs to be trained)
Nos. Trained till the reporting month for current FY
Nos. Trained in the reporting month
8 Equipment Kit No. of ASHAs given Equipment Kit till the reporting month for current FY
Items given in the equipment kit (list the items)
9 Drug kit No. of ASHAs ever given Drug Kit till the reporting month for current FY
No. of ASHAs given Drug Kit in the month (new ASHA)
Frequency of replenishment / level of replenishment
10 HBNC Incentives No. of ASHAs completed HBNC visit till the reporting month
No. of High risk new born refered by ASHA under HBNC to higher centers
No. of High risk mother refered by ASHA under HBNC to higher centers
No. of new born deaths reported under HBNC
No. of ASHAs given HBNC incentives till the reporting month for current
FY
No. of ASHAs given HBNC incentives in the month
11 Status of grievance redressal & No. of Blocks with functional system
functioning No. of complaints received vs. addressed till the reporting month for
current FY
No. of complaints received vs. addressed in the month
12 ASHA data base Numbers & percentage of dropout till the reporting month for current FY
Numbers & percentage of dropout in the month
13 Incentives Minimum incentive amount earned by ASHAs for the reporting month
Max. incentive amount earned by ASHAs for the reporting month
14 Career opportunities No. of ASHAs elected as PRI representatives
15 Monthly Asha Review meeting at field No. of review meetings (other than monthly) in the reporting month
level No. of monthly meetings in the reporting month
Number of Block where all monthly review meetings are being attended
by 70% or more ASHAs
16 VHND No. of VHNDs conducted in the month
No. of VHNDs attended by M.O. in the month
No. of VHNDs attended by Female Health worker in the month
17 ASHA Progress No. Total Incentive
disbursed for the
activity (for the
month)
a No. of Complete ANCs facilitated by ASHA in the month
b No. of Institutional delivery facilitated by ASHA in the month
c No. of deaths reported by ASHA in the month
d No. complete HBNC visits by undertaken by ASHA in the month
e No. of child deaths reported by ASHA in the month
f No. of immunization session mobilized by ASHA in the month
g No. of Complete immunization under one year by ASHA in the month
h No. of Complete immunization at two year by ASHA in the month
i No. of Tubectomy facilitated by ASHA in the month
j No. of Vasectomy/NSV facilitated by ASHA in the month
k No. of PPIUDs insertion facilitated by ASHA in the month
l No. of CAT-I treatment completed by ASHA in the month
m No. of CAT-II treatment completed by ASHA in the month
n No. of CAT-IV treatment completed by ASHA in the month
o No. of Paucibacillary leprosy treatment completed by ASHA in the
month
p No. of Multibacillary leprosy treatment completed by ASHA in the
month
q No. of blood slides prepared by ASHA in the month
r No. of cataract surgery facilitated by ASHA in the month
18 Other comments & issues

Signature of Chief Medical Officer: Signature of the Nodal Programme Officer Name of Dealing Assistant:
Email ID: Mobile No.
 Monthly input Format for Blood Storage Units

Section I : Monthly input Format for Blood Storage Units

Name of BSU
Address of BSU
District
Block
Name of Mother Blood Bank
Status of Approval (valid up to ) From DD/MM/YYYY To DD/MM/YYYY
Reporting Period: Month/Year MM/YYYY
Name of Medical Officer, In-Charge :
Section-II ( Whole Blood units)
Blood Group Balance at the Blood Units Blood Units Blood Units returned to Blood Units Blood Units No. of Blood
beginning of the Received Issued Mother Blood isued isued units
month Bank for for Discarded
Maternal others causes /Reasons
A Positive
B Positive
AB Positive
O Positive
A Negative
B Negative
AB Negative
O Negative
Section - III (Status of equipments)
Name of equipment Number Make/Brand Date of Installation Functional AMC Status
Status Yes/NO Yes/No
Blood Bank refrigerator
Deep Freezer
Insulated carrier boxes
Microscope
Generator
Domestic Referigerator for reagents
Air Conditioner (Split 1.5 Ton)
Water bath
Incubator
Centrifuge
Section - IV (Stock of Consumables)
Name of Balance at the Number/ Number used Number Balance
Consumables beginning of the Quantity during the damaged/Wasted during
month received month month
during the
month
Pasteur Pipette
Glass tubes
Glass Slides
Test Tube Racks
Rubber Teats
Gloves Disposable
Blotting/tissue paper
Marker Pen
(Alcohol Based)
Tooth Picks
Anti-A
Anti-B
Anti-AB
Anti-D
Antihuman
Globulin
(Polyclonal-IgG
Section -V (Staff Position)
Staff In Place Training Remarks
(Yes/No) required
(Yes/No)
Medical Officer
Laboratary Technician

Signature of Chief Medical Officer: Signature of the Nodal Programme Officer:

Email ID: