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USAID / BASICS
Rapid Integrated Health Facility Assessment
4. EQUIPMENT AND SUPPLY CHECKLIST
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{PRONUM} Province Number/Name ## (F9) {PRONAME} ____________________________
{FACNUM} Facility Number/Name ## (F9) {FACNAME} ____________________________
{FACTYPE} Facility type # (1=Hospital, 2=Health center, 3=Health Station)
{FACSTAT} Facility status # (1=Public, 2=Private)
{INUM} Interviewer no. ##
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Category of health staff with child case management responsibilities
(Curative and preventive)
Category Nb Assigned to facility Nb Present the day of the survey
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{MDA} Physician ## {MDP} ##
{RNA} Nurse ## {RNP} ##
{MWA} Midwife ## {MWP} ##
{HAA} Health Assistant ## {HAP} ##
{CHWA} Community Health W. ## {CHWP} ##
Patient and Worker Accommodation
(1=YES, 2=NO)
{SEAT} 1. Is there adequate seating for patients? ........ #
{CWA} 2. Is there a covered waiting area? ............... #
{PWAT} 3. Is there potable water? ........................ #
{FLAT} 4. Is there a functional toilet or latrine? ....... #
{FWD} 5. Is there a functional waste disposal area/pit? . #
{HIP} 6.a Are health information posters displayed? ...... #
{WLL} .b IF YES, Are they written in the local language? #
{ORT} 7. Is an ORT corner present and being used? ....... #
Equipment and supplies
Are the following equipment and supplies present in the clinic:
8. Transportation In working order?
(1=YES, 2=NO) (1=YES, 2=NO)
{VEHIC} Vehicle # {VEHICW} #
{MOTO} Motorcycle # {MOTOW} #
{BICYC} Bicycle # {BICYCW} #
9. Social Mob. equipment In working order?
(1=YES, 2=NO) (1=YES, 2=NO)
{MEGA} Megaphone # {MEGAW} #
{FLIP} Flipchart # {FLIPW} #
{CCARD} Counsel.cards # {CCARDW} #
10. Weighing material In working order?
(1=YES, 2=NO) (1=YES, 2=NO)
{AWSC} Adult weight scale # {AWSCW} #
{BWSC} Baby weight scale # {BWSCW} #
{SALT} Salter ............ # {SALTW} #
Medical supplies In working order?
(1=YES, 2=NO) (1=YES, 2=NO)
{THERM} 11. Thermometer # {THERMW} #
12. Stethoscope
{RSTE} -Regular # {RSTEW} #
{OSTE} -Obstetrical # {OSTEW} #
{OTOS} 13. Otoscope # {OTOSW} #
{TD} 14. Tongue depressor # {TDW} #
15. Watch with a
second hand/other
{WATCH} timing device # {WATCHW} #
{STST} 16. Steam sterilizer # {STSTW} #
{COOK} 17. Cooker or stove # {COOKW} #
{UTEN} 18. Measur. utensils #
{CUPS} 19. Cups and spoons #
{FRIGE} 20.a Refrigerator # (1=YES, 2=NO)
If NO, go to question 21
.b If YES:
{FRIGTYP} Type .....# (1=Electric, 2=Kerosene, 3=Gas, 4=Solar, 5=Mixt)
{FRIGCON} Condition # (1=Good, 2=Fair, 3=Poor 4=Non functional)
{FWI} Freeze-watch indicator? # (1=YES, 2=NO)
{FTHERM} Thermometer inside? # (1=YES, 2=NO) {FTEMP} Temp: ##.# C
{TEMPC} Temperature chart? # (1=YES, 2=NO)
If NO, go to Q. 21
.c
{TEMPUTD} In the last 30 days, temperature record up to date? # (1=YES, 2=NO)
{TEMP8} Temperature above 8C ## (number of days)
{TEMP0} Temperature below OC ## (number of days)
{CPACK} 21. Cold packs ........ # (1=YES, 2=NO)
{COLDBOX} 22. Cold boxes ........ # (1=YES, 2=NO)
{CBCOND} Condition ......... # (1=Good, 2=Fair, 3=Poor, 4=Non functional)
Availability of Drugs and Other Supplies the Day of the Survey:
Supplies Available Available
23. Drugs for pneumonia: (1=YES, 2=NO) (1=YES, 2=NO)
{PENI} Penicillin tab/syrup .... # {AMPI} Ampi/Amox.tab/syr #
24. Drugs for Shigella:
{COTRI} Cotrimoxazole ........... # {NALAC} Nalidix acid .... #
25. Drugs for malaria:
{CHLO} Chloroquine tabs ........ # {FANS} Fansidar ........ #
{IQUIN} Injectable Quinine ...... #
{IPENI} 26. Injectable Penicillin ... #
{ICHL} 27. Inj. Chloramphenicol .... #
{PARA} 28. Paracetamol ............. #
{ASP} 29. Aspirin ................. #
{TEYE} 30. Tetracycline eye ointment #
{VIOLET} 31. Gentian violet .......... #
{IRON} 32. Iron .................... #
{VITA} 33. Vitamin A ............... #
{MEB} 34. Mebendazole ............. #
{STWAT} 35. Sterile water/injection #
{ORS} 36 ORS ..................... #
{IVSOL} 37. IV solution/severe dehyd. #
{NEEDL} 38. Needles ................. #
{SYR} 39. Syringes ................ #
{EXPD} 40.a Are expired drugs in the health facility? # (1=YES, 2=NO)
.b If YES, which ones?
{EXPD1} __________ {EXPD2} __________ {EXPD3} __________
Vaccines Available
(1=YES, 2=NO, 9=N/A)
{BCG} 41. BCG .................... #
{OPV} 42. OPV .................... #
{DPT} 43. DPT .................... #
{MEAS} 44. Measles ................ #
{TT} 45. Tetanus Toxoid ......... #
{EXPV} 46.a Are expired vaccines in the refrigerator? # (1=YES, 2=NO, 9=N/A)
.b If YES, which ones?
{EXPV1} ___ {EXPV2} ___ {EXPV3} ___
{FRVIAL} 47. Are frozen vials of DPT or TT in refriger? # (1=YES, 2=NO, 9=N/A)
{RUPTSTK} 48. Rupture of stock in the last 30 days? .... # (1=YES, 2=NO)
If YES :
Item Number of Days of Stock-Outs/Last 30 days
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{VACC} Vaccines .................... ## (number of days)
{SYRNEED} Syringes/needles ............ ## ( " " " )
{ORSS} ORS ......................... ## ( " " " )
{ESSDRUG} Essential drugs ............. ## ( " " " )
{CARDS} Cards/forms ................. ## ( " " " )
49. Are drugs and other supplies adequately
{ASTORE} organized and appropriately stored? .... # (1=YES, 2=NO)
Documentation and record keeping
Are the following items present in the health facility?
(1=YES, 2=NO)
{IREG} 50.a Immunization register ................... #
{IREGUTD} 50.b If YES, is it up to date? ............... #
{ITSH} 51. Immunization tally sheets ............... #
{VACCARD} 52. Stock of vaccination/child health cards . #
{TTCARD} 53. Stock of TT/maternal health cards ....... #
{ESDCARD} 54. Stock of essential drugs cards .......... #
{NDRF} 55. Notifiable disease report forms ......... #
{MRF} 56.a All essential monthly reporting forms ... #
{MRFUTD} 56.b If YES, are they up to date? ............ #
{PREG} 57.a Is a patient register kept? ............. #
{PREGUTD} 57.b If YES, is it up to date? ............... #
{NBP} 58. Number of patients seen in last month ####
{NBCHILD} 59. Number of patients 0-4 seen in last month ###
{ANBP} 60. Average No. of patients seen per day ###
END OF EQUIPMENT AND SUPPLY CHECKLIST
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