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Version 3/14/00

DELIVERY OF IMPROVED SERVICES FOR HEALTH SURVEY

HEALTH WORKER INTERVIEW AND FACILITY INVENTORY QUESTIONNAIRE

*DON'T FORGET SERVICE STATISTICS

Read greeting:

We are carrying out a survey of health facilities that provide reproductive, maternal and child health services to find ways of improving services. We would be interested to know from you about your experiences with these services. Could I ask you some questions about this? Please be assured that this discussion is strictly confidential. May I continue?

1. GENERAL FACILITY INFORMATION
No.	QUESTIONS	CODING CATEGORIES	SKIP
101	RECORD THE TIME	HOUR MINUTES
102	What is your job title or type of cadre?	DOCTOR 1 CLINICAL OFFICER 2 NURSE/MIDWIFE 3 NURSE 4 MIDWIFE 5 NURSE'S AIDE 6 ADMINISTRATOR 7 OTHER 8
103	Are you the in charge?	YES 1 NO 2	->105
104	Why is the in charge not available?	AT TRAINING 1 OUT OF OFFICE 2 IN MEETING 3 SEEING CLIENTS 4 OTHER 5
105	Under what authority is this facility operated?	GOVERNMENT MOH 1 OTHER GOVN'T 2 PRIVATE MARIE STOPES 3 FPAU 4 OTHER PRIVATE 5 RELIGIOUS SEVENTH DAY ADVENTIST 6 CATHOLIC 7 PROTESTANT 8 OTHER RELIGIOUS 9 EMPLOYER BASED CLINIC 10 OTHER 11
106	What is the level of this facility? [Circle only one.]	HOSPITAL HEALTH SUB-DISTRICT HOSP 1 OTHER HOSPITAL 2 HEALTH CENTER HEALTH SUB-DISTRICT HC 3 OTHER HC 4 DISPENSARY WITH MATERNITY UNIT 5 NO MATERNITY 6 SUB-DISPENSARY 7 CLINIC 8 OTHER 9
107	How many days per week is the facility open?	DAYS
108	In what year did this facility open? PROBE: This question is very important. Can you tell me how old this facility is? For example would you say it is about 5 years old? 10 years old? (etc.) FILL IN YEAR OPENED OR YEARS OLD.	YEAR OPENED YEARS OLD DON'T KNOW 9998
109	How many permanent staff of each types (cadre) does this facility/ have? (A) Doctors (B) Clinical Officers/Medical Assistants (C) Nurse/Midwives (D) Nurses (E) Midwives (F) Nurse's Aides (G) Laboratory Technicians/Assistants Other Medical (I) Non-medical	DOCTORS CLINICAL OFFICERS NURSE/MIDWIVES NURSES MIDWIVES NURSE'S AIDES LAB TECH/.ASST. OTHER MEDICAL NON-MEDICAL

105	Is there a waiting area?	Yes 1 No 2	-> 108
106	Does the waiting area have shade	Yes 1 No 2
107	Are fees posted in the waiting area?	Yes 1 No 2
108	Does this facility have the following in working order now? VERIFY BY VISUAL INSPECTION. (A) Reliable water supply (B) Electricity (C) Refrigerator (D) Telephone (E) Radio Call (F) Latrine (G) Incinerator Rubbish Pit	NOT SEEN SEEN RELIABLE WATER.. 1 2 ELECTRICITY 1 2 REFRIGERATOR 1 2 TELEPHONE 1 2 RADIO CALL 1 2 LATRINE 1 2 INCINERATOR 1 2 RUBBISH PIT 1 2
109	Where do exams take place?	1. Separate room, no ability to see into the room from outside 2. Behind a curtain 3. Other area that ensures privacy (specify)_________________ 4. No privacy
110A 110B 110C 110D 110E 110F	What is the source of running water for this clinic? Piped water into clinic Piped water from public tap Well water on clinic premises Well water from a public well Other (specify) _____________________________________ No running water available	Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 Yes 1 No 2
111	What was the date of the last 'outside' supervisory visit? (Observe and Ask)	/ month year
112	Are there any written guidelines and protocols for delivering services issued in the last five years?	Yes 1 No 2 Don't know ..................................8
113A 113B 113C 113D	What methods do you have for determing client options? Client suggestion box Provider asks client Other staff asks client Other (specify)_____________________________________________	Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 Yes 1 No 2
114	In the past quarter (3 months), have any changes been made in the program based on feedback from clients?	Yes 1 No 2
115A 115B 115C 115D	What methods do you have for determining provider optioons? Staff suggestion box Staff meetings Internal clinic evaluations Other (specify) _________________________________	Yes 1 No 2 Yes 1 No 2 Yes 1 No 2 Yes 1 No 2

116

How many clients received services in the last month?

Number

2. GENERAL MATERNAL CHILD HEALTH AND FAMILY PLANNING

201

Which of the following equipment and supplies does this facility have available and in working order for general MCH and FP clinic services?

VERIFY BY VISUAL INSPECTION.

(01) Examination couch

(02) Flashlight

(03) Cheattle's Forceps and jar

(04) Dressing trolley

(05) Sphygmomanometer

(06) Stethoscope

(07) Trash bin

(10) Sharps collector

(11) Large tray with cover

(12) Medium tray with cover

(13) Flat tray

(14) Large Cusco's vaginal speculum

(15) Medium Cusco's vaginal speculum

(16) Small Cusco's vaginal speculum

(17) Adult weighing scale

(18) Adult height measurement

(19) Child weighing scale

(20) Child height measurement

(21) Large kidney dish

(22) Medium kidney dish

(23) Iodine cup

(24) Autoclave

(25) Sterilizing drum

(26) Instrument pan sterilizer with cover

(27) Pinard fetal stethscope

(28) Sponge holding forceps

(29) Artery forceps

(30) Steam sterilizer

(31) Blood pressure cuff

(32) Thermometer

(33) Disposible needles

(34) Disposable gloves

(35) Cotton wool

(36) Gauze

(37) Antiseptics

(38) Jik (Bleach)

(39) Bucket for decontamination

(40) Bucket for soiled rubish

(41) Tenaculum

(42) Cervical Dilator

(43) Uristix

(44) Tallquist / Sahli / haemometer

(45) Cerviograph

(46) Sterilization equipment (?)

NOT

SEEN SEEN

EXAM COUCH 1 2

FLASHLIGHT 1 2

CHEA FORCEPS 1 2

DRESS TROLLEY 1 2

SPHYGMOMANO 1 2

STETHOSCOPE 1 2

TRASH BIN 1 2

SHARPS COLLEC 1 2

LARGE TRAY 1 2

MEDIUM TRAY 1 2

FLAT TRAY 1 2

LARGE VAG SPEC 1 2

MED VAG SPEC 1 2

SMALL VAG SPEC 1 2

ADULT SCALE 1 2

ADULT HEIGHT MSR 1 2

CHILD SCALE 1 2

CHILD HEIGHT MSR 1 2

LG KIDNEY DISH 1 2

MED KIDNEY DISH 1 2

IODINE CUP 1 2

AUTOCLAVE 1 2

STERIL DRUM 1 2

INSTRUM STERIL 1 2

FETAL STETHO 1 2

SPONGE HLD FORC 1 2

ARTERY FORC 1 2

STEAM STERIL 1 2

BP CUFF 1 2

THERMOMETER 1 2

DISPOS NEEDLES 1 2

DISPOS GLOVES 1 2

COTTON WOOL 1 2

GAUZE 1 2

ANTISEPTICS 1 2

JIK 1 2

BUCKET (DECO) 1 2

BUCKET (RUBISH) 1 2

TENACULUM 1 2

CERVICAL DILATOR 1 2

URISTIX 1 2

TALLQUIST 1 2

CERVIOGRAPH 1 2

STERILIZATION EQUIP 1 2

3. MATERNAL & CHILD HEALTH, STD/HIV SERVICES

SERVICE	301. Is SERVICE available to clients at this facility?		302. How Many Days per Week is SERVICE offered?
(A) Ante-natal care	YES 1 NO 2	-> (B)	DAYS
(B) Post-natal care	YES 1 NO 2	-> (C)	DAYS
(C) Delivery	YES 1 NO 2	-> (D)	DAYS
(D) Emergency Obstetric care	YES 1 NO 2	-> (E)	DAYS
(E) Post Abortion care	YES 1 NO 2	-> (F)	DAYS
(F) Immunization	YES 1 NO 2	-> (G)	DAYS
(G) Sick child care	YES 1 NO 2	-> (H)	DAYS
(H) Growth monitoring and nutrition counseling	YES 1 NO 2	-> (I)	DAYS
(I) STD treatment	YES 1 NO 2	-> (J)	DAYS
(J) HIV/AIDS testing	YES 1 NO 2	-> (K)	DAYS
(K) HIV/AIDS counseling	YES 1 NO 2	-> 501	DAYS

2. FAMILY PLANNING
201	Do you offer Family Planning?	YES 1 NO 2	->203 ->202
202	Do you refer clients?	YES 1 NO 2	->
203	Where do you refer clients?	YES 1 NO 2

5. LONG TERM FAMILY PLANNING
501	Is this facility equipped to offer long term family planning methods? (e.g. Norplant, Sterilization)	Yes 1 No 2

2.1 Type of Contraceptive

Which contraceptive methods are provided at this facility?

Record below which contraceptive methods are usually provided at this SDP. If the method is usually provided, determine if it is available today. For each method provided, ask whether there has been a stockout in the last month?

METHOD	204. Is METHOD available to clients at this facility?		205. Is the method available today?	206. Was there a stockout last month?
(A) Combined Pill	YES 1 NO 2	-> (B)	YES 1 NO 2	YES 1 NO 2
(B) Projesterone-only pill	YES 1 NO 2	-> (C)	YES 1 NO 2	YES 1 NO 2
(C) Injectable	YES 1 NO 2	-> (D)	YES 1 NO 2	YES 1 NO 2
(D) IUD	YES 1 NO 2	-> (E)	YES 1 NO 2	YES 1 NO 2
(E) Female Sterilization	YES 1 NO 2	-> (F)	YES 1 NO 2	YES 1 NO 2
(F) Male Sterilization	YES 1 NO 2	->(G)	YES 1 NO 2	YES 1 NO 2
(G) Norplant	YES 1 NO 2	-> (H)	YES 1 NO 2	YES 1 NO 2
(H) Condoms	YES 1 NO 2	-> (I)	YES 1 NO 2	YES 1 NO 2
(I) Spermicide	YES 1 NO 2	-> (J)	YES 1 NO 2	YES 1 NO 2
(J) Other (specify) _____________	YES 1 NO 2	- 307	YES 1 NO 2	YES 1 NO 2

2.2 Which services are offered at this facility?

For each service, first record if it is provided, and then record whether the service has been available at all times in the last six months. If the service has NOT been available at all time in the last six months, mark the reason why it was last not available. (Observe and Ask)

Type of Service

207. Is the service provided?

208. Was the service available at all times in the past month?

209. If the service was not available, why was it not available?

(A-1) Female Sterilization (minilap, local anesthetic)

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

(A-2) Female Sterilization (minilap, general anesthetic)

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

(A-3) Female Sterilization (laparotomy)

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

(B) Vasectomy

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

(D) Natural Family Planning

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

(E) Other

(specify) ______________

YES 1

NO 2

YES 1

NO 2

1. Supplies not available

2. Equipment not available

3. Trained staff not available

4. Other _________________

210.

Does this facility offer condoms for family planning or STD/HIV prevention?

YES 1

NO 2

-> 401

211. How Many Days per week are condoms available?

DAYS

310. What year were condoms first offered at this facility?

BEFORE 1990 = 7777

DON'T KNOW = 9998

311. What is the number of condoms distributed in September?

condoms

3. SEXUALLY TRANSMITTED DISEASE

301

Is this facility equipped to test for syphilis?

Yes 1

No 2

-> 401

TEST

302. Is TEST available now?

303. In September, were there any stock outs for TEST?

(A) VDRL test

SEEN 1

NOT SEEN 2

-> (B)

YES 1

NO 2

(B) RPR test

SEEN 1

NOT SEEN 2

-> 304

YES 1

NO 2

4. DELIVERIES AND EMERGENCY OBSTETRIC CARE
401	Is this facility equipped for deliveries and emergency obstetric care?	Yes 1 No 2	->

402

Which of the following equipment and supplies does this facility have available and in working order for deliveries and emergency obstetric care?

VERIFY BY VISUAL INSPECTION.

(01) Couch with stirrups

(02) Dressing trolley

(03) Large Cusco's vaginal speculum

(04) Medium Cusco's vaginal speculum

(05) Large kidney dish

(06) Medium kidney dish

(07) Iodine cup

(08) Bowl

(09) Large tray with cover

(10) Medium tray with cover

(11) Small tray with cover

(12) Flashlight

(13) Angle poise lamp

(14) Cheattle's Forceps and jar

(15) Sphygmomanometer

(16) Stethoscope

(17) Thermometer

(18) Autoclave

(19) Large sterilizing drum

(20) Small sterilizing drum

(21) Sterilizer (HLD)

(22) Disposible gloves

(23) Disposible needles

(24) Cotton wool

(25) Gauze

(26) Antiseptics

(27) Jik (bleach)

Gum Boots

(29) Mackintosh

(30) Delivery bed

(31) Instrument pan sterilizers with cover

(32) Adult weighing scale

(33) Baby weighing scale

(34) Pinard fetal stethscope

(35) Straight scissors

(36) Episiotomy scissors

(37) Straight artery forceps

(38) Smooth sponge forceps

Artery forceps non toothed

(40) Needle holder

(41) Tissue thumb forceps

(42) Round body needles for episiotomy repair

(43) Urethral catheter

(44) Suction bulb

(45) Ambu bag

(46) Eye goggles

(47) Uristix

(48) Cord scissors

(49) Cord ligature

(50) Adult airway

(51) Baby airway

(52) Syringes 5cc

(53) Syringes 2cc

Plastic Aprons
Suction Catheters (baby / adult)
IV-Infusion Sets
C-section kit
Manual vacuum equipment/ vacuum extractor
Blood transfusion equipment

NOT

SEEN SEEN

COUCH/STIRRUPS 1 2

DRESS TROLLEY 1 2

LARGE VAG SPEC 1 2

MED VAG SPEC 1 2

LG KIDNEY DISH 1 2

MED KIDNEY DISH 1 2

IODINE CUP 1 2

BOWL 1 2

LARGE TRAY 1 2

MEDIUM TRAY 1 2

SMALL TRAY 1 2

FLASHLIGHT 1 2

ANGLE POISE LAMP 1 2

CHEA FORCEPS 1 2

SPHYGMOMANO 1 2

STETHOSCOPE 1 2

THERMOMETER 1 2

AUTOCLAVE 1 2

LG STERIL DRUM 1 2

SM STERIL DRUM 1 2

HLD STERIL 1 2

DISPOS GLOVES 1 2

DISPOS NEEDLES 1 2

COTTON WOOL 1 2

GAUZE 1 2

ANTISEPTICS 1 2

JIK 1 2

GUM BOOTS 1 2

MACKINTOSH 1 2

DELIVERY BED 1 2

INSTRUM STERIL 1 2

ADULT SCALE 1 2

CHILD SCALE 1 2

FETAL STETHO 1 2

STRGHT SCISSORS 1 2

EPIS SCISSORS 1 2

STR ART FORCEPS 1 2

SMOOTH SPONGE FORC 1 2

ARTERY FORCEPS 1 2

NEEDLE HOLDER 1 2

TISSUE THUMB FORCEP 1 2

ROUND BODY NEEDLE 1 2

URETHAL CATH 1 2

SUCTION BULB 1 2

AMBU BAG 1 2

EYE GOGGLES 1 2

URISTIX 1 2

COREL SCISSORS 1 2

CORD LIGATUR 1 2

ADULT AIRWAY 1 2

BABY AIRWAY 1 2

SYRINGES 5CC 1 2

SYRINGES 2CC 1 2

PLASTIC APRONS 1 2

SUCTION CATH. 1 2

IV INFUSION 1 2

C-SECTION KIT 1 2

MANUAL VACUUM 1 2

BLOOD TRANSFUSION. 1 2

403

Is this facility equipped for post abortion care?

Yes 1

No 2

-> 501

6. Integrated Management of Childhood Illness

601

Which of the following IMCI equipment and supplies does this facility have available and in working order?

VERIFY BY VISUAL INSPECTION

(1) Weighing scale for babies

(3) Containers for mixing ORS

(3) Spoons

(4) Functional watch or clock with second hand

(5) Thermometer

(6) Fridge

(7) Ice packs

(8) Vacine carriers

(9) Vaccine monitors (color indicators)

NOT

SEEN SEEN

WEIGHING SCALE 1 2

CONTAINER FOR MIX. ORS 1 2

SPOONS 1 2

WATCH/CLOCK 1 2

THERMOMETER 1 2

FRIDGE 1 2

ICE PACKS 1 2

VACCINE CARRIER 1 2

VACCINE MONITOR 1 2

VACCINE	204. Is VACCINE available now?		205. In 1999, where there any stock outs for VACCINE?
(A) Measles	SEEN 1 NOT SEEN 2	-> (B)	YES 1 NO 2
(B) Polio	SEEN 1 NOT SEEN 2	-> (C)	YES 1 NO 2
(C) BCG	SEEN 1 NOT SEEN 2	-> (D)	YES 1 NO 2
(D) DPT	SEEN 1 NOT SEEN 2	-> (E)	YES 1 NO 2
(E) Tetanus Toxoid (TT)	SEEN 1 NOT SEEN 2	-> 301	YES 1 NO 2

4. OTHER SERVICES
401	Does this facility offer observation/ inpatient care?	YES 1 NO 2	-> 403
402	How many total beds are available for inpatient care in this facility?
403	Does this facility normally use disposable needles?	YES 1 NO 2	-> 406
404	Is this facility out now or has it run out of its supply of disposable needles at any time in the last 6 months?	YES 1 NO 2
405	Does this facility ever have to reuse disposable needles?	YES 1 NO 2
406	Does this facility normally use disposable gloves?	YES 1 NO 2	->
407	Is this facility out now or has it run out of disposable gloves at any time in the last six months?	YES 1 NO 2
408	Does this facility ever have to reuse disposable gloves?	YES 1 NO 2

5. REPORTING AND SUPERVISION
501	Is the Health Unit Summary Report for September available?	YES 1 NO 2	-> 504
502	Is this report complete? (VERIFY VISUALLY)	YES 1 NO 2
503	Is there insight/action at the local level?	YES 1 NO 2
504	How long ago was the last supervisory visit?	WITHIN LAST WEEK 1 WITHIN LAST MONTH 2 WITHIN LAST 3 MONTHS 3 WITHIN LAST 6 MONTHS 4 MORE THAN 6 MONTHS 5 NEVER VISITED 6 NOT APPLICABLE 8 DON'T KNOW 9	-> 601 -> 601 -> 601

6. OUTREACH AND, INFORMATION, EDUCATION, AND COMMUNICATION
601	Does this facility have an outreach program?	Yes 1 No 2	-> 603
602	Which outreach services does the facility offer?	1. ANC 2. EPI/GM 3. Other ___________________
603	In the last month how many ANC outreach sessions were planned? IF DON'T KNOW, RECORD 98	NUMBER
604	In the last month how many ANC outreach sessions were accomplished? IF DON'T KNOW, RECORD 98	NUMBER
605	In the last month how many EPI/GM outreach sessions were planned? IF DON'T KNOW, RECORD 98	NUMBER
606	In the last month how many EPI/GM outreach sessions were accomplished? IF DON'T KNOW, RECORD 98	NUMBER
607	Do CHWs and TBAs refer clients to this facility?	Yes 1 No 2	-> 609
608A 608B 608C	How many community workers refer clients? TBAs CHWs Others (specify) ______________________________________________ IF DON'T KNOW, RECORD 98	NUMBER NUMBER NUMBER
609A 609B 609C	How many referrals were made last month? TBAs CHWs Others (specify) _______________________________________________ IF DON'T KNOW, RECORD 998	NUMBER NUMBER NUMBER
610	Does the staff conduct heath education talks for waiting clients?	Yes 1 No 2	-> 6
611	Has this facility ever received a flip chart ?	Yes 1 No 2	-> 613
	Has this facility ever received a flip chart on:
612A	Family planning?	Yes 1 No 2
612B	STDs?	Yes 1 No 2
612C	Safe Motherhood?	Yes 1 No 2
613	Has this facility ever received Health Matters Newsletters?	Yes 1 No 2	-> 701
	Has this facility ever received a Health Matters Newsletter on:
614A	Family planning?	Yes 1 No 2
614B	Maternal health?	Yes 1 No 2
614C	Infant nutrition?	Yes 1 No 2
614D	HIV counseling and testing?	Yes 1 No 2
614E	STDs ?	Yes 1 No 2

7,	Costing
701	Is there a fee chaarged for any services?	Yes 1 No 2
702	Do these fees cover costs at the health facility level?	Yes 1 No 2
703	Do service providers share in the fees collected?	Yes 1 No 2

7. INFORMATION, EDUCATION AND COMMUNICATION
	RECORD WHICH OF THE FOLLOWING POSTERS AND CHARTS ARE DISPLAYED IN PLAIN VIEW AT THE FACILITY.	NOT SEEN SEEN
701A	Family planning poster	FP POSTER 1 2
701B	Maternal health poster	MH POSTER 1 2
701C	Breastfeeding poster	BF POSTER 1 2
701D	STD poster	STD POSTER 1 2
701E	HIV counseling and testing poster	HIV POSTER 1 2
701F	Family Planning Flip Chart	FP CHART 1 2
701G	STD Flip Chart	STD CHART 1 2
701H 701I	ANC Flip chart Counseling aids	ANC CHART 1 2 COUNSEL AIDS 1 2

8. PHARMACY
MEDICINE	801. Is MEDICINE available now?		802. In September, were there any stock outs for MEDICINE?
(1) Mebendazole	SEEN 1 NOT SEEN 2	-> (2)	YES 1 NO 2
(2) Oral rehydration solution packets	SEEN 1 NOT SEEN 2	-> 803	YES 1 NO 2(3)
(3) Delivery kit	SEEN 1 NOT SEEN 2		YES 1 NO 2
(4) Antiseptic skin	SEEN 1 NOT SEEN 2		YES 1 NO 2
(5) Disinfectant	SEEN 1 NOT SEEN 2		YES 1 NO 2

ANTI-MALARIAL	803. Is ANTI-MALARIAL available now?		804. In September, where there any stock outs for ANTI-MALARIAL?
(1) Chloroquine	SEEN 1 NOT SEEN 2	-> (2)	YES 1 NO 2
(2) Sulfadoxine + Pyrimethamine (Fansidar)	SEEN 1 NOT SEEN 2	-> (3)	YES 1 NO 2
(3) Quinine	SEEN 1 NOT SEEN 2	-> (4)	YES 1 NO 2
(4) Other antimalarial drugs (specify) ___________________________ (specify) ___________________________ (specify) ___________________________	SEEN 1 NOT SEEN 2	-> 805	YES 1 NO 2

*NEED TO ADD STI DRUGS

805

Does this facility have the medicines needed for syndromic management of STDs?

Yes 1

No 2

->808

ANTIBIOTIC	806. Is ANTIBIOTIC available now?		807. In September, where there any stock outs for ANTIBIOTIC?
(01) Penicillin (injection) Benyl	SEEN 1 NOT SEEN 2	-> (02)	YES 1 NO 2
(02) Benzathine Penicillin	SEEN 1 NOT SEEN 2	-> (03)	YES 1 NO 2
(03) Gentamicin (injection)	SEEN 1 NOT SEEN 2	-> (04)	YES 1 NO 2
(04) Doxycycline	SEEN 1 NOT SEEN 2	-> (05)	YES 1 NO 2
(05) Erythromycin	SEEN 1 NOT SEEN 2	-> (06)	YES 1 NO 2
(06) Tetracycline	SEEN 1 NOT SEEN 2	-> (07)	YES 1 NO 2
(07) Clotrimazole pessaries	SEEN 1 NOT SEEN 2	-> (08)	YES 1 NO 2
(08) Co-trimoxazole (Septrin)	SEEN 1 NOT SEEN 2	-> (09)	YES 1 NO 2
(09) Nizoral (cream,pessaries, tablets)	SEEN 1 NOT SEEN 2	-> (10)	YES 1 NO 2
(10) Nystatin (ointment, pessaries)	SEEN 1 NOT SEEN 2	-> (11)	YES 1 NO 2
(11) Gentian Violet (GV) paint	SEEN 1 NOT SEEN 2	-> (12)	YES 1 NO 2
(12) Podophylline	SEEN 1 NOT SEEN 2	-> (13)	YES 1 NO 2
(13) Ciprofloxacin	SEEN 1 NOT SEEN 2	-> (14)	YES 1 NO 2
(14) Amoxacyllin 250 capsules	SEEN 1 NOT SEEN 2	-> (15)	YES 1 NO 2
(15) Amoxacyllin 125/5 ml	SEEN 1 NOT SEEN 2	-> (16)	YES 1 NO 2
(14) Ceftriaxone	SEEN 1 NOT SEEN 2	-> (17)	YES 1 NO 2
(15) Spectinomycin	SEEN 1 NOT SEEN 2	-> (18)	YES 1 NO 2
(16) Silver nitrate eye drops	SEEN 1 NOT SEEN 2	-> (19)	YES 1 NO 2
(17) Tetracycline eye ointment	SEEN 1 NOT SEEN 2	-> (20)	YES 1 NO 2
(19) Metronidazole	SEEN 1 NOT SEEN 2	-> 808	YES 1 NO 2

DELIVERY AND OBSTETRIC CARE	808. Is DELIVERY AND OBS. drug available now?		809. In September, where there any stock outs for DELIVERY AND OBS. DRUG?
(01) Xylocaine SC	SEEN 1 NOT SEEN 2	-> (02)	YES 1 NO 2
(02) Ergometrine inj or Tablets	SEEN 1 NOT SEEN 2	-> (03)	YES 1 NO 2
(03) Syntometrine inj	SEEN 1 NOT SEEN 2	-> (04)	YES 1 NO 2
(04) Syntocinon inj	SEEN 1 NOT SEEN 2	-> (05)	YES 1 NO 2
(05) Oral anticonvulsant	SEEN 1 NOT SEEN 2	-> (06)	YES 1 NO 2
(05) Hydrallazine inj	SEEN 1 NOT SEEN 2	-> (07)	YES 1 NO 2
(06) Valium 1m inj	SEEN 1 NOT SEEN 2	-> (08)	YES 1 NO 2
(07) IV Fluids	SEEN 1 NOT SEEN 2	-> (09)	YES 1 NO 2
(08) Analgesia (IM) (specify) _________________________ (specify) _________________________ (specify) _________________________	SEEN 1 NOT SEEN 2	-> 810	YES 1 NO 2
IMCI	810. Is IMCI drug available now?		811. In September, where there any stock outs for IMCI DRUG?
(01) Paracetamal tabs 100mg /500 mg	SEEN 1 NOT SEEN 2	-> (02)	YES 1 NO 2
(02) Cotrimoxazole tabs (80mg/400mg)	SEEN 1 NOT SEEN 2	-> (03)	YES 1 NO 2
(03) Chloroquine tabs 150mg	SEEN 1 NOT SEEN 2	-> (812)	YES 1 NO 2
SUPPLEMENTS	812. Is the supplement available now?		813. In September, where there any stock outs for SUPPLEMENT?
(04) Folic Acid tabs 1mg and 5mg	SEEN 1 NOT SEEN 2	-> (05)	YES 1 NO 2
(05) Vitamin A capsule	SEEN 1 NOT SEEN 2	-> (06)	YES 1 NO 2
(06) Iron tablets/ folate	SEEN 1 NOT SEEN 2	-> (07)	YES 1 NO 2
(07) Iron syrup	SEEN 1 NOT SEEN 2	-> 9	YES 1 NO 2

9. RECORDS
	RECORD WHICH OF THE FOLLOWING RECORDS AND FORMS ARE AVAILABLE AT THE FACILITY.	NOT SEEN SEEN
901A	Antenatal Care Cards/Books (given to client)	1 2
901B	Child Health Cards /Immunisation Card	1 2
10. AVAILABILITY OF GUIDELINES AND STANDARDS (Locally adapt)		SEEN NOT SEEN

11 GENERAL OBSERVATIONS
1101	RECORD WHETHER CLIENTS HAVE VISUAL PRIVACY, AURAL PRIVACY, BOTH, OR NEITHER DURING THEIR COUNSELING SESSIONS.	VISUAL 1 AURAL 2 BOTH 3 NEITHER 4
1102	RECORD WHETHER CLIENTS HAVE VISUAL PRIVACY, AURAL PRIVACY, BOTH, OR NEITHER DURING THEIR EXAMINATIONS.	VISUAL 1 AURAL 2 BOTH 3 NEITHER 4
	RANK THE QUALITY OF THE FACILITY FROM 1 TO 5 ON: 1=Very Poor, 2=Poor, 3=Fair, 4=Good, 5=Very Good, and 9=Don't know	Very Very Poor Poor Fair Good Good DK
1103a	Physical appearance	1 2 3 4 5 9
1103b	Overall cleanliness	1 2 3 4 5 9
1104	RECORD THE TIME	HOUR MINUTES

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