l

I

I

d

Stata:

Distrlct:

Block:

Ory/rom/Village:

Facilfty Nairi

Faciilty tvpe-

Lo€don

of 8, Numbet dischaiiedunder 48 hours of delivery

of cases where Jananl Surakha Yogna incentiye pald to

or AWW (only for HPS Stotes)

2.2-2

2.2.2 (a)

,r-, tat

2.2.2 l.t

I

.I,J

'f:?.,1

,J

I-1

Monthly- DH-SDH-CHC' ,,of7

LLdlq

Printed ar on 10/09/2008

NRHM/ DH-SDH-CHC/3/M

il Wfi;;tiiii,l l.l#Wi ,.*r.l

: -section deliveries performed at facility 1.2

iiii,l4il#ll.:l: I,,= w 1I

10 Pregnancy Outcome (in number) 7

10.1 Llve Birth 4.1.7

(a) Maleo,

(b temole t?, llbt

Iotal ({a} to {b}} *-1lo.2 Still BIrth f,d.

10.3 Abortion (spontaneous/induced) t:f?

11 Details of Newborn children welghed

11.1 Number of newborns weiShed at birth x irl 4-2.1

lt.i Number of newborns having weight less than 2.5 kg t't: 4.2-2

t2 Number of newborns breast fed within t hour of birth e +lu ?

rllH$$..s*':,::W

13Number of cases of pregnant women with obstetric Complications and

attended at facility

t4 Number of C.omplicated pregnancies treated with

L4.L lV Antibioti6 a7 1

L4.2 lV Antihypertensive/Magsulph injection 0d.- 2

L4.a lV Oxytocin Gv- ,-3

14-4 Blood Transfusion

,{fiffiIi}l ll::ijli !18 : ,l

15 Women receiving post partum checkups within 48 hours after delivery ot 7

16 Women getting a post partum check up between 48 hours and 14 days

L7 PNc maternal complications attended 3

niti' e: w

18 {umber of MTPs conducted at fucllity 7.1

18.1 Up to 12 weeks of pregnancy

-7-1.1

18.2 More than 12 weeks of pregnancy 7.2

Total {(18.1) to (18.2)}

rriffiil{ix1, U.ffi,i iitiffi ,jiJ..i.r r: w.;

1.9 Number of new RTI/STI tor whlch treatment initiated

(a) Male oL-(b 'emole ?5 r(b)

rotal {(a} to (b)} tq-20 Number of wet mount tests conducted

Monthly- DH-SDH{HC

2ol7Printed as on 10/09/2008

,:r$&

Number of lnfants 0 to tl months old who ,eceived the followln$

NRHM/ DH.SDHTHC/3/M

1.1 (b)

(b)

(b)

1 (b)

1(c t

9.s.1A

9,O5

9-O7

e.71.2 (a)

s.11.2 (b)

9.71.3

9.11,3(a)

9.r1.3lbl

70-L8

70.1.(E

10.1.O7

70.7-B

10-7.drA

10.1.tx)

,.10

Monthly- DH-SDH-CHC

, ol7

1

It

Printed as on 10/09/2008

NRHM/ DH-SDH.CHC/3/M

between 9 nronths and 5 yea.s

_number of children aged bBtween 9 and 1l months who have been fully immunised+ErPT123/pentavalentl23+OpV123+Measles) during the month

Number of children more than 15 months who received the following

Status

Total number of children aged between 12 and 23 monthi who have been fully immunised3+OPvl23+Measles) during the month

Adwrs€ Event Following tmmunisation (AEFtl

Number of lmmunisataon sesslons during the month

(Japanese Encephalltls (JEl erc. please Spectfy)

2nd.dose (No. of children more than 16 months of age)

of Children aged 9 to 12 months who

Total {(a} to (b}}

more than 5 years given DPTs/DT5

more than 1,0 years given TT10

more than 16 years given TT16

Numbeir of sessions where ASHAS were present

Number of children more than 15 months of age who received Japanese Encephalitis (JE) vaccine

Printed as on 10/092008Monthly- DH-SDH-CHC

4 ol7

I

.lluiil ,, e*r*"B& !d

NRHM/ DH.SDH-CHC/3/M

12.1

72.2

1

,3.2

1r-3

13.4

7r-s

3-6

Monthly- DH-SDH{HC

5 ol7

14.07

14-01

14.05

,1.06

74-O'

., ' , *;r,,ira;*ri,ir..*i&d

Printed as on 10/09/2008

NRHM/ DH-SD}I-CHC/3/M

57.3 n-Paiient Head Count at midnlght 47031 It

58 )utpatlent12

58.1 )PD attendance (All) 31")< I

!,

1a-14

i9 )pe.atlon Theare

lpeiatlon major (General and spinal anaesthesia)59.1

59.1A' !w of 59.i qy6;cology- HYsterectomy surgeries

s9.?. )peratipn minor-[No or local anaesthesia),q?)

t1.14-1

i0 Others (lnclude other seNlccs like dental, Ophthalmology, AYUSH etc.)

(a) AYUSH i.v--l(b) Dentol Procedures

11.11.2

(c) Adolesce nt counse I li n g'se Nice s 11.14.3

ffi .tlrrii...r+,,:;=i.ffi*iiffi :,t.]"i:-;i;;r !trJ:

61 -ab Tests Details75.7

51.1 Total Number of tests for Hb 37 ts.l.t pi 1

6L.2 Of which Number having Hb < 7 mg s{ (b) I

32 ${gFPFotith. 75-7.2

(a Mole ))o(b) Female-Non ANC tb [s.1.2(bl

(c) Femole with ANC )9 15.1,21ct

Total {(a} to (c)} 7q53 widal tests conducted Gbi4 VDRL tests conducted 15.3

(a) Male15-3.7

(b lFemole-Non ANC ol 1S-3.2

(c iFemole with ANc

irotal {(a) to (c)}

oDob

i5 Malaria tesd conducted

55.1 i Blood smears examinedI

,1{ ,s.4.1 . l

65.2 Plasmodium Vivax test Positiveo3 ,5-4.2

65.3 Plasmodium Falciparum test positive o &-. ts-4-3

' !4x

66 Mortallty Detalls - Each case is to be entered in a separate line. Only deaths occuring at the facility to be reported.

i&H6;?::::-:

lXiLlil#F$-: i ' ti

r,i .ko. aga. - _; - ,rl :::l;Ii '";.Mr 1" : .i:rits '

.:,:;Jil.'::ffil$S Cod+

1r, Select Select Selecl

2 Select Select Selecl

3 , I select I 'select

-

I I

4 Select Select Select

5 select Selecl Select

6 Select Select

7 sel€ct Select

Monthly- DH-sDH{HC

6ol7Printed as on 10/09/2008

:;.iri$i5il::t:;r:, :'