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Name of State: Name of District Name of BlockNumber of ASHAs Reporting Month JANUARY Reporting Year 2020-2021
Male Female Total
1701 1623 3324
1701 1623 33242627 2554 5181
14464 14021 28485
18562 17693 36255
3 0 3
Sl No 3 0 31 0 0 02 0 0 03 2 0 24 1 0 15 0 0 0
No of children visited in current month 0 0 06.1 06.2 06.3 06.4 0
6.5 0
Primary care (PHC/CHC)
Secondary Care
(DH/SDH/SNCU)
Tertiary Care (DEIC)
/MCTotal
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 2 2
0 0 0 0
0 0 1 1
0 0 0 0
0 0 0 0
0 0 0 0Male 0 0 0 0Female 0 0 0 0
Ministry of Health & Family WelfareGovernment of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (ASHA,HBNC) - FORM No - II
Tripura
Cleft Lip & Palate
ASHA, HBNCBirth-6 weeks
Total number of deliveries reported in catchment area of ASHA in the reporting month
Total number of New borns to be visited in the current monthNumber of newborn visited by the ASHA in HBNC visit in the month
Cumulative Number of deliveries in the year 2020-2021 From APRIL To JANUARY
Cumulative Number of Children screened for defects at birth during HBNC visits in the year 2020-2021 From APRIL To JANUARY
Total Number of Children identified with Defect at Birth by ASHA
Defects at Birth: Neural tube defectDown’s Syndrome
Neural tube defectMale
Female
Club footDevelopmental dysplasia of the hip
6Developmental Delay identified as per revised MCP card
Age of child
At 3 monthsAt 6 monthsAt 9 monthsAt 12 months
At 15 months
Total Children Refered
Down’s SyndromeMale
Female
Cleft Lip & Palate Male
Female
Club footMale
Female
Developmental dysplasia of the hip
Male
Female
3 Months
Male 0 0 0 0Female 0 0 0 0Male 0 0 0 0Female 0 0 0 0Male 0 0 0 0Female 0 0 0 0Male 0 0 0 0Female 0 0 0 0Male 0 0 0 0Female 0 0 0 0
Report verified by ANM
Name
Signature
Date
Developmental Delay
6 Months
9 Months
12 Months
15 Months
Total Referred
Report prepared by Asha Report verified by ASHA supervisor
State: District Name of Block MHT Team Code Reporting Year
Male 93753 3927 21750 23% 126 126 99588 3395 14702 15% 244 244 246553 9976 13737 6% 693 693Female 90102 3722 21205 23% 106 106 96961 3267 14674 15% 225 225 250652 10265 14421 6% 722 722Total 183855 7649 42955 23% 232 232 196549 6662 29376 15% 469 469 497205 20241 28158 6% 1415 1415
Annual plan : Total visit to be planned in this
year
Total AWC/School visit planned in this
month by Mobile Health Teams
Total AWC/School visit conducted this
month by Mobile Health Teams
Cumulative gap including carry forward from
previous month of the current
year
Male Female Male Female Male Female Doctors Pharmacist ANM/SN
Visit 1 9911 Approved 48 48 48 48 0 0 48 96 48 48Visit 2 0 In-place 48 37 45 29 4 0 23 82 33 23
4638 Trained 22 19 19 13 1 0 0 38 14 0
Functional 48 37 45 29 4 0 23 82 33 23
Male Female Total Male Female Total Male Female Total Male Female Total
3927 3722 7649 3395 3267 6662 9976 10265 20241 17298 17254 34552
13 14 27 5 1 6 11 12 23 29 27 56
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
6 3 9 0 0 0 1 0 1 7 3 10
1 1 2 2 1 3 1 1 2 4 3 7
0 0 0 0 0 0 0 0 0 0 0 0
1 1 2 0 0 0 2 1 3 3 2 5
0 0 0 0 0 0 0 3 3 0 3 3
5 9 14 3 0 3 7 7 14 15 16 31
0 0 0 0 0 0 0 0 0 0 0 0
Microcephaly 0 0 0 0 0 0 0 0 0 0 0 0
Macrocephaly 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 5 4 9 17 26 43 22 30 52
0 0 0 0 0 0 5 11 16 5 11 16
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 0 0 1 1
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 4 5 9 4 5 9
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 5 3 8 8 10 18 13 13 26
121 100 221 228 209 437 551 496 1047 900 805 1705
72 56 128 69 58 126 171 155 326 312 269 581
7 9 16 13 9 22 17 15 32 37 33 70
0 0 0 0 0 0 0 0 0 0 0 0
19 18 37 37 36 73 59 54 113 115 108 223
22 17 39 109 106 215 303 272 575 434 395 829
1 0 1 0 0 0 1 0 1 2 0 2
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
3 5 8 4 5 9 87 87 174 94 97 191
1 2 3 0 1 1 56 56 112 57 59 116
0 0 0 3 0 3 5 4 9 8 4 12
0 0 0 0 1 1 5 2 7 5 3 8
1 0 1 0 0 0 1 3 4 2 3 5
0 2 2 0 0 0 5 6 11 5 8 13
1 1 2 1 1 2 4 2 6 6 4 10
0 0 0 0 2 2 0 2 2 0 4 4
0 0 0 0 0 0 0 2 2 0 2 2
0 0 0 0 0 0 1 1 2 1 1 2
0 0 0 0 0 0 10 9 19 10 9 19
0 0 0 0 0 0 3 67 70 3 67 70
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 5 5 0 5 5
0 0 0 0 0 0 0 28 28 0 28 28
0 0 0 0 0 0 3 5 8 3 5 8
0 0 0 0 0 00 0 0 0 0 0
0 0 0 0 0 0 0 29 29 0 29 29
Primary care (PHC/CHC)
Secondary Care (DH/SDH/
SNCU)
Tertiary Care (DEIC)/MC
Primary care (PHC/CHC)
Secondary Care (DH/SDH/
SNCU)
Tertiary Care (DEIC)/MC
Primary care (PHC/CHC)
Secondary Care (DH/SDH/
SNCU)
Tertiary Care (DEIC)/MC
Primary care (PHC/CHC)
Secondary Care
(DH/SDH/SNCU)
Tertiary Care (DEIC)/MC
Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 1 0 0 1Male 0 1 4 0 0 0 0 0 1 0 1 5Female 0 0 3 0 0 0 0 0 0 0 0 3Male 0 1 1 0 0 2 0 1 0 0 2 3Female 0 0 1 0 0 1 0 0 1 0 0 3Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 1 0 0 0 0 0 2 0 0 3Female 0 0 1 0 0 0 0 0 1 0 0 2Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 1 2 0 1 2Male 0 2 2 0 0 3 0 0 7 0 2 12Female 0 0 8 0 0 0 0 0 8 0 0 16Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0
Ministry of Health & Family WelfareGovernment of India
Rashtriya Bal Swasthya Karyakram (RBSK)MONTHLY REPORTING FORMAT (MHT) - FORM No - III
Tripura West Tripura Reporting Month JANUARY 2020-2021
6 weeks to 3 years (MHT) 3-6 years enrolled in Govt and Govt aided schools (MHT) 6-18 years enrolled in Govt and Govt aided schools (MHT)
Target : Total children to be screened in
complete year by M.H.T.
No. of children screened in
current month /Yearby M.H.T.
No. of children screened
cumulative till current month
Percentage of total children
screened till this month
(Cumulative)
Found positive for selected
health conditions in current month/year
Referred for this current month/year
Screening details at AWCs Composition of Mobile Health Team
MHT Details Total Number of MHT
Doctors Pharmacist ANM/ Staff nurse Total
Referred for this current
month/year
Target : Total children to be screened in
complete year by M.H.T.
No. of children screened in
current month/year by
M.H.T.
No. of children screened
cumulative till current month
Percentage of total children
screened till this month
(Cumulative)
Found positive for selected
health conditions in current month
Referred for this current month/year
Target : Total children to be screened in
complete year by M.H.T.
No. of children screened in
current month/year by
M.H.T.
No. of children screened cumulative
till current month
Percentage of total children screened
till this month (Cumulative)
Found positive for selected health
conditions in current month
Remarks by MHT TeamScreened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition
AWCs
Govt and Govt aided schools
Number of Children screened in
……………………………….
(Reporting Month)
6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total Number of Children Screened
Developmental dysplasia of the hip
Congenital cataract
Congenital deafness
Congenital heart diseases
Retinopathy of Prematurity
Deficiencies:Total
Defects at Birth: Total Defect at BirthNeural tube defect
Down’s Syndrome
Cleft Lip & Palate
Club foot
A) SAM
B) Severe Thinning
C) Obesity
DeficienciesSevere Anaemia
Vitamin A deficiency (Bitot spot)
Vitamin D Deficiency, (Rickets)
Skin conditions
Otitis Media
Rheumatic heart disease
Goitre
Severe Stunting
Vitamin B complex deficiency.
Childhood Diseases:Total Childhood Diseases
Childhood leprosy Disease
Childhood T.B.
Childhood Extra Pulmonary T. B.
Developmental Delays including Disabilities:Total Developmental Delays including Disabilities
Vision impairment
Reactive airway disease
Dental Conditions
Convulsive disorders
Cognitive delay
Language delay
Behaviour disorder (Autism)
Hearing Impairment
Neuro motor impairment
Motor delay
Adolescent Health:Total Adolescent HealthGrowing up concerns
Substance abuse
Learning disorder
Attention deficit hyperactivity disorder
Others
Pain or burning sensation while urinating
Discharge/ foul smelling discharge from the genitor-urinary area
Pain during menstruation
Feel depressed
Delay in menstruation cycles
Irregular periods
Neural tube defect
Down’s Syndrome
Total Children Refered with Heatlth Conditions
6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total Number of Children Refered at
Refer Children for Health Conditions at facility
Developmental dysplasia of the hip
Congenital cataract
Cleft Lip & Palate
Club foot
Retinopathy of Prematurity
Microcephaly
Macrocephaly
Congenital deafness
Congenital heart diseases
Male 0 0 0 0 0 0 4 1 0 4 1 0Female 0 0 0 0 0 0 10 1 0 10 1 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 1 0 0 0 0 0 1 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 4 0 2 4 0 2Female 0 0 0 0 0 0 4 1 1 4 1 1Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 3 0 2 4 0 4 0 0 6 7 0Female 0 1 0 2 4 0 6 0 0 8 5 0Male 52 12 0 46 20 0 105 59 0 203 91 0Female 42 11 0 38 16 0 97 52 0 177 79 0Male 5 0 0 11 2 0 14 2 1 30 4 1Female 5 0 0 9 0 0 10 5 0 24 5 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 20 0 0 35 2 0 56 6 0 111 8 0Female 18 0 0 35 0 0 56 4 0 109 4 0Male 18 3 2 77 25 5 180 90 21 275 118 28Female 14 2 1 73 25 5 157 83 20 244 110 26Male 0 1 0 0 0 0 0 1 0 0 2 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 1 0 0 0 12 13 31 12 13 32Female 0 0 3 0 0 1 11 11 34 11 11 38Male 0 0 0 0 0 3 0 0 6 0 0 9Female 0 0 0 0 0 0 0 2 2 0 2 2Male 0 0 0 0 0 0 0 0 5 0 0 5Female 0 0 1 0 0 1 0 0 2 0 0 4Male 0 0 1 0 0 0 0 0 1 0 0 2Female 0 0 0 0 0 0 0 0 3 0 0 3Male 0 0 1 0 0 0 0 0 5 0 0 6Female 0 0 2 0 0 0 0 0 6 0 0 8Male 0 0 0 0 0 1 0 0 4 0 0 5Female 0 0 1 0 0 1 0 0 2 0 0 4Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 2 0 0 2 0 0 4Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 2 0 0 2Male 0 0 0 0 0 0 0 0 1 0 0 1Female 0 0 0 0 0 0 0 0 1 0 0 1Male 0 0 0 0 0 0 33 0 2 33 0 2Female 0 0 0 0 0 0 35 2 2 35 2 2Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 5 0 0 5 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 8 8 12 8 8 12Male 0 0 0 0 0 0 3 0 0 3 0 0Female 0 0 0 0 0 0 5 0 0 5 0 0Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 20 9 0 20 9 0Male 0 4 8 0 0 5 0 1 10 0 5 23Female 0 0 13 0 0 1 0 1 13 0 1 27Male 0 3 0 2 4 0 12 1 2 14 8 2Female 0 1 0 3 4 0 20 2 1 23 7 1Male 95 16 2 169 49 5 355 158 22 619 223 29Female 79 13 1 155 41 5 320 144 20 554 198 26
Male 0 0 3 0 0 4 45 13 55 45 13 62
Female 0 0 7 0 0 5 46 15 56 46 15 68
Male 0 0 0 0 0 0 3 0 0 3 0 0
Female 0 0 0 0 0 0 38 17 12 38 17 12
Male 95 23 8 171 53 20 415 173 105 681 249 133Female 79 10 17 158 45 22 424 179 119 661 234 158
Severe Anaemia
A)SAM
B)Severe Thinning
Vitamin A deficiency (Bitot spot)
Vitamin D Deficiency, (Rickets)
Severe Stunting
Vitamin B complex deficiency.
Skin conditions
Ottis Media
C)Obesity
Goitre
Dental Conditions
Convulsive Disorders
Rheumatic Heart Disease
Reactive Airway Disease
Hearing Impairment
Neuro motor impairment
Childhood leprosy Disease
Childhood T.B.
Childhood Extra Pulmonary T. B.
Vision impairment
Language delay
Behaviour disorder (Autism)
Motor delay
Cognitive delay
Others
Growing up concerns
Learning disorder
Attention deficit hyperactivity disorder
Delay in menstruation cycles
Irregular periods
Substance abuse
Feel depressed
Pain during menstruation
Defects at Birth
Pain or burning sensation while urinating
Discharge/ foul smelling discharge from the genitor-urinary area
Developmental Delays
Adolescent Health
Grand Total
Deficiencies
Childhood Diseases
Date
Report prepared by Report verified by Block/ District / State Nodal person
Name of the Nodal PersonSignature
Designation
Male 93753 3927 21750 0.23 126 126 99588 3395 14702 0.15 244 244 246553 9976 13737 0.06 693 693Female 90102 3722 21205 0.23 106 106 96961 3267 14674 0.15 225 225 250652 10265 14421 0.06 722 722
Total 183855 7649 42955 0.2336352 232 232 196549 6662 29376 0.149459 469 469 497205 20241 28158 0.0566326 1415 1415
Male Female Total Male Female Total Male Female Total
Number Number Number Number Approved 48 48 48 96 48 0 48 48 48Visit 1 9911 0 0 0 In-place 48 37 45 82 29 4 33 23 23Visit 2 0 0 0 0 Trained 22 19 19 38 13 1 14 0 0
4638 0 0 0 Operational 48 37 45 82 29 4 33 23 23
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total1701 1623 3324 3927 3722 7649 3395 3267 6662 9976 10265 20241 18999 18877 37876
3 0 3 13 14 27 5 1 6 11 12 23 32 27 590 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 02 0 2 6 3 9 0 0 0 1 0 1 9 3 121 0 1 1 1 2 2 1 3 1 1 2 5 3 80 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 2 0 0 0 2 1 3 3 2 50 0 0 0 0 0 0 3 3 0 3 35 9 14 3 0 3 7 7 14 15 16 310 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 5 4 9 17 26 43 22 30 520 0 0 0 0 0 5 11 16 5 11 160 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 00 0 0 0 1 1 0 1 1
0 0 0 0 0 00 0 0 4 5 9 4 5 9
0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 00 0 0 5 3 8 8 10 18 13 13 26
0 0 0 121 100 221 228 209 437 551 496 1047 900 805 170572 56 128 69 58 127 171 155 326 312 269 5817 9 16 13 9 22 17 15 32 37 33 70
0 0 0 0 0 019 18 37 37 36 73 59 54 113 115 108 22322 17 39 109 106 215 303 272 575 434 395 8291 0 1 0 0 0 1 0 1 2 0 20 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0
0 0 0 3 5 8 4 5 9 87 87 174 94 97 191
1 2 3 0 1 1 56 56 112 57 59 1160 0 0 3 0 3 5 4 9 8 4 120 0 0 0 1 1 5 2 7 5 3 81 0 1 0 0 0 1 3 4 2 3 50 2 2 0 0 0 5 6 11 5 8 131 1 2 1 1 2 4 2 6 6 4 100 0 0 0 2 2 0 2 2 0 4 4
0 2 2 0 2 21 1 2 1 1 210 9 19 10 9 19
Adolescent Health:Total 0 0 0 0 0 0 0 0 0 3 67 70 3 67 700 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 00 0 0 0 5 5 0 5 50 0 0 0 28 28 0 28 28
0 0 0 3 5 8 3 5 8
0 0 0 0 0 0 0 0 00 0 0 0 29 29 0 29 29
Primary care
(PHC/CHC)
Secondary Care (DH/SDH/MC)
Tertiary Care (DEIC)
Primary care (PHC/CHC)
Secondary Care
(DH/SDH/SNCU)
Tertiary Care
(DEIC)/MC
Primary care
(PHC/CHC)
Secondary Care
(DH/SDH/SNCU)
Tertiary Care (DEIC)/MC
Primary care
(PHC/CHC)
Secondary Care
(DH/SDH/SNCU)
Tertiary Care
(DEIC)/MC
Primary care
(PHC/CHC)
Secondary Care (DH/SDH/
SNCU)
Tertiary Care (DEIC)/MC
Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Female 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1
Male 0 0 2 0 1 4 0 0 0 0 0 1 0 1 7Female 0 0 0 0 0 3 0 0 0 0 0 0 0 0 3Male 0 0 1 0 1 1 0 0 2 0 1 0 0 2 4
Female 0 0 0 0 0 1 0 0 1 0 0 1 0 0 3
Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 1 0 0 0 0 0 2 0 0 3Female 0 0 1 0 0 0 0 0 1 0 0 2
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 1 2 0 1 2
Male 0 2 2 0 0 3 0 0 7 0 2 12
Female 0 0 8 0 0 0 0 0 8 0 0 16
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Ministry of Health & Family WelfareGovernment of India
Rashtriya Bal Swasthya Karyakram (RBSK)MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV
Name of State/UT: Tripura No of Reported Districts: No of Blocks : 58 Reporting Month JANUARY Reporting Year 2020-20216 weeks to 3 years (MHT) 3-6 years years enrolled in Govt and Govt aided schools (MHT) 6-18 years enrolled in Govt and Govt aided schools (MHT)
Target :
Total children to be screened in
complete year by M.H.T.
No. of children
screened in current
month /Yearby M.H.T.
No. of children screened
cumulative till current month
Percentage of total children screened till this month
(Cumulative)
Found positive for selected health
conditions in current month
Referred for this current month/year
Screening details at AWCs DEIC and MHT Information Annual
plan :
Total visit
to be planned in
this year
Total AWC/School visit planned in this month by Mobile Health
Teams
Total AWC/School visit conducted this month by Mobile Health
Teams
Cumulative gap including carry forward from
previous month of the current year
Percentage of total children screened till this month
(Cumulative)
Found positive for selected health
conditions in current
month
Referred for this current month/year
Target :
Total children to
be screened in complete
year by M.H.T.
No. of children
screened in current
month/year by M.H.T.
No. of children screened
cumulative till current month
Percentage of total children
screened till this month
(Cumulative)
Found positive for selected
health conditions in current month/year
Referred for this current month/year
Target :
Total children to
be screened in complete
year by M.H.T.
No. of children
screened in current
month/year by M.H.T.
No. of children screened
cumulative till current month
Total MHT
Doctors Pharmacist ANM/ Staff nurse Remarks by State RBSK Team
6 years to 18 years Total childrenScreened Children with Health
Condition Screened Children with Health Condition
Defects at Birth: Total Defect at BirthNeural tube defectDown’s Syndrome
AWC
Govt and Govt aided schools
Number of Children screened in the year : Current Reporting Month (From) APRIL (To) End of Rerpoting Month JANUARY
Birth-6 weeks 6 weeks to 3 years 3 years to 6 years
ASHA, HBNC Screened Children with Health Condition Screened Children with Health Condition
Congenital cataractCongenital deafnessCongenital heart diseases
Cleft Lip & Palate Club footDevelopmental dysplasia of the hip
Deficiencies:Total DeficienciesSevere AnaemiaVitamin A deficiency (Bitot spot)
Retinopathy of PrematurityMicrocephaly Macrocephaly
C) ObesityGoitre Severe Stunting
Vitamin D Deficiency, (Rickets)A) SAM B) Severe Thinning
Otitis MediaRheumatic heart disease Reactive airway disease
Vitamin B complex deficiency.
Childhood Diseases:Total Childhood DiseasesSkin conditions
Childhood T.B. Childhood Extra Pulmonary T. B.
Developmental Delays including Disabilities:Total
Developmental Delays including Disabilities
Dental Conditions Convulsive disordersChildhood leprosy Disease
Motor delay Cognitive delayLanguage delay
Vision impairmentHearing ImpairmentNeuro motor impairment
Others
Adolescent HealthGrowing up concernsSubstance abuse
Behaviour disorder (Autism)Learning disorderAttention deficit hyperactivity disorder
Pain or burning sensation while urinating
Discharge/ foul smelling discharge from the genitor-urinary areaPain during menstruation
Feel depressedDelay in menstruation cyclesIrregular periods
Neural tube defect
Down’s Syndrome
Refer Children for Health Conditions at other facility
ASHA, HBNC Refered Children with Health Condition Refered Children with Health Condition Refered Children with Health Condition Refered Children with Health Condition
Total Children Refered
Birth-6 weeks 6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total Children Referred from Facilities
Developmental dysplasia of the hip
Congenital cataract
Cleft Lip & Palate
Club foot
Retinopathy of Prematurity
Microcephaly
Congenital deafness
Congenital heart diseases
Macrocephaly
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 4 1 0 4 1 0
Female 0 0 0 0 0 0 10 1 0 10 1 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0
Female 0 0 0 1 0 0 1 0 0
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0 4 0 2 4 0 2
Female 0 0 0 0 0 0 4 1 1 4 1 1
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 3 0 2 4 0 4 0 0 6 7 0
Female 0 1 0 2 4 0 6 0 0 8 5 0
Male 52 12 0 46 20 0 105 59 0 203 91 0
Female 42 11 0 38 16 0 97 52 0 177 79 0
Male 5 0 0 11 2 0 14 2 1 30 4 1
Female 5 0 0 9 0 0 10 5 0 24 5 0
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 20 0 0 35 2 0 56 6 0 111 8 0
Female 18 0 0 35 0 0 56 4 0 109 4 0
Male 18 3 2 77 25 5 180 90 21 275 118 28
Female 14 2 1 73 25 5 157 83 20 244 110 26
Male 0 1 0 0 0 0 0 1 0 0 2 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 1 0 0 0 12 13 31 12 13 32
Female 0 0 3 0 0 1 11 11 34 11 11 38
Male 0 0 0 0 0 3 0 0 6 0 0 9
Female 0 0 0 0 0 0 0 2 2 0 2 2
Male 0 0 0 0 0 0 0 0 5 0 0 5
Female 0 0 1 0 0 1 0 0 2 0 0 4
Male 0 0 1 0 0 0 0 0 1 0 0 2
Female 0 0 0 0 0 0 0 0 3 0 0 3
Male 0 0 1 0 0 0 0 0 5 0 0 6
Female 0 0 2 0 0 0 0 0 6 0 0 8
Male 0 0 0 0 0 1 0 0 4 0 0 5
Female 0 0 1 0 0 1 0 0 2 0 0 4
Male 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 2 0 0 2 0 0 4
Male 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 2 0 0 2
Male 0 0 0 0 0 1 0 0 1
Female 0 0 0 0 0 1 0 0 1
Male 0 0 0 33 0 2 33 0 2
Female 0 0 0 35 2 2 35 2 2
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Female 5 0 0 5 0 0
Male 0 0 0 0 0 0
Female 8 8 12 8 8 12
Male3 0 0
3 0 0
Female 5 0 0 5 0 0
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Female 20 9 0 20 9 0
Male 0 0 3 0 4 8 0 0 5 0 1 10 0 5 26
Female 0 0 0 0 0 13 0 0 1 0 1 13 0 1 27
Male 0 0 0 0 3 0 2 4 0 12 1 2 14 8 2
Female 0 0 0 0 1 0 3 4 0 20 2 1 23 7 1
Male 0 0 0 95 16 2 169 49 5 355 158 22 619 223 29
Female 0 0 0 79 13 1 155 41 5 320 144 20 554 198 26
Male 0 0 0 0 0 3 0 0 4 45 13 55 45 13 62
Vitamin A deficiency (Bitot spot)
Vitamin D Deficiency, (Rickets)
Severe Anaemia
C)Obesity
Goitre
A)SAM
B)Severe Thinning
Skin conditions
Ottis Media
Severe Stunting
Vitamin B complex deficiency.
Dental Conditions
Convulsive Disorders
Rheumatic Heart Disease
Reactive Airway Disease
Hearing Impairment
Neuro motor impairment
Childhood leprosy Disease
Childhood T.B.
Childhood Extra Pulmonary T. B.
Vision impairment
Language delay
Behaviour disorder (Autism)
Motor delay
Cognitive delay
Others
Growing up concerns
Learning disorder
Attention deficit hyperactivity disorder
Delay in menstruation cycles
Irregular periods
Substance abuse
Feel depressed
Pain during menstruation
Defects at Birth
Pain or burning sensation while urinating
Discharge/ foul smelling discharge from the genitor-urinary area
Developmental Delays
Deficiencies
Childhood Diseases
Female 0 0 0 0 0 7 0 0 5 46 15 56 46 15 68
Male 0 0 3 95 23 13 171 53 14 412 173 89 678 249 119
Female 0 0 0 79 14 21 158 45 11 386 162 90 623 221 122
Developmental Delays
Grand Total
Date
Report prepared by Report verified by Block/ District / State Nodal personName
Signature Designation
58 Reporting Year
Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Birth-6 weeksASHA,HBNC 2 0 0 0 0 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 06 Weeks- 3 Yrs 7 2 0 0 1 0 4 2 0 0 0 0 6 3 0 0 0 1 1 1 0 0 5 13- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 0Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 2 1 0 0 2 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 13- 6 Yrs 2 1 0 0 0 0 2 1 0 0 0 0 2 1 0 0 0 0 0 0 0 0 2 16-18 Yrs 2 1 0 0 2 0 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 1Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 1 1 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 13- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 2 1 0 0 0 0 2 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 1Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 4 0 0 0 2 0 2 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 3Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 6 9 0 0 2 0 1 8 0 0 0 0 4 8 0 0 1 0 0 0 0 0 4 63- 6 Yrs 3 0 0 0 0 0 3 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 2 06-18 Yrs 4 5 0 0 0 0 4 6 0 0 0 0 1 2 0 0 0 0 0 2 0 0 1 2Birth-6 weeksASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 5 11 4 10 1 1 0 0 0 0 0 0 5 11 5 11 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 6 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 03- 6 Yrs 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 5 6 6 5 0 1 2 1 0 0 0 0 3 5 1 2 0 0 0 0 0 0 2 36 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 67 53 49 43 10 8 0 0 0 0 0 0 67 55 59 47 0 0 0 0 0 0 7 53- 6 Yrs 73 63 52 41 20 15 0 0 0 0 0 0 65 52 60 47 0 0 0 0 0 0 2 26-18 yrs 187 172 117 110 56 50 0 0 0 0 0 0 140 124 116 102 0 0 0 0 0 0 10 156 Weeks- 3 Years 11 15 7 7 0 0 0 0 0 0 0 0 7 8 2 2 0 0 0 0 0 0 5 63- 6 Yrs 17 15 15 15 2 0 0 0 0 0 0 0 8 8 5 4 0 0 0 0 0 0 3 46-18 yrs 18 15 16 10 2 5 0 0 0 0 0 0 14 13 11 10 0 0 0 0 0 0 3 36 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 9 5 5 5 0 0 0 0 0 0 0 0 7 4 4 3 0 0 0 0 0 0 1 13- 6 Yrs 27 27 25 25 2 0 0 0 0 0 0 0 25 25 17 21 0 0 0 0 0 0 8 36-18 yrs 42 33 36 29 6 4 0 0 0 0 0 0 39 29 25 21 0 0 0 0 0 0 14 86 Weeks- 3 Years 19 15 16 13 3 2 0 0 0 0 0 0 24 23 22 23 0 0 0 0 0 0 2 03- 6 Yrs 113 110 82 77 23 24 4 3 0 0 0 0 92 89 84 84 0 0 0 0 0 0 8 76-18 yrs 322 302 202 190 86 80 19 18 0 0 0 0 256 239 202 191 4 3 9 6 0 0 36 396 Weeks- 3 Years 1 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 1 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 1 2 0 0 0 0 1 3 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 03- 6 Yrs 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 16-18 yrs 60 57 16 12 13 11 31 34 0 0 0 0 54 53 15 16 0 0 24 24 0 0 12 96 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 3 0 0 0 0 0 3 0 0 0 0 0 3 0 1 0 0 0 1 0 0 0 1 06-18 yrs 5 5 0 1 0 2 5 2 0 0 0 0 4 3 1 1 0 0 1 1 0 0 2 16 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Ministry of Health & Family WelfareGovernment of India
Rashtriya Bal Swasthya Karyakram (RBSK)MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
JANUARY 2020-2021
S.No Health Condition Details
Number of children with selected health conditions
Identified through screeningReferal
ConfirmedManaged
Name of State/UT: Tripura No of Reported Districts: 8 No of Blocks : Reporting Month
Waiting for service accessPrimary care (PHC/CHC)
Secondary Care (DH/Medical)
Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling
4 Club foot
5 Developmental dysplasia of the hip
6 Congenital cataract
1 Neural tube Defect
2 Down Syndrome
3 Cle Lip & Palate
10 Severe Anaemia
11 Vitamin A deficiency (Bitot spot)
12 Vitamin D Deficiency, (Rickets)
7 Congenital Deafness
8 Congenital Heart Diseases
9 Retinopathy of Prematurity
16 Otitis Media
17 Rheumatic heart disease
18 Reactive airway disease
A) SAM
B) Severe Thinning
C) Obesity
14 Goitre
15 Skin conditions
22 Hearing Impairment
23 Neuro motor impairment
19 Dental Condi ons
20 Convulsive disorders
21 Vision impairment
6-18 yrs 5 2 0 0 0 0 5 2 0 0 0 0 5 2 0 0 0 0 0 0 0 0 5 26 Weeks- 3 Years 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 1 3 0 0 0 0 1 3 0 0 0 0 1 3 0 0 0 0 0 0 0 0 1 36 Weeks- 3 Years 0 2 0 0 0 0 0 2 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 5 6 0 0 0 0 5 6 0 0 0 0 5 6 0 0 0 0 0 0 0 0 4 46 Weeks- 3 Years 1 1 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 13- 6 Yrs 1 1 0 0 0 0 1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 16-18 yrs 4 2 0 0 0 0 4 2 0 0 0 0 4 2 0 0 0 0 0 0 0 0 4 26 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 2 0 0 0 0 0 2 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 16-18 yrs 0 2 0 0 0 0 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 13- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 2 0 0 0 0 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 1 1 0 0 0 0 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 1 13- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 12 10 10 6 0 2 2 2 0 0 0 0 11 9 11 8 0 0 0 0 0 0 0 2
31 Growing up concerns 6-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 032 Substance abuse 6-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 033 Feel depressed 6-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 034 Delay in menstruation cycles 6-18 yrs 0 5 0 5 0 0 0 0 0 0 0 0 0 5 0 5 0 0 0 0 0 0 0 035 Irregular periods 6-18 yrs 0 29 0 8 0 9 0 12 0 0 0 0 0 27 0 27 0 0 0 0 0 0 0 136
Pain or burning sensation while urinating
6-18 yrs 3 5 3 5 0 0 0 0 0 0 0 0 3 5 3 5 0 0 0 0 0 0 0 0
37Discharge/ foul smelling discharge from the genitor-urinary area
6-18 yrs
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0
38 Pain during menstruation 6-18 yrs 0 33 0 20 0 13 0 0 0 0 0 0 0 28 0 25 0 0 0 0 0 0 0 36 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
41 6 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Birth-6 weeks 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Birth-6 weeks 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 1 0 0 0 03- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 Weeks- 3 Years 0 0 0 0 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 03- 6 Yrs 5 3 2 2 4 4 0 0 0 0 0 0 5 3 5 3 0 0 0 0 0 0 0 06-18 yrs 8 10 4 6 0 0 0 0 0 0 0 0 8 10 8 10 0 0 0 0 0 0 0 0Birth-6 weeksASHA,HBNC 2 0 0 0 0 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 06 Weeks- 3 Yrs 16 13 0 0 5 0 6 12 0 0 0 0 12 14 0 1 1 1 1 2 0 0 11 103- 6 Yrs 5 1 0 0 0 0 5 1 0 0 0 0 4 1 0 0 0 0 0 0 0 0 4 16-18 Yrs 9 11 0 0 2 2 7 10 0 0 0 0 4 7 0 0 0 0 0 3 0 0 4 76 Weeks- 3 Years 0 0 0 0 3 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 03- 6 Yrs 5 4 2 3 4 4 0 0 0 0 0 0 5 4 5 4 0 0 0 0 0 0 0 06-18 yrs 18 27 14 21 1 2 2 1 0 0 0 0 16 26 14 23 0 0 0 0 0 0 2 36 Weeks- 3 Years 107 88 77 68 14 10 0 0 0 0 0 0 106 90 88 75 0 0 0 0 0 0 15 123- 6 Yrs 230 215 174 158 47 39 4 3 0 0 0 0 190 174 166 156 0 0 0 0 0 0 21 166-18 yrs 570 522 371 339 151 139 19 18 0 0 0 0 450 405 355 324 4 3 9 6 0 0 63 65ASHA Visited As per MCP Card 0 0 0 0 0 06 Weeks- 3 Years 3 5 0 0 0 0 3 6 0 0 0 0 2 4 0 0 0 0 2 1 0 0 0 13- 6 Yrs 4 5 0 0 0 0 4 5 0 0 0 0 3 4 1 0 0 0 1 0 0 0 1 36-18 yrs 93 90 26 19 13 15 54 56 0 0 0 0 85 81 27 25 0 0 25 25 0 0 30 25
Adolescent Health 6-18 yrs 3 72 3 38 0 22 0 12 0 0 0 0 3 65 3 62 0 0 0 0 0 0 0 4Birth-6 weeksASHA,HBNC 3 0 0 0 0 0 3 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0
6 Weeks- 3 Years 126 106 77 68 22 20 27 18 0 0 0 0 120 109 88 77 1 1 3 3 0 0 28 283- 6 Yrs 244 225 176 161 51 43 17 21 0 0 0 0 202 183 172 160 0 0 1 0 0 0 29 236-18 yrs 693 722 414 445 167 180 112 97 0 0 0 0 558 584 399 434 4 3 34 34 0 0 121 113
24 Motor delay
28 Learning disorder
29Attention deficit hyperactivity disorder
30 Others
25 Cognitive delay
26 Language delay
27 Behaviour disorder (Autism)
Severe Stunting
42 Microcephaly
43 Macrocephaly
44 Vitamin B complex deficiency
39 Childhood leprosy Disease
40 Childhood T.B.
40.1 Childhood Extra Pulmonary T. B.
Developmental Delays including Disabilities
Total Children identified
Report prepared by
Defect at Birth
Deficiency
Childhood Diseases
Report verified by Block/ District / State Nodal person
Name
Signature
Designation
Date