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:, :'
Recommended