Stata:

Distrlct:
Block:

Ory/rom/
Village:
Facilfty

Nairi

Faciilty tvpe-

Lodon

of 8, Numbet dischaiiedunder 48 hours of delivery

of cases where Jananl Surakha Yogna incentiye pald to

2.2-2
2.2.2 (a)

or AWW (only

for

HPS Stotes)

,r-,

tat

2.2.2

l.t

.I
,J

'f

:?
.,1
,J
I

-1

Monthly- DH-SDH-CHC

Printed ar on 10/09/2008

'

,,of7

I
I

Ldlq

NRHM/ DH-SDH-CHC/3/M

il

Wfi;;tiiii,l

r.l

l.l#Wi

,.*
1.2

: -section deliveries performed at facility

I,,=

iiii,l4il#ll.:l:
10

4.1.7

Llve Birth

10.1

o,

(a) Male
(b

t?,

temole

Iotal

1I

Pregnancy Outcome (in number)

llbt

*-1

({a} to {b}}

lo.2 Still BIrth

f,d.

10.3 Abortion (spontaneous/induced)

t:f?

Details of Newborn children welghed

11

11.1 Number of newborns weiShed at birth

lt.i

Number of newborns having weight less than 2.5 kg

Number of newborns breast fed within

t2

hour of birth

irl
t't:
e

4-2.1
4.2-2

+lu

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

13

Number of cases of pregnant women with obstetric Complications and

attended at facility

t4

Number of C.omplicated pregnancies treated with

L4.L lV
L4.2
L4.a

a7

Antibioti6

lV Antihypertensive/Magsulph

injection

lV Oxytocin

0d.-

Gv-

,-3

14-4 Blood Transfusion

ll::ijli

,{fiffiIi}l
15

Women receiving post partum checkups within 48 hours after delivery

16

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

L7

PNc maternal complications attended

!18

ot

w
7.1

{umber of MTPs conducted at fucllity

18.1

Up to 12 weeks of pregnancy

18.2

More than 12 weeks of pregnancy

,l

e:

niti'
18

7-1.1

7.2

Total {(18.1) to (18.2)}

rriffiil{ix1,

U.ffi,i iitiffi

r:

w.;

Number of new RTI/STI tor whlch treatment initiated

1.9

(a) Male
(b

'emole
rotal {(a} to (b)}

20

,jiJ..i.r

oL-

?5

r(b)

tq-

Number of wet mount tests conducted

Monthly- DH-SDH{HC
Printed as on 10/09/2008

2ol7

,:r$&

NRHM/ DH.SDHTHC/3/M

1.1

(b)
(b)
(b)

(b)
1

1(c

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

Number of lnfants 0 to

tl

months old who ,eceived the followln$

70-L8
70.1.(E
10.1.O7

70.7-B
10-7.drA
10.1.tx)

,.10

Printed as on 10/09/2008

Monthly- DH-SDH-CHC

, ol7

NRHM/ DH-SDH.CHC/3/M

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

of Children aged 9 to 12 months who

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

Total {(a} to (b}}

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 immunised
3+OPvl23+Measles) during the month

more than 5 years given DPTs/DT5

more than

1,0

years given TT10

more than 16 years given TT16

Adwrs Event Following tmmunisation (AEFtl

Number of lmmunisataon sesslons during the month

Numbeir of sessions where ASHAS were present

(Japanese Encephalltls (JEl erc. please Spectfy)

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

between 9 nronths and

Printed as on

10/092008

yea.s

Monthly- DH-SDH-CHC
4

ol7

.ll
ui

il

,,

e*r*"B& !d

NRHM/ DH.SDH-CHC/3/M

12.1
72.2

,3.2
1r-3
13.4

7r-s
3-6

14.07
14-01
14.05

,1.06
74-O'

Monthly- DH-SDH{HC
Printed as on 10/09/2008

.,

ol7

',

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

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

47031

n-Paiient Head Count at midnlght

57.3

12

)utpatlent

58

31")<

)PD attendance (All)

58.1

It

)pe.atlon Theare

i9

lpeiatlon major

59.1

!w

59.1A'

of

!
,

(General and spinal anaesthesia)

59.i qy6;cology-

q?)

HYsterectomy surgeries

)peratipn minor-[No or local anaesthesia),

s9.?.

1a-14

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

i0

i.v--l

(a) AYUSH

11.11.2

(b) Dentol Procedures

11.14.3

(c) Adolesce nt counse I li n g'seNice s

ffi

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

!trJ:
75.7

-ab Tests Details

61

37

Total Number of tests for Hb

51.1

s{

Of which Number having Hb < 7 mg

6L.2

${gFPFotith.

32
(a

tb

(b) Female-Non ANC

Total {(a} to (c)}

53

widal tests conducted

i4

VDRL tests conducted

15-3.7

ol

1S-3.2

oD

iFemole with ANc

75-7.2

15.3

ob

{(a) to (c)}

Malaria tesd conducted

55.1

,1{

Blood smears examined

,s.4.1 .

65.2

Plasmodium Vivax test Positive

o3

,5-4.2

65.3

Plasmodium Falciparum test positive

o &-.

ts-4-3

66

Gb

(b lFemole-Non ANC

i5

(b)

15.1,21ct

Male

irotal

pi

[s.1.2(bl

)9
7q

(c) Femole with ANC

(c

ts.l.t

))o

Mole

(a)

t1.14-1

Mortallty Detalls -

Each case is

to be entered in

'
!4x
separate line. Only deaths occuring at the facility to be reported.
i&H6;?::::-:

lXiLlil#F$

1r,

Select

Select

II

select II

r,i

-: i '

ti

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

.:,:;Jil.'::
:

'

ffil$S Cod+

Select

Selecl

Select

Selecl

'select

Select

Select

Select

select

Selecl

Select

Select

Select

selct

Select

4
5

Monthly- DH-sDH{HC
Printed as on 10/09/2008

6ol7

:;.iri$i5il::t:;r:,

:'