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Basic
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Basic+
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Comprehensive
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Response
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I. HEALTH FACILITY IDENTIFICATION
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1
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What is the type of entry that you are making? (select
Health Facility, Organization, or Program)
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Record ID
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Date of data collection
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Source of data:
email, on-line, PDA
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Respondent Name
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Respondent position
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Interviewer Name
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Interviewer Sponsor Agency
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Data entered
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Data updated
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Source of information
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2
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What is the name of the health facility
for which you are providing information?
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Facility ID
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3
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Who is the proprietor of this facility?
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A.
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What is the Email address of the
proprietor?
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B.
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Do we have your permission to display
the above email address?
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4
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What are the major partnering agencies
for this facility? (List up to three)
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C.
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Are there other partnering agencies?
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D.
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Does this facility receive governmental
assistance? If yes …
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Financial assistance?
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Material assistance?
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Other assistance?
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5
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Country in which this facility is
located?
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6
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State, Region or Province
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7
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District / Health Zone
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E.
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Is this
facility part of an organized health district (or similar structure?
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What is the role of this facility within the health
district
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What is the total population of the health district?
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What is the catchment population of this health
facility?
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How many outreach posts exist within the catchment
area of this facility?
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How many Community-Based Health Worker operate in the
catchment area under the supervision of this facility?
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Location:
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Name of Diocese, Parish, or other non-medical
geographic unit
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GPS Coordinates – Latitude of the facility
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GPS Coordinates – Longitude of the facility
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Address:
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Name of Contact Person
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PO Box
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Address 1
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Address 2
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City
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ZipCode
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International dialing code
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Telephone Area/City code
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Phone number
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Facility Telephone
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Facility fax number
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Infrastructure:
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Provide a brief description of
the facilities, e.g., type of construction, year, etc)
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How many medical buildings comprise this health facility?
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How many in-patient beds are available?
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How many maternity beds?
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OPD Annual patients
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Logistics:
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Does facility use facility or privately owned cellular phones?
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Does facility have functioning short-wave radio for radio calls?
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Does facility have functioning computer?
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Does facility have functioning internet services for staff?
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Staffing:
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Nbr of Medical doctors/physicians
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Nbr of assistant doctors?
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Nbr of Certified registered midwives (including nurse midwives)
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Nbr of Certified registered nurses
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Nbr of other nurses
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Nbr of auxiliary health staff
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Nbr of Laboratory technicians/technologists
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Nbr of Pharmacists and dispensers available
Nbr of HMIS personnel?
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Nbr of Record assistants?
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Nbr of other Administrative personnel?
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Services: Which of the following services are provided at your
facility?
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Maternity
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Pediatric
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Operating Room
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Laboratory
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Dental
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Orthopedics
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Eye Care
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Etc.
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II. PROGRAM INTERVENTIONS & SUPPORT
SYSTEMS
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F.
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EPI: Do your health services include an immunizations
program?
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Frigo: Do you have a functional refrigerator for vaccine
storage?
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Plan: Is there a district-wide micro plan for EPI that
includes your facility?
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Type: Do you provide routine or campaign vaccinations (or both)?
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Outreach: Do you also provide vaccinations at outreach sites?
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DPT3: What is the DPT3 coverage for your catchment area?
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G.
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Malaria: Do your health services include a malaria
program?
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Test: Is Giemsa stain for malaria and microscope available for malaria
diagnosis?
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ITP: Do you provide Intermittent Treatment Protocol as part of prenatal
care?
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ITN: Do you distribute Insecticide Treated Nets as part of your program?
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If yes, what is the ITN coverage of
households for your area
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H.
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Tuberculosis: Do your health services include a TB
program? If so…
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Test: Is smear microscopy available in this facility for TB diagnosis?
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Reg: Is a register of suspected TB cases kept at this facility?
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Tx: Is TB Treatment available in this facility? If so, what type?
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DOTS: Is direct observation of treatment of TB provided (DOTS)
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Rate: What is your TB detection rate?
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I.
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HIV/AIDS: Do your health services include an HIV/AIDS
program?
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Test: Is your facility equipped to test blood for HIV before a blood
transfusion?
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VCT: Does your program include Voluntary Counseling & Testing for
HIV/AIDS?
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PMTCT: Does your program include Preventing Mother-to-Child
Transmission (PMTCT)?
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ARV: Does your program include treatment with ARV? If
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If you provide ARVs, how many people
are currently enrolled in this program?
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J.
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Maternal & New-Born Care : Do your health
services include Maternal & New-Born Care?
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CPN: What percent of pregnant women attend at least two CPN sessions?
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MAT: What percent of deliveries are done in a nurse-supervised health
facility?
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ITP: Do you provide Intermittent Treatment Protocol as part of prenatal
care?
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TBA: Does this program involve Community-Based Traditional Birth
Attendants?
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K.
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Nutrition & Micronutrients: Do your health
services include Nutrition interventions?
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GM: Do you do hold monthly Growth Monitoring sessions?
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Outreach: How many outreach sites in addition to the health
facility?
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Vit A: Do you distribute Vitamin A in conjunction with
Growth Monitoring Sessions?
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EPI: Do you provide EPI integrated with Growth Monitoring Sessions?
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Do you provide nutrition rehabilitation services? If so, please select the type.
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L.
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Family Planning & Reproductive Health: Do your
health services include FP & RH?
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MFP: Do you provide counseling and products for modern family planning?
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NFP: Do you provide counseling and products for natural family planning?
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CBD: Do you provide Community-Based Distribution for some contraceptives?
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CYP: What was your Couple-Years of Protection for last year?
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M.
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END: Do your health services include
endemic disease control programs?
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ONC: Do you have activities for onchocerciasis, e.g., ivermection distribution
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TRP: Do you have activities for trypanosomiasis, e.g. community-based fly
traps?
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GW: Do you have community-based programs to combat guinea worm?
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ARI: Do you have community-based programs for Pneumonia?
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CDD: Do you have community-based programs for Control of Diarrheal
Disease?
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OTH: What other endemic disease control do you combat at the community
level?
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N.
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WSH: Do your health services include Water,
Sanitation and Hygiene (WSH)?
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Hands: Do you promote and assist with household handwashing
stands
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Store: Do you promote and assist with household water
storage protection?
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Latrines: Do you promote and assist with latrine construction?
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Sources: Do you promote and assist with community construction
of water points?
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Repair: Do Community-Based committees or CHWs for repair and
maintenance exist?
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O.
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Essential Medicines: Does your facility
provide curative care services?
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TPs: Does your facility follow written treatment protocols (algorithms)?
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IMCI: Do you follow written guidelines for Integrated
Management of Childhood Illnesses?
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Fees: Do you charge for medicines and/or curative care services?
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Type Fees: If so, are charges per prescription, per cure or a
combination system?
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Ordering: Do you order/purchase medicines by requisition or
receive them via a kit system?
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Need: Are drug needs calculated from a) monthly consumption data, b)
population based disease data or c) institutions best estimate of need?
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Sources: What are your top three in-country sources for
medicines and supplies?
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Imports: What are your top three sources for importing
medicines & supplies (if applicable)?
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Value: What is the yearly (or monthly) value of essential
medicines for your facility?
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P.
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Do you have
a regular reporting system to the Ministry of Health and/or to your FBO
network?
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Does your facility complete a monthly HMIS report for the Ministry of
Health?
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If so, how often is
this report submitted?
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Do you have a reporting system independent of the MOH for your FBO
network?
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Does your facility prepare an annual report?
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Q.
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Do you have a particular approach for
Community Organization?
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Mgmt: Is the community involved in facility co-management? If so, briefly
describe.
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Orgs: Do community-based organizations exist? If so, briefly describe.
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CHWs: Do community-based health workers exist? If so, briefly describe.
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CBD: Do you support Community-Based Distribution of services (CBD). If so,
describe
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C-IMCI: Do you have a program for Community-Based IMCI
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R.
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Do you accept volunteers?
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Type: What type of volunteers are you looking for?
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Duration: What duration of volunteers are you looking for?
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Housing: Do you provide housing for volunteers?
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Faith: Must volunteers be Christian?
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Denom: Must volunteers be of a particular denomination? If
yes, specify which.
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C.
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Do you have Information to provide in
other formats, e.g., reports, maps, etc.
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S.
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Do you have program descriptions,
reports, maps, and studies about your work?
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Maps (indicate name of document or filename)
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Descriptions (indicate name of document or filename)
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Reports (indicate name of document or filename)
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Studies (indicate name of document or filename)
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Articles (indicate name of document or filename)
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