Supportive Supervision Checklist

I Cl: Nam e of the supervisor -~l)~ l~c,.Q:: IC2: Designation - fv\.L~~ f3: Level of superv isor - Block/ District/ St~/Nati onal / Other A • ' • I L P.W (... _!:, f-l C,.

C£/~ r vC4: Fa~ a~_e - /Co~J-t I~eility Type - SC/ Non 24*7 PHC /24*7 PHC/Non- FRU CHC/FRU ICG: faci lity Level - Ll/ L2/ L3 Block yL--/ District ~ a, {-j . C C/SDH/DH/AREA HOSP/other IC7: Date ofv isit - Q/ ~/I 6 ICS: Name of Facility in-charge/nodal officer - m .,lJ--tv . '5>---/­ C9: Designation of In-charge- /4--- D '

Ipt,t; (h ( E Drugs/supplies availability (If possible, verify physically)Data of previous month from facility

El: Reproductive Health ,,, E3: New Born Health E7. Antibiotics Dl Number of deliveries in facility ' --E']'El.1: IUCD 375, 380A E. 7 .1 Antibiotics as per RMNCH+A SXS -E3.l : lnj. Vit K1(1 mg/ml) ~t9----­

Matrix ( Amoxycl ill in, Ampicillin, Total Deliveries /q Ampicillin, Gentamicin, Metronidazole, / SNormal Trimet hoprim &Sulpha methoxazole,

)(.._Assisted Vagina l Delivery Cef rtiaxone (oral/lM/IV as applicable) ~

C-section 1-.. El.2: OCP E3.2: Mucus Extractor µa 0ES: Other essential supplies l)YReferred out cases

&equipments(check Live births

functionality & utilization)

D ,g---­El.3: ECP E3.3: Bag and mask E8.l Weighing Machine ..u..---­~ D2 Number of new-borns (240 ml) with both pre & term mask (size 0,1)

-z­ l-{1'immunized before discharge El.4: Condoms E8 .2: Hub cutt er with needle destroyer (v"~E3.4: Clean linen/ towels for receiving new born

ELS: M ifepristone + Misoprostol (MMA} E3.5: Sterile cord cutting equipment E8.3 : Refrigerator -\8"'" !Sv"1­El.6: MVA Kit/EVA E3.6: Designated Newborn Care Corner E8.4: RTI/STI Kit 1\0"~ 0

D3 IPD load E3.7: Functional Radiant Warmer E8.S: Bleaching Powder E2: Maternal Health V~a J: .,..-A. I U R E2.l: lnj. Oxytocin (check whether stored E8.6: Oxygen Cylinder functional 'CY' E4: Child HealthD4 OPDload ~ ·°Kin co ld box/refrigerator) c.­

[)/E2.2: Tab Misoprostol Gr E4.1 ORS fl ES. 7: BP apparatus with stethoscopeD5 IUCD inserted in facility

tSv ,.._E4.2: Zinc (10mg & 20 mg)E2.3: Anti hypertensive (alpha E8.8: Thermometer VInterva l //6 9'methyldopa/Labetalol or Nifedipine) Postpartum E2.4: lnj. Magnesium Sulfa te E8.9: PPIUCD Forceps0 E4.3: Syp Salbutamol/Salbutamol Nebulizing 0 V x._ ?(_Post Abortion Solution "' 1

/ -D6 Sterilization done E2.S: lnj. Tetanus Toxoid 14-Q E4.4: Tablet Albendazole \jJ/ E8.10: Fetoscope/ Doppler g,-' ...­

Female i nterval sterilization X E2.6: Sterile pads w E8.11: Autoclave/Boiler E.S: Adolescent Health -- IJY,,,,­Female post partum sterilization ~ c;y ,,,,,,E2.7: IFA Tablet ES.1: Dicyclomine --IT E8. 12: Running water KMale sterilization ~

E2.8: Pregnancy Test Kit (only at sub­ ES.2: Weekly Iron folic acid supplementation E8.13: Soap 0 IJY'07 No. of clients received I '\ . Rcentres and w ith ASHAs) tablets X ./ICAC services E2.9: Functional Blood Bank/blood E 5.3 Tablet Albendazole ES.14: Color coded bins and bagsJJ--"" D/DB No of women received IFA tab storage units ~ /09 No. of ANC clients with high g.,'

­E2.10: Haemoglobinometer 18.15: Electricity back-upEG: Vaccines W'arisk conditions £6.1: BCG E8.16: Toilet near LR J)/E2.11: Urine albumin kit erici----­

D10 HR deployed/posted in Labor Room (9--""E 2. 12: Blood grouping typing E6. 2: OPV11J"'"Post Trained in

E 2.13:HIV screening E6.3: Hep B a--­11'-­ed PPIUCD NSSKSBA/--........ liJ...,­E 2.14:Hepatitis B screening I~ I ._\ E6.4: DPTD E8.17: Cold box, ILR, Deep freezer SV'

./

s~~oc present for vaccine storage as perE.6.5: Measles il­E2. 15: Partog_r;~ lb~ J:j} (~ -2'

..._ ,,:_A_......~~ r ~I>~MO '..!'i .t:­ 0C-t requirement

' E2.16: Protocols displayed in LR E.6.6: Syrup Vit . A ANM/Sta !1/;v.- '7 ~ ~D "D 0 /ff nurse q,.,..,....._ E2.17: IV Fluids Y:J E.6.7: Pentavalent vaccine (in relevant states) E 8.18 MCP cards 'Er IY F 2.18 lni Dexamethasone ~ E.6.8 JE Vaccine /where relevant) ~ ~

Fl. Ante

Natal Care

-

II . I· .,,, t-' ..

F2. Intra­

partum and

Immediate post-partum practices

F3. Essential

new born care (ENBC) and New­born Resuscitation (NBR)

F4. Family Planning

,_.

' ' -,. .

FS. Client Satisfaction

,·

Response

Fl.1 Blood Pressure Measured during ANC visits llJ.-"ies D No D NA Fl.2 Haemoglobin measured during ANC visits JJ.--Yes D No D NA Fl.3 Blood Glucose measured during ANC visits l:vYes D No D NA Fl.4 Urine Albumin measured during ANC visits ~D No D NA Fl.S Appropriate management/referral of high risk clients (identified on the basis of High BP/ Blood sugar/Haemoglobin) D--Yes D No D NA Fl.6 Family Planning Counselling happening during ANC visits JJ.-res D No D NA F2.1 Fetal Heart Rate (FHR) recorded at the time of admission a----Yes D No

F2.2 Mother's temperature and BP recorded at the time of admission I' '\ 0-----Ves D No

F2.3 Partograph used to monitor progress of labor Jvv1-­ ~ ,....,/, .-l( IA pA'_ tf•vk,vC ) ·r,-~ 1 ; ~ Yes D No

F2.4 Antenatal corticosteroids used for preterm labour '--­ I,._, / h ;:-;-L ./2­ D Yes fil...-1ro D NA Magnesium Sulphate used to manage severe Pre-eclampsia and Eclampsia cases " F2.S D Yes 0---fio

F2.6 Uterotonic (Oxytocin or M isoprosto l) given to mother immediately after birth of baby 0--4"es D No

F3.1 Newborn care corner adequately equipped (bag-and-mask, radiant warmer, mucous extractor, shoulder roll, thermometer, clock, Oxygen source) 0----"Yes D No

F3.2 Early initiation of breastfeeding practices g---- Yes D No

F3.3 Practice of skin to skin contact being promoted Yes D No

F3.4 Babies dried with clean and sterile sheets/towels just after delivery Yes D No

F3.S Provider aware about the steps of new-born resuscitation (Positioning, suctioning, stimulation, reposit ioning, PPV using Ambu bag) ffves 0 No

F3.6 New-borns given BCG,OPV, Hep-B within 24 hours of birth Yes 0 No

F4. l Fam ily planning counselling being done ~Yes 0 No

F4.2 Postpartum IUCD insertions being done D Yes No~ F4.3 Interva l IUCD insertions being done tvYes 0 No D NA F4.4 Sterilization procedures being done (Fixed Day Services or Fixed day Camps) D Yes ,8( No

F4.S Postpartum sterilization being done 0 Yes 0( No

F.S.l Privacy during delivery? ~es D No

F.5.2 Is transport being provided for drop back? !SJ.-,4'es D No

F.5.3 Staff was well behaved with you during your stay? B-"Ves D No

F.5.4 Were you informed about the procedures before they were undertaken ~Yes D No

F.5.5 Free diet provided? g.-/Yes D No

F.5.6 Would you suggest vis iting this facility to your relatives/friends? .__o.--yes D No

F6. Facility FG.l Is utilization of untied fund adequate? C /ft ~~ ~ + _r;:;Pr. D Yes D No mechanisms

F6.2 Awareness generation (use of IEC/BCC)- Posters, audio visual aids, display of citizen charter? G-'i'es D Noand others FG.3 Is grievance redressal mechanism in place? ~ D No

F7 F 7.1 '=xclusive breastfeeding practised upto six months (no water) 19--res D No Functionality F. 7.2 Complementary feeding practised 0/'fes D No of programs

F.7.3 ORS and Zinc available with ASHAs and distributed in community CJ-Ves D Noat community

F.7.4 Growth monitoring at AWW ce nters and VHNDs 19--Yes 0 No

F.7.5 Malnourished children referred to Nutritional Rehabilitation Centres Q-Yes 0 No

F.7.6 Incentives to ASHAs for delaying and spacing of births I!J-yes D No

F.7.7 Incentives to ASHAs for accompanying clients for PPIUCD insertions &-Yes 0 No

• F.7.8 Weekly IFA supplementation (WIFS) 0 Yes ~o

F.7.9 Community based distribution of Misoprostol for PPH prevention 0 Yes O No ,0::. NA

F7.10 Home-based new born care by ASHA ,g---,{es D No

F.7.11 HBNC kits available with ASHA IQ---Yes D No .

F7.12 Referrals of sick newborns or newborns with danger signs being undertaken llJ---Y"es D No

F.7.13 Home delivery of contraceptives by ASHAs 9-4es D No D NA

F.7.14 Menstrual hygiene practices being promoted r;;J---1es D No D NA F.7.15 VHNDs being conducted on a monthly basis (Services include ANC, Growth Monitoring, Immun ization, Health Messages etc) za--ves D No

F7.16 JSSK (JSSK entitlements being given?) r!v'i'es D No

F7.17 JSY (JSY entitlements being given?) v---1es D No

F7.18 Rashtriya Bal Swasthya Karyakram operational frP J"Y1 '° / L c R_f!,,S,!C_ "Y.P.)<~~ D Yes )-_ No

Major findings from last visit

Action taken on interventions/

activities identified from last visit

Plan of Action

Major findings from this visit Intervention/ Activities identified Level of intervention Responsibility Timeline

Reproductive Health/Family Planning Maternal Health

Newborn Health

Child Health

Adolescent Health -