Health Delivery and Health Status in Rajasthan, India
Public Facility Survey
Facility Name
Facility Type
ID Number
GPS Location
Interviewer Codes
N:
E:
PB.A
Date 1
PB.B
PB.C
PB.D
Day 1: Start time
Day 1: End time
Forms completed on Day 1
PB.E
PB.F
INTERVIEWER CHECKPOINT: Are all
sections complete?
Date 2
PB.G
PB.H
PB.I
Day 2: Start time
Day 2: End time
Sections completed on Day 2
Day [ ][ ]
Month [ ][ ]
Year [ ][ ][ ][ ]
[ ][ ].[ ][ ]
[ ][ ].[ ][ ]
PB0……………………………….0
PB1……………………………….1
PB2……………………………….2
PB3…………………………….…3
PB4……………………………….4
Yes………………………………..1
No………………………………...2
Day [ ][ ]
Month [ ][ ]
Year [ ][ ][ ][ ]
[ ][ ].[ ][ ]
[ ][ ].[ ][ ]
PB0……………………………….0
PB1……………………………….1
PB2……………………………….2
PB3…………………………….…3
PB4……………………………….4
END
PB0
PB0.1
PB0.2
PB0.3
PB0.4
PB0.5
PB0.6
PB0.7
PB0.8
PB0.9
PB0.10
PB0.11
FACILITY IDENTIFICATION
INTERVIEWER CHECKPOINT:
Which type of facility is this?
How many villages does this facility
serve, including the village in which the
facility is located?
What are
Vill. A. Name of village
the names No.
of the
villages
this
facility
serves and
their
distance
from the
1
facility?
2
3
4
5
6
7
8
9
10
11
12
To which sector does this facility
belong?
How far is this facility from the PHC
that heads this sector?
When is the monthly meeting for this
sector?
INTERVIEWER CHECKPOINT: What
is the code number of the facility that
heads this sector?
To which block does this facility
belong?
How far is this facility from the facility
that heads this block?
When is the monthly meeting for this
block?
INTERVIEWER CHECKPOINT: What
is the code number of the facility that
heads this block?
PB0.12
PB0.8
CHC………………………………..1
PHC………………………………..2
Aidpost…………………………….3
Subcentre…………………………..4
Other................................................996
Number of villages[
B. Does the
facility serve the
whole village or
only some
hamlets in the
village?
PB1
]
C. Distance from facility
(Km)
whole village....1
partial village....2
min [
min [
min [
min [
min [
min [
min [
min [
min [
min [
min [
min [
[
][
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][
][
][
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][
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max[
max[
max[
max[
max[
max[
max[
max[
max[
max[
max[
max[
][
][
][
][
][
][
][
][
][
][
][
][
]
]
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]
]
]
]
]
]
]
]
][ ][ ] Km
Date 1 [ ][ ]
Date 2 [
Code [ ][ ][ ]
][ ]
Facility not in sample...........................998
[
][ ][ ] Km
Date [ ][ ]
Code [ ][ ][ ]
Facility not in sample...........................998
2
PB0.12
PB0.13
PB0.14
PB0.15
PB0.16
CHC……………………………….1
PHC………………………………..2
Aidpost…………………………….3
Subcentre…………………………..4
Other.............................................996
How many subcentres, aidposts, and
Subcentres [ ][ ][ ]
PHCs come under this CHC?
Aidposts [ ][ ][ ]
PHCs
[ ][ ][ ]
What are the
Fac. A. Name/location
B. Distance C. Facility code
names/locations
No.
of facility
from facility (998 if not in sample)
of the PHCs that
(Km)
come under this
1
[ ][ ]
[ ][ ][ ]
facility and how
2
[ ][ ]
[ ][ ][ ]
far are they from 3
[ ][ ]
[ ][ ][ ]
this facility?
4
[ ][ ]
[ ][ ][ ]
5
[ ][ ]
[ ][ ][ ]
6
[ ][ ]
[ ][ ][ ]
7
[ ][ ]
[ ][ ][ ]
8
[ ][ ]
[ ][ ][ ]
9
[ ][ ]
[ ][ ][ ]
10
[ ][ ]
[ ][ ][ ]
11
[ ][ ]
[ ][ ][ ]
12
[ ][ ]
[ ][ ][ ]
What are the
Fac. A. Name/location
B. Fac. type C.
D. Facility
names, locations, No.
of facility
1-AP
Distance code
and facility types
2-Subcentre from
(998 if not in
of the facilities
facility
sample)
that come under
(Km)
this PHC and how 1
1 2
[ ][ ] [ ][ ][ ]
far are they from 2
1 2
[ ][ ] [ ][ ][ ]
this PHC?
3
1 2
[ ][ ] [ ][ ][ ]
4
1 2
[ ][ ] [ ][ ][ ]
5
1 2
[ ][ ] [ ][ ][ ]
6
1 2
[ ][ ] [ ][ ][ ]
7
1 2
[ ][ ] [ ][ ][ ]
8
1 2
[ ][ ] [ ][ ][ ]
9
1 2
[ ][ ] [ ][ ][ ]
10
1 2
[ ][ ] [ ][ ][ ]
11
1 2
[ ][ ] [ ][ ][ ]
12
1 2
[ ][ ] [ ][ ][ ]
INTERVIEWER CHECKPOINT:
WHICH TYPE OF FACILITY IS
THIS?
How many people does this facility
serve?
PB0.15
PB0.16
PB0.16
PB0.16
PB0.12
Number of people [ ][ ][ ][ ][ ][ ]
PB1
PERSONNEL IN THE FACILITY
ASK QUESTIONS PB1.1 TO PB1.16 FOR EACH TYPE OF PERSONNEL AND RECORD
ANSWERS IN THE GRID
PB1.1 How many sanctioned posts are
there for _______ at this facility?
3
PB1.2
A. Doctors/Medical Officers
B. Compounders or male nurses
C. Pharmacists
D. Multipurpose workers
E. ANMs
F. Staff nurses
G. LHVs (lady health visitors)
H. Lab technicians
I. Radiographers
J. Divisional clerk (L.D.C/U.D.C)
K. Sector supervisor
L. Driver
M. Fourth class
How many of these sanctioned posts
for _______ are currently vacant?
1 or more, specify number………[ ][ ]
Don't know...........................................999
[ ][ ]
Don't know..........................999
PB1.3
How many ________ are on the roll
at this facility?
1 or more, specify number………[
PB1.4
PB1.5
PB1.6
PB1.7
PB1.8
PB1.9
PB1.10
PB1.11
PB1.12
PB1.13
How many of the ________ who are
posted at this facility are deputed to
another public facility?
How many ________ are actually
working at this facility?
How many of the ________ who are
actually working at this facility are
not posted at this facility but are
deputed from another public facility?
How many of the ________ who are
actually working at this facility are
paid privately?
How many of the _________ who
are actually working at this facility
are women?
How many of the _________ who
are actually working at this facility
live in the facility?
How many of the _________ who
are actually working at this facility
live locally (within 5 km of the
facility)?
How many of the _________ who
are actually working at this facility
live in Udaipur?
How many of the _________ who
are actually working at this facility
have a separate private practice?
How many of the _________ who
[
][ ]
][ ]
None…………………………………….0
PB1.1
1 or more, specify number………[
(NEXT
TYPE)
[
][ ]
[
][ ]
[
][ ]
[
][ ]
[
][ ]
[
][ ]
[
][ ]
][ ]
4
are actually working at this facility
[ ][ ]
work at this facility part time?
PB1.14 How many of the _________ who
are actually working at this facility
[ ][ ]
are in the facility right now?
PB2
ACTIVITIES OF THE FACILITY
PB2.1 What are the facility's official hours
during the winter?
1. Monday
to Saturday
(write morning hours in row 1 and
evening hours in row 2)
2. Sunday
PB2.2
What are the facility's official hours
during the summer?
(write morning hours in row 1 and
evening hours in row 2)
PB2.3
PB2.4
Does the facility follow the official
schedule of open and close times?
Does the facility have regular hours?
PB2.5
What are the facility's actual hours?
(write morning hours in row 1 and
evening hours in row 2)
PB2.6
On average, how many hours is the
facility actually open each day of the
week?
PB2.7
INTERVIEWER CHECKPOINT:
Are there any doctors who are
actually working in this facility?
Are any of the doctors who work in
this facility specialists?
PB2.8
1. Monday
to Saturday
Open:
Close:
A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
A. [ ][ ].[ ][
B. [ ][ ].[ ][ ]
Open:
A. [ ][ ].[ ][
B. [ ][ ].[ ][ ]
] [ ][ ].[ ][ ]
[ ][ ].[ ][ ]
Close:
] [ ][ ].[ ][ ]
[ ][ ].[ ][ ]
2. Sunday
A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
Open:
Close:
1. Monday
A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
2. Tuesday
A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
3. Wednesday A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
4. Thursday A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
5. Friday
A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
6. Saturday A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
7. Sunday
A. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
B. [ ][ ].[ ][ ] [ ][ ].[ ][ ]
Day of the week
Number of hours
Monday............... [ ]
Tuesday............... [ ]
Wednesday.......... [ ]
Thursday............. [ ]
Friday.................. [ ]
Saturday.............. [ ]
Sunday................ [ ]
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
PB2.7
PB2.6
PB2.7
PB2.11
PB2.11
5
PB2.9
How many of the doctors who work
in this facility are specialists?
PB2.10 In which type of treatment/illnesses
does each doctor specialize?
Number of specialists [ ]
Specialist 1.................................
Specialist 2.................................
PB2.11 Does this facility sponsor or
participate in health camps?
PB2.12 How often does this facility sponsor
or participate in health camps?
PB2.13 Which health issues/illnesses do
these camps address?
(CIRCLE ALL THAT APPLY)
Specialist 3.................................
Yes………………………………..1
No………………………………...2
Number of camps….[ ][ ]
Time interval:
Year………………………..1
Month……………………..2
Week..……………………..3
Family planning............................1
Immunization/vaccination............2
STDs/RTI.....................................3
General health..............................4
Eyes/vision...................................5
Other (specify__________).........996
Yes………………………………..1
No………………………………...2
PB2.14 Does any staff member treat patients
in his/her home (either as part of this
same job or as part of another job)?
PB2.15 How many staff members treat
patients in their home (either as part
of this same job or as part of another [ ][ ]
job)?
PB2.16 ASK QUESTIONS PB2.17 TO PB2.22 FOR EACH STAFF MEMBER WHO
TREATS PATIENTS IN THEIR HOME EITHER AS PART OF THIS SAME JOB
OR AS PART OF ANOTHER JOB AND RECORD ANSWERS IN THE GRID. (2)
PB2.17 What is the designation of the staff Doctor/Medical officer.…………....1
member who treats patients in
Compounder or male nurse..………2
his/her home?
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………...7
Lab technician....................................8
Radiographer.....................................9
Clerk..................................................10
Sector supervisor..............................11
PB2.18 How far from the facility is this
staff member's home?
[ ][ ] Km
PB2.19 Does this staff member treat
At regular intervals.………..1
patients from his/her home at
For emergencies..…………..2
regular intervals, in the case of
Both……..…………………3
emergencies only, or both?
PB2.20 INTERVIEWER CHECKPOINT:
Yes………………………………..1
Does this staff member live in the
No………………………………...2
PB2.14
PB2.24
PB2.23
PB2.23
6
facility?
PB2.21 How often does this staff member
see patients in his/her home?
PB2.22 On an average day when this staff
member is seeing patients in his/her
home, how many hours does he/she
spend seeing patients?
PB2.23 Does this staff member take fees
when he/she sees patients in his/her
home?
PB2.24 Does any staff member visit
villages/hamlets for outreach
activities?
PB2.25 How many staff members visit
villages/hamlets for outreach
activities?
PB2.26 Which
Vill A. Village
villages/ha
No. name
mlets do
staff
members
visit for
outreach
activities,
how often
does
someone
from the
facility visit
each of
these
1
villages/ha
mlets, and
how far is
2
each of
these
villages/ha
mlets from
the facility? 3
4
Number of days….[ ][ ]
Time interval:
Year………………………..1
Month……………………..2
Week..……………………..3
Do not know...................–999
Number of hours [
][ ]
Do not know...................–999
Yes………………………………..1
No………………………………...2
Do not know...................–999
Yes………………………………..1
No………………………………...2
Number of staff members [
B. Do staff
members
from the
facility visit
the whole
village or
only some
hamlets in the
village?
PB2.31
]
C. Frequency of
visits
D. Dist. from
fac.
(Km)
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
min [ ][ ]
whole
village....1
partial
village....2
max[
][ ]
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
7
5
6
7
8
9
10
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
min [ ][ ]
max[
][ ]
PB2.27 ASK QUESTIONS PB2.27 TO PB2.29 FOR EACH STAFF MEMBER WHO VISITS
VILLAGES FOR OUTREACH ACTIVITIES AND RECORD ANSWERS IN THE
GRID.
PB2.28 What is the designation of the staff
Doctor/Medical officer.…………....1
member who visits villages for
Compounder or male nurse..………2
outreach activities?
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………...7
Lab technician....................................8
Radiographer.....................................9
Clerk..................................................10
Sector supervisor..............................11
PB2.29 Does this staff member visit villages At regular intervals.………..1
at regular intervals, on call, or both?
On call…….………………..2
Both……..…………………3
PB2.30 How often does this staff member
Number of days….[ ][ ]
visit villages for outreach activities?
Time interval
Year………………………..1
Month……………………..2
Week………………………..3
PB2.31 INTERVIEWER CHECKPOINT:
Yes………………………………..1
Is the facility a PHC or CHC?
No………………………………...2
PB2.32 Does any staff member visit
Yes………………………………..1
subcentres/aidposts as a supervisor?
No………………………………...2
PB2.33 How many staff members visit
Number of staff members [ ]
subcentres/aidposts as supervisors?
PB2.31
PB2.38
PB2.38
8
PB2.34 Which
subcentres/aid
posts does a
staff member
visit as a
supervisor,
how often does
a staff member
visit these
facilities, and
how far is each
of these
facilities from
this one?
Fac
No.
1
2
3
4
5
6
7
8
9
10
11
12
A.
Name/location
of facility
B. Frequency of
visits
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
C.
Distance
from
facility
(Km)
D. Facility
code (998 if
not in
sample)
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][ ]
[ ][ ]
[
][ ][ ]
]
]
]
9
PB2.35 ASK QUESTIONS PB2.36 AND PB2.37 FOR EACH STAFF MEMBER WHO
VISITS SUBCENTRES/AIDPOSTS AS A SUPERVISOR AND RECORD
ANSWERS IN THE GRID.
PB2.36 What is the designation of the staff
Doctor/Medical officer.…………....1
member who visits
Compounder or male nurse..………2
subcentres/aidposts as a supervisor?
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………...7
Lab technician....................................8
Radiographer.....................................9
Clerk..................................................10
Sector supervisor..............................11
PB2.37 How often does this staff member visit Number of days….[ ][ ]
subcentres/aidposts as a supervisor?
Time interval
Year………………………..1
Month……………………..2
Week………………………..3
PB2.38 Does any staff member at this facility Yes………………………………..1
ever work in another public facility?
No………………………………...2
PB2.39 How many staff members at this
facility also work in other public
Number of staff members [ ]
facilities?
PB2.40 ASK QUESTIONS PB2.41 TO PB2.44 FOR EACH STAFF MEMBER AT THIS
FACILITY WHO ALSO WORKS IN ONE OR MORE OTHER PUBLIC
FACILITIES AND RECORD ANSWERS IN THE GRID.
PB2.41 What is the designation of the staff
Doctor/Medical officer.…………....1
member who also works in one or
Compounder or male nurse..………2
more other public facilities?
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………...7
Lab technician....................................8
Radiographer.....................................9
Clerk..................................................10
Sector supervisor..............................11
Driver................................................12
Fourth class......................................13
PB2.42 Does this staff member have the same Yes………………………………..1
designation at the other public facility No………………………………...2
that they have at this facility?
PB2.43 In what capacity does this staff
Doctor/Medical officer.…………....1
member work in one or more other
Compounder or male nurse..………2
public facilities?
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………...7
PB2.45
PB2.44
10
PB2.44
PB2.45
PB2.46
PB2.47
PB2.48
PB2.49
PB2.50
Lab technician....................................8
Radiographer.....................................9
Clerk..................................................10
Sector supervisor..............................11
Driver.................................................12
Fourth class......................................13
Operation assistant...........................14
Other (specify__________).............996
How often does this staff member
Number of days….[ ][ ]
work in another public facility?
Time interval
Year………………………..1
Month……………………..2
Week..……………………..3
INTERVIEWER CHECKPOINT: Is
Yes………………………………..1
this facility a CHC or PHC?
No………………………………...2
Is the facility ever closed during the
Yes………………………………..1
regular scheduled hours?
No………………………………...2
In the last 30 days, how many Because staff member(s) is/are: A. No. of B. No. of
full days or half days was the
half days full days
facility closed during the
1. Working in a health camp
[ ][ ]
[ ][ ]
regular scheduled hours for
2. Visiting villages for outreach [ ][ ]
[ ][ ]
each of the following
activities
reasons?
3. Supervising other facilities
[ ][ ]
[ ][ ]
4. Treating patients in their own [ ][ ]
[ ][ ]
home
5. Attending a meeting
[ ][ ]
[ ][ ]
6. Working in another public
[ ][ ]
[ ][ ]
facility
7. On holiday
[ ][ ]
[ ][ ]
996. Other (specify__________) [ ][ ]
[ ][ ]
Is there ever a time when the facility
Yes………………………………..1
is open but no one who treats patients No………………………………...2
is there?
In the last 30 days, how many Because staff member(s) is/are: No. of
No. of full
full days or half days was the
half days days
facility open during the
1. Working in a health camp
[ ][ ]
[ ][ ]
regular scheduled hours but
2. Visiting villages for outreach [ ][ ]
[ ][ ]
no one who treats patients
activities
was there for each of the
3. Supervising other facilities
[ ][ ]
[ ][ ]
following reasons?
4. Treating patients in their own [ ][ ]
[ ][ ]
home
5. Attending a meeting
[ ][ ]
[ ][ ]
6. Working in another public
[ ][ ]
[ ][ ]
facility
7. On holiday
[ ][ ]
[ ][ ]
996. Other (specify__________) [ ][ ]
[ ][ ]
How many patients did providers from
this facility see in the last 7 days:
PB2.50
PB2.48
PB2.50
A. at the facility...................................
11
Number of patients [ ][ ][ ][ ]
B. during village visits.........................
Number of patients [ ][ ][ ][ ]
Yes………………………………..1
No………………………………...2
PB2.51 Do you refer patients to other
facilities?
PB2.52 How many cases did you refer to other
facilities in the last month?
[ ][ ]
PB2.53 To how many different facilities do
you refer patients?
[ ][ ]
PB2.54 ASK QUESTIONS PB2.55 TO PB2.61 FOR EACH FACILITY TO WHICH THIS
HEALTH PROVIDER REFERS PATIENTS AND RECORD ANSWERS ON GRID.
PB2.55 If you refer a patient to another
facility, where do you send them?
Facility Name..………………………..
RECORD IN GRID
PB2.56 What type of facility is this?
RECORD ON GRID
PB2.57 What is the distance [from this
facility]?
RECORD ON GRID
PB2.58 What form of transportation does the
patient usually use to travel to this
facility?
CIRCLE ALL THAT APPLY
RECORD ON GRID
PB2.59 If a patient is in serious or critical
condition when referred to another
facility, does the staff from this
facility accompany the patient?
RECORD ON GRID
PB2.60 Who usually accompanies the patient?
CIRCLE ALL THAT APPLY
RECORD ON GRID
PB2.62
Village/Town………………..……….
District/Tehsil...…………………......
PHC/CHC……………….………...1
Government referral hospital……...2
Private hospital………………….…3
Aryuvedic hospital…………….…..4
Subcentre/Aidpost…………….…...5
Dispensary…………………….…...6
NGO clinic…………………….…..7
Private qualified doctor/
compounder/pharmacist….…....8
Other (Specify____________)....996
[ ][ ][ ] Km
Don’t know
Ambulance (belonging to this facility) ………..1
Ambulance (belonging to another facility).……2
Common transport (public or private)…............3
Patient’s own transportation………...............…4
Catch ride on road………………….............…..5
Foot………………………………….................6
Other (specify_____________)………......…..996
Yes, always.………………………1
PB2.61
No…………………………………2
Yes, sometimes……………………3
Doctor/Medical officer...…………..1
Compounder or male nurse.……….2
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………..7
Lab technician...................................8
12
Radiographer.....................................9
Clerk.................................................10
Sector supervisor..............................11
Driver................................................12
Fourth class......................................13
Other (specify____________)…….996
PB2.61 Is there any other facility to which you Yes………………………………..1
refer patients?
No………………………………...2
RECORD ON GRID
PB2.55
13
PB2.62 Does this facility provide
________services?
A.
B. If YES:
Where is the
service
provided? (circle
all that apply)
Yes No
1. First aid/curative care
2. Preventative care
3. Diagnostic care
Stitching of wounds:
4. first stitch
5. additional stitches
6. Changing of wound
dressing
7. Incision of abscess,
piercing of boils
8. Medical treatment for
TB [TBC]
9. Dental exam
10. Prenatal care
11. Postnatal care
12. Delivery
13. Nutrition
supplementation
Child immunization
14. BCG
15. DPT
16. Anti polio
17. Measles
18. Immunization of
pregnant women for
tetanus toxoid
19. Immunization against
Hepatitis B
Supply of contraceptives
20. condoms
21. oral
22. IUD
23. injections
24. sterilization for
men
In facility ...... 1
During village
visits ............. 2
Health camp.. 3
Anganwadi..... 4
Other ...........996
C. If YES: how many days
per week or per month is the
service provided?
9 = if the service is offered with
special conditions or arrangements
per week......1
per month....2
[
[
[
] days 1
] days 1
] days 1
2
2
2
[
[
[
] days 1 2
] days 1 2
] days 1 2
[
] days 1
2
1
1
1
2
2
2
1 2 3 4 996
1 2 3 4 996
1 2 3 4 996
1
1
1
2
2
2
1 2 3 4 996
1 2 3 4 996
1 2 3 4 996
1
2
1 2 3 4 996
[
] days 1
2
1
2
1 2 3 4 996
1
1
1
1
1
2
2
2
2
2
1
1
1
1
1
[
[
[
[
[
] days
] days
] days
] days
] days
1
1
1
1
1
2
2
2
2
2
[
[
[
[
[
] days
] days
] days
] days
] days
1
1
1
1
1
2
2
2
2
2
[
] days 1
2
[
[
[
[
[
] days
] days
] days
] days
] days
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
996
996
996
996
996
996
996
996
996
996
1 2 3 4 996
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
996
996
996
996
996
1
1
1
1
1
14
PB2.63
PB2.64
PB2.65
PB2.66
25. sterilization for
1
women
26. Treatment for STDs
1
27. Family planning
1
check-up/counseling
Laboratory exams
28. Hemoglobin (Hb)
1
29. Leukocyte
1
calculation
30. Blood type
1
calculation
31. Erythrocyte
1
calculation
32. Urinalysis
1
33. Pregnancy test
1
34. Feces examination
1
35. First Sputum
1
examination
36. Following sputum
1
tests
37. Blood test for
1
STDs
Syndromic diagnosis of
STD's
38. Genital ulcers
1
39. Discharge
1
40. Lower abdominal
1
pain
Does this facility provide inpatient
services?
Does the facility provide
observation services?
Does this facility charge any fees
for registration, treatment, or any
other services?
Do you charge fees for
any of the following
services?
Yes No
1. Registration
2. Consultation
3. Medication
4. Drip
5. Inpatient stay
6. Laboratory exams
7. Operation
996. Other (specify)
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
1 2 3 4 996
[
] days 1
2
2
2
1 2 3 4 996
1 2 3 4 996
[
[
] days 1
] days 1
2
2
2
2
1 2 3 4 996
1 2 3 4 996
[
[
] days 1
] days 1
2
2
2
1 2 3 4 996
[
] days 1
2
2
1 2 3 4 996
[
] days 1
2
2
2
2
2
1
1
1
1
996
996
996
996
[
[
[
[
] days
] days
] days
] days
2
1 2 3 4 996
[
] days 1
2
2
1 2 3 4 996
[
] days 1
2
2
2
2
1 2 3 4 996
1 2 3 4 996
1 2 3 4 996
[
[
[
] days 1
] days 1
] days 1
2
2
2
2
2
2
2
3
3
3
3
4
4
4
4
1 2
1 2
1 2
1 2
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
PB3
IF YES, how much do you charge for this service?
Min: Rs. [
Min: Rs. [
Min: Rs. [
Min: Rs. [
Min: Rs. [
Min: Rs. [
Min: Rs. [
Min: Rs. [
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
] Max: Rs. [
] Max: Rs. [
] Max: Rs. [
] Max: Rs. [
] Max: Rs. [
] Max: Rs. [
] Max: Rs. [
] Max: Rs. [
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
][
]
]
]
]
]
]
]
]
15
PB3
PB3.1
PB3.2
AVAILABILITY OF INSTRUMENTS, MEDICINES, VACCINES, LAB
EQUIPMENT, ETC.
Are vaccines ever available at this facility?
Yes………………………………..1
No………………………………...2
Are ________
A.
B.
C.
D.
vaccines
IF YES: Is Is a stock of IF STOCK IS KEPT IN
available at this
this
this vaccine FACILITY: How many
facility?
vaccine
kept in this
weeks in the last 6 months
available
facility?
were there no vaccines/did
today?
you run out of vaccines of
this type?
PB3.6
 more than 3 days = 1 week
Yes No
PB3.3
PB3.4
PB3.5
PB3.6
PB3.7
PB3.8
Yes No
Yes No
Don’t know....................99
Not in stock at all in last
6 months.........................88
[ ][ ] weeks
1
2
[ ][ ] weeks
1
2
[ ][ ] weeks
1
2
[ ][ ] weeks
1
2
[ ][ ] weeks
1
2
[ ][ ] weeks
1
2
Vaccine refrigerator/freezer……………1
Special vaccine cooling box….........…..2
Regular refrigerator……………………3
Non-electrical refrigerator….………….4
No storing place for vaccines available..5
What kind of needle is used at this facility
Disposable………………………...........1
for vaccinations?
Non-disposable…………..........….........2
Both disposable and non-disposable.......3
None........................................................4
What kind of needle or syringe is used at this Disposable only………………………...1
facility for general use?
Non-disposable only…………...………2
Both disposable and non-disposable.......3
None..................………………………..4
What method of sterilization is used at this
Sterilizer………………………………1
facility?
Boil the needle in water................……2
Rinse it in alcohol…………………….3
(CIRCLE ALL THAT APPLY)
Heat the needle with fire……………..4
Non-sterilized………………………..5
None………………………………….6
Other (specify___________)……….996
INTERVIEWER CHECKPOINT
Yes………………………………..1
Is this facility a subcentre or an aidpost?
No………………………………...2
How often does this subcentre/aidpost get
Number of days[ ][ ]
supplies in needles and/or syringes from the Time interval:
sector PHC or block PHC/CHC?
Year…………..........1
Month……………..2
Week..……………..3
1. BCG
1
2
1
2
2. DPT
1
2
1
2
3. Anti polio
1
2
1
2
4. Measles
1
2
1
2
5. Tetanus Toxoid 1
2
1
2
6. Hepatitis B
1
2
1
2
Where are vaccines usually kept at this
facility?
PB3.9
16
PB3.9
Are _______
medicines
provided at this
facility?
A.
B.
If NO: Are
________
medicines
prescribed
here?
Yes No
Yes No
C.
If YES: Where are
these medicines
provided? (circle
all that apply)
D.
If YES:
is it
in stock
today?
In facility ...... 1
During village
visits ............. 2
Health camp.. 3
Anganwadi.....4
Other ..........996
E.
In the last
6 months
how many
weeks was
this
medicine
not in
stock?
 more than
3 days = 1
week
Yes No
Don’t
know.....99
Not in stock
at all in last
6 months.88
17
1. Antibiotic
2. Analgesic
PB3.11
1
2
2
1
1
2
1
2
1
2
4. Antifungal
1
2
1
2
5. Anti-TBC
1
2
1
2
6. Anti-malaria
1
2
1
2
7. Skin disease
1
2
1
2
8. Antidehydration
(ORS/IV fluids)
1
2
1
2
9. Pre/post-natal
care (IFA,
Vitamin A)
1
10. Antidepressant
1
11. Antiasthmatic
1
12. Muscle
relaxants
1
13. Anti-venom
1
1
2
2
2
2
2
2
1
1
1
1
1
1
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
1 2 3 4 996
1
2
[
][ ]
2
3. Antipyretic
14. Anti-diabetic
PB3.10
1
2
2
2
2
2
2
15. Emergency
1
2
1
2
medicines
INTERVIEWER CHECKPOINT
Is this facility a subcentre or an aidpost?
How often does this subcentre/aidpost get
supplies in medicine from the sector PHC
or block PHC/CHC?
1 2 3 4 996 1 2
[ ][ ]
Yes………………………………..1
No………………………………...2
Number of days[ ][ ]
Time interval:
Year…………..........1
Month……………..2
Week..……………..3
PB3.12
18
PB3.12
Does the facility have ________today?
a.
Yes
1. Stethoscope
2. Blood pressure instrument
3. Thermometer
4. Needles
5. Syringes
6. Torchlight
7. Gloves
8. Adult weighing scale
9. Infant weighing scale
10. Vehicle
11. Cooling box
12. Slide/ready-made glass
13. Drip stand
14. Telephone
15. Spirit lamp
16. Microscope
17. Electricity
PB4
PB4.1
PB4.2
PB4.3
PB4.4
PB4.5
PB4.6
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
b. If YES:
Is it working now?
No
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2 PB4
Yes
No
1
2
1
2
1
2
XXXX
XXXX
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
18. Sterilizer
1
2
1 2
19. Refrigerator
1
2
1 2
20. Freezer
1
2
1 2
21. Echocardiogram
1
2
1 2
22. X-ray machine
1
2
1 2
23. Centrifuge
1
2
1 2
PHYSICAL CONDITION OF THE BUILDING AND ROOMS
When did this facility first open for
services at this location?
Year [ ][ ][ ][ ]
Do not know………………….-999
INTERVIEWER CHECKPOINT
Yes………………………………..1
Is this facility a subcentre?
No………………………………...2
Does the facility have a building?
Yes………………………………..1
No………………………………...2
Where does the ANM from this facility
sit?
INTERVIEWER CHECKPOINT: Is
Yes………………………………..1
there electricity at this facility?
No………………………………...2
What is the main electricity source
PLN (State Electricity Company)………1
used by this facility?
Local Government/Government Agency.2
Generator………………………………..3
CIRCLE MORE THAN ONE ONLY
Public/Community Initiative……………4
IF SOURCES ARE EQUALLY
Private Company/Cooperative………….5
SHARED
Other (specify____________)…………996
PB4.5
PB4.5
PB4.8
19
PB4.7
PB4.8
Is this electricity source working right
now?
What is the main water source used by
this facility?
CIRCLE MORE THAN ONE ONLY
IF SOURCES ARE EQUALLY
SHARED
PB4.9
PB4.10
Is this _____water transported by
pipes?
Is this water source in the building?
PB4.11
How far is it from the building?
PB4.12
Is this water source working/does it
have water right now?
What is the water source used by this
facility right now?
PB4.13
PB4.14
PB4.15
Is this _____water transported by
pipes?
Is this water source in the building?
PB4.16
How far is it from the building?
PB4.17
Does this facility have a bathroom?
PB4.18
Which type of toilet facility is used?
PB4.19
Do patients use this bathroom?
Yes………………………………..1
No………………………………...2
Piped water (PAM)…….………………..1
Pump water (manual pump)…………..…2
Tubewell....................................................3
Well water…………………………….…4
Spring water………………………….….5
Rain water…………………………….…6
River water………………………….…..7
Lake water………………………….……8
Purchased from vendor…………….…….9
Water tank………………...……………10
Other (specify_____________)……….996
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
Less than 10 meters………………1
10 to 30 meters…………………...2
30 to 100 meters…………….........3
More than 100 meters.....................4
Yes………………………………..1
No………………………………...2
Piped water (PAM)…….…………….......…..1
Pump water (electric/manual pump)…........…2
Tubewell...........................................................3
Well water…………………….......……….…4
Spring water………………….......……….….5
Rain water…………………….......……….…6
River water…………………….......…….…..7
Lake water……………………….......….……8
Purchased from vendor………….......….…….9
Water tank………………...…….......………10
Other (specify_____________)….....……..996
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
Less than 10 meters………………1
10 to 30 meters…………………...2
30 to 100 meters…………….........3
More than 100 meters.....................4
Yes………………………………..1
No………………………………...2
Private toilet with septic tank…….1
Private toilet without septic tank…2
Common toilet……………………3
No toilet………………………….4
Yes………………………………..1
No………………………………...2
PB4.12
PB4.17
PB4.17
PB4.20
20
PB4.20
PB4.21
PB4.22
PB4.23
PB4.24
PB4.25
PB4.26
PB4.27
PB4.28
PB4.29
What is the main waste-water disposal
system at this facility?
(CIRCLE MORE THAN ONE ONLY
IF EQUALLY USED)
What is the main solid waste disposal
system at this facility?
Running…………………………...1
Collection…………………………2
Tossed out (without collection)......3
Other (specify_____________)…996
Burning……………………………1
Piled………………………………2
Removed………………………….3
Buried…………………………….4
Other (specify_____________)..996
(CIRCLE MORE THAN ONE ONLY
IF EQUALLY USED)
How many examination beds does this
facility have?
[ ][ ] examination beds
How many beds does this facility have
(excluding examination beds)?
[ ][ ] beds
How many rooms does this facility
have?
[ ][ ] rooms
ASK QUESTIONS PB4.26 TO PB4.34 FOR EACH ROOM IN THE FACILITY
AND FILL RESPONSES IN THE GRID.
What is the official function of this
Registration room…………………….1
room?
Waiting room…………………………2
(CIRCLE ALL THAT APPLY)
Examination room…………………….3
Injection room…………………………4
FP/MCH consultation room...................5
FP service room......................................6
Delivery room........................................7
Inpatient room........................................8
Observation room....................................9
Dressing room........................................10
Storage room..........................................11
Pharmacy……………………………...12
Vaccine storage room…………………13
Operation……………………………..14
Laboratory…………………………….15
Living quarters.......................................16
OPD (out-patient department)...............17
X-ray room............................................18
Record keeping......................................19
Garage....................................................20
Staff break room………………………21
Bathroom………………………………22
Other (specify__________)………….996
Is this room in use now?
Yes………………………………..1
No………………………………...2
Is this room used for its official
Yes………………………………..1
function?
No………………………………...2
What is the actual function of this
Registration room…………………….1
room?
Waiting room…………………………2
Examination room…………………….3
(CIRCLE ALL THAT APPLY)
Injection room…………………………4
FP/MCH consultation room...................5
PB4.44
PB4.30
21
PB4.30
PB4.31
PB4.32
PB4.33
PB4.34
PB4.35
PB4.36
PB4.37
PB4.38
PB4.39
PB4.40
PB4.41
PB4.42
FP service room......................................6
Delivery room........................................7
Inpatient room........................................8
Observation room....................................9
Dressing room........................................10
Storage room..........................................11
Pharmacy……………………………...12
Vaccine storage room…………………13
Operation……………………………..14
Laboratory…………………………….15
Living quarters.......................................16
OPD (out-patient department)...............17
X-ray room............................................18
Record keeping......................................19
Garage....................................................20
Staff break room………………………21
Bathroom………………………………22
Other (specify__________)………….996
Does this room experience leaks during Yes………………………………..1
the rainy season?
No………………………………...2
Does the room flood during the rainy
Yes………………………………..1
season?
No………………………………...2
Is the room locked right now?
Yes………………………………..1
No………………………………...2
Does the key holder work in this
Yes………………………………..1
facility?
No………………………………...2
Is the key holder in the facility now?
Yes………………………………..1
No………………………………...2
FOR QUESTIONS PB4.36 TO 4.43, OBSERVE THE ROOM AND RECORD
ANSWERS IN THE GRID.
Are the walls clean?
Yes………………………………..1
No………………………………...2
No = if there are many spider webs,
scribbling, moisture or paint peeling
Is the floor clean?
Yes………………………………..1
No………………………………...2
No = if dust, food remnants, and/or
garbage on floor
Does the room have a window?
Yes………………………………..1
No………………………………...2
Does/do the windows have a screen?
Yes………………………………..1
No………………………………...2
Does the window have shutters?
Yes………………………………..1
No………………………………...2
Is/are the windows in good condition?
Yes………………………………..1
No………………………………...2
No = if it is broken
Does the room have _______?
Is it working
now?
(CIRCLE ALL THAT APPLY)
Yes No
Fan…………………….…..1 1
2
Bed [not exam]....…….…..2 1
2
PB4.35
PB4.44
PB4.42
22
PB4.43
What provisions are made for washing
hands in this room?
Is the wash stand working right now?
PB4.44
PB5
PB5.1
Are there any other rooms in the
facility?
RESPONDENT IDENTIFICATION
What is the main respondent’s name?
PB5.2
What is the main respondent’s
designation?
PB5.3
Did someone other than the main
respondent answer any section?
Which section(s)?
(circle all that apply)
PB5.4
PB5.5
PB5.6
What is the name of the other person
who answered this/these sections?
What is this other person’s
designation?
Exam bed…………………3 1
Trash can…………….....…4 1
Bench or chair………….....5 1
Cupboard…………….…....6 1
Desk……………………....7 1
Attached bathroom………..8 1
Other (specify_____)…..996 1
Wash stand with running water…..1
Wash basin with clean water……..2
Bucket with clean water………….3
Not available……………………..4
Yes………………………………..1
No………………………………...2
Yes………………………………..1
No………………………………...2
2
2
2
2
2
2
2
Doctor/Medical officer...…………..1
Compounder or male nurse.……….2
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………..7
Lab technician...................................8
Radiographer.....................................9
Clerk.................................................10
Sector supervisor..............................11
Driver................................................12
Fourth class......................................13
Other (specify____________)…….996
Yes………………………………..1
No………………………………...2
PB0……………………………….0
PB1……………………………….1
PB2……………………………….2
PB3……………………………….3
PB4……………………………….4



PB4.26
PB6
Doctor/Medical officer...…………..1
Compounder or male nurse.……….2
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………..7
Lab technician...................................8
Radiographer.....................................9
23
PB5.7
Did someone else answer any section?
PB5.8
Which section(s)?
(circle all that apply)
PB5.9
What is the name of the other person
who answered this/these sections?
What is this other person’s
designation?
PB5.10
Clerk.................................................10
Sector supervisor..............................11
Driver................................................12
Fourth class......................................13
Other (specify____________)……996
Yes………………………………..1
No………………………………...2
PB0……………………………….0
PB1……………………………….1
PB2……………………………….2
PB3……………………………….3
PB4……………………………….4
PB6
Doctor/Medical officer...…………..1
Compounder or male nurse.……….2
Pharmacist…………………………3
Multipurpose worker………………4
ANM………………………………5
Staff nurse.......................…………..6
LHV………………………………..7
Lab technician...................................8
Radiographer.....................................9
Clerk.................................................10
Sector supervisor..............................11
Driver................................................12
Fourth class......................................13
Other (specify____________)……996
24