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1 |
[record_id] |
Record ID |
text |
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2 |
[name_of_the_nurse] |
Name of the nurse |
text, Required Field Annotation: @APPUSERNAME-APP |
|
3 |
[section_1_facility_informa] |
Section 1: Facility Information |
descriptive |
|
4 |
[name_of_the_healthcare_fac] |
1.Name of the healthcare facility: |
text, Required |
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5 |
[facility_type] |
2.Facility Type |
dropdown, Required1 | HWC | 2 | SC | 3 | PHC | 4 | CHC | 5 | SDH | 6 | District Hospital | 7 | Private Clinic | 8 | Other |
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6 |
[facility_type_othr]
Show the field ONLY if:
[facility_type] = '8'
|
Other |
text, Required |
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7 |
[name_of_village] |
3.Name of village |
text, Required |
|
8 |
[name_of_sub_centre] |
4. Name of sub-centre: |
text, Required |
|
9 |
[block] |
5.Block |
dropdown, Required1 | Bhawanigarh | 2 | Dhuri | 3 | Dirba | 4 | Lehragaga | 5 | Moonak | 6 | Sherpur | 7 | Sunam | 8 | Other |
|
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10 |
[block_other]
Show the field ONLY if:
[block] = '8'
|
Other |
text |
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11 |
[name_of_district] |
6. Name of District |
text, Required |
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12 |
[name_of_pmsma_nodal_office] |
7. Name of PMSMA Nodal Officer: |
text, Required |
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13 |
[contact_information_of_nod] |
8. Contact Information of Nodal Officer: |
text (number, Min: 5555555555, Max: 9999999999), Required Field Annotation: @FORCE-MINMAX |
|
14 |
[date_of_pmsma_session_obse] |
9. Date of PMSMA session observation: |
text (date_dmy), Required |
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15 |
[total_hours_dedicated_to_p] |
10. Total hours dedicated to PMSMA session: |
text, Required |
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16 |
[section_2_service_delivery] |
Section 2: Service Delivery |
descriptive |
|
17 |
[num_of_asha_workers_present] |
11. Number of ASHA workers present: |
text (number), Required |
|
18 |
[number_of_anms_present] |
12. Number of ANMs present: |
text (number), Required |
|
19 |
[number_of_obstetricians_av] |
13. Number of Obstetricians available |
text (number), Required |
|
20 |
[number_of_gynaecologists_a] |
13.1 Number of Gynaecologists available |
text (number), Required |
|
21 |
[number_of_beneficiar_examin] |
14. Total number of beneficiaries examined |
text (number), Required |
|
22 |
[number_of_antenatal_check] |
15.Number of antenatal check-ups conducted: |
text (number), Required |
|
23 |
[number_of_high_risk_pregna] |
16. Number of high-risk pregnancies identified |
text (number), Required |
|
24 |
[number_of_beneficiaries_refrred] |
17. Number of beneficiaries referred for specialist consultation |
text (number), Required |
|
25 |
[services_provided_mark_all] |
Services provided (mark all that apply) |
descriptive |
|
26 |
[i_general_antenatal_check] |
I. General antenatal check-up |
yesno, Required Custom alignment: RH |
|
27 |
[ii_gestational_age_recorde] |
II. Gestational age recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
28 |
[iii_whether_a_functional_w] |
III. Whether a functional weighing machine available |
yesno, Required Custom alignment: RH |
|
29 |
[iv_weight_measurement_done] |
IV. Weight measurement done |
yesno, Required Custom alignment: RH |
|
30 |
[v_was_weight_recorded_in_a] |
V. was weight recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
31 |
[vi_whether_a_functional_sp] |
VI. Whether a functional sphygmomanometer and stethoscope available |
yesno, Required Custom alignment: RH |
|
32 |
[blood_pressure_measure] |
VII. Blood pressure measurement done |
yesno, Required Custom alignment: RH |
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33 |
[viii_was_blood_pressure_re] |
VIII. Was Blood pressure recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
34 |
[ix_were_diagnostic_service] |
IX. were diagnostic services available for hemoglobin screening |
yesno, Required Custom alignment: RH |
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35 |
[x_hemoglobin_estimation_do] |
X. Hemoglobin estimation done |
yesno, Required Custom alignment: RH |
|
36 |
[xi_was_hemoglobin_estimati] |
XI. was hemoglobin estimation recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
37 |
[xii_were_diagnostic_servic] |
XII. were diagnostic services available for Blood Glucose screening |
yesno, Required Custom alignment: RH |
|
38 |
[xiii_blood_sugar_testing] |
XIII. Blood sugar testing |
yesno, Required Custom alignment: RH |
|
39 |
[xiv_was_glucose_estimation] |
XIV. was glucose estimation recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
40 |
[xv_diagnostic_service] |
XV. were diagnostic services available for urine test for sugar/protein screening |
yesno, Required Custom alignment: RH |
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41 |
[xvi_urine_test_for_sugar_p] |
XVI . Urine test for sugar/protein |
yesno, Required Custom alignment: RH |
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42 |
[xvii_were_urine_test_resul] |
XVII. were urine test results for sugar/protein recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
43 |
[xviii_were_diagnostic_serv] |
XVIII. were diagnostic services available for USG screening |
yesno, Required Custom alignment: RH |
|
44 |
[xix_ultrasound_examination] |
XIX. Ultrasound examination done |
yesno, Required Custom alignment: RH |
|
45 |
[xx_was_usg_of_hrp_recorded] |
XX. was USG of HRP recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
46 |
[were_functional_instruments_available] |
XXI. were functional instruments available for checking the FHS |
yesno, Required Custom alignment: RH |
|
47 |
[xxii_was_fhs_checked] |
XXII. was FHS checked |
yesno, Required Custom alignment: RH |
|
48 |
[was_fhs_recded_in_anc_registartion] |
XXIII. was FHS recorded in ANC registers |
yesno, Required Custom alignment: RH |
|
49 |
[were_diagnostic_servives_vdrl] |
XXIV. were diagnostic services available for VDRL/Syphilis screening |
yesno, Required Custom alignment: RH |
|
50 |
[xxv_was_vdrl_syphilis_scre] |
XXV. was VDRL/Syphilis screening done |
yesno, Required Custom alignment: RH |
|
51 |
[xxvi_were_vdrl_syphilis_sc] |
XXVI. were VDRL/Syphilis screening results recorded in ANC registers |
yesno, Required Custom alignment: RH |
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52 |
[xxvii_were_hrps_identified] |
XXVII. were HRPs identified |
yesno, Required Custom alignment: RH |
|
53 |
[xxviii_were_line_list_of_h] |
XXVIII. were line-list of HRPs maintained (including place of deliveries) |
yesno, Required Custom alignment: RH |
|
54 |
[xxix_were_hrps_referred_to] |
XXIX. were HRPs referred to higher facility |
yesno, Required Custom alignment: RH |
|
55 |
[xxx_counseling_on_diet_and] |
XXX. Counseling on diet and nutrition |
yesno, Required Custom alignment: RH |
|
56 |
[xxxi_counseling_on_birth_p] |
XXXI. Counseling on birth planning/preparedness |
yesno, Required Custom alignment: RH |
|
57 |
[xxxii_counseling_on_birth] |
XXXII. Counseling on birth complication readiness/danger signs of pregnancy given |
yesno, Required Custom alignment: RH |
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58 |
[xxxiii_counseling_on_jssk] |
XXXIII. Counseling on JSSK benefits given |
yesno, Required Custom alignment: RH |
|
59 |
[xxxiv_was_calcium_suppleme] |
XXXIV. was Calcium supplementation provided |
yesno, Required Custom alignment: RH |
|
60 |
[xxxv_was_ifa_supplementati] |
XXXV. was IFA supplementation provided |
yesno, Required Custom alignment: RH |
|
61 |
[xxxvi_were_iec_material_s] |
XXXVI. were IEC material/s available |
yesno, Required Custom alignment: RH |
|
62 |
[xxxvii_did_the_venue_has_c] |
XXXVII. Did the venue has clean toilet and drinking water available |
yesno, Required Custom alignment: RH |
|
63 |
[xxxviii_other_specify] |
XXXVIII. Other (Specify): |
text, Required Custom alignment: RH |
|
64 |
[section_3_data_collection] |
Section 3: Data Collection and Reporting |
descriptive |
|
65 |
[was_the_standardized_pmsma] |
19. Was the standardized PMSMA data format used for data entry? |
yesno, Required Custom alignment: RH |
|
66 |
[were_the_service_details_c] |
20. Were the service details compiled and submitted by the ANM to the facility in-charge? |
yesno, Required Custom alignment: RH |
|
67 |
[did_the_facility_submit_th] |
21. Did the facility submit the compiled report to the district authorities within the stipulated timeframe? |
yesno, Required Custom alignment: RH |
|
68 |
[were_any_discrepancies_not] |
22. Were any discrepancies noted in data collection or reporting? |
yesno, Required Custom alignment: RH |
|
69 |
[specify]
Show the field ONLY if:
[were_any_discrepancies_not] = '1'
|
specify |
text, Required Custom alignment: RH |
|
70 |
[section_4_monitoring_and_s] |
Section 4: Monitoring and Supervision |
descriptive |
|
71 |
[were_monitoring_officials] |
23. Were monitoring officials present on the PMSMA day? |
yesno, Required Custom alignment: RH |
|
72 |
[specify_their_designation_23]
Show the field ONLY if:
[were_monitoring_officials] = '1'
|
specify their designation: |
text, Required Custom alignment: RH |
|
73 |
[were_any_gaps_or_challenge] |
24. Were any gaps or challenges identified in service delivery? |
yesno, Required Custom alignment: RH |
|
74 |
[specify_24]
Show the field ONLY if:
[were_any_gaps_or_challenge] = '1'
|
specify |
text, Required Custom alignment: RH |
|
75 |
[were_corrective_actions_su] |
25. Were corrective actions suggested and implemented? |
yesno, Required Custom alignment: RH |
|
76 |
[specify_25]
Show the field ONLY if:
[were_corrective_actions_su] = '1'
|
specify |
text, Required Custom alignment: RH |
|
77 |
[section_5_pmsma_app_e_pmsm] |
Section 5: PMSMA App & e-PMSMA Tracking |
descriptive |
|
78 |
[was_the_pmsma_app_used_for] |
26. Was the PMSMA app used for volunteer registration and engagement? |
yesno, Required Custom alignment: RH |
|
79 |
[were_private_voluntary_ret] |
27. Were private/voluntary/retired doctors involved in providing free antenatal services? |
yesno, Required Custom alignment: RH |
|
80 |
[specify_number_27]
Show the field ONLY if:
[were_private_voluntary_ret] = '1'
|
specify number |
text (number), Required Custom alignment: RH |
|
81 |
[was_e_pmsma_used_to_track] |
28. Was e-PMSMA used to track high-risk pregnancies? |
yesno, Required Custom alignment: RH |
|
82 |
[number_of_high_risk_pregna_updated_in_e_pmsma] |
29. Number of high-risk pregnancies updated in the e-PMSMA system |
text (number), Required Custom alignment: RH |
|
83 |
[section_6_feedback_and_rec] |
Section 6: Feedback and Recommendations |
descriptive |
|
84 |
[challenges_faced_during_pm] |
30. Challenges faced during PMSMA implementation |
text, Required Custom alignment: RH |
|
85 |
[suggestions_for_improving] |
31.Suggestions for improving PMSMA service delivery |
text, Required Custom alignment: RH |
|
87 |
[filled_by] |
Filled by |
text, Required Custom alignment: RH |
|
88 |
[designation] |
Designation: |
text, Required Custom alignment: RH |
|
89 |
[date] |
Date: |
text (date_dmy), Required Custom alignment: RH Field Annotation: @HIDEBUTTON |
|
90 |
[form_1_complete] |
Section Header: Form Status
Complete?
|
dropdown0 | Incomplete | 1 | Unverified | 2 | Complete |
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