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Department of Health & Family Welfare, Govt. of Assam
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National Health Mission, Assam
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Annex reporting format for SC and Equivalent Institutions
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District :______________________________________________
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Health Block : _________________________________________
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Name of Health Institution : ______________________________
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Facility Type : __________________________________________
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Ownership : Public / Private II Physical / Notional
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Report for the month of : _________________________________
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Data ElementsNumbers reported
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AAnte Natal Care (ANC) Services
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1No. of mothers given MCP Card
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2No of preterm labour (Less than 34 weeks) cases received antenatal corticosteriod during labour
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High Risk Pregnant Women (HRPW)
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3Number of High Risk Pregnant Women (HRPW) detected
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4Out of total identified high risk PW with other causes
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5Number of HRPW referred to higher facility
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JSSK benefits availedPregnant WomenSick Infant
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6Free Medicines and consumables under JSSK
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7Free Diagnostics under JSSK
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8Free Home to facility transport under JSSK
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9Interfacility transfers when needed under JSSK
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10Free Drop Back home under JSSK
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11No of Pregnant women tested for Hb%
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12No of Pregnant women tested for Albumin/ Sugar (Urine)
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BDeliveries
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Deliveries conducted at Home
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13Number of Home Deliveries attended by Skill Birth Attendant(SBA) (Doctor/Nurse/ANM)
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14Number of Home Deliveries attended by Non SBA (Trained Birth Attendant(TBA) /Relatives/etc.)
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Deliveries conducted at the Facility
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15Deliveries conducted during day time (From 8 AM to 8 PM)
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16Deliveries conducted during Night time (From 8 PM to 8 AM)
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Number of newborns having
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17Weight between 1 Kg to 1.49 Kg (VLBW)
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18Weight between 1.5 Kg to 2.49 Kg (LBW)
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Home base Newborn Care (HbNC)
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19No. of LBW/ high risk babies reported out of those visited (under HbNC)
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20No of Infants referred under HbNC
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Home base Young Child (HbYC)
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21No of Children received HbYC Visit for 3 months
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22No of Children received HbYC Visit for 6 months
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23No of Children received HbYC Visit for 9 months
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24No of Children received HbYC Visit for 12 months
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25No of Children received HbYC Visit for 15 months
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26Number of Infant exclusively breast fed for 6 months (HbYC visit at 6 months)
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27Number of Children initiated complementary feeding for 6 months (HbYC visit at 6 months)
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CChild Health
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New Born Care Corner (NBCC)
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28Whether the facility has Operational Newborn Care Corner (NBCC)?
(Yes-1, No-0)
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29No of Beds (Radiant Warmers) in NBCC
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30No of functional Bag and Musk in NBCC
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31No of asphyxiated newborn resuscitated
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Outcome of resuscitation
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32 No of Newborn Survived
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33 No of referred
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34 No of Death
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Children received Vitamin A Doses between 9 months and 5 years
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35Vitamin A Dose-2
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36Vitamin A Dose-3
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37Vitamin A Dose-4
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38Vitamin A Dose-6
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39Vitamin A Dose-7
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40Vitamin A Dose-8
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41No of children given ORS
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42No of children given Zinc for 14 days
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43Number of Infant received Inj Gentamicin by ANM before referral in suspected sepsis cases
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National Iron Plus Initiative (NIPI)
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NIPI (6-59)BoyGirlTotal
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44No of Children consumed 8 to 10 doses of IFA syrup per month
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45No of children identified with mild anaemia <11mg/dl in the month
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46No of children identified with moderate anaemia <9 mg/dl in the month
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47No of children identified with Severe anaemia <7 mg/dl in the month
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48No of childern refered to Health Institution for severe anaemia in the month
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49No fo children consumed albendazole in the month
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NIPI - Woman in Reproductive Age Group
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50No of woman consumed 4 to 5 red IFA tablet per month
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51No of woman identified with moderate anaemia <11 mg/dl in the month
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52No of identified with severe anaemia <9 mg/dl in the month
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53No of Woman refered to HI for severe anaemia in the month
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54No of woman consumed albendazole
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WIFS - Weekly Iron and Folic Acid Supplementation
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WIFS JuniorBoyGirlTotal
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55No of children consumed 4 to 5 pink IFA tablet per month in AWC
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56No of children sonsumed 4 to 5 pink IFA tablet per month in school
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57No of children identified with moderate anaemia <11 mg/dl
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58No of children identified with moderate anaemia <9 mg/dl
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59No of children identified with severe anaemia <7 mg/dl
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60No of children referred to HI for severe anaemia
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61No fo children consumed albendazole
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WIFS
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62No of children consumed 4 to 5 blue IFA tablet per month in AWC
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63No of children sonsumed 4 to 5 blue IFA tablet per month in school
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64No of children identified with moderate anaemia <11 mg/dl
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65No of children identified with moderate anaemia <9 mg/dl
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66No of children identified with severe anaemia <7 mg/dl
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67No of children refered to HI for severe anaemia
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68No fo children consumed albendazole
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DFamily Planning