ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJAKALAMANAOAPAQ
1
Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
DEIC Monthly Reporting Checklist
2
Name of the StateKeralaMonth of Reporting
3
Name of the DistrictYear
4
Name of facility where DEIC locatedHMIS/MCTS Facility code of DH (As aviliable)
5
Total deliveries as per HMIS in current reporting month in DH where the DEIC is located ( Reproted Delivery only in DH (HMIS) )Total live birth as per HMIS in current reporting month in DH where the DEIC is located Pre term
6
No of SNCUs in the DistrictWeight of newborn on Admission
Write Number 		<1000gm
7
As per SNCU online in current reporting month Total New borns AdmissionTotal Discharge1500-2499 gm1000-1499 gm
8
SNCU 1 Name
9
SNCU 2 Name
10
SNCU 3 Name
11
Total"--Select-"
12
Q1
Is DEIC functionally and structurally integrated with SNCU and MCH wing/ward ? Y/N
13
Data ItemsPrevious MonthApril "Financial Year"- till date
14
1.1Number of children referred to the DEIC from Mobile Health Teams #NAME?
15
(a)less than 1 year
16
(b)1-3 years
17
(c)4-6 years
18
(d)6-18 years
19
1.2Number of children referred to the DEIC from other public facilities
20
(a)less than 1 year
21
(b)1-3 years
22
(c)4-6 years
23
(d)6-18 years
24
1.3Number of children referred to the DEIC from other private facilities
25
(a)less than 1 year
26
(b)1-3 years
27
(c)4-6 years
28
(d)6-18 years
29
1.4Number of children walked into the DEIC on their own
30
(a)less than 1 year
31
(b)1-3 years
32
(c)4-6 years
33
(d)6-18 years
34
1.5Number of children referred by ASHAs in the DEIC
35
a.1For Birth Defect
36
a.1.1less than 1 year
37
a.1.21-3 years
38
a.1.34-6 years
39
a.1.46-18 years
40
a.2For Developmental delays from revised MCP card
41
a.2.1less than 1 year
42
a.2.21-3 years
43
a.2.34-6 years
44
1.6Number of repeat visit children in the DEIC
45
(a)less than 1 year
46
(b)1-3 years
47
(c)4-6 years
48
(d)6-18 years
49
2
Number of Children managed in DEIC
50
(a)less than 1 year
51
(b)1-3 years
52
(c)4-6 years
53
(d)6-18 years
54
3Number of Children referred to secondary and tertiary facilities 77
55
(a)less than 1 year
56
(b)1-3 years
57
(c)4-6 years
58
(d)6-18 yearsAvailable ? Y/NFunctional Y/N
59
AMedical Equipments ( A1- A8)Essential / Optionalnumber for each DEIC
60
A1Stethoscope (Paediatric)
61
A2Sphygmomanometer with Paediatric cuff with 3 different sizes (Infant, Child and Adult) Reusable
62
A3Infantometer with integrated head piece and sliding leg positioner 10-99cm
63
A4Electronic Baby Weighing Scale
64
A5Electronic Adult Weighing Scale (Platform Type)
65
A6Height Measuring scale -Stadiometer
66
A7MUAC tape
67
A8Head circumference tape-Non stretchable TEFLON synthetic materialY
68
Dedicated space available for medical check up for the patient, (Y/N)20 X 15
69
if available, write Length X Breadth (in ft.) of the space.If Trained date of training at Nodal centre
70
DesignationName of StaffDate of JoiningTrained in Basic DEIC 15 days training at Nodal Centre, Y/N2014
71
Paedatirician
72
MBBS (MO)
73
Available ? Y/NFunctional Y/N
74
BECG EquipmentsEssential / Optionalnumber for each DEIC
75
B1ECG machine with pediatric Chest leads:OptionalONE
76
B2Ultrasound cum ECHO Machine for Pediatric and neonateOptionalONE
77
Q4If ECG digital machine and ECHO machines are available, please respond to followingsPrevious MonthApril "Financial Year"- till date
78
1
Number of Children managed with CHD/RHD
79
(a)Less than 1 year
80
(b)1-3 years
81
(c)4-6 years
82
(d)6-18 years
83
2Number of Children referred to secondary and tertiary facilities
84
(a)Less than 1 year
85
(b)1-3 years
86
(c)4-6 years
87
(d)6-18 years
88
Available ? Y/NFunctional Y/N
89
CHearing Equipments Essential / Optionalnumber for each DEIC
90
C1Screener pediatric audiometerE
91
C2PURE TONE AUDIOMETER WITH BONE CONDUCTOR:DIAGNOSTICE
92
C3Paediatric Video Auroscope (Otoscope)E
93
C4Portable handheld Tympanometer/Impedance Audiometer-Table topE
94
C5Oto-acoustic emission(OAE) instrumentE
95
C6Automatic ABR screener without disposable electrodes Stimulation level 35 dBHL
96
C7Brainstem Evoked Response Audiometer with insert phone BERA or with both Bone-conduction auditory brain-stem response (BCA BR) and Air-conducted (AC ). Bone vibrator and baby insert phone ABR with ASSR (Optional)E
97
C8Tuning Fork 1 set-4 tuning fork of 4 different freq 128 Hz, 256 Hz, 512 Hz and 1024 HzE
98
C9Speech and Voice softwareE
99
C10OPD material.
100
C11LED Head light E