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Monthly Service Delivery Reporting format
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Monthly Format for SC and Equivalent Institutions
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State : _____________________________________
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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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Report upload on or before 5th of following Month
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Indicator NumberIndicator NameNumbers reported
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Part AREPRODUCTIVE AND CHILD HEALTH
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M1Ante Natal Care (ANC) Services
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1.1Total number of pregnant women registered for ANC
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1.1.1Out of the total ANC registered, number registered within 1st trimester (within 12 weeks)
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1.2ANC services
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1.2.1Number of PW given TT1/ Td1
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1.2.2Number of PW given TT2 / Td2
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1.2.3Number of PW given TT Booster/ Td Booster
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1.2.4Number of PW provided full Course 180 Iron Folic Acid (IFA) tablets
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1.2.5Number of PW provided full Course 360 Calcium tablets
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1.2.6Number of PW given one Albendazole tablet after 1st trimester
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1.2.7Number of PW received 4 or more ANC check ups
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1.2.8Number of PW given ANC Corticosteroids in Pre Term Labour
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1.3Pregnant women (PW) with Hypertension (BP > 140/90)
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1.3.1New cases of PW with hypertension detected
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1.3.1.aOut of the new cases of PW with hypertension detected, cases managed at institution
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1.4Pregnant women (PW) with Anaemia
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1.4.1Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective ANCs
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1.4.2Number of PW having Hb level<11 (out of total tested cases) (7.1 to 10.9)
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1.4.3Number of PW having Hb level<7 (out of total tested cases)
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1.5Pregnant Women (PW) with Syphilis
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1.5.1Point of Care (POC) tests conducted for Syphilis
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1.5.1.aNumber of PW tested using POC test for Syphilis
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1.5.1.bOut of above,number of PW found sero positive for Syphilis
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M2Deliveries
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2.1Deliveries conducted at Home
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2.1.1Number of Home Deliveries attended by
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2.1.1.aNumber of Home Deliveries attended by Skill Birth Attendant(SBA) (Doctor/Nurse/ANM/ Midwife)
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2.1.1.bNumber of Home Deliveries attended by Non SBA (Trained Birth Attendant(TBA) /Relatives/etc.)
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2.1.2Number of PW given Tablet Misoprostol during home delivery
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2.1.3Number of newborns received 7 Home Based Newborn Care (HBNC) visits in case of Home delivery
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2.2Number of Institutional Deliveries conducted (Including C-Sections)
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2.2.1Out of total institutional deliveries number of women discharged within 48 hours of delivery
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2.2.2Number of newborns received 6 HBNC  visits after Institutional Delivery
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M3Pregnancy outcome & details of new-born
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3.1Pregnancy Outcome (in number)
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3.1.1Live Birth
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3.1.1.aLive Birth - Male
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3.1.1.bLive Birth - Female
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3.1.2Number of Pre term newborns (< 37 weeks of pregnancy)
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3.1.3Still Birth
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3.2Abortion (spontaneous)
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3.3Details of Newborn children
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3.3.1Number of newborns weighed at birth
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3.3.2Number of newborns having weight less than 2.5 kg
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3.3.3Number of Newborns breast fed within 1 hour of birth 
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M4Post Natal Care (PNC)
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4.1Women receiving 1st post partum checkups within 48 hours of home delivery
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4.2Women receiving 1st post partum checkup between 48 hours and 14 days
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4.3Number of mothers provided full course of 180 IFA tablets after delivery
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4.4Number of mothers provided full course of 360 Calcium tablets after delivery
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M5Family Planning
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5.1Number of Interval IUCD Insertions (excluding PPIUCD and PAIUCD)
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5.2Number of Postpartum (within 48 hours of delivery) IUCD insertions
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5.3Number of IUCD Removals
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5.4Number of complications following IUCD Insertion
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5.5Injectable Contraceptive-Antara Program- First Dose
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5.6Injectable Contraceptive-Antara Program- Second Dose
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5.7Injectable Contraceptive-Antara Program- Third Dose
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5.8Injectable Contraceptive-Antara Program- Fourth or more than fourth
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5.9Number of Combined Oral Pill cycles distributed
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5.1Number of Condom pieces distributed
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5.11Number of Centchroman (weekly) pill strips distributed
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5.12Number of Emergency Contraceptive Pills (ECP) given
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5.13Number of Pregnancy Test Kits (PTK) used
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5.14Quality in sterilization services
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5.14.1Complications following male sterilization
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5.14.2Complications following female sterilization
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M6CHILD IMMUNISATION
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6.1Number of Infants 0 to 11 months old who received:
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6.1.1Child immunisation - Vitamin K (Birth Dose)
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6.1.2Child immunisation - BCG
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6.1.3Child immunisation - DPT1
86
6.1.4Child immunisation - DPT2
87
6.1.5Child immunisation - DPT3
88
6.1.6Child immunisation - Pentavalent 1
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6.1.7Child immunisation - Pentavalent 2
90
6.1.8Child immunisation - Pentavalent 3
91
6.1.9Child immunisation - OPV 0 (Birth Dose)
92
6.1.10Child immunisation - OPV1
93
6.1.11Child immunisation - OPV2
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6.1.12Child immunisation - OPV3
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6.1.13Child immunisation - Hepatitis-B0 (Birth Dose)
96
6.1.14Child immunisation - Hepatitis-B1
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6.1.15Child immunisation - Hepatitis-B2
98
6.1.16Child immunisation - Hepatitis-B3
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6.1.17Child immunisation - Inactivated Injectable Polio Vaccine 1 (IPV 1)
100
6.1.18Child immunisation - Inactivated Injectable Polio Vaccine 2 (IPV 2)