NRHM/HSC/3/M

●
Ministry of Health & Family Welfare
(Monitoring & Evaluation Division)
Monthly Format for Sub Center and Equivalent Institutions

State: Due for Submission on 5th of following Month

District: Month June

Block: Year 2019

City/ Town/
Village:

Facility name

Facility type Public ● Private

Location Rural ● Urban

Numbers reported during the

month Ref No.

Part A REPRODUCTIVE AND CHILD HEALTH

M1 Ante Natal Care (ANC)
1.1 Total number of pregnant women registered for ANC 1.1
1.1.1 Out of the total ANC registered, number registered within 1st trimester (within 12 weeks) 1.1.1
1.2 ANC services 1.2
1.2.1 Number of PW given TT1 1.2.1
1.2.2 Number of PW given TT2 1.2.2
1.2.3 Number of PW given TT Booster 1.2.3
1.2.4 Number of PW given 180 Iron Folic Acid (IFA) tablets 1.2.4
1.2.5 Number of PW given 360 Calcium tablets 1.2.5
1.2.6 Number of PW given one Albendazole tablet after 1st trimester 1.2.6
1.2.7 Number of PW received 4 or more ANC check ups 1.2.7
1.2.8 Number of PW given ANC Corticosteroids in Pre Term Labour 1.2.8
1.3 Pregnant women (PW) with Hypertension (BP>140/90) 1.3
1.3.1 New cases of PW with hypertension detected 1.3.1
1.3.1.a Out of the new cases of PW with hypertension detected, cases managed at institution 1.3.1.a
1.4 Pregnant women (PW) with Anaemia 1.4
1.4.1 Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective ANCs 1.4.1
1.4.2 Number of PW having Hb level<11 (tested cases)(7.1 to 10.9) 1.4.2
1.4.3 Number of PW having Hb level<7 (tested cases) 1.4.3
1.5 Pregnant Women (PW) with Syphilis 1.6
1.5.1 Point of Care (POC) tests conducted for Syphilis 1.6.1
1.5.1.a Number of PW tested using POC test for Syphilis 1.6.1.a
1.5.1.b Out of above, number of PW found sero positive for syphilis 1.6.1.b
M2 Deliveries M2
2.1 Deliveries conducted at Home 2.1
2.1.1 Number of Home Deliveries attended by 2.1.1
2.1.1.a Number of Home Deliveries attended by Skill Birth Attendant(SBA) (Doctor/Nurse/ANM) 2.1.1.a
2.1.1.b Number of Home Deliveries attended by Non SBA (Trained Birth Attendant(TBA) /Relatives/etc.) 2.1.1.b
2.1.2 Number of PW given Tablet Misoprostol during home delivery 2.1.2
2.1.3 Number of newborns received 7 Home Based Newborn Care (HBNC) visits in case of Home delivery 2.1.3
2.2 Number of Institutional Deliveries conducted 2.2
2.2.1 Out of total institutional deliveries number of women discharged within 48 hours of delivery 2.2.1
2.2.2 Number of newborns received 6 HBNC visits after Institutional Delivery 2.2.2
M3 Pregnancy outcome & details of new-born M4

3.1 Pregnancy Outcome (in number) 4.1

3.1.1 Live Birth 4.1.1
3.1.1.a Live Birth - Male 4.1.1.a
3.1.1.b Live Birth - Female 4.1.1.b
3.1.2 Number of Pre term newborns ( < 37 weeks of pregnancy) 4.1.2
3.1.3 Still Birth 4.1.3
3.2 Abortion (spontaneous) 4.2
3.3 Details of Newborn children 4.4
3.3.1 Number of newborns weighed at birth 4.4.1
3.3.2 Number of newborns having weight less than 2.5 kg 4.4.2
3.3.3 Number of Newborns breast fed within 1 hour of birth 4.4.3
M4 Post Natal Care (PNC) M6
4.1 Women receiving 1st post partum checkup within 48 hours of home delivery 6.1
4.2 Women receiving 1 post partum checkup between 48 hours and 14 days
st
6.2
4.3 Number of mothers provided full course of 180 IFA tablets after delivery 6.3
4.4 Number of mothers provided 360 Calcium tablets after delivery 6.4

M5 Family Planning M8

5.1 Number of Interval IUCD Insertions (excluding PPIUCD and PAIUCD) 8.3
5.2 Number of Post Partum (within 48 hours of delivery) IUCD insertions 8.4
5.3 Number of IUCD Removals 8.6
5.4 Number of complications following IUCD Insertion 8.7
5.5 Injectable Contraceptive-Antara Program- First Dose 8.8
5.6 Injectable Contraceptive-Antara Program- Second Dose 8.9
5.7 Injectable Contraceptive-Antara Program- Third Dose 8.10
5.8 Injectable Contraceptive-Antara Program- Fourth or more than fourth 8.11
5.9 Number of Combined Oral Pill cycles distributed 8.12
5.10 Number of Condom pieces distributed 8.13
5.11 Number of Centchroman (weekly) pill strips distributed 8.14
5.12 Number of Emergency Contraceptive Pills (ECP) given 8.15
5.13 Number of Pregnancy Test Kits (PTK) used 8.16
5.14 Quality in sterilization services 8.17
5.14.1 Complications following male sterilization 8.17.1
5.14.2 Complications following female sterilization 8.17.2

M6 CHILD IMMUNISATION M9

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6.1 Number of Infants 0 to 11 months old who received: 9.1
6.1.1 Child immunisation - Vitamin K1 (Birth Dose) 9.1.1
6.1.2 Child immunisation - BCG 9.1.2
6.1.3 Child immunisation - DPT1 9.1.3
6.1.4 Child immunisation - DPT2 9.1.4
6.1.5 Child immunisation - DPT3 9.1.5
6.1.6 Child immunisation - Pentavalent 1 9.1.6
6.1.7 Child immunisation - Pentavalent 2 9.1.7
6.1.8 Child immunisation - Pentavalent 3 9.1.8
6.1.9 Child immunisation - OPV 0 (Birth Dose) 9.1.9
6.1.10 Child immunisation - OPV1 9.1.10
6.1.11 Child immunisation - OPV2 9.1.11
6.1.12 Child immunisation - OPV3 9.1.12
6.1.13 Child immunisation - Hepatitis-B0 (Birth Dose) 9.1.13
6.1.14 Child immunisation - Hepatitis-B1 9.1.14
6.1.15 Child immunisation - Hepatitis-B2 9.1.15
6.1.16 Child immunisation - Hepatitis-B3 9.1.16
6.1.17 Child immunisation - Inactivated Polio Vaccine 1 (IPV 1) 9.1.17
6.1.18 Child immunisation - Inactivated Polio Vaccine 2 (IPV 2) 9.1.18
6.1.19 Child immunisation - Rotavirus 1 9.1.19
6.1.20 Child immunisation - Rotavirus 2 9.1.20
6.1.21 Child immunisation - Rotavirus 3 9.1.21
6.2 Number of Children 9-11 months who received: 9.2
6.2.1 Child immunisation (9-11months) - Measles & Rubella (MR)- 1st Dose 9.2.1
6.2.2 Child immunisation (9-11months) - Measles 1st dose 9.2.2
6.2.3 Child immunisation (9-11months) - JE 1st dose 9.2.3
6.2.4 Number of children aged between 9 and 11 months fully immunized (BCG+DPT123/ pentavalent123+OPV123+Measles/ MR) 9.3
6.2.4.a Children aged between 9 and 11 months fully immunized- Male 9.2.4.a
6.2.4.b Children aged between 9 and 11 months fully immunized - Female 9.2.4.b
6.3 Children given following vaccination after 12 months 9.3
6.3.1 Child immunisation - Measles & Rubella (MR)- 1st Dose 9.3.1
6.3.2 Child immunisation - Measles-1st dose 9.3.2
6.3.3 Child immunisation - JE 1st dose 9.3.3
6.4 Number of Children more than 12 months who received: 9.4
6.4.1 Child immunisation - Measles & Rubella (MR)- 2nd Dose (16-24 months) 9.4.1
6.4.2 Child immunisation - Measles 2nd dose (More than 16 months) 9.4.2
6.4.3 Child immunisation - DPT 1st Booster 9.4.3
6.4.4 Child immunisation - OPV Booster 9.4.4
6.4.5 Child immunisation - Measles, Mumps, Rubella (MMR) Vaccine 9.4.5
6.4.6 Number of children more than 16 months of age who received Japanese Encephalitis (JE) vaccine 9.4.6
6.5 Number of Children more than 23 months who received: 9.5
6.5.1 Child immunisation - Typhoid 9.5.1
6.5.2 Children more than 5 years received DPT5 (2nd Booster) 9.5.2
6.5.3 Children more than 10 years received TT10 9.5.3
6.5.4 Children more than 16 years received TT16 9.5.4

6.6 Adverse Event Following Immunisation (AEFI) 9.6

6.6.1 Number of cases of AEFI - Abscess 9.6.1
6.6.2 Number of cases of AEFI - Death 9.6.2
6.6.3 Number of cases of AEFI - Others 9.6.3
6.7 Number of Immunisation sessions 9.7
6.7.1 Immunisation sessions planned 9.7.1
6.7.2 Immunisation sessions held 9.7.2
6.7.3 Number of Immunisation sessions where ASHAs were present 9.7.3
6.8 Children received Vitamin A Doses between 9 months and 5 years 9.8
6.8.1 Child immunisation - Vitamin A Dose - 1 9.8.1
6.8.2 Child immunisation - Vitamin A Dose - 5 9.8.2
6.8.3 Child immunisation - Vitamin A Dose - 9 9.8.3
6.9 Number of children (6-59 months) provided 8-10 doses (1ml) of IFA syrup (Bi weekly) 9.9
6.10 Number of children (12-59 months) provided Albendazole 9.10
6.11 Number of severely underweight children provided Health Checkup (0-5 yrs) 9.11
M7 Number of cases of Childhood Diseases (0-5 years) M10
7.1 Childhood Diseases - Tuberculosis (TB) 10.7
7.2 Childhood Diseases - Acute Flaccid Paralysis(AFP) 10.8
7.3 Childhood Diseases - Measles 10.9
7.4 Childhood Diseases - Malaria 10.10
7.5 Childhood Diseases - Diarrhoea 10.11
M8 National Vector Borne Disease Control Programme (NVBDCP) M11
8.1 Malaria 11.1
8.1.1 Rapid DiagNumberstic Test (RDT ) 11.1.1
8.1.1.a RDT conducted for Malaria 11.1.2.a
8.1.1.b Malaria (RDT) - Plasmodium Vivax test positive 11.1.2.b
8.1.1.c Malaria (RDT) - Plamodium Falciparum test positive 11.1.2.c
Part B Health Facility Services Part B.
M9 Patient Services M14
9.1 Out Patient Department (Outpatients) by disease/ health condition 14.1
9.1.1 Outpatient - Diabetes 14.1.1
9.1.2 Outpatient - Hypertension 14.1.2
9.1.3 Outpatient - Stroke (Paralysis) 14.1.3
9.1.4 Outpatient - Acute Heart Diseases 14.1.4
9.1.5 Outpatient - Mental illness 14.1.5
9.1.6 Outpatient - Epilepsy 14.1.6
9.1.7 Outpatient - Ophthalmic Related 14.1.7
9.1.8 Outpatient - Dental 14.1.8
9.2 Outpatient attendance (All) 14.2
9.2.1 Allopathic- Outpatient attendance 14.2.1
9.2.2 Ayush - Outpatient attendance 14.2.2
9.3 Number of Anganwadi centres/ UPHCs reported to have conducted Village Health & Nutrition Day (VHNDs)/ Urban Health & Nutrition Day (UHNDs)/ 14.16
Outreach / Special Outreach
M10 Laboratory Testing M15
10.1 Hb Tests Conducted 15.2
10.1.1 Number of Hb tests conducted 15.2.1
10.1.2 Out of the total number of Hb tests done, Number having Hb < 7 mg 15.2.2
10.2 (Human Immunodeficiency Virus) HIV tests conducted 15.3
10.2.1 Pregnant women screened for HIV 15.3.4

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10.2.1.a Number of pregnant women screened for HIV 15.3.4.a
10.2.1.b Out of the above, number screened positive 15.3.4.b
M11 Stock Related Data
11.1 Drugs
11.1.1 Last Date of Supply of essential drugs(DD/MM/YYYY)
11.1.2 Items Adequate/ Inadequate

11.1.2.a IFA tablets

11.1.2.b IFA syrup with dispenser
11.1.2.c Vit A syrup
11.1.2.d ORS packets
11.1.2.e Zinc tablets
11.1.1.f Inj Magnesium Sulphate
11.1.1.g Inj Oxytocin
11.1.1.h Misoprostol tablets
11.1.1.i Antibiotics
11.1.1.j Availability of drugs for common ailments e.g PCM, anti- allergic drugs etc.
11.1.1.k IFA tablets (Blue)
11.1.1.l Tab. Albendazole
11.2 Contraceptives
11.2.1 Last Date of Supply of essential contraceptives (DD/MM/YYYY)
11.2.2 Items Adequate/ Inadequate

11.2.2.a IUCD
11.2.2.b Combined Oral Pills (in cycles)
11.2.2.c Condom (in pieces)
11.2.2.d Injectable Contraceptive MPA (vials)
Part C Mortality Details Part C.
M12 Details of deaths reported with probable causes: M16
12.1 Infant deaths within 24 hrs(1 to 23 Hrs) of birth 16.1
12.2 Infant Deaths up to 4 weeks (1 to 28 days) due to 16.2
12.2.1 Infant Deaths up to 4 weeks due to Sepsis 16.2.1
12.2.2 Infant Deaths up to 4 weeks due to Asphyxia 16.2.2
12.2.3 Infant Deaths up to 4 weeks due to Other causes 16.2.3
12.3 Infant Deaths Between 1 month (more than 28 days) and less than 12 months due to 16.3
12.3.1 Number of Infant Deaths (1 -12 months) due to Pneumonia 16.3.1
12.3.2 Number of Infant Deaths (1 -12 months) due to Diarrhoea 16.3.2
12.3.3 Number of Infant Deaths (1 -12 months) due to Fever related 16.3.3
12.3.4 Number of Infant Deaths (1 -12 months) due to Measles 16.3.4
12.3.5 Number of Infant Deaths (1 -12 months) due to Others 16.3.5
12.4 Child Deaths between 1 year and less than 5 years due to 16.4
12.4.1 Number of Child Deaths (1 -5 years) due to Pneumonia 16.4.1
12.4.2 Number of Child Deaths (1 -5 years) due to Diarrhoea 16.4.2
12.4.3 Number of Child Deaths (1 -5 years) due to Fever related 16.4.3
12.4.4 Number of Child Deaths (1 -5 years) due to Measles 16.4.4
12.4.5 Number of Child Deaths (1 -5 years) due to Others 16.4.5
12.5 Maternal Deaths (15 to 49 yrs.) due to 16.5
12.5.1 Number of Maternal Deaths due to Bleeding 16.5.1
12.5.2 Number of Maternal Deaths due to High fever 16.5.2
12.5.3 Number of Maternal Deaths due to Abortion 16.5.3
12.5.4 Number of Maternal Deaths due to Obstructed/prolonged labour 16.5.4
12.5.5 Number of Maternal Deaths due to Severe hypertesnion/fits 16.5.5
12.5.6 Number of Maternal Deaths due to Other Causes (including causes Not known) 16.5.6
12.6 Other Deaths (except Infant, Child & Maternal Deaths) 5 years and above due to 16.7
12.6.1 Number of Adolscent / Adult deaths due to Diarrhoeal diseases 16.7.1
12.6.2 Number of Adolscent / Adult deaths due to Tuberculosis 16.7.2
12.6.3 Number of Adolscent / Adult deaths due to Respiratory diseases including infections (other than TB) 16.7.3
12.6.4 Number of Adolscent / Adult deaths due to Other Fever Related 16.7.4
12.6.5 Number of Adolscent / Adult deaths due to HIV/AIDS 16.7.5
12.6.6 Number of Adolscent / Adult deaths due to Heart disease/Hypertension related 16.7.6
12.6.7 Number of Adolscent / Adult deaths due to Cancer 16.7.7
12.6.8 Number of Adolscent / Adult deaths due to Neurological disease including strokes 16.7.8
12.6.9 Number of Adolscent / Adult deaths due to Accidents/Burn cases 16.7.9
12.6.10 Number of Adolscent / Adult deaths due to Suicide 16.7.10
12.6.11 Number of Adolscent / Adult deaths due to Animal bites and stings 16.7.11
12.6.12 Number of Adolscent / Adult deaths due to known Acute Disease 16.7.12
12.6.13 Number of Adolscent / Adult deaths due to known Chronic Disease 16.7.13
12.6.14 Number of Adolscent / Adult deaths due to Causes Not known 16.7.14
12.7 Deaths due to Vector Borne Diseases ( all age groups) 16.8
12.7.1 Number of Deaths due to Malaria- Plasmodium Vivax 16.8.1
12.7.2 Number of Deaths due to Malaria- Plasmodium Falciparum 16.8.2

Printed as on 10/09/2008 Monthly - H Subcenter

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