Form 1

National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for Sub Centre
Name of the Sub-centre_______________ PHC _______________ Block/ Mandal ________________ District_____________ State______________

Month____________________ Year ________________________ PBS Yes/ No Population Persons screened in previous month
Outreach Yes/ No Eligible population Cumulative number of persons screened
Part A: Hypertension and Diabetes Screening

No. of new persons Suspected for No. of new persons Suspected for No. of known cases of DM on Follow- No. of known cases of HTN on
Name of the Total No. of NCD Checkups Done No. of eligible population for NCDs DM and refered for Confirmation HTN and refered for Confirmation up Follow-up
village
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total

Total

Part B: Screening for Common Cancers

No. of persons suspected with cancer and refered to PHC/ CHC/ GH No. of persons referred by the
Subcentre last month who Total No. of known Cancer patients
No. of persons screened for cancers underwent investigations at higher in the Village
Name of the
Village Oral facility

Male Female Total Male Female Total Breast Cervical Total Male Female Total Male Female Total

Total

____________________________
Signature
Name and Designation

Date of reporting_____________________

*The Report should be filled by ANM of Sub centre and sent to MO I/C PHC on last day of the same month.
 Form 2A
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)

Reporting format for Primary Health Centre OPD

Name and Address of the PHC _______CHC__________ District__________State_________

Month_________________ Year_______________________
Implementing PBS - Yes/ No
During the Reporting Month
Indicator Male Female Total

I. Common NCDs under NPCDCS

1.Total no. of persons attended Clinic for NCD (New and Follow up)
A. Diabetes Only
2. No. newly diagnosed with B. Hypertension Only
C. HTN & DM (both)
A. Cardiovascular diseases
B. Stroke
C. COPD
3. No. of persons suspected and
referred for D. Oral Cancer
E. Breast cancer
F. Cervical cancer
G. Other cancers
A. Diabetes Only
4. No of newly diagnosed
patients initiated on treatment B. Hypertension Only
C. HTN & DM
A. Diabetes Only
B. Hypertension Only
C. HTN & DM
D. Cardiovascular diseases
5. Patients on treatment Follow
Up
 5. Patients on treatment Follow E. Stroke
Up
F. COPD
G. Oral Cancer
H. Breast cancer
I. Cervical cancer
J. Other cancers
6. Total No. of persons referred to CHC/ District Hospital/ Higher Centres

7. No. of persons counselled for health promotion & prevention of NCD

II. Comorbid Conditions

A. No. of known TB cases on ATT

8. Among all confirmed Diabetic
patients [New (2A+2C) & Follow B. No. screened for TB Symptoms
up (5A+5C)]
C. No. suspected for TB & refered to DMC/
PI

Signature:
Name and Designation
Date of reporting_____________________

*This report should be generated from CHC OPD screening data.

This report should be verified and signed by Medical Officer I/c CHC.
This report should be sent to District NCD Cell by 7th day of every month.
 Form 2
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for Primary Health Centre (PHC)
Name of the PHC_______________ Name of the linked Block PHC/CHC _______________ District_____________ State______________

Month ___________ Year_______________________

Implementing PBS - Yes/ No Population Persons screened in previous month
No. of Sub-centres under the PHCs _________ No. of Sub-centres reported during the month:___________ Eligible population Cumulative number of persons screened
Part A (Screening for HTN and Diabetes)
No. of new persons Suspected for No. of new persons Suspected for No. of known cases of DM on No. of known cases of HTN
Total NCD Checkups Done No. of eligible population for NCDs HTN and refered for
Name Of the Sub Centre / PHC DM and refered for Confirmation Follow-up on Follow-up
Confirmation
PBS/ Outreach Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
PHC

SC1
SC2
SC3
SC4
SC5
SC6
Data from PBS
Data from outreach
Overall Total

Part B: Screening for Common Cancers

No. of persons suspected and refered to PHC/ CHC/ GH
No. of persons screened for Cancers No. of known Cancer patients
Name of the Sub Centre/ PHC Oral
Breast Cervical Total
Male Female Total Male Female Total Male Female Total
Name Of the PHC

SC 1
SC2
SC3
SC4
SC5
SC6
SC7
Sub Centre total
Data from PBS
Data from outreach
Overall Total

Name and Designation ________________

Date of reporting_____________________
*This report should be generated from PHC OPD screening data and also by compiling data of Form 1 of all sub-
centres under the PHC.
This report should be verified and signed by Medical Officer I/c PHC.
This report should be sent to Block PHC/CHC by 5th day of every month.
 Form 3A
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)

Reporting format for NCD Clinic at Community Health Centre (CHC)/ Sub District Hospital(SDH)

Name and Address of the SDH / CHC _______Block/ Taluk/ Mandal/ Zone__________ District__________State_________

Month_________________ Year_______________________

During the Reporting Month

Indicator Male Female Total

I. Common NCDs under NPCDCS

1.Total no. of persons attended NCD Clinic (New and Follow up)
A. Diabetes Only
2. No. newly diagnosed with B. Hypertension Only
C. HTN & DM
A. Cardiovascular diseases
B. Stroke
C. COPD
3. No. of persons suspected and D. CKD
referred for
E. Oral Cancer
F. Breast cancer
E. Cervical cancer
G. Other cancers
A. Diabetes Only
4. No of newly diagnosed B. Hypertension Only
patients initiated on treatment
C. HTN & DM
A. Diabetes Only
B. Hypertension Only
C. HTN & DM
D. Cardiovascular diseases
E. Stroke
5. Patients on treatment Follow
Up F. COPD
G. CKD
H. Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
6. Total No. of persons referred to District Hospital/ Higher Centres

7. No. of persons counselled for health promotion & prevention of NCD

II. Comorbid Conditions

A. No. of known TB cases on ATT

8. Among all confirmed Diabetic
patients [New (2A+2C) & Follow B. No. screened for TB Symptoms
up (5A+5C)]
C. No. suspected for TB & refered to DMC/
PI

Signature:
Name and Designation
Date of reporting_____________________

*This report should be generated from CHC OPD screening data.

This report should be verified and signed by Medical Officer I/c CHC.
This report should be sent to District NCD Cell by 7th day of every month.
 Form 3B
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for Community Health Centre (CHC)/Block PHC/ SDH

Name and Address _______________________________________________________________________________________ Block/ Taluk/ Mandal/ Zone_________________ District__________

Month_______________Year____________________
Population Persons screened in previous month
Total No. of PHC in the District __________________ Total No. Of PHCs reported________ Eligible population Cumulative number of persons screened

Part A : Screening for HTN and Diabetes

No. of new persons Suspected No. of new persons Suspected for
Total NCD Checkups Done No. of eligible population for for DM and refered for HTN and refered for No. of known cases of DM on No. of known cases of HTN on
Source Of Data NCDs Confirmation Confirmation Follow-up Follow-up

Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
PHC 1
PHC2
PHC3
PHC4
PHC5
PHC6
PHC7
Data from PBS
Data from outreach
Data from OPDs
Overall Total

PART B: Screening for Common Cancers

No. of persons suspected with Cancer and refered to PHC/ CHC/
No. of persons screened for other GH No. of Known Cancer patients
Source of Data Cancers Oral
Breast Cervical Total
Male Female Total Male Female Total Male Female Total
PHC 1
PHC2
PHC3
PHC4
PHC5
PHC6
PHC7
Data from PBS
Data from outreach
Data from OPDs
Overall Total

Signature:

Name and Designation ________________

Date of reporting_____________________
*This report should be generated by compiling data of Form 2 of all PHCs under the Block/Taluk/Mandal.

This report should be verified and signed by Medical Officer I/c .

This report should be sent to District NCD Cell by 7th day of every month.
 Form 4
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for District NCD Clinic
Name of Health Facility where located :______________________________District _____ State____________-

Month_____________________Year___________________________
All information below are for the reporting month
During the Reporting Month
Indicator Male Female Total

I. Common NCDS under NPCDCS

1. Total no. of persons attended NCD Clinic in the reporting month (New and Follow up) 3 1 4
A.Diabetes Only
B. Hypertension Only
C. HTN & DM (Both) 1
D. CVDs
E. Stroke
2. No. newly diagnosed with F. COPD
G. CKD
H.Oral Cancer
I. Breast cancer
J.Cervical cancer
K.Other cancers
A. CVDs
C. Stroke
D. COPD
3. Suspected and referred cases of CVDs & Cancer (In E. CKD
Resource limited settings where there are No capacity
to perform confirmatory diagnosis) F. Oral Cancer
G. Breast cancer
H. Cervical cancer
I. Other cancers
A.Diabetes Only
B. Hypertension Only
C. HTN & DM (Both) 1
4.No of newly diagnosed patients initiated on D. CVDs
Treatment E. Stroke
F. COPD
G. CKD
H. Cancer (Including Day Care Centres)
5. No. of Patients treated at CCU A. CVDs
B. Stroke
A. Diabetes Only 1
B. Hypertension Only 1
C. DM & HTN (Both) 1
D. CVD (Only OPD data)
6. No Of patients on follow up
E. Stroke (Only OPD data)
F. COPD
G. CKD
H. Cancer (Including Day Care Centres)
A.Diabetes
B. Hypertension
C. CVD
7.No. of person referred to Tertiary hospital/TCCC D. Stroke
E. COPD
F. CKD
G. Cancer
8. Patients attended Day Care facility for Cancer care
9. No. of persons counselled for health promotion & prevention of NCDs 3 1 4
11. No. of patients underwent physiotherapy
II. Comorbid Conditions
A. No. of known TB cases on ATT
8. Among all confirmed Diabetic patients [New (2A+2C)
& Follow up (6A+6C)] B. No. screened for TB Symptoms
C. No. suspected for TB & refered to DMC/ PI

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated from District NCD Clinic /OPD screening data of District Hospitals.
This report should be verified and signed by Medical Officer I/c .
This report should be sent to District NCD Cell by 7th day of every month.
 Form 5A
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for District NCD Cell
District________________ State____________________

Month_______________Year____________________

During the Reporting Month Cumulative since April during current Financial year
Indicator
Male Female Total Male Female Total
I. Common NCDS under NPCDCS
1. No. of persons attended NCD Clinics (New and follow up)
A. Diabetes Only
B.Hypertension Only
C. HTN & DM
D. CVDs
E. Stroke
2. No. newly diagnosed with F. COPD
G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
3. Number of persons suspected A. CVDs
(Confirmatory Diagnosis not available/ B. Stroke
Pending) C.Cancers
A. Diabetes Only
B.Hypertension Only
C. HTN & DM
D. CVDs
E. Stroke
4. No. of newly diagnosed patients put
F. COPD
on Treatment
G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
A. Diabetes Only
B.Hypertension Only
C. HTN & DM
D. CVDs
E. Stroke
5. No. of persons on treatment follow
F. COPD
up
G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
A. Diabetes (Complications)
B. Hypertension
( Complications)
C. CVDs
D. Stroke
6. No.of person referred to Tertiary F. COPD
hospital/TCCC G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
7. No. of Patients treated at CCU A. CVDs

B. Stroke
8. No of cancer patients treated in Day
Care facility
9. No. of persons counselled for health
promotion & prevention of NCDs
10. No. of patients underwent Physiotherapy

II. Co-morbidities
A. No. of known TB cases on
ATT
1. Among all confirmed Diabetic
patients [New (2A+2C) & Follow up B. No. screened for TB
(5A+5C)] Symptoms
C. No. suspected for TB &
refered to DMC/ PI

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 3A (CHC NCD Clinics) and Form 4 (District NCD Clinic) data
This report should be verified and signed by District Nodal Officer.
This report should be sent to State NCD Cell by 10th day of every month.
 Form 5B
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for District NCD Cell
Name and Address of the District NCD Cell District________________ State____________________

Month_______________Year____________________ Population Persons screened in previous month

Total No. of PHC in the District ________________ Total No. Of PHCs reported __________Eligible population Cumulative

Part A : Screening for HTN and Diabetes

No. of eligible population for No. of new persons Suspected for DM No. of new persons Suspected for No. of known cases of No. of known cases of
Total NCD Checkups Done NCDs and refered for Confirmation HTN and refered for Confirmation DM on Follow-up HTN on Follow-up
Source Of Data
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
CHC 1
CHC2
CHC3
CHC4
CHC5
CHC6
CHC7
Data from PBS
Data from outreach
Overall Total

PART B: Screening for Common Cancers

No. of persons suspected with Cancer and refered to PHC/ CHC/ other
No. of persons screened for GH
Cancers No. of Known Cancer patients
Source of Data Oral
Breast Cervical Total
Male Female Total Male Female Total Male Female Total
CHC 1
CHC2
CHC3
CHC4
CHC5
CHC6
CHC7
Data from PBS
Data from outreach
Overall Total

Part B2: Screening for other NCDs

No. of persons suspected and refered to PHC/ CHC/ GH
Stroke CVD COPD CKD
Male Female Male Female Male Female Male Female
CHC 1
CHC2
CHC3
CHC4
CHC5
CHC6
CHC7
Total

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 3B of all Blocks/Mandals/Taluks under the District
This report should be verified and signed by District Nodal Officer.
This report should be sent to State NCD Cell by 10th day of every month.
 Form 6
National Programme on Prevention & Control of Cancer, Diabetes, CVDs & Stroke (NPCDCS)
Reporting format for State NCD Cell
Name of the State: ……………………………… Reporting Month: ….…………………Year…………..
No. of district NCD Cells……………………………. No. Of District NCD Cells reported ………………..
Population Persons screened in previous month
Eligible population Cumulative number of persons screened
Part A. Programme Data (Compiled data of Form 5A)
During the Reporting Month Cummulative since April (Finanacial Year Data)
Indicator
Male Female Total Male Female Total
i). Common NCDS under NPCDCS
1. Total no. of persons attended NCD Clinics (New and Follow Up)
A. Diabetes Only
B.Hypertension Only
C. HTN & DM (Both)
D. CVDs
E. Stroke
2. No. newly diagnosed with F. COPD
G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
A. Diabetes Only
B.Hypertension Only
C. HTN & DM (Both)
D. CVDs
E. Stroke
3. No of new patients initiated on
F. COPD
treatment
G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
A. Diabetes Only
B.Hypertension Only
C. HTN & DM (Both)
D. CVDs
E. Stroke
4. No of Patients on Follow up F. COPD
G. CKD
H.Oral Cancer
I. Breast cancer
J. Cervical cancer
K. Other cancers
A. Diabetes
B. Hypertension
C. CVDs
5. No. of Patients Referred to
D. Stroke
Tertiary Care/TCCC
E. COPD
F. CKD
G.Cancers
A. CVDs
6. No of patients treated at CCU
B. Stroke
7. No. of persons attended day care centre
8. No. of Persons counselled for health promotion and prevention of NCDs
9. No. of patients attended physiotherapy

ii). Comorbid Conditions

A. No. of known TB cases on ATT
10. Among all confirmed Diabetic B. No. screened for TB Symptoms
patients [New (2A+2C) & Follow
up (4A+4C)] C. No. suspected for TB & refered to DMC/
PI

B1. Other Programme Markers (Compiled data of non PBS CHCs from Form 5B)
Total No. of NCD check ups done
Diabetes only
Hypertension Only
HTN & DM (Both)
COPD
Total No. Of Persons Suspected
CKD
and refered for
Oral Cancers
Breast Cancers
Cervical Cancers
Other Cancers
HTN /Diabetes/ Both HTN and DM
No. of diagnosed patients on COPD
follow up in PHC and Sub centres CKD
Cancer patients

B2. Other Programme Markers (Compiled data of PBS CHCs from Form 5B)
Total No. of NCD check ups done
Diabetes only
Hypertension Only
HTN & DM (Both)
COPD
Total No. Of Persons Suspected
CKD
and refered for
Oral Cancers
Breast Cancers
Cervical Cancers
Other Cancers
HTN /Diabetes/ Both HTN and DM
No. of diagnosed patients on COPD
follow up in PHC and Sub centres CKD
Cancer patients

C. Physical targets and achievements

 Achievement during Cumulative Cumulative
Annual Target for
Name of Facility the reporting achievement since 1st achievement since Remarks
the year 2016-17
month Apr 2018 beginning
District NCD Cells
District NCD Clinics
District CCU facilities
District Day Care Centres
CHC NCD Clinics
Others

Signature:
Name and Designation ________________
Date of reporting_____________________
*This report should be generated by compiling data of Form 5A & Form 5B of all Districts in the State
This report should be verified and signed by State Nodal Officer.
This report should be sent to National NCD Cell by 15th day of every month.