TB/HIV Supervision Checklist for FACILITY (District code number 4 digits)

Date of visit ........................................................................

Time: From ................................... To.......................................
Name of Supervisor: ..
Region: ...................................................................................................................................
District: ....................................................................................................................................
Name of Health Facility: .................................................................................................
Type of ownership (Private/Public /Faith-based/NGO
Data type and list of sub questions and options answers
GENERAL QUESTIONS
Name of the person in charge of the health
facility
The title of the person in charge of health
facility
Type of TB, TB/HIV Services rendered

# staff providing TB/HIV

collaborative services:

Text
Clinician/Nurse
options (DIRECT OBSERVATION TREATMENT, DIAGONISTIC, UNDER ONE
ROOF, REFERRAL
If the option selected above is referral ask name of referral facility.............................
And ask the distance to referral facility...................................................
Int
Then based on the number given above, for each of them
i)
ask their title whether is clinician, nurse, lab technician, lab assistant, lab
attendant, sputum fixer, medical attendant
If chooses lab on the above ask whether is (lab tech, lab assistant)
ii.) Training whether is (TB/HIV, Other training
If other training select (DOT , infection control, ART , sputum fixer, AFB
microscopy)

Quarterly Facility staff experience

sharing meetings

TB CLINIC SECTION
Total of all notification (Number of all TB
patients)(last month)
# tested for HIV
# HIV+
# referred to CTC
# started ART
# started CPT
Is there defaulters?
How many defaulters
# missed appointment)
How many have been traced
Arrangement and result of defaulter tracing
Who is responsible for tracing?
Performing HIV test at TB clinic?
Is there adequate space for TB, TB/HIV
services
Availability of TB/HIV referral form
Are the tools such as unit registers, patient
card, treatment card etc well filled and
updated?
Cross check district register with unit register
are those records matching?

Options (present, not present)

if not present why?
if present go to the next question
# of meetings done
then remind to check minutes
Int
Int
Int
Int
Int
Int
Yes/No
Int
Int
Options (Good, Average and Poor)
text
Yes/No (if yes # performing HIV question )
if no
Where? Options (referring patient to VCT or Lab for the test).
Yes/No
If No please advice
Yes/No
Yes/No

Yes/No
2

Cross check unit register with patient

treatment cards, are the records matching?
CTC SECTION

Yes/No

# of HIV patients screened for TB last month

# of HIV patients referred for TB diagnosis
# HIV patients diagnosed (confirmed) with
TB
# HIV patients with TB put on anti TB
therapy

Int
Int
Int

Availability of Sputum request form

Availability of TB screening tool

Yes/No
Yes/No

LAB SECTION
# specimen collected last month
# smear positive
# smear negative
Status of microscope
Lab supplies & reagents
General condition of the lab
Slide keeping for lab quality assurance

Check lab register if updated and well

completed

Int

Int
Int
Int
Functional/Not functional
if not function
display (please report to district lab technicians)
Adequate/Not adequate
If not adequate display multi-select list of supplies (sputum containers, reagents,
microscope slides, referral forms)
Display multi-select (Space, ventilation, cleanness, presence of water, security,
source of power, waste disposal method)
ask after how many slides

Yes/No
3

Are SOP for smear in place?

Drug Store
Are the TB drugs and supplies kept in the
general pharmacy?
What is the condition of the drug storage
TB Drug CPT stalk position
Does the TB drug match with number of
patients?
Check the expired TB drugs
VCT (fourth person) section
Availability of TB Screening tool
Availability Sputum examination forms
Availability of referral forms
HIV Test kits stock
14

Yes/No

Yes/No
Good/poor
If poor please advice
Adequate/in adequate (check ledger)
Yes/No (compare check ledger and patient records)
Verify with ledger

Yes/No
Yes/No
Yes/No
Yes/No

OTHERS

Availability of TB/HIV services

directory

Yes/No

Availability of reference material

Yes/No

Availability and use of TB and

TB/HIV Manuals

Yes/No

15

Availability of Condoms
Availability of Information Education
Communication (IEC) material
# of ACSM activities conducted last
month/quarter
STAFF KNOWLEDGE & SKILLS
Does the facility provide TB, TB/HIV
health education?
If yes how often
Observe
Is the schedule of health education in
place

Yes/No
Yes/No
Int

Yes/No
String
Knowledge & Skills with options (basic facts about TB, basic facts about HIV,
relationship between TB & HIV, TB treatment, TB prevention, infection control,
Patient centred treatment (PCT))
Yes/No

Signature of supervisor: