PHC B.charbhatha Oct.2015

NRHM/PHC/3/M
Ministry of Hea
(Monitoring &
Monthly Format for PH
State:
District:
Block:
City/ Town/
Village:
Facility name
Facility type
Location
Part A.
M1
1
1.1
2
3
4
4.1
Printed as on 10/09/2008
Monthly- PHC
1 of 100
NRHM/PHC/3/M
4.2
5
6
6.1
6.2
7
7.1
M2
8
8.1
8.2
(a)
(b)
(c)
M3
9
Monthly- PHC
2 of 100
NRHM/PHC/3/M
M4
10
10.1
(a)
(b)
11
12
13
13.1
13.2
14
M5
15
16
16.1
16.2
16.3
M6
17
Monthly- PHC
3 of 100
NRHM/PHC/3/M
18
19
M7
20
20.1
20.2
21
M8
22
(a)
(b)
23
Monthly- PHC
4 of 100
NRHM/PHC/3/M
M9
24
25
26
27
28
28A
29
30
31
32
33
34
34.1
(a)
(b)
34.2
(a)
(b)
Monthly- PHC
5 of 100
NRHM/PHC/3/M
34.3
(a)
(b)
34.4
M10
35
35.01
35.02
35.03
35.04
35.04A
35.04B
35.04C
35.05
35.06
35.07
35.08
35.09A
35.09
35.10
Monthly- PHC
6 of 100
NRHM/PHC/3/M
35.11
35.12
35.12B
35 A
35.13
(a)
(b)
36
36.1
36.2
36.3
37
37.1
(a)
(b)
37.2A
37.2
Monthly- PHC
7 of 100
NRHM/PHC/3/M
37.3
37.4
(a)
(b)
(c)
38
38.1
38.2
38.3
39
39.1
M11
40
40.1
40.2
40.3
M12
41
42
43
Monthly- PHC
8 of 100
NRHM/PHC/3/M
44
45
46
47
48
49
Part C.
M13
50
51
52
53
Part D.
M14
54
55
56
57
58
58.1
Monthly- PHC
9 of 100
NRHM/PHC/3/M
(a)
(b)
58.2
(a)
(b)
59
60
60.1
61
61.1
61.1 A
61.2
62
(a)
(b)
(c)
M15
63
63.1
Monthly- PHC
10 of 100
NRHM/PHC/3/M
63.2
64
(a)
(b)
(c)
65
66
(a)
(b)
(c)
67
67.1
67.2
67.3
Part E.
66
Sl.No.
Monthly- PHC
11 of 100
NRHM/PHC/3/M
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Monthly- PHC
12 of 100
NRHM/PHC/3/M
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
Monthly- PHC
13 of 100
NRHM/PHC/3/M
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
Monthly- PHC
14 of 100
NRHM/PHC/3/M
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
Monthly- PHC
15 of 100
NRHM/PHC/3/M
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
Monthly- PHC
16 of 100
NRHM/PHC/3/M
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
Monthly- PHC
17 of 100
NRHM/PHC/3/M
143
144
145
146
147
148
149
150
Code
C01
C02
C03
C04
C05
C06
C07
C08
C09
M01
M02
M03
M04
M05
M06
A01
A02
A03
A04
Monthly- PHC
18 of 100
NRHM/PHC/3/M
A05
A06
A07
A08
A09
A10
A11
A12
A13
A14
Monthly- PHC
19 of 100
NRHM/PHC/3/M
Monthly- PHC
20 of 100
NRHM/PHC/3/M
Ministry of Health & Family Welf
(Monitoring & Evaluation Divisi
Monthly Format for PHC & Equivalent I
CHHATTISGARH
RAJNANDGAON
DONGARGAON
PHC B.charbhata
Public
Private
Rural
Urban
REPRODUCTIVE AND CHILD HEALTH

Ante Natal Care Services (ANC)
Total number of pregnant women Registered for ANC
Of which Number registered within first trimester(within 12 weeks)
New women registered under Janani Suraksha Yogna
Number of pregnant women received 3 ANC check ups
Number of pregnant women given
TT1
Monthly- PHC
21 of 100
NRHM/PHC/3/M
TT2 or Booster
Total number of pregnant women given 100 IFA tablets
Pregnant women with Hypertension (BP>140/90)
New cases detected at facility
Number of Eclampsia cases managed during delivery
Pregnant women with Anaemia
Number having Hb level<11 (tested cases)
Deliveries
Deliveries conducted at facility (Including C-Sections)
Out of 8, Number discharged under 48 hours of delivery
Number of cases where Janani Suraksha Yogna incentive paid to
Mothers
ASHAs
ANM or AWW (only for HPS States)
Number of Caesarean (C-Section) deliveries performed at
C -Section deliveries performed at facility
Monthly- PHC
22 of 100
NRHM/PHC/3/M
Pregnancy outcome & details of new-born

Pregnancy Outcome (in number)
Live Birth
Male
Female
Total {(a) to (b)}
Still Birth
Abortion (spontaneous/induced)
Details of Newborn children weighed
Number of Newborns weighed at birth
Number of Newborns having weight less than 2.5 kg
Number of Newborns breast fed within 1 hour of birth
Complicated pregnancies
Number of cases of pregnant women with Obstetric Complications and atten

Number of Complicated pregnancies treated with
IV Antibiotics
IV Antihypertensive/Magsulph injection
IV Oxytocis
Post - Natal Care
Women receiving post partum checkups within 48 hours after delivery
Monthly- PHC
23 of 100
NRHM/PHC/3/M
Women getting a post partum check up between 48 hours and 14 days

PNC maternal complications attended
Medical Termination of Pregnancy (MTP)
Number of MTPs conducted at facility
Up to 12 weeks of pregnancy
More than 12 weeks of pregnancy
Total {(20.1) to (20.2)}
Number of MTPs conducted at Private Facilities
Reproductive Tract Infections/Sexually transmitted infections (RTI/ST

Number of new RTI/STI for which treatment initiated
Male
Female
Total {(a) to (b)}
Number of wet mount tests conducted
Monthly- PHC
24 of 100
NRHM/PHC/3/M
Family Planning
Number of NSV/Conventional Vasectomy conducted at facility
Number of Laparoscopic sterilizations conducted at facility
Number of Mini-lap (other than post-partum) sterilizations conducted at facil
Number of Minilap Post-Partum (within 7 days of delivery) sterilizations condu

Number of new IUD Insertions at facility
Out of 28, Post Partum (within 48 hours of delivery) IUD insertions
Number of IUD removals
Number of Oral Pills cycles distributed
Number of Condom pieces distributed
Number of Centchroman (weekly) pills given
Number of Emergency Contraceptive Pills distributed
Quality in sterilization services
Number of complications following sterilization
Male
Female
Total {(a) to (b)}
Number of failures following sterilization
Male
Female
Total {(a) to (b)}
Monthly- PHC
25 of 100
NRHM/PHC/3/M
Number of deaths following sterilization

Male
Female
Total {(a) to (b)}
Does the Institution have NSV trained doctors?(0 - yes & 1 - No)
CHILD IMMUNISATION
Number of Infants 0 to 11 months old who received the following
BCG
DPT1
DPT2
DPT3
Pentavalent 1
Pentavalent 2
Pentavalent 3
OPV 0 (Birth Dose)
OPV1
OPV2
OPV3
Hepatitis-B0
Hepatitis-B1
Hepatitis-B2
Monthly- PHC
26 of 100
NRHM/PHC/3/M
Hepatitis-B3
Measles
Measles 2nd dose (No. of children more than 16 months of age)
No. of Children aged 9 to 12 months who received JE 1st
dose
Total number of children aged between 9 and 11 months who have been fully
(BCG+DPT123/pentavalent123+OPV123+Measles) during the month
Male
Female
Total {(a) to (b)}
Number of children more than 16 months who received the following

DPT Booster
OPV Booster
Measles, Mumps, Rubella (MMR) Vaccine
Immunisation Status
Total number of children aged between 12 and 23 months who have been fu
(BCG+DPT123/pentavalent123+OPV123+Measles) during the month
Male
Female
Total {(a) to (b)}
Children more than 5 years given DPT5/DT5
Children more than 10 years given TT10
Monthly- PHC
27 of 100
NRHM/PHC/3/M
Children more than 16 years given TT16

Adverse Event Following Immunisation (AEFI)
Abscess
Death
Others
Number of Immunisation sessions during the month
Number of sessions planned
Number of sessions held
Number of sessions where ASHAs were present
Others (Japanese Encephalitis (JE) etc. Please Specify)
Number of children more than 16 months of age who received
Japanese Encephalitis (JE) vaccine
Number of Vitamin A doses
Administered between 9 months and 5 years
Dose-1
Dose-5
Dose-9
Number of cases of Childhood Diseases reported during the month(0

Diphtheria
Pertussis
Tetanus Neonatorum
Monthly- PHC
28 of 100
NRHM/PHC/3/M
Tetanus others
Polio
Measles
Diarrhoea and dehydration
Malaria
Numbers admitted with Respiratory Infections
Other Programmes
Blindness Control Programme
Number of Patients operated for cataract
Number of Intraocular Lens(IOL) implantations
Number of School children detected with Refractive errors
Number of children provided with free glasses
Health Facility Services
Patient Services
Is the facility functioning 24X7 (2 Staff Nurses)?(0 - yes & 1 - No)
If RKS exists at facility, number of RKS meetings held during the month
Does the facility have Ambulance services (Assured Referral Services) availa
If so, number of times it was used for transporting patients during the month
Inpatient
Admissions
Monthly- PHC
29 of 100
NRHM/PHC/3/M
Male
Female
Total {(a) to (b)}
Deaths
Male
Female
Total {(a) to (b)}
In-Patient Head Count at midnight
Outpatient
OPD attendance (All)
Operation Theatre
Operation major (General and spinal anaesthesia)
Out of 61.1,Gynaecology- Hysterectomy surgeries
Operation minor (No or local anaesthesia)
Others (Include other services like Dental, Ophthalmology, AYUSH et

AYUSH
Dental Procedures
Adolescent counselling services
Laboratory Testing
Laboratory test details
Number of Hb tests conducted
Monthly- PHC
30 of 100
NRHM/PHC/3/M
Of which Number having Hb < 7 mg

HIV tests conducted
Male
Female-Non ANC
Female with ANC
Total {(a) to (c)}
Widal tests conducted

VDRL tests conducted
Male
Female-Non ANC
Female with ANC
Total {(a) to (c)}
Malaria tests conducted
Blood smears examined
Plasmodium Vivax test positive
Plasmodium Falciparum test positive
Line Listing of Deaths
Mortality Details - Each case is to be entered in a separate line. Only death

Name and village of deceased
Monthly- PHC
31 of 100
NRHM/PHC/3/M
Monthly- PHC
32 of 100
NRHM/PHC/3/M
Monthly- PHC
33 of 100
NRHM/PHC/3/M
Monthly- PHC
34 of 100
NRHM/PHC/3/M
Monthly- PHC
35 of 100
NRHM/PHC/3/M
Monthly- PHC
36 of 100
NRHM/PHC/3/M
Monthly- PHC
37 of 100
NRHM/PHC/3/M
Probable Causes of Death Description

Infant Deaths (upto 1 year of age)
Within 24 hrs of birth
Sepsis
Asphyxia
Low Birth Weight (LBW) for Children upto 4 weeks of age only
Pneumonia
Diarrhoea
Fever related
Measles
Others
Maternal Deaths by major cause
Abortion
Obstructed/prolonged labour
Severe hypertension/fits
Bleeding
High fever
Other Causes (including causes not known)
Adolescents & Adults
Diarrhoeal diseases
Tuberculosis
Respiratory diseases including infections (other than TB)
Malaria
Monthly- PHC
38 of 100
NRHM/PHC/3/M
Other Fever Related

HIV/AIDS
Heart disease/Hypertension related
Neurological disease including strokes
Trauma/Accidents/Burn cases
Suicide
Animal bites and stings
Other Diseases
Known Acute Disease
Known Chronic Disease
Causes not known
Select
C01-Within 24 hrs of birth

C02-Sepsis
C03-Asphyxia
C04-Low Birth Weight (LBW) for Children upto 4 weeks of age only
C05-Pneumonia
C06-Diarrhoea
C07-Fever related
C08-Measles
C09-Others
M01-Abortion
M02-Obstructed/prolonged labour
M03-Severe hypertension/fits
M04-Bleeding
M05-High fever
M06-Other Causes (including causes not known)
A01-Diarrhoeal diseases
A02-Tuberculosis
A03-Respiratory diseases including infections (other than TB)
A04-Malaria
A05-Other Fever Related
A06-HIV/AIDS
A07-Heart disease/Hypertension related
A08-Neurological disease including strokes
A09-Trauma/Accidents/Burn cases
A10-Suicide
A11-Animal bites and stings
A12-Known Acute Disease
A13-Known Chronic Disease
A14-Causes not known
Monthly- PHC
39 of 100
NRHM/PHC/3/M
A12-Known Acute Disease

A13-Known Chronic Disease
A14-Causes not known
Monthly- PHC
40 of 100
NRHM/PHC/3/M
of Health & Family Welfare
ng & Evaluation Division)
for PHC & Equivalent Institutions
Due for submission on 5th of following Month
Month
Year
October
2015
n 12 weeks)
Monthly- PHC
41 of 100
NRHM/PHC/3/M
centive paid to
rformed at
Monthly- PHC
42 of 100
NRHM/PHC/3/M
mplications and attended at facility
s after delivery
Monthly- PHC
43 of 100
NRHM/PHC/3/M
urs and 14 days
ed infections (RTI/STI) Cases
Monthly- PHC
44 of 100
NRHM/PHC/3/M
ons conducted at facility
ry) sterilizations conducted at facility
D insertions
Monthly- PHC
45 of 100
NRHM/PHC/3/M
& 1 - No)
ed the following
Monthly- PHC
46 of 100
NRHM/PHC/3/M
hs who have been fully immunised

ng the month
ceived the following
ths who have been fully immunised

ng the month
Monthly- PHC
47 of 100
NRHM/PHC/3/M
during the month(0-5 years)
Monthly- PHC
48 of 100
NRHM/PHC/3/M
s & 1 - No)
uring the month
ferral Services) available(0 - yes & 1 - No)
ents during the month
Children (< 19 yrs)
Monthly- PHC
49 of 100
NRHM/PHC/3/M
0
0
0
almology, AYUSH etc.)
Monthly- PHC
50 of 100
NRHM/PHC/3/M
Number Tested
11
11
parate line. Only deaths occuring at the facility to be reported.

Sex
Unit
Age
Monthly- PHC
51 of 100
NRHM/PHC/3/M
Select
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Monthly- PHC
52 of 100
NRHM/PHC/3/M
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Monthly- PHC
53 of 100
NRHM/PHC/3/M
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Monthly- PHC
54 of 100
NRHM/PHC/3/M
Select
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Monthly- PHC
55 of 100
NRHM/PHC/3/M
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Monthly- PHC
56 of 100
NRHM/PHC/3/M
Select
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Monthly- PHC
57 of 100
NRHM/PHC/3/M
Select
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Monthly- PHC
58 of 100
NRHM/PHC/3/M
Monthly- PHC
59 of 100
NRHM/PHC/3/M
Monthly- PHC
60 of 100
NRHM/PHC/3/M
th of following Month
October
MM
2015
YYYY
Numbers reported
during the month
Ref.No
M1
1.1
1.1.1
1.2
1.3
1.4
1.4.1
Monthly- PHC
61 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
1.4.2
1.5
1.6
1.6.1
1.6.2
1.7
1.7.1
M2
2.2
2.2.1
2.2.2
2.2.2 (a)
2.2.2 (b)
2.2.2 (c)
M3
3.1.1
Monthly- PHC
62 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
M4
4.1
4.1.1
4.1.1 (a)
4.1.1 (b)
4
0
4.1.2
4.1.3
4.2
4.2.1
4.2.2
4.3
M5
5.1.1
5.3
5.3.1
5.3.2
5.3.3
M6
6.1
Monthly- PHC
63 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
6.2
6.3
M7
7.1
7.1(a)
7.1(b)
0
0
7.2
M8
8.1
8.1.1
8.1.2
0
0
8.2
Monthly- PHC
64 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
M9
9.1.1
9.2.1
9.3.1
9.4.1
9.5.1
9.5.1 A
9.06
9.07
9.08
9.09
9.10
9.11
9.11.1
9.11.1(a)
9.11.1(b)
0
9.11.2
9.11.2 (a)
9.11.2(b)
0
Monthly- PHC
65 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
9.11.3
9.11.3 (a)
9.11.3 (b)
0
1
9.12
M10
10.1
10.1.01
10.1.02
10.1.03
10.1.04
10.1.04A
10.1.04B
10.1.04C
10.1.05
10.1.06
10.1.07
10.1.08
10.1.09A
10.1.09
10.1.10
Monthly- PHC
66 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
10.1.11
10.1.12
10.1.12B
10.1 A
10.1.13
10.1.13 (a)
10.1.13 (b)
0
10.2
10.2.1
10.2.2
10.2.3
10.3
10.3.1
10.3.1 (a)
10.3.1(b)
0
0
10.3.2
10.3.3
Monthly- PHC
67 of 100
NRHM/PHC/3/M
Numbers reported
during the month
0
Ref.No
10.3.4
10.3.5
10.3.5 (a)
10.3.5 (b)
10.3.5 ( c)
10.4
10.4.1
10.4.2
10.4.3
10.5
10.5.1
M11
11.1
11.1.1
11.1.2
11.1.3
M12
12.1
12.2
12.3
Monthly- PHC
68 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
12.4
12.5
12.6
12.7
12.8
12.9
M13
13.1.1
13.1.2
13.1.3
13.1.4
M14
14.02
14.05
14.06
14.07
14.10
Adults
14.10.1
Monthly- PHC
69 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
14.10.1(a)
14.10.1 (b)
17
14.10.2
14.10.2 (a)
14.10.2(b)
0
4
14.11
14.12
981
14.12.1
14.13
14.13.1
14.13.1 A
14.13.2
14.14
14.14.1
14.14.2
14.14.3
Total
16
M15
15.1.1 (a)
Monthly- PHC
70 of 100
NRHM/PHC/3/M
Numbers reported
during the month
0
Number Positive
Ref.No
15.1.1 (b)
15.1.2
15.1.2 (a)
15.1.2 (b)
15.1.2 (c)
0
Number Tested
15.2
15.3
15.3 (a)
15.3 (b)
15.3 (c)
0
15.4
58
15.4.1
15.4.2
15.4.3
orted.
Cause Code
Monthly- PHC
71 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Monthly- PHC
72 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Monthly- PHC
73 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Monthly- PHC
74 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Err:501
Monthly- PHC
75 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Monthly- PHC
76 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Monthly- PHC
77 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Select
Err:501
Monthly- PHC
78 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Monthly- PHC
79 of 100
NRHM/PHC/3/M
Numbers reported
during the month
Ref.No
Monthly- PHC
80 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
81 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
82 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
83 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
84 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
85 of 100
NRHM/PHC/3/M
Validation Alert
Cross Check : Number of infants
Monthly- PHC
86 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
87 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
88 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
89 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
90 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
91 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
92 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
93 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
94 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
95 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
96 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
97 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
98 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
99 of 100
NRHM/PHC/3/M
Validation Alert
Monthly- PHC
100 of 100

PHC B.charbhatha Oct.2015

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PHC B.charbhatha Oct.2015

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NRHM/PHC/3/M

Monthly Format for PH

Ministry of Health & Family Welf

(Monitoring & Evaluation Divisi

Monthly Format for PHC & Equivalent I

REPRODUCTIVE AND CHILD HEALTH

Pregnancy outcome & details of new-born

Number of cases of pregnant women with Obstetric Complications and atten

Women getting a post partum check up between 48 hours and 14 days

Reproductive Tract Infections/Sexually transmitted infections (RTI/ST

Number of Mini-lap (other than post-partum) sterilizations conducted at facil

Number of Minilap Post-Partum (within 7 days of delivery) sterilizations condu

Number of deaths following sterilization

Number of children more than 16 months who received the following

Children more than 16 years given TT16

Number of cases of Childhood Diseases reported during the month(0

Others (Include other services like Dental, Ophthalmology, AYUSH et

Of which Number having Hb < 7 mg

Widal tests conducted

Mortality Details - Each case is to be entered in a separate line. Only death

Probable Causes of Death Description

Other Fever Related

C01-Within 24 hrs of birth

A12-Known Acute Disease

of Health & Family Welfare

ng & Evaluation Division)

for PHC & Equivalent Institutions

Due for submission on 5th of following Month

mplications and attended at facility

urs and 14 days

ed infections (RTI/STI) Cases

ons conducted at facility

ry) sterilizations conducted at facility

hs who have been fully immunised

ceived the following

ths who have been fully immunised

during the month(0-5 years)

uring the month

ferral Services) available(0 - yes & 1 - No)

ents during the month

Children (< 19 yrs)

almology, AYUSH etc.)

parate line. Only deaths occuring at the facility to be reported.

Cross Check : Number of infants

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