Annexure-II Monthly Reporting Format on Delivery Points on key Performance Indicators(KPI) Name of the For the month of- Monthly Avg of (Q1 + Q2) of 2012-13 i.e. April 2012 to Sep, 2012 to be taken for calculation purposes) Name of the District Sl.No (Delivery Point) Name and Type of the Facility (MC,DH, DWH, SDH, CHC-FRU, CHC- 24x7 PHC, Other PHC, SC, Any other Type of Facility Total deliveries in the reporting month in the No. of (where Total No. of PW detected with Hb level 7 gm and below Number of Maternal Deaths in the facility in the reporting month Fn LR with Fn OT (Y/N) Fn BSU/ BB (Y/N) of Essen. Drugs (Y/N) BMW (Y/N) MOs Mention No of Anesth. OBG, Pedia. LSAS / EmOC/ BeMOC Trained MO and other MO NO. of SNs/ ANMs posted at the facility Ukhrul District 1 District Hospital 12 0 7 0 N N N N Y MO=8 SN=13 2 CHC Kamjong 2 0 0 0 N N N N N MO=04 SN=6 ANM=3 3 PHC Somdal 0 0 0 0 N N N N N MO=02 SN=3 ANM=1 4 CHSRC (private) 30 59 3 0 Y Y N N Y Gyne=1 MO=1 SN=8 LCH (private) 14 26 4 0 N Y N N Y Gyne=1 MO=1 SN=6 Note : Please add more rows as per the no of delivery points and districts Annexure-III
Annexure-V Information required for LSAS & EmOC trained doctors by Govt. of India Name of the State: ………………………… S.No. Name of District Posting and performance of EmOC Trained doctor Posting and performance of LSAS Trained doctor Name of EmOC Trained Doctor Name and type of Facility EmOC Trained doctor is posted of EmOC Trained doctor (No. of and /Any other ) Name of LSAS Trained Doctor Name and type of Facility where LSAS Trained doctor is posted of LSAS Trained doctor(No. of C-section assisted & No. of Spinal Anaesthesia given/Any other ) 1 Ukhrul 0 0 0 0 0 0
Annexure-VII QUALITY ASSURANCE CELL Has established QA Cell? YES NO If yes, at what N State level N District level N Any other level N Field Visits by QA Cell No. of Proposed visits in 2012-13 No. of Visits conducted State level 0 N District level 0 N Any other level 0 N Meeting by QA Cell No. of Proposed Meetings in 2012-13 No. of Meetings conducted level 0 0 District level 0 0 Any level 0 0 Reports No. of Reports Submitted No. of Reports Analyzed State level 0 0 District level 0 0 Any other level 0 0 Annexure-VIII
MMA Drugs Reflected in FMR code 0 0 MVA/ EVA Equipments Reflected in FMR code 0 0 MTP-Training MOs Reflected in FMR code 0 0 MTP training of other field functionaries (counselling and post abortion care) Reflected in FMR code 0 0 MTP-IEC/BCC activities Reflected in FMR code 0 0
Annexure-XII PERFORMANCE INCENTIVES under MH Name of the Scheme/ Activity Type of work being incentivized Level of Facility (CHCs/ PHCs/ Sub- Centers Amount Of Incentive No of workers given incentive Type of worker Performance Expected Quantifiable Output JSY ASHA Ensure full 3 ANC for PW Rs. 350/- per case 7-9 live birth per 1000 population ASHA 600 Immunization ASHA Ensure Immunisation Day/VHND Rs. 150/- per case 230 villages* 6-8 visits per year ASHA 1610 VHND HBNC ASHA Ensure 2 PNC Rs. 250/- per case 7-9 live birth per 1000 population ASHA 600 Hospital Stay during Institutional Delivery ASHA To ensure accompanied PW to health facility by ASHA Rs. 600/- per case for 2 days stay in health facility 600 Outreach Visits for ANM ANM Mobility by foot and stay at village during out reached sessions for VHND (three days allowances) i) Less than-2 km ii)Between- km iii)4 & km Rs. 200/- per visit Rs. 400/- visit Rs. 600/- Once visit in a month