| District | Dispensary Name | Dispensary NIN | Latitude | Longitude | Category | Type |
|---|---|---|---|---|---|---|
| Ifsc | Name of the Bank | Branch Name | Account Number | Complete Address of Bank | ||
| 1. Is the facility accessible through road ? | if No(i),Mention Issue | 2. What is the nearest higher health facilty | if yes, then Distance with the selected HWC | if Yes,Name of the Nearest higher health facilty | Contact No of Nearest Health Facility. |
|---|---|---|---|---|---|
| 3. Name of Identified officer for regular monitoring/feedback. | Designation of Identified officer | Contact No of Identified officer | 4. Is there a signage/way-finding of the facility at a prominent place | 5. Is the facade branding as per HWC Norms available at the facility(ii) | If No/Not Installed or Damaged, Please Mention Issue |
| 6. Does the facility require any repair ? | If Yes , Mention Repair Work | Details of Repair Work | 7. Can this facility (Infrastructure) be upgraded in the pattern HWC? | If No, Mention Reason | |
| 8. Does the facility require any renovation ? | if Yes, Share Renovation Details | 9. Does the facility require whitewash ? | if Yes - Share Details (facility require whitewash) | 10. Is there a boundary-wall around the facility | 11. If available, Harbal/Garden Area Maintained |
| 12. Is there adequate parking available ? | 13. Is your facility elderly and differntly-abled friendly ? | if yes (facility elderly and differntly-abled friendly) | 14. Does your facility have a working wheelchair | 15. Does your facility have electricity connection | |
| Ramp- | |||||
| 16. Total number of functional fans, tube-lights, bulbs, air-conditioner in the facility | 17. Total number of Non-functional fans, tube-lights, bulbs, air-conditioner in the facility | 18. Is there a power backup available at the facility | Number of Invertor and Generator Available | 19. Is there a functional water cooler/R.O./water dispenser available in the facility | If Yes (water cooler/R.O./water dispenser) ,Mention monthly charges for refilling |
| Total Functional Fans- 0 Total Tube Lights- 0 Total Bulbs- 0 Total AC- 0 Total Other Electrical Gadget- 0 | Total Non-Functional Fans- 0 Total Non-Functional Total Lights- 0 Total Non-Functional Bulbs- 0 Total Non-Functional AC- 0 Total Non-Functional Other Electrical Gadget- 0 | Invertor-, Total Invertor-, Generator-, Total Invertor-, Inverter/Generator Functioning- |
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| 20. Is the fire-safety equipment/cylinders available? | If yes, Is the cylinder filled | If No (cylinder filled) mention Issues | Is the staff trained to use them | If No (staff trained) mention Issues | If yes, has the expiry been checked |
| If No (expiry been checked) mention Issues | If No (fire-safety equipment/cylinders) mention Issues | 21. Is the facility prepared for any Disaster/Emergency | If Yes (prepared for any Disaster/Emergency) | 22. Are there seperate washrooms for male,female and differntly-abled person | |
|
Functional Strecther-No Functional Wheel Chair-No Emergency Medicine Tray-No IV Fluids-No Functional Oxygen Cylinders-No |
Male - No, Female - No, Differently-abled person - - No, |
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| 23. Is the bio-medical management system in place at the facility | if yes(bio-medical management system ) | if yes(bio-medical management system ) | |||
| Vendor -, Payment Mode -, Charges - |
Frequency of lifting the waste monthly -, Validity of contract-, Are you following the color coding and bin-system -, |
| 24. What is the total number of rooms in the facility | 25. Doctor Room - Is there a table for the doctor | If No, Mention Issue | Is there a chair for the doctor in the doctor room | If No, Mention Issue | Is there an examination table in the doctor room | If No, Mention Issue |
|---|---|---|---|---|---|---|
|
Total Room-0 Doctor Room-0 Pharmacy Room-0 Lab Room-0 Waiting Room-0 Storage Room-0 Other Room-0 | ||||||
| Does the room have a functional Air-conditioning | If No, Mention Issue | Doctor Room - items available for use from the tool-kit | 26. Waiting Room - Is the sitting arrangement adequate for 20 people or more | If No, Mention how many available | Is any health related IEC displayed in waiting room | Is the Citizen Charter displayed |
| 27. Sampling Room - Is there a functional basin with water | Sampling Room - functional basin with water If No, Mention Issue | Is there sitting arrangement for the staff and the patient | Sitting arrangement for the staff and the patient If No, Mention Issue | Arrangement for Bio-Medical Waste Disposal | Sampling Room - Bio-Medical Waste Disposal If No, Mention Issue | |
| 28. Pharmacist Room - Is there sitting arrangement for the staff | Pharmacist Room - Is there sitting arrangement No - Mention Issue | Pharmacist Room - Availability of Storage Facility | 29. Electrical Gadgets - Is there a functional fridge/cold storage/ILR/deep-freezer? | |||
|
Total Almirah- 0 Total Racks- 0 Total Shelves- 0 Total Cabinet- 0 Total Others- 0 |
Fridge- 0 Coldstorage- 0 ILR- 0 Deep Freezer- 0 |
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| Upload Pre-Assessment Pictures - Outdoor | Upload Pre-Assessment Pictures - Areas requiring repair or renovation | Upload Pre-Assessment Pictures - Toilets | Upload Pre-Assessment Pictures - All Rooms | Upload Pre-Assessment Pictures - Others | ||
| Infrastructure Remarks | ||||||
| 1. Total Number of AMO Available at present at the facility | 2. Total Number of Upvaid avialable at the facility | 3. Total no of Sweeper/Helper/Class-4 available at the facility | 4. Total no of Trained DAI available at the facility | 5. Total no of Other Staff available at the facility |
|---|---|---|---|---|
| 6. Is the iHRMS implemented in your facility | 7. Are the Job Descriptions for all the categories of staff definied? | Job Descriptions(If No) Details | 8. Is performance assessment being conducted for all category of staff? | If No, Mention Categories for which assessment not defined. |
| Total Number of UMO avialable at the facility (If the Dispensary is Unani) | Human Resource Remarks | |||
| 1. No. of Drugs to be made available as per norms? | 2. How many drugs are available at present | 3. Any Other drug Available? | 4. Any specific drug requirement |
|---|---|---|---|
| Drugs Remarks | |||
| Does the facility have functional computer/desktops/tablets at the facility | Total Computer | Total Tablet | Mention Issues If No, functional computer/desktops/tablets | Is there an active internet connection avialable? | Wi-FI set up Type |
|---|---|---|---|---|---|
| Wi-FI set up Charges | Mention Issues If No,functional Wi-FI set up | Is there a functional printer | Is the printer connected with the computer/desktops/tabs | Mention Issues If No,functional printer | |
| IT Remarks | |||||
| Is the District Health Society formed | Mention Issues If No,Is the District Health Society formed | Is the Monitoring/Supervision Committee formed | Mention Issues If No,Is the Monitoring/Supervision Committee formed | SDM Name | SDM Name Contact No |
|---|---|---|---|---|---|
| Detail of the Identified officer for regular monitoring/feedback- Name | Identified officer- Designation | Identified officer- Contact No | Is the excutive agency identified | Is Administrative unit identified | Name of executive agencies identified for each block |
| Are the estimates prepared as per the standard plan | If Yes - Estimates prepared standard plan (Rough Cost Rs) | If Yes - Upload Rough Cost Estimate Plan | |||
| Have the sanction limits being given | Is Zero balance account openend in Bank of Baroda | DAO Name | DAO Contact No | Issue of 20% Mobilisation advance | |
| If Yes, Mention Date - 20% Mobilisation advance | 20% physical progress of work achieved | If Yes, Mention Date - 20% physical progress of work achieved | Issue of 50% of the estimate | If Yes, Mention Date -Issue of 50% of the estimate | Utilisation of 70% funds/ Submission of UC |
| If Yes, Mention Date - Utilisation of 70% funds/ Submission of UC | Issue of 30% of funds | If Yes, Mention Date -Issue of 30% of funds | Submission of complete UC (within 2 months of release of final instalment of funds) | If Yes, Mention Date - Submission of complete UC | |
| Budget/Finance Remarks | |||||
| Entry User Name | Entry User Designation | Entry User mobile |
|---|---|---|
Application Status - Entry User/Nodal Officer |
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Application Status - State Level |
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