HMIS Monthly Service Delivery Report for the month.................., Year: ….......... SSK/SC NAME: …......................................

Indicator
Indicator Name For the Month Since April
Number
In-Facility Outreach In-Facility Outreach
Part A REPRODUCTIVE AND CHILD HEALTH
M1 Ante Natal Care (ANC) Services & High Risk Pregnancies
1.1 Total number of NEW Pregnant Women registered for ANC
1.1.a Out of total number of NEW Pregnant Women registered with age <15 years
1.1.b Out of total number of NEW Pregnant Women registered with age 15-19 years
1.1.c Out of total number of NEW Pregnant Women registered with age >19 to 49 years
1.1.d Out of total number of NEW Pregnant Women registered with age >49 years
1.1.1 Out of the total NEW ANC registered, number registered within 1st trimester (within 12 weeks)
1.1.2 Total ANC footfall/cases (Old cases + New Registration) attended
1.2 ANC services
1.2.1 Number of PW given Td1 (Tetanus Diptheria dose 1)
1.2.2 Number of PW given Td2 (Tetanus Diptheria dose 2)
1.2.3 Number of PW given Td Booster (Tetanus Diptheria dose booster)
1.2.4 Number of PW provided full course 180 Iron Folic Acid (IFA) tablets
1.2.5 Number of PW provided full course 360 Calcium tablets
1.2.6 Number of PW given one Albendazole tablet after 1st trimester
1.2.7 Number of PW received 4 or more ANC check ups
1.2.8 Number of PW given ANC Corticosteroids in Pre-Term Labour
1.3 Pregnant Women (PW) with Hypertension (BP>140/90)
1.3.1 New cases of PW with hypertension detected
1.4 Pregnant Women (PW) with Anaemia
1.4.1 Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective ANCs
1.4.2 Number of PW having Hb level<11(7.1 to 10.9 g/dl) (Out of total tested cases)
1.4.3 Number of PW having Hb level<=7 g/dl (Out of total tested cases)
1.5 Pregnant Women (PW) with Gestational Diabetes Mellitus (GDM)
1.5.1 Number of PW tested for Blood Sugar using OGTT(Oral Glucose Tolerance Test)
1.5.2 Number of PW tested positive for GDM out of total OGTT(Oral Glucose Tolerance Test) conducted
1.5.3 Number of PW given Metformin out of total tested positive for GDM
1.6 Pregnant Women (PW) with Syphilis
1.6.1 Syphilis test conducted for Pregnant Women
1.6.1.a Number of pregnant/Direct-In-Labor (DIL) women screened/tested (with VDRL/RPR/TPHA/RDT/PoC) for Syphilis
1.6.1.b Number of pregnant/DIL women found Seropositive for Syphilis by VDRL/RPR/TPHA/RDT/PoC test
1.6.1.c Number of pregnant/DIL women found Syphilis-Seropositive and given treatment with injection Benzathine Penicillin (IM)

1.6.1.d Number of live births among Syphilis Seropositive Pregnant Women

1.6.1.e Number of babies born to Syphilis-Seropositive Pregnant Women tested positive/ clinically diagnosed for congenital Syphilis

1.6.1.f Out of above, babies with congenital Syphilis received curative treatment
1.7 Tuberculosis test conducted for Pregnant Women
1.7.1 Number of Pregnant Women screened for TB
1.7.2 Number of Pregnant Women identified with Presumptive TB symptoms
1.7.3 Number of Pregnant Women referred out of those identified with Presumptive TB symptoms
1.8 High Risk /Complicated Pregnancies
1.8.1 Total High Risk Pregnancy (HRP) Intrapartum including following:
Number of Pregnant Women with Post-Partum Haemorrhage(Immediately after
1.8.1.a
delivery) in the facility.
1.8.1.b Number of Pregnant Women with Sepsis in the facility.
1.8.1.c Number of Pregnant Women identified with Eclampsia in the facility
1.8.1.d Number of Pregnant Women identified with obstructed labour in the facility.
1.8.2 Total High Risk Pregnancy (HRP) Antepartum (Only New Cases are to be reported)
1.8.3 Total no. of ANC or PNC cases referred to Higher/ any other facility

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 M2 Deliveries
2.1 Deliveries conducted at Home
2.1.1 Number of Home Deliveries attended by
2.1.1.a Number of Home Deliveries attended by Skill Birth Attendant(SBA) (Doctor/Nurse/ANM)
Number of Home Deliveries attended by Non SBA (Trained Birth Attendant(TBA)
2.1.1.b
/Relatives/etc.)
2.1.2 Number of PW given Tablet Misoprostol during home delivery
2.1.3 Number of newborns received 7 Home Based Newborn Care (HBNC) visits in case of Home delivery
2.2 Number of Institutional Deliveries conducted (Including C-Sections)
Out of total institutional deliveries(excluding C-section), number of women stayed for
2.2.1
48 hours or more after delivery
Out of total Institutional deliveries, number of Institutional Deliveries (Excluding C-
2.2.2
Sections) conducted at night (8 PM- 8 AM)
2.3 Age wise total number of delivery (Home +Institutional) reported (2.3.1+2.3.2+2.3.3+2.3.4)
2.3.1 Out of total number of delivery, PW with age <15 years
2.3.2 Out of total number of delivery, PW with age 15-19 years
2.3.3 Out of total number of delivery, PW with age >19-49 years
2.3.4 Out of total number of delivery, PW with age > 49 years
2.4 Number of newborns received 6 HBNC visits after Institutional Delivery
2.5 No. of identified Sick new-borns referred by ASHA to facility under HBNC Programme
2.6 Total number of Children received all scheduled 5 Home visits under HBYC
M3 Pregnancy outcome & details of new-born/children
3.1 Pregnancy Outcome (in number)
3.1.1 Live Birth
3.1.1.a Live Birth - Male
3.1.1.b Live Birth - Female
3.1.2 Number of Pre-term newborns ( < 37 weeks of pregnancy)
3.1.3 Still Birth
3.1.3.a Intrapartum (Fresh) Still Birth
3.1.3.b Antepartum (Macerated) Still Birth
3.2 Abortion (spontaneous)
3.3.1 Post-abortion/MTP Complications
3.3.1.a Total Post-abortion/MTP Complications Identified
Post-abortion/MTP complications identified (where abortions were carried out in
3.3.1.b.
facilities other than public and accredited private health facilities)
3.4 Details of Newborn children
3.4.1. Number of Newborns weighed at birth
3.4.2. Number of Newborns having weight less than 2500 gms
3.4.2.a Out of the above, number of Newborns having weight less than 1800 gms
3.4.3. Number of Newborns breast fed within 1 hour of birth
3.4.4. No. of Newborns discharged from the facility were exclusively breastfed till discharge
3.5. Rashtriya Bal Swasthaya Karyakram (RBSK)
Number of Newborns screened for defects at birth (as per Comprehensive Newborn
3.5.1
Screening, RBSK)
Number of Newborns identified with visible birth defects (including Neural tube defect,
3.5.1.a
Down's Syndrome, Cleft Lip & Palate, Club foot and Developmental dysplasia of the hip)

M4 Anaemia Mukt Bharat

4.1 IFA Coverage
Number of women of reproductive age (WRA) 20-49 years (non-pregnant, non-
4.1.1.
lactating), provided 4 Red Iron and folic acid (IFA) tablets in a month
4.1.2. Number of children (6-59 months old) provided 8-10 doses (1ml) of IFA syrup (Bi weekly)

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4.1.3 Number of children 5-9 years provided Weekly Iron Folic Acid (IFA Pink) tablets in a month
4.1.3.a Number of out of school children (5 -9 years) given 4-5 IFA Pink tablets at Anganwadi Centres
4.2 Anaemia- Identified & Treated
4.2.1 Beneficiaries identified with Mild and Moderate Anaemia
4.2.1.a Number of out of school adolescent girls (10-19 years) having anaemia (Hb 8.1-11.9 g/dl)
4.2.1.b Number of lactating mothers (of 0-6 months old child) having anaemia (Hb 8.1-11.9 g/dl)
Number of women of reproductive age (non-pregnant, non-lactating) (20-49 years)
4.2.1.c
having anaemia (Hb 8.1-11.9 g/dl)
4.2.2 Beneficiaries identified with Severe Anaemia
4.2.2.a Number of out of school adolescent girls (10-19 years) having severe anaemia (Hb <8 g/dl)
4.2.2.b Number of lactating mothers (of 0-6 months old child) having severe anaemia ((Hb <8 g/dl)
Number of women of reproductive age (non-pregnant, non-lactating) (20-49 years)
4.2.2.c
having severe anaemia (Hb <8 g/dl)
4.2.3 Beneficiaries diagnosed with mild and moderate Anaemia, put on treatment
4.2.3.a Number of anaemic in-school Children (5-9 years) put on treatment
4.2.3.b Number of anaemic in-school adolescent girls (10-19 years) put on treatment
4.2.3.c Number of anaemic out of school adolescent girls (10-19 years) put on treatment
4.2.3.d Number of anaemic in-school adolescent boys (10-19 years) put on treatment
4.2.3.e Number of anaemic lactating mothers (of 0-6 months old child) put on treatment
Number of anaemic women of reproductive age (non-pregnant, non-lactating) (20-49
4.2.3.f
years) put on treatment
M5 Post Natal Care (PNC)
5.1. In case of home delivery, number of women receiving 1st Postpartum checkups within 48 hours
Number of women receiving Postpartum checkup between 48 hours and 14 days after
5.2.
Institutional delivery
5.3. Number of mothers provided full course of 180 IFA tablets after delivery
5.4. Number of mothers provided full course 360 Calcium tablets after delivery
M6 Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI) Cases
6.1 Number of new STI/RTI cases identified
6.1.1. Number of males assessed for STI/RTI
6.1.1.a Out of the above, number of males diagnosed with STI/RTI
6.1.1.b Out of the above, number of males treated for STI/RTI
6.1.2. Number of females (all females) assessed for STI/RTI
6.1.2.a Out of the above, number of females (all females) diagnosed with STI/RTI
6.1.2.b Out of the above, number of females (all females) treated for STI/RTI
6.1.3. Number of H/TG assessed for STI/RTI
6.1.3.a Out of the above, number of H/TG people diagnosed with STI/RTI
6.1.3.b Out of the above, number of H/TG people treated for STI/RTI
M7 Family Planning
7.1. Number of Interval IUCD Insertions (excluding PPIUCD and PAIUCD)
7.2. Number of Postpartum (within 48 hours of delivery) IUCD insertions
7.3. Number of IUCD Removals
7.4. Number of complications following IUCD Insertion
7.5. Injectable Contraceptive MPA- First Dose
7.6. Injectable Contraceptive MPA- Second Dose
7.7. Injectable Contraceptive MPA- Third Dose
7.8. Injectable Contraceptive MPA- Fourth and above Dose
7.9. Number of Combined Oral Pill cycles distributed to the beneficiary
7.10. Number of Condom pieces distributed to the beneficiary
7.11. Number of Centchroman (weekly) pill strips distributed to the beneficiary
7.12. Number of Emergency Contraceptive Pills (ECP) given to the beneficiary
7.13. Number of Pregnancy Test Kits (PTK) utilized
7.14 Quality in sterilization services
7.14.1 Complications following male sterilization
7.14.2 Complications following female sterilization

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 M8 CHILD IMMUNISATION
8.1 Number of Infants 0 to 11 months old who received:
8.1.1. Child immunisation - Vitamin K (Birth Dose)
8.1.2. Child immunisation - BCG
8.1.3. Child immunisation - Pentavalent 1
8.1.4. Child immunisation - Pentavalent 2
8.1.5. Child immunisation - Pentavalent 3
8.1.6. Child immunisation - OPV 0 (Birth Dose)
8.1.7. Child immunisation - OPV1
8.1.8. Child immunisation - OPV2
8.1.9. Child immunisation - OPV3
8.1.10. Child immunisation - Hepatitis-B0 (Birth Dose)
8.1.11. Child immunisation - Inactivated Injectable Polio Vaccine 1 (IPV 1)
8.1.12. Child immunisation - Inactivated Injectable Polio Vaccine 2 (IPV 2)
8.1.13. Child immunisation - Rotavirus 1
8.1.14. Child immunisation - Rotavirus 2
8.1.15. Child immunisation - Rotavirus 3
8.1.16. Child immunisation - PCV1
8.1.17. Child immunisation - PCV2
8.2 Number of Children 9-11 months who received:
8.2.1. Child immunisation(9 - 11 months) - Inactivated Injectable Polio Vaccine 3 (IPV 3)
Child immunisation (9-11months) - Measles & Rubella (MR)/Measles containing
8.2.2.
vaccine(MCV) - 1st Dose
8.2.3. Child immunisation (9-11months) - JE 1st dose
8.2.4. Child immunisation - PCV Booster
Number of children aged between 9 and <12 months FULLY IMMUNIZED {BCG +OPV123+ Pentavalent123+
8.2.5
MR/ Measles Containing Vaccine (MCV)-1st Dose}
8.2.5.a FULLY IMMUNIZED children aged between 9 and <12 months- Male
8.2.5.b FULLY IMMUNIZED children aged between 9 and <12 months- Female
8.3 Children given following vaccination after 12 months (delayed vaccinations)
Child immunisation(after 12 months-delayed vaccination) - Measles & Rubella
8.3.1.
(MR)/Measles containing vaccine(MCV)- 1st Dose
8.3.2. Child immunisation (after 12 months-delayed vaccination) - JE 1st dose
8.3.3. Child immunisation - DPT 1 after 12 months of age (delayed vaccination)
8.3.4. Child immunisation - DPT 2 after 12 months of age (delayed vaccination)
8.3.5. Child immunisation - DPT 3 after 12 months of age (delayed vaccination)
8.3.6. Child immunisation - DPT Booster after 24 months of age (delayed vaccination)
8.3.7. Child immunisation - OPV Booster after 24 months of age (delayed vaccination)
8.3.8. Child immunisation - JE Booster after 24 months of age (delayed vaccination)
8.4 Number of Children more than 12 months who received:
8.4.1. Child immunisation - Measles & Rubella (MR)/ Measles containing vaccine(MCV)- 2nd Dose (16-24 months)

8.4.2. Child immunisation - DPT 1st Booster

8.4.3. Child immunisation - OPV Booster
Number of children more than 16 months of age who received Japanese Encephalitis
8.4.4.
(JE) vaccine- 2nd dose (16-24 months)
8.5 Number of Children more than 23 months who received:
8.5.1. Child Immunization- Typhoid
8.5.2. Children more than 5 years received DPT5 (2nd Booster)
8.5.3. Children more than 10 years received Td10 (Tetanus Diptheria10)
8.5.4. Children more than 16 years received Td16 (Tetanus Diptheria16)
8.6 Adverse Event Following Immunisation (AEFI)
8.6.1. Number of cases of AEFI -Minor (eg.- fever, rash, pain etc)
Number of cases of AEFI - Severe (eg.- anaphylaxis, fever>102 degrees, not requiring
8.6.2.
hospitalization etc.)
8.6.3. Number of cases of AEFI - Serious (eg.- hospitalization, death, disability , cluster etc.)
8.6.3.a Out of Number of cases of AEFI - Serious , total number of AEFI deaths

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 8.7 Number of Immunisation sessions
8.7.1. Immunisation sessions planned
8.7.2. Immunisation sessions held
8.8 Children received Vitamin A Doses between 9 months and 5 years
8.8.1. Child immunisation - Vitamin A Dose - 1
8.8.2. Child immunisation - Vitamin A Dose - 5
8.8.3. Child immunisation - Vitamin A Dose - 9
M9 Number of cases of Childhood Diseases
9.1 New cases of Childhood Diseases (0-5 years) & Leprosy (0-14 years) Include new cases of
9.1.1. Childhood Diseases - Malaria
9.1.2. Childhood Diseases - Diarrhoea
9.1.3. Childhood Diseases - Diarrhoea treated with ORS
9.1.4. Childhood Diseases - Diarrhoea treated with Zinc for 14 days
Part B National Programmes
M10 National Vector Borne Disease Control Programme(NVBDCP)
10.1 Malaria
10.1.1 Rapid Diagnostic Test (RDT )
10.1.1.a RDT conducted for Malaria
10.1.1.b Malaria (RDT) - Plasmodium Vivax test positive
10.1.1.c Malaria (RDT) - Plasmodium Falciparum test positive
10.1.1.d Malaria (RDT) - Mixed test positive
10.2 Lymphatic Filaraisis
10.2.1. Number of persons that consumed MDA(Mass Drug Administration) drugs during the MDA round
Number of Lymphatic Filarisis lymphoedema patients received MMDP(Morbidity
10.2.2.
Management And Disability Prevention) kits
M11 Adolescent Health
11.1. Coverage under MHS- Menstrual Hygiene Scheme (GOI supported)
11.1.1. Number of adolescent girls provided sanitary napkin packs by ASHA
11.1.2. Number of sanitary napkin packs distributed free to ASHA (for her personal use)
11.1.3. Number of adolescent girls attended monthly meeting
Number of adolescent girls provided sanitary napkin packs by State/UT supported
11.1.4.
Menstrual Hygiene Scheme (MHS)
11.2 Peer Educator Programme
11.2.1. Number of Peer Educators selected
11.2.2. Out of the selected Peer Educators, numbers trained
11.2.3. Number of Adolescent Health & Wellness Days organized
11.2.4. Number of Adolescent Friendly Club Meetings organized
M12 National TB Elimination Programme (NTEP)
12.1. Number of notified TB patients who are on Anti Tuberculosis Therapy
12.2. Number of Presumptive TB (ie with 4 Symptom complex of TB) identified
Number of Presumptive TB (ie with 4 Symptom complex of TB) identified and sent for
12.3.
any TB testing
Number of Presumptive TB (ie with 4 Symptom complex of TB) identified and sent for
12.3.a
any TB testing within the facility
Number of Presumptive TB (ie with 4 Symptom complex of TB) identified and sent for
12.3.b
any TB testing outside the facility
12.4. Of the number sent for testing, number who were tested (by any test) for TB within the facility
12.5. Of the number sent for testing, number who were tested (by any test) for TB outside the facility
12.6. Of the number tested, number of persons diagnosed as TB patients.
12.7. Number of TB patients availing treatment through a Treatment supporter for the reporting month
12.8. Number of Directly Observed Treatment, Short-course (DOTS) cases completed successfully

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 Part C Health facility Services
M13 Patient Services
13.1 Out Patient Department (OPD in Facility) by disease/ health condition (excluding teleconsultation)
13.1.1. Outpatient - Diabetes
13.1.2. Outpatient - Hypertension
13.1.3. Outpatient - Stroke (Paralysis)
13.1.4. Outpatient - Cardiovascular Disease
13.1.5. Outpatient - Mental illness
13.1.6. Outpatient - Epilepsy
13.1.7. Outpatient - Ophthalmic Related
13.1.8. Outpatient - Dental
13.1.9. Outpatient - ENT
13.1.10. Outpatients- Asthma
13.1.11. Outpatient - COPD
13.1.12. Outpatient - Tuberculosis
13.1.13. Outpatient - Palliative Care
13.1.14. Other Services
13.1.14.a Number of Palliative Patients visited at home
13.2 Outpatient attendance (All) (excluding teleconsultation)
13.2.1. Allopathic- Outpatient attendance
13.2.2. Ayush - Outpatient attendance
13.3 Inpatient details
13.3.1 Total Number of cases Referred out (OPD+IPD+Emergency)
13.3.1.a Total cases Referred out (OPD+IPD+Emergency)-During Day
13.3.2 Day Care Admissions
13.3.3 Total number of telemedicine consultation provided
13.4 Janani Shishu Suraksha Karyakram (JSSK)
13.4.1 Number of Pregnant Women(PW) and Post Natal Care (PNC) Beneficiaries provided
13.4.1.a Total number of PW and PNC - JSSK Beneficiaries
13.4.1.b Number of PW and PNC benificiaries provided - Free Medicines under JSSK
13.4.1.c Number of PW and PNC benificiaries provided - Free Diet under JSSK
13.4.1.d Number of PW and PNC benificiaries provided - Free Diagnostics under JSSK
13.4.1.e Number of PW and PNC benificiaries provided - Free Home to facility transport under
13.4.1.f Number of PW and PNC benificiaries provided - Interfacility transfers when needed
13.4.1.g Number of PW and PNC benificiaries provided - Free Drop Back home under JSSK
13.4.2 Number of sick infants provided
13.4.2.a Number of infants admitted at facility due to any sickness- JSSK Beneficiaries
13.4.2.b Number of sick infants provided - Free Medicines under JSSK
13.4.2.c Number of sick infants provided - Free Home to facility transport under JSSK
13.4.2.d Number of sick infants provided - Interfacility transfers when needed under JSSK
13.4.2.e Number of sick infants provided - Free Drop Back home under JSSK
13.5. Number of Jan Arogya Samiti (JAS) meetings held
Number of Anganwadi centres reported to have conducted atleast one Village Health &
13.6
Nutrition Day (VHNDs)/UHND/ Outreach / Special Outreach sessions
13.7 Total number of UHND/VHND sessions conducted in the reporting month
13.8 Total number of Outreach/Special Outreach camps conducted in the reporting month
13.9 Stock outs
13.9.a Total no. of essential drugs for which stock-outs reported
13.10. National Viral Hepatitis Control Program (Diagnosis and Management of viral hepatitis)
13.10.1 Total number of blood samples screened by ELISA/Rapid tests for viral hepatitis
Total number of blood samples screened by ELISA/Rapid tests for viral hepatitis B i.e.
13.10.1.a
HBsAg (excluding pregnant women)
13.10.1.b Total number of blood samples screened by ELISA/Rapid tests for viral hepatitis C(Anti-
13.10.2 Total number of blood samples tested positive by ELISA/ Rapid tests for viral hepatitis & its management
Total number of blood samples tested positive by ELISA/ Rapid tests for Hepatitis B (out
13.10.2.a
of those tested for HBsAg excluding pregnant women)
Total number of blood samples tested positive by ELISA/ Rapid tests for Hepatitis C (out
13.10.2.b
of those tested for Anti-HCV)

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 13.10.3 Hepatitis B in pregnancy
13.10.3.a Number of Pregnant Women tested for HBsAg
13.10.3.b Number of Pregnant Women who are HBsAg positive(out of those tested for Hepatitis B i.e. HBsAg)
13.10.3.c Number of Pregnant Women found positive for HBsAg referred out to higher centre for institutional delivery
13.10.3.d Number of newborn who received birth dose of Hepatitis B vaccine born to HBsAg positive pregnant women
M14 Laboratory Testing
14.1 Total Number of Lab Tests
14.1.1 Total Number of Lab Tests done- Inhouse
14.1.2 Total Number of Lab Tests done- Outsourced
14.2 Hb Tests Conducted
14.2.1 Number of Hb tests conducted including kit tests
14.2.2 Out of the total number of Hb tests done, Number having Hb < 7 mg
14.3 HIV tests
14.3.1.a Number of males screened for HIV by Whole Blood Finger Prick/RDT test/POC test
14.3.1.b Out of the above, No. of males found reactive for HIV
14.3.1.c Number of HIV reactive males subjected to HIV test at Confirmatory Centre (Stand Alone-ICTC)
14.3.1.d Out of the above, No. of males confirmed as HIV Positive
14.3.2.a Number of females (non-ANC) screened for HIV by Whole Blood Finger Prick/RDT test/POC test
14.3.2.b Out of the above, No. of females (non-ANC) found reactive for HIV
14.3.2.c Number of HIV reactive females (non-ANC) subjected to HIV test at Confirmatory Centre (Stand Alone-ICTC)
14.3.2.d Out of the above, No. of females (non-ANC) confirmed as HIV Positive
14.3.3.a Number of Pregnant Women (PW-ANC) screened for HIV by Whole Blood Finger Prick/RDT test/POC test
14.3.3.b Out of the above, No. of PW(ANC) found reactive for HIV
14.3.3.c Number of HIV reactive PW(ANC) subjected to HIV test at Confirmatory Centre (Stand Alone-ICTC)
14.3.3.d Out of the above, No. of PW(ANC) confirmed as HIV Positive
14.3.3.e Number of Pregnant Women (ANC&DIL) screened for HIV more than once(Repeated testing)
14.3.4.a Number of H/TG people screened for HIV by Whole Blood Finger Prick/RDT test/POC test
14.3.4.b Out of the above, No. of H/TG people found reactive for HIV
14.3.4.c Number of HIV reactive H/TG people subjected to HIV test at Confirmatory Centre (Stand Alone-ICTC)
14.3.4.d Out of the above, No. of H/TG people confirmed as HIV Positive
14.4 STI/RTI attendees Tested for Syphilis
14.4.1.a Total number of males tested for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
14.4.1.b Out of the above, number of males tested reactive for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
14.4.1.c Out of the above, number of males treated for Syphilis
14.4.2.a Total number of female (non-ANC) tested for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
14.4.2.b Out of the above, number of females (non-ANC) tested reactive for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
14.4.2.c Out of the above, number of females (non-ANC) treated for Syphilis
14.4.3.a Total number of H/TG people tested for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
14.4.3.b Out of the above, number of H/TG people tested reactive for Syphilis (RPR/VDRL/PoC/ RDT/TPHA)
14.4.3.c Out of the above, number of H/TG people treated for Syphilis
Part D Mortality Details
M15 Details of deaths reported
New born deaths within 24 hrs(1 to 23 Hrs 59 minutes) of birth at Facility/Facility to
15.1.1.a
facility in transit
New born deaths within 24 hrs(1 to 23 Hrs 59 minutes) of birth in Community (at home
15.1.1.b
or home to facility transit)
15.1.2.a New born deaths within 1 week (1 to 7 days) at Facility/Facility to facility in transit
New born deaths within 1 week (1 to 7 days) At Community (at home or home to facility
15.1.2.b
transit)
15.1.3.a New born deaths within 8 to 28 days at Facility/Facility to facility in transit
15.1.3.b New born deaths within 8 to 28 days At Community (at home or home to facility transit)
15.1.4.a Infant Deaths (>28 days to 12 months) at Facility/Facility to facility in transit
Infant Deaths (>28 days to 12 months) At Community (at home or home to facility
15.1.4.b
transit)

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 15.2 Neonatal Deaths up to 4 weeks (0 to 28 days) due to
15.2.1. Neonatal Deaths up to 4 weeks (0 to 28 days) due to Sepsis
15.2.2. Neonatal Deaths up to 4 weeks (0 to 28 days) due to Asphyxia
15.2.3. Neonatal Deaths up to 4 weeks (0 to 28 days) due to complications of Prematurity
15.2.4. Neonatal Deaths up to 4 weeks (0 to 28 days) due to Other causes
15.3 Infant Deaths Between more than 28 days and less than 12 months due to
15.3.1. Number of Infant Deaths (>28 days - 12 months) due to Pneumonia
15.3.2. Number of Infant Deaths (>28 days - 12 months) due to Diarrhoea
15.3.3. Number of Infant Deaths (>28 days - 12 months) due to Fever related
15.3.4. Number of Infant Deaths (>28 days - 12 months) due to Measles
15.3.5. Number of Infant Deaths (>28 days - 12 months) due to Others
15.4 Child Deaths between 1 year and less than 5 years due to
15.4.1. Number of Child Deaths (1 -5 years) due to Pneumonia
15.4.2. Number of Child Deaths (1 -5 years) due to Diarrhoea
15.4.3. Number of Child Deaths (1 -5 years) due to Fever related
15.4.4. Number of Child Deaths (1 -5 years) due to Measles
15.4.5. Number of Child Deaths (1 -5 years) due to Others
15.5 Maternal Deaths due to
15.5.1. Number of Maternal Deaths due to APH (Antepartum Haemmorhage)
15.5.2. Number of Maternal Deaths due to PPH (Post-Partum Haemmorhage)
15.5.3. Number of Maternal Deaths due to Pregnancy related infection and sepsis, Fever
15.5.4. Number of Maternal Deaths due to Abortive complication
15.5.5. Number of Maternal Deaths due to Obstructed/prolonged labour
Number of Maternal Deaths due to Severe hypertension/fits & Hypertensive disorder in
15.5.6.
pregnancy, birth and puerperium
15.5.7. Number of Maternal Deaths due to Other/Unknown Causes
15.5.8. Age wise total Maternal Deaths, occurred at Facility
15.5.8.a Out of total number of maternal deaths, deaths with age<15 years
15.5.8.b Out of total number of maternal deaths, deaths with age 15-19 years
15.5.8.c Out of total number maternal deaths, deaths with age more than >19-49 years
15.5.8.d Out of total number maternal deaths, deaths with age more than >49 years
15.6 Other Deaths (except Infant, Child & Maternal Deaths) 5 years and above due to
15.6.1. Number of deaths due to Diarrhoeal diseases
15.6.2. Number of deaths due to Tuberculosis
15.6.3. Number of deaths due to Respiratory diseases including infections (other than TB)
15.6.4. Number of deaths due to Other Fever Related
15.6.5. Number of deaths due to Heart disease/Hypertension related
15.6.6. Number of deaths due to Cancer
15.6.7. Number of deaths due to Neurological disease including strokes
15.6.8. Number of deaths due to Accidents/Burn cases
15.6.9. Number of deaths due to Self Harm
15.6.10. Number of deaths due to Animal bites and stings
15.6.11. Number of deaths due to Known Acute Disease
15.6.12. Number of deaths due to Known Chronic Disease
15.6.13. Number of deaths due to Other Causes
15.7. Deaths due to Vector Borne Diseases ( all age groups)
15.7.1. Number of Deaths due to Malaria- Plasmodium Vivax
15.7.2. Number of Deaths due to Malaria- Plasmodium Falciparum
15.8 Total Deaths (above 5 years of age)
15.8.1 Above 5 years to below 10 years
15.8.2 Above 10 years to below 19 years
15.8.3 Adult above >19 years
Part E Quality Control
M16 QA (Quality Assurance) & BEMMP (Biomedical Equipment Management & Maintenance Program)
16.1 EQAS Compliance
16.1.1. Total Quantity of Bio medical waste generated in Kg for the month (All Yellow, Red, white & Blue)
16.1.2. Total Quantity of General waste generated in Kg for the month

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