Nascop: If Yes To Q2 Go To Section A If No To Q2 Go To Section B

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NASCOP

ADOLESCENT HIV CLINIC


FACILITY ASSESSMENT CHECKLIST
Facility Name: _KITALE DISTRICT
HOSPITAL________________________________________________
Facility Mobile/Phone Contacts: ___________________________________
Email
[email protected]__________________________________________
____
Supporting Partner/s___AMPATH__________________________________________
______________________________________________
1. How many HIV infected adolescent are currently enrolled in this facility
a) On Care__830___________________
b) On ART___640__________________
2. Is there a functional adolescent friendly clinic in this facility?
a) Yes
b) No
If Yes to Q2 go to section A
If No to Q2 go to section B
Section A
3. Does the adolescent clinic have furniture and equipments (tick if available
and functional)
a) TV
b) DVD player
c) Darts
d) Pool table
e) Chairs/benches
f) Table/s
g) Other (Specify)
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Section B
4. Does the hospital administration have any plans of starting and equipping an
adolescent clinic?
a) Yes
b) No

5. If Yes to Q4 above what will be the funding source?


a) Hospital funds (FIF)
b) Partner funding
c) Other (Specify)________________________________________________________

6. If No to Q4 above is there a structure or room in the facility that can be


refurbished for use as an adolescent clinic?
a) Yes
b) No
If yes to Q6 go to Section C below

Section c
7. Approximately how much would it cost to refurbish (flooring, painting etc) the
room?
____________500,000__________________________________________________________
______________________________________________________________________________
________
8. Are there any equipments or furniture in the facility that can be availed to
furnish the room once it is refurbished in order to open an adolescent friendly
clinic?
a) Yes
b) No
9. If yes to Q8 above what are some of these equipments and furniture?(please
tick appropriately)
a) Television
b) DVD player
c) Darts
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d) Pool table
e) Chairs/benches
f) Others (specify)__________________________________
10.Any Remarks or Comments
____Currently the clients meet once a month in the hospital resource room but
there is no special clinic for
them____________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
______
CCC in charge Details
Name: ___PETER MWATHI__________________________________________
Designation: ___SCO__________________________
Contacts:
Mobile _0720212618___________________________________
[email protected]___________________________________
Date: ___12-4-2013___________________________________

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