CHC Nrhm-Mis

NRHM/ DH-SDH-CHC/3/M
Ministry of Health & Family Welfare

(Monitoring & Evaluation Division)
Monthly Format for CHC-SDH-DH and Equivalent Institutions
State: Due for submission on 5th of following Month
District: Month: MMM
Block: Year: YYYY
City/ Town/
Village:
Facility Name
Facility type Public Private
Location Rural Urban
Numbers
reported during
the month
Part A. REPRODUCTIVE AND CHILD HEALTH
M1 Ante Natal Care Services (ANC)
1 Total number of pregnant women Registered for ANC
1.1 Of which Number registered within first trimester
2 New women registered under Janani Suraksha Yogna
3 Number of pregnant women received 3 ANC check ups
4 Number of pregnant women given
4.1 TT1
4.2 TT2 or Booster
5 Total number of pregnant women given 100 IFA tablets
6 Pregnant women with Hypertension (BP>140/90)
6.1 New cases detected at institution
6.2 Number of Eclampsia cases managed during delivery
7 Pregnant women with Anaemia
7.1 Number having Hb level<11 (tested cases)
7.2 Number having severe anaemia (Hb<7) treated at institution
M2 Deliveries
8 Deliveries conducted at the facility
8.1 Of which Number discharged under 48 hours of delivery
8.2 Number of cases where Janani Suraksha Yogna incentive paid to
(a) Mothers
(b) ASHAs
(c) ANM or AWW (only for HPS States)
Printed as on 10/09/2008 Monthly- DH-SDH-CHC

1 of 28
Numbers
reported during
the month
M3 Number of Caesarean (C-Section) deliveries
9 C -Section deliveries performed at facility
M4 Pregnancy outcome & details of new-born
10 Pregnancy Outcome (in number)
10.1 Live Birth
(a) Male
(b) Female
Total ({a} to {b})
10.2 Still Birth
10.3 Abortion (spontaneous/induced)
11 Details of Newborn children weighed
11.1 Number of newborns weighed at birth
11.2 Number of newborns having weight less than 2.5 kg
12 Number of newborns breast fed within 1 hour
M5 Complicated pregnancies
Number of cases of pregnant women with Obstetric Complications

13
and attended at facility
14 Number of Complicated pregnancies treated with
14.1 IV Antibiotics
14.2 IV Antihypertensive/Magsulph injection
14.3 IV Oxytocin
14.4 Blood Transfusion
M6 Post - Natal Care
15 Women receiving post partum checkups within 48 hours after delivery

16 Women getting a post partum check up between 48 hours and 14 days
17 PNC maternal complications attended
M7 Medical Termination of Pregnancy (MTP)
18 Number of MTPs conducted at facility
18.1 Up to 12 weeks of pregnancy
18.2 More than 12 weeks of pregnancy
Total {(18.1) to (18.2)}
M8 Reproductive Tract Infections/Sexually transmitted infections (RTI/STI) Cases
19 Number of new RTI/STI for which treatment initiated
(a) Male
(b) Female
Total {(a) to (b)}
20 Number of wet mount tests conducted

2 of 28
Numbers
reported during
the month
M9 Family Planning
21 Number of NSV/Conventional Vasectomy conducted at facility
22 Number of Laparoscopic sterilizations conducted at facility
23 Number of Mini-lap sterilizations conducted at facility
24 Number of Post-Partum sterilizations conducted at facility
25 Number of new IUD Insertions at facility
26 Number of IUD removals
27 Number of Oral Pills cycles distributed
28 Number of Condom pieces distributed
29 Number of Centchroman (weekly) pills given
30 Number of Emergency Contraceptive Pills distributed
31 Quality in sterilization services
31.1 Number of complications following sterilization
(a) Male
(b) Female
Total {(a) to (b)}
31.2 Number of failures following sterilization
(a) Male
(b) Female
Total {(a) to (b)}
31.3 Number of deaths following sterilization
(a) Male
(b) Female
Total {(a) to (b)}
32 Does the Institution have NSV trained doctors? YES/NO
M10 CHILD IMMUNISATION
33 Number of Infants 0 to 12 months old who received the following:
33.01 BCG
33.02 DPT1
33.03 DPT2
33.04 DPT3
33.05 OPV 0 (Birth Dose)
33.06 OPV1
33.07 OPV2
33.08 OPV3
33.09 Hepatitis-B1
33.10 Hepatitis-B2

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Numbers
reported during
the month
33.11 Hepatitis-B3
33.12 Measles
Total number of children aged between 9 and 11 months who have been fully
33.13
immunised (BCG+DPT123+OPV123+Measles) during the month
(a) Male
(b) Female
Total {(a) to (b)}
33.14 Number of children more than 16 months who received the following
33.15 DPT Booster
33.16 OPV Booster
33.17 Measles Rubella Vaccine
34 Immunisation Status
Total number of children aged between 12 and 23 months who have been fully
34.1
immunised (BCG+DPT123+OPV123+Measles) during the month
(a) Male
(b) Female
Total {(a) to (b}
34.2 Children more than 5 years given DT5
34.3 Children more than 10 years given TT10
34.4 Children more than 16 years given TT16
34.5 Adverse Event Following Immunisation (AEFI)
(a) Abscess
(b) Death
(c) Others
34.6 Number of Immunisation sessions during the month
(a) Sessions planned
(b) Sessions held
(c) Number of sessions where ASHAs were present
35 Others (Japanese Encephalitis (JE) etc. Please Specify)
35.1
35.2
35.3
M11 Number of Vitamin A doses
36 Administered between 9 months and 5 years

36.1 Dose-1
36.2 Dose-5
36.3 Dose-9

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Numbers
reported during
the month
M12 Number of cases of Childhood Diseases reported during the month(0-5 years)
37 Diphtheria
38 Pertussis
39 Tetanus Neonatorum
40 Tetanus others
41 Polio
42 Measles
43 Diarrhoea and dehydration
44 Malaria
45 Number admitted with Respiratory Infections
Part B. Other Programmes
M13 Blindness Control Programme
46 Number of Patients operated for cataract
47 Number of Intraocular Lens(IOL) implantations
48 Number of School children detected with Refractive errors
49 Number of children provided with free glasses
50 Number of eyes collected
51 Number of eyes utilised
Part C. Health Facility Services
M14 Patient Services
52 Is the facility functioning as an FRUs? Yes/ No
53 Does the facility have a Rogi Kalyan Samiti Yes/ No
53.1 If so, Number of RKS meetings held during the month
54 Does the facility have Ambulance services (Assured Referral Services) available Yes/ No
54.1 If so, number of times it was used for transporting patients during the month
55 Whether Facility has Operational Sick New Born and Child Care Units? Yes/ No
56 Number of functional Laparoscopes in the Facility
57 Inpatient
Children (<19
57.1 Admissions yrs.)
Adults
(a) Male
(b) Female
Total {(a) to (b)}
57.2 Deaths
(a) Male
(b) Female
Total {(a) to (b)}

5 of 28
Numbers
reported during
the month
57.3 In-Patient Head Count at midnight
58 Outpatient
58.1 OPD attendance (All)
59 Operation Theatre
59.1 Operation major (General and spinal anaesthesia)
59.2 Operation minor (No or local anaesthesia)
60 Others (Include other services like dental, Ophthalmology, AYUSH etc.)
(a) AYUSH
(b) Dental Procedures
(c) Adolescent counselling services
(d)
(e)
M15 Laboratory Testing
61 Lab Tests Details
61.1 Total Number of tests for Hb
61.2 Of which Number having Hb < 7 mg
62 HIV tests conducted Number Tested Number Positive
(a) Male
(b) Female-Non ANC
(c) Female with ANC
Total {(a) to (c)}
Number Tested
63 Widal tests conducted
64 VDRL tests conducted
(a) Male
(b) Female-Non ANC
(c) Female with ANC
Total {(a) to (c)}
65 Malaria tests conducted
65.1 Blood smears examined
65.2 Plasmodium Vivax test positive
65.3 Plasmodium Falciparum test positive

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Numbers
reported during
the month
Part D. Mortality Details
M16 Details of deaths reported during the month with probable causes:
66 Infant deaths within 24 hrs of birth

Up to 1
Between 1 week & 4
67 Infant Deaths up to 4 weeks by cause Weeks of
weeks of birth Total
Birth
67.1 Sepsis
67.2 Asphyxia
67.3 LBW
67.4 Others
Between 1
Between 1 year & 5
68 Infant/Child Deaths up to 5 years by cause month and 11
years Total
months
68.1 Pneumonia
68.2 Diarrhoea
68.3 Fever related
68.4 Measles
68.5 Others
69 Adolescent/Adult deaths by cause 6-14 yrs 15-55 yrs. Above 55 yrs. Total
69.01 Diarrhoeal diseases
69.02 Tuberculosis
Respiratory diseases including infections

69.03
(other than TB)
69.04 Malaria
69.05 Other Fever Related
69.06 HIV/AIDS
69.07 Heart disease/Hypertension related
69.08 Neurological disease including strokes

69.09 Maternal
(a) Abortion
(b) Obstructed/prolonged labour
(c ) Severe hypertesnion/fits
(d) Bleeding
(e) High fever
(f) Other Causes (including causes not known)
69.10 Trauma/Accidents/Burn cases

69.11 Suicide
69.12 Animal bites and stings
69.13 Other Diseases
(a) Known Acute Disease
(b) Known Chronic Disease
(c) Causes not known

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Ref No.
M1
1.1
1.1.1
1.2
1.3
1.4
1.4.1
1.4.2
1.5
1.6
1.6.1
1.6.2
1.7
1.7.1
1.7.2
M2
2.2
2.2.1
2.2.2
2.2.2 (a)
2.2.2 (b)
2.2.2 (c)

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Ref No.
M3
3.1.2
M4
4.1
4.1.1
4.1.1(a)
4.1.1(b)
4.1.2
4.1.3
4.2
4.2.1
4.2.2
4.3
M5
5.1.2
5.3
5.3.1
5.3.2
5.3.3
5.3.4
M6
6.1
6.2
6.3
M7
7.1
7.1.1
7.1.2
M8
8.1
8.1(a)
8.1(b)
8.2

9 of 28
Ref No.
M9
9.1.1 (b)
9.2.1 (b)
9.3.1 (b)
9.4.1 (b)
9.5.1 (c )
9.06
9.07
9.08
9.09
9.10
9.11
9.11.1
9.11.1(a)
9.11.1(b)
9.11.2
9.11.2 (a)
9.11.2 (b)
9.11.3
9.11.3 (a)
9.11.3 (b)
9.12
M10
10.1
10.1.01
10.1.02
10.1.03
10.1.04
10.1.05
10.1.06
10.1.07
10.1.08
10.1.09
10.1.10

10 of 28
Ref No.
10.1.11
10.1.12
10.1.13
10.1.13(a)
10.1.13(b)
10.2
10.2.1
10.2.2
10.2.3
10.3
10.3.1
10.3.1(a)
10.3.1(b)
10.3.2
10.3.3
10.3.4
10.3.5
10.3.5.1
10.3.5.2
10.3.5.3
10.4
10.4.1
10.4.2
10.4.3
10.5
10.5.1
10.5.2
10.5.3
M11
11.1
11.1.1
11.1.2
11.1.3

11 of 28
Ref No.
M12
12.1
12.2
12.3
12.4
12.5
12.6
12.7
12.8
12.9
M13
13.1
13.2
13.3
13.4
13.5
13.6
M14
14.01
14.04
14.05
14.06
14.07
14.08
14.09
14.10
14.10.1
14.10.1(a)
14.10.1(b)
14.10.2
14.10.2(a)
14.10.2(b)

12 of 28
Ref No.
14.11
14.12
14.12.1
14.13
14.13.1
14.13.2
14.14
14.14.1
14.14.2
14.14.3
14.14.4
14.14.5
M15
15.1
15.1.1 (a)
15.1.1 (b)
15.1.2
15.1.2(a)
15.1.2(b)
15.1.2(c)
15.2
15.3
15.3.1
15.3.2
15.3.3
15.4
15.4.1
15.4.2
15.4.3

13 of 28
Ref No.
M17
17.1
17.2
17.2.1
17.2.2
17.2.3
17.2.4
17.3
17.3.1
17.3.2
17.3.3
17.3.4
17.3.5
17.4
17.4.01
17.4.02
17.4.03
17.4.04
17.4.05
17.4.06
17.4.07
17.4.08
17.4.09
17.4.09(a)
17.4.09(b)
17.4.09(c )
17.4.09(d )
17.4.09(e )
17.4.09(f )
17.4.10
17.4.11
17.4.12
17.4.13
17.4.13(a)
17.4.13(b)
17.4.13(c )

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LokLF; ,oa ifjokj dY;k.k ea=ky;

fujh{k.k ,oa ewY;kadu foHkkx
ekfld izi= leqnkf;d LokLF; dsUnz flfoy vLirky ftyk vLirky
jkT; tek djus dh fnukad gj ekg dh 25 rkj
ftyk ekg
fodkl[k.M o"kZ
'kgj@dLck@
xkao
laLFkk dk
uke
laLFkk dk
ljdkjh Hkou ● fdjk;s dk Hkou
izdkj
{ks= xzkeh.k 'kgjh
Hkkx B. iztuu ,oa f'k'kq LokLF;
M1 Ante Natal Care Services (ANC)
M1 izlo iwoZ lsok;sa ¼ANC½
1 dqy iathd`r efgykvksa dh la[;k
1.1 izFke frekgh esa iathd`r xHkZorh efgyk,Wa
2 bl ekg esa tuuh lqj{kk ;kstuk esa iathd`r efgyk,¡
3 xHkZorh efgyk,Wa ftudh 3 tkapsa gqbZ gSa
4 xHkZorh efgykvksa dh la[;k ftUgsa fuEu lqfo/k nh xbZ
4.1 TT1
4.2 TT2 ;k cwLVj
5 dqy xHkZorh efgyk,wa ftUgsa 100 IFA xksyh nh
6 mPp jDrpki okyh xHkZorh efgyk,W ¼BP>140@90½
6.1 laLFkk esa bl ekg ntZ u, dsl
6.2 ,DyksfE'k;k izca/ku ds dsl dh la[;k
7 [kwu dh deh okyh xHkZorh efgyk,Wa
7.1 ftudk Hb Lrj 11 ls de gS ¼tkap ds ckn½
7.2 vfr xaHkhj ,uhfe;k ¼7 th-,e-½ ds dsl ftudk mipkj laLFkk esa gqvk
M2 izlo
8 laLFkkxr izlo
8.1 izloksa dh la[;k tks 48 ?kaVs rd laLFkk esa jgs
8.2 tuuh lqj{kk ;kstuk jkf'k dk Hkqxrku fd;k
(a) izlwrk efgyk dks
(b) vk'kk dks
(c) ,-,u-,e@vkaxuokM+h dk;ZdrkZ dks ¼dsoy HPS jkT;ksa esa½

15 of 28
M3 vkWijs'ku }kjk izlo
9 laLFkk esa gq, vkWijs'ku }kjk izlo dh la[;k
M4 xHkkZoLFkk dk ifj.kke o uotkr f'k'kq tkudkjh
10 xHkkZoLFkk ifj.kke ¼la[;k½
10.1 thfor tUe
(a) ckyd
(b) ckfydk
dqy ({a} + {b})
11 e`r tUe
12 xHkZikr
13 otu fy, x, uotkr f'k'kq dh tkudkjh
13.1 uotkr f'k'kq dh la[;k ftudk tUe ds le; otu fy;k
13.2 2-5 fdyks ls de otu ds uotkr f'k'kqvksa dh la[;k
14 uotkr f'k'kqvksa dh la[;k ftUgsa 1 ?k.Vs ds vanj Lruiku djk;k x;k
M5 tfVy izlo
15 laLFkk ij tkap dh xbZ xHkZorh efgyk,Wa ftUgsa tfVyrk Fkh
16 tfVy izlo dk izca/ku fd;k
16.1 vk;-oh- ,UVhck;ksfVDl
16.2 vk;-oh- ,UVhgk;ijVsfUlo@esxlYQ batsD'ku
16.3 vk;-oh- vkWDlhVksflDl
M6 izlo Ik'pkr ns[kHkky ¼PNC½
17 izlwrk efgyk ftUgsa 48 ?k.Vs ds vanj izlo Ik'pkr lqfo/kk feyh
18 izlwrk efgyk ftUgsa 48 ?k.Vs o 14 fnu ds vanj izlo Ik'pkr lqfo/kk feyh
19 izlo Ik'pkr tfVyrk izca/ku dh la[;k
M7 xHkZikr
20 laLFkk esa fd, x, xHkZikr dh la[;k
20.1 xHkkZoLFkk ds 12 g¶rs rd
20.2 xHkkZoLFkk ds 12 g¶rs ls vf/kd
dqy {(21.1) to (20.2)}
21 futh laLFkkvksa esa fd, x, xHkZikr dh la[;k
M8 RTI/STI dsl
22 u;s dslksa dh la[;k ftudk mipkj 'kq: fd;k
(a) iq:"k
(b) efgyk
dqy {(a) (b)}
23 bl ekg fd;s x;s osV ekmUV tkap dh la[;k

16 of 28
M9 Family Planning
24 laLFkk esa dh xbZ NSV/iq:"k ulcanh dh la[;k
25 laLFkk esa dh xbZ LTT dh la[;k
26 laLFkk esa fd;s x;s feuhysi ulcUnh dh la[;k
27 laLFkk esa fd;s x,s izlo Ik'pkr ulcUnh dh la[;k
28 bl ekg laLFkk esa fd, x, ywi fuos'ku dh la[;k
29 ywi dh la[;k fudkys x,
30 forfjr vksjy fiy pØ dh la[;k
31 forfjr fd, x, fujks/k dh la[;k
32 forfjr lkIrkfgd xksyh ¼lsUVØkseku½ dh la[;k
33 forfjr vkikrdkyhu xHkZfujks/kd dh la[;k
34 ulcanh lsokvksa dh xq.koRrk
34.1 ulcanh ds dkj.k mith tfVyrk
(a) iq:"k
(b) efgyk
dqy {(a) (b)}
34.2 vlQy ulcUnh
(a) iq:"k
(b) efgyk
dqy {(a) (b)}
34.3 ulcUnh ds ckn e`R;q
(a) iq:"k
(b) efgyk
dqy {(a) (b)}
34.4 laLFkk esa NSV izf'kf{kr fpfdRld gSa
M10 Vhdkdj.k
35 0&12 ekg ds cPps ftUgsa fuEu Vhds fn, x,
35.01 ch-lh-th-
35.02 Mh-ih-Vh- 1
35.03 Mh-ih-Vh- 2
35.04 Mh-ih-Vh- 3
35.05 iksfy;ks 0 ¼tUe ds le;½
35.06 iksfy;ks 1
35.07 iksfy;ks 2
35.08 iksfy;ks 3
35.09 fgi ch 1
35.10 fgi ch 2

17 of 28
35.11 fgi ch 3
35.12 ehtYl
35.13 9&12 ekg ds cPpksa dh la[;k ftudk bl ekg esa iw.kZ Vhdkdj.k gqvk ¼chlhth $ MhihVh 1 2 3 $ iksfy;ks 1 2 3 $ ehtYl½
(a) ckyd
(b) ckfydk
dqy {(a) (b)}
33.14 5 o"kZ rd ds cPps ftUg DTS fn;kA
36.1 MhihVh cwLVj
36.2 iksfy;ks cwLVj
36.3 ehtYl] ;Eil] :csyk ¼MMR½
37 Vhdkdj.k Lrj
37.1 12&23 ekg ds cPpksa dh la[;k ftudk bl ekg esa iw.kZ Vhdkdj.k gqvk ¼chlhth $ MhihVh 1 2 3 $ iksfy;ks 1 2 3 $ ehtY
(a) ckyd
(b) ckfydk
dqy {(a) (b)}
37.2 10 o"kZ ls vf/kd cPps ftUgsa TT10 fn;k
37.3 16 o"kZ ls vf/kd cPps ftUgsa TT16 fn;k
37.4 Vhdkdj.k Ik'pkr~ izfrdwy izHkko
(a) QksM+k
(b) e`R;q
(c) vU;
38 ekg esa Vhdkdj.k l= dh la[;k
38.1 fu;ksftr l=
38.2 vk;ksftr l=
38.3 l= tgka vk'kk mifLFkr Fkh
39 vU; ¼tsiuhl budsQsykbfVl½
39.1
39.2
39.3
M11 foVkfeu , [kqjkd dh la[;k
40 9 ekg ls 5 o"kZ ds chp nh xbZ [kqjkd
40.1 [kqjkd 1
40.2 [kqjkd 5
40.3 [kqjkd 9
40.4 Dose-9

18 of 28
M12 0&5 o"kZ ds cPpksa esa chekjh
37 fMIFksfj;k
38 ijV~;wfll
39 fVVusl ¼uotkr f'k'kq esa½
40 fVVusl ¼vU;½
41 iksfy;ks
42 ehtYl
43 nLr o futZyhdj.k
44 eysfj;k
45 Nkrh ds laØe.k ds HkrhZ ejht
Hkkx B. vU; dk;ZØe
M13 vU/kRo fuokj.k dk;ZØe
50 eksfr;kfcUn ds vkWijs'ku gq, jksfx;ksa dh la[;k
51 jksxh ftuesa IOL yxk,
52 fjQzsDVjh ,jj dh igpku fd, x, Ldwyh cPpksa dh la[;k
53 cPPkksa dh la[;k ftUgsa eq¶r p'esa forfjr fd,
50 us=nku gsrq us= tek gq,
51 us=nku ls ejhtksa esa us= yxk, x,
Part C. LokLF; laLFkk lqfo/kk
M14 ejhtksa dks lqfo/kk
52 D;k laLFkk FRU ds :Ik esa dk;Z dj jgh gSA
53 laqLFkk eas jksxh dY;k.k lfefr xfBr gSA
53.1 ;fn gka rks bl ekg fdruh cSBds gqbZA
54 laLFkk esa ,EcwysUl vFkok ifjogu dh lqfo/kk miyC/k gS\
54.1 ;fn gka rks bl ekg fdruh ckj ejhtksa ds fy, bldk mi;ksx gqvk\
55 D;k laLFkk esa SNW dk;Z'khy gS\
56 laLFkk esa fdrus ysijksLdksi pkyw gkyr esa gS\
58.1 HkrhZ 19 o"kZ rd cPps
(a) ckyd
(b) ckfydk
dqy {(a) (b)}
58.2 e`R;q
(a) iq:"k e`R;q
(b) efgyk
dqy {(a) (b)}

19 of 28
59 jkr esa fdrus ejht laLFkk esa HkrhZ Fks
60 ckg~; jksxh
60.1 dqy ckg~; jksxh
61 vkWijs'ku fFk;sVj
61.1 cM+h 'kY; fØ;k ¼tujy@LikbZuy ,usLFksfl;k fn;k½
61.2 NksVh 'kY; fØ;k ¼yksdy ,usLFksfl;k fn;k½
62 vU; ¼nar fpfdRlk us= jksx] vk;q"k vkfn½
(a) vk;q"k
(b) nar fpfdRlk
(c) fd'kksjksa dks ijke'kZ lqfo/kk
(d)
(e)
M15 iz;ksx'kkyk esa tkap
63 foLr`r tkudkjh
63.1 fd, x, Hb VsLV dh la[;k
63.2 VsLV fd, x, esa ls 7 gm ls de Hb
64 HIV VsLV Number Tested
(a) iq:"k
(b) efgyk ¼xHkZorh ugha½
(c) xHkZorh efgyk
dqy {(a) ls (c)}
65 foMky VsLV dh la[;k
66 VDRL VsLV dh la[;k
(a) iq:"k
(b) efgyk ¼xHkZorh ugha½
(c) xHkZorh efgyk
dqy {(a) ls (c)}

67 eysfj;k VsLV
67.1 jDr iV~Vh dh tkap
67.2 Plasmodium Vivax ik, x,
67.3 Plasmodium Falciparum ik, x,

20 of 28
Hkkx E. e`R;q dh foLr`r tkudkjh
M16 ekg esa gqbz e~R;q ds dkj.k
68 tUe ds 24 ?kaVs ds vUnj gqbZ uotkr f'k'kq dh e`R;q
tUe ds 1
69 4 g¶rs ds vUnj gqbZ uotkr f'k'kq e`R;q ds dkj.k g¶rs rd
tUe ds 1&4 g¶rs rd
69.1 laØe.k
69.2 lkal ysus esa rdyhQ
69.3 de out
69.4 vU;
1 ekg ls 11
70 5 lky rd ds cPpksa dh e`R;q ds dkj.k ekg dh mez
1&5 o"kZ dh mez
70.1 fueksfu;ks
70.2 nLr
70.3 cq[kkj
70.4 ehtYl
70.5 vU;
71 fd'kksj@o;Ld e`R;q ds dkj.k 6&14 o"kZ 15&55 o"kZ > 55 o"kZ
71.01 nLr
71.02 {k;jksx
71.03 lkal dh chekjh `¼{k;jksx ds vykok½
71.04 eysfj;k
71.05 vU; cq[kkj lacaf/kr
71.06 ,p-vk;-oh@,M~l
71.07 fny@mPp jDrpki dh chekjh
71.08 rkaf=dh@nkSjk
71.09 ekr` e`R;q
(a) xHkZikr
(b) vo:)@foyafcr izlo
(c ) mPp jDrpki@>Vds
(d) jDrL=ko
(e) rst cq[kkj
(f) vU; dkj.k
71.10 pksV@nq?kZVuk@ty tkus ds dkj.k
71.11 vkRegR;k
71.12 Ik'kq@dhM+s ds dkVus ls
71.13 vU; chekjh
(a) xaHkhj chekjh
(b) yach chekjh
(c) dkj.k irk ugha

21 of 28
fjokj dY;k.k ea=ky;

a ewY;kadu foHkkx
F; dsUnz flfoy vLirky ftyk vLirky
tek djus dh fnukad gj ekg dh 25 rkjh[k
ekg dh miyC/kh jsQjsUl Øekad
M1
1.1
1.1.1
1.2
1.3
1.4
1.4.1
1.4.2
1.5
1.6
1.6.1
1.6.2
1.7
1.7.1
1.7.2
M2
2.2
2.2.1
2.2.2
2.2.2 (a)
2.2.2 (b)
2.2.2 (c)

22 of 28
M3
3.1.2
M4
4.1
4.1.1
4.1.1(a)
4.1.1(b)
4.1.2
4.1.3
4.2
4.2.1
4.2.2
4.3
M5
5.1.2
5.3
5.3.1
5.3.2
5.3.3
5.3.4
M6
6.1
6.2
6.3
M7
7.1
7.1.1
7.1.2
M8
8.1
8.1(a)
8.1(b)
8.2

23 of 28
M9
9.1.1 (b)
9.2.1 (b)
9.3.1 (b)
9.4.1 (b)
9.5.1 (c )
9.06
9.07
9.08
9.09
9.10
9.11
9.11.1
9.11.1(a)
9.11.1(b)
9.11.2
9.11.2 (a)
9.11.2 (b)
9.11.3
9.11.3 (a)
9.11.3 (b)
YES/NO 9.12
M10
10.1
10.1.01
10.1.02
10.1.03
10.1.04
10.1.05
10.1.06
10.1.07
10.1.08
10.1.09
10.1.10

24 of 28
10.1.11
10.1.12
w.kZ Vhdkdj.k gqvk ¼chlhth $ MhihVh 1 2 3 $ iksfy;ks 1 2 3 $ ehtYl½ 10.1.13
10.1.13(a)
10.1.13(b)
10.2
10.2.1
10.2.2
10.2.3
10.3
iw.kZ Vhdkdj.k gqvk ¼chlhth $ MhihVh 1 2 3 $ iksfy;ks 1 2 3 $ ehtYl½ 10.3.1
10.3.1(a)
10.3.1(b)
10.3.2
10.3.3
10.3.4
10.3.5
10.3.5.1
10.3.5.2
10.3.5.3
10.4
10.4.1
10.4.2
10.4.3
10.5
10.5.1
10.5.2
10.5.3
M11
11.1
11.1.1
11.1.2
11.1.3
11.1.4

25 of 28
M12
12.1
12.2
12.3
12.4
12.5
12.6
12.7
12.8
12.9
M13
13.1
13.2
13.3
13.4
13.5
13.6
M14
gkWa@ ugha 14.01
gkWa@ ugha 14.04
14.05
gkWa@ ugha 14.06
14.07
gkWa@ ugha 14.08
14.09
c;Ld 14.10
14.10.1
14.10.1(a)
14.10.1(b)
14.10.2
14.10.2(a)
14.10.2(b)

26 of 28
14.11
14.12
14.12.1
14.13
14.13.1
14.13.2
14.14
14.14.1
14.14.2
14.14.3
14.14.4
14.14.5
Total M15
15.1
15.1.1 (a)
15.1.1 (b)
Number Positive 15.1.2
15.1.2(a)
15.1.2(b)
15.1.2(c)
Number Tested
15.2
15.3
15.3.1
15.3.2
15.3.3
15.4
15.4.1
15.4.2
15.4.3

27 of 28
M17
17.1
dqy 17.2
17.2.1
17.2.2
17.2.3
17.2.4
dqy 17.3
17.3.1
17.3.2
17.3.3
17.3.4
17.3.5
dqy 17.4
17.4.01
17.4.02
17.4.03
17.4.04
17.4.05
17.4.06
17.4.07
17.4.08
17.4.09
17.4.09(a)
17.4.09(b)
17.4.09(c )
17.4.09(d )
17.4.09(e )
17.4.09(f )
17.4.10
17.4.11
17.4.12
17.4.13
17.4.13(a)
17.4.13(b)
17.4.13(c )

28 of 28

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NRHM/ DH-SDH-CHC/3/M

Ministry of Health & Family Welfare

State: Due for submission on 5th of following Month

District: Month: MMM

Block: Year: YYYY

Facility type Public Private

Location Rural Urban

M1 Ante Natal Care Services (ANC)

1 Total number of pregnant women Registered for ANC

1.1 Of which Number registered within first trimester

2 New women registered under Janani Suraksha Yogna

3 Number of pregnant women received 3 ANC check ups

4 Number of pregnant women given

4.2 TT2 or Booster

5 Total number of pregnant women given 100 IFA tablets

6 Pregnant women with Hypertension (BP>140/90)

6.1 New cases detected at institution

6.2 Number of Eclampsia cases managed during delivery

7 Pregnant women with Anaemia

7.1 Number having Hb level<11 (tested cases)

7.2 Number having severe anaemia (Hb<7) treated at institution

8 Deliveries conducted at the facility

8.1 Of which Number discharged under 48 hours of delivery

8.2 Number of cases where Janani Suraksha Yogna incentive paid to

(c) ANM or AWW (only for HPS States)

Printed as on 10/09/2008 Monthly- DH-SDH-CHC

M3 Number of Caesarean (C-Section) deliveries

9 C -Section deliveries performed at facility

M4 Pregnancy outcome & details of new-born

10 Pregnancy Outcome (in number)

10.1 Live Birth

Total ({a} to {b})

10.2 Still Birth

10.3 Abortion (spontaneous/induced)

11 Details of Newborn children weighed

11.1 Number of newborns weighed at birth

11.2 Number of newborns having weight less than 2.5 kg

12 Number of newborns breast fed within 1 hour

Number of cases of pregnant women with Obstetric Complications

14 Number of Complicated pregnancies treated with

14.2 IV Antihypertensive/Magsulph injection

14.4 Blood Transfusion

M6 Post - Natal Care

15 Women receiving post partum checkups within 48 hours after delivery

M7 Medical Termination of Pregnancy (MTP)

18 Number of MTPs conducted at facility

18.1 Up to 12 weeks of pregnancy

18.2 More than 12 weeks of pregnancy

Total {(18.1) to (18.2)}

M8 Reproductive Tract Infections/Sexually transmitted infections (RTI/STI) Cases

19 Number of new RTI/STI for which treatment initiated

Total {(a) to (b)}

20 Number of wet mount tests conducted

Printed as on 10/09/2008 Monthly- DH-SDH-CHC

21 Number of NSV/Conventional Vasectomy conducted at facility

22 Number of Laparoscopic sterilizations conducted at facility

23 Number of Mini-lap sterilizations conducted at facility

24 Number of Post-Partum sterilizations conducted at facility

25 Number of new IUD Insertions at facility