Sara Reference Manual Chapter2

HEALTH FACILITY ASSESSMENT OF SERVICE AVAILABILITY AND READINESS
Service Availability and Readiness

Assessment (SARA)
An annual monitoring
system for service delivery
Reference Manual
WHO/HIS/HSI/2014.5 Rev.1
© World Health Organization 2015
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Cover photo credit: WHO/Evelyn Hockstein

Service Availability and Readiness
Assessment (SARA)
An annual monitoring
system for service delivery
Reference Manual
Version 2.2
Revised July 2015
Acknowledgements
The service availability and readiness assessment (SARA) methodology was developed through a joint World
Health Organization (WHO) – United States Agency for International Development (USAID) collaboration. The
methodology builds upon previous and current approaches designed to assess service delivery including the
service availability mapping (SAM) tool developed by WHO, and the service provision assessment (SPA) tool
developed by ICF International under the USAID-funded MEASURE DHS project (monitoring and evaluation to
assess and use results, demographic and health surveys) project, among others. It draws on best practices and
lessons learned from the many countries that have implemented health facility assessments as well as
guidelines and standards developed by WHO technical programmes and the work of the International Health
Facility Assessment Network (IHFAN).
Particular thanks are extended to all those who contributed to the development of the service readiness
indicators, indices, and questionnaires during the workshop on "Strengthening Monitoring of Health Services
Readiness" held in Geneva, 22–23 September 2010.
Many thanks to The Norwegian Agency for Development Cooperation (Norad) whom has supported Statistics
Norway to take part in the development of the SARA tools. The support has contributed to the development
and implementation of a new electronic questionnaire in CSPro and data verification guidelines.
A special thanks to the Medicines Information and Evidence for Policy unit at WHO for their contribution to the
SARA training materials and to the Unidad de Calidad y Seguridad de la Atención Médica-Hospital General de
México for their contribution of photographs to the SARA data collectors' guide.
Project Management Group

The SARA methodology and tool were developed under the direction and management of Kathy O’Neill and
Ashley Sheffel with valuable inputs from Ties Boerma and Marina Takane.
Project Advisory Group

Carla AbouZahr, Maru Aregawi Weldedawit, Sisay Betizazu, Paulus Bloem, Krishna Bose, Maurice Bucagu,
Alexandra Cameron, Daniel Chemtob, Meena Cherian, Richard Cibulskis, Mario Dal Poz, Sergey Eremin, Jesus
Maria Garcia Calleja, Sandra Gove, Neeru Gupta, Teena Kunjumen, Thierry Lambrechts, Richard Laing, Blerta
Maliqi, Shanthi Mendis, Claire Preaud, Andrew Ramsay, Leanne Riley, Cathy Roth, Willy Urassa, Adriana
Velasquez Berumen, Junping Yu, Nevio Zagaria, and Evgeny Zheleznyakov.
2
Service Availability and Readiness Assessment (SARA) | Reference Manual, Version 2.2
Table of contents
Acknowledgements ...........................................................................................................2
Abbreviations ....................................................................................................................4
CHAPTER 1 | OVERVIEW ....................................................................................................5

1.1 Background ....................................................................................................................................7
1.2 Survey overview .............................................................................................................................9
1.3 Pre-survey preparation ................................................................................................................16
1.4 Planning the survey ......................................................................................................................22
1.5 Training field supervisors, data collectors and data entry personnel..........................................25
1.6 Preparing for data collection in the field .....................................................................................30
1.7 Data collection in the field ...........................................................................................................36
1.8 Data entry and processing ...........................................................................................................40
1.9 Data analysis ................................................................................................................................46
1.10 Data archiving ..............................................................................................................................55
References ..............................................................................................................................................63
CHAPTER 2 | CORE INSTRUMENT ..................................................................................... 65
CHAPTER 3 | INDICATORS INDEX.................................................................................... 125

3.1 Indicators ID numbers ................................................................................................................127
3.2 SARA general service availability indicators...............................................................................127
3.3 SARA general service readiness indicators ................................................................................131
3.4 SARA service specific availability and readiness indicators .......................................................136
3
Abbreviations
AIDS acquired immunodeficiency syndrome
ALT alanine aminotransferase
CBR crude birth rate
CSV comma-separated values
DBS dried blood spot
DCMI Dublin Core Metadata Initiative
DDI Data Documentation Initiative
DQRC Data quality report card
DV Data verification
EDC electronic data collection device
FBO faith-based organization
GIS geographical information system
GPS global positioning system
HIV human immunodeficiency virus
HMIS health management information system
HRIS human resources information system
ID identification
IHFAN International Health Facility Assessment Network
IHP+ International Health Partnership and related initiatives
IHSN International Household Survey Network
M&E monitoring and evaluation
MDG Millennium Development Goal
MFL master facility list
MNCH maternal, newborn and child health
MoH ministry of health
NADA national data archive
NGO nongovernmental organization
OECD Organisation for Economic Co-operation and Development
PMTCT prevention of mother-to-child transmission (of HIV)
RDT rapid diagnostic test
SAM service availability mapping
SARA service availability and readiness assessment
SPA service provision assessment
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
XML extensible markup language
4
2. Core instrument
65
2. Core instrument
SARA core instrument

Version 2.2 July, 2015
The SARA core instrument is a questionnaire broken down into the following sections:
• Section 1: Cover page
− Interviewer visits
− Facility identification
− Geographic coordinates
− General information
• Section 2: Staffing
• Section 3: Inpatient and observation beds
• Section 4: Infrastructure
− Communications
− Ambulance/transport for emergencies
− Power supply
− Basic client amenities
− Infection control
− Processing of equipment for reuse
− Health care waste management
− Supervision
− Basic equipment
− Infection control precautions
• Section 5: Available services
− Family planning
− Antenatal care
− Prevention of mother-to-child transmission of HIV
− Obstetric and newborn care
− Caesarean section
− Immunization
− Child preventative and curative care
− Adolescent health
− HIV counselling and testing
− HIV treatment
− HIV care and support
− Sexually transmitted infections
− Tuberculosis
− Malaria
− Non-communicable diseases
− Surgery
− Blood transfusion
• Section 6: Diagnostics
• Section 7: Medicines and commodities
• Section 8: Interviewer’s observations
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Number Question Result

SECTION 1: COVER PAGE
INTERVIEWER VISITS
001 Facility number
002 Is this a supervisor validation check of a DATA COLLECTION FOR FACILITY ASSESSMENT…………… 1
facility? SUPERVISOR VALIDATION .…………………………………………… 2
FINAL VISIT
1 2 3
Date _______________ _________________ _______________ DAY

MONTH
YEAR
Interviewer _______________ _________________ _______________ INT. NUMBER
Name
FACILITY IDENTIFICATION
003 Name of facility
____________________________________
004 Location of facility
____________________________________
005 Region/Province
006 District
007 Type of facility* NATIONAL REFERRAL HOSPITAL ...................................... 1

DISTRICT/PROVINCIAL HOSPITAL .................................... 2
* These should be adapted at country HEALTH CENTRE/CLINIC................................................... 3
level prior to implementation* HEALTH POST ................................................................... 4
MATERNAL/CHILD HEALTH CLINIC .................................. 5
OTHER (SPECIFY) _______________________________ 96
008 Managing Authority GOVERNMENT/PUBLIC .................................................... 1
NGO/NOT-FOR-PROFIT .................................................... 2
PRIVATE-FOR-PROFIT ....................................................... 3
MISSION/FAITH-BASED .................................................... 4
OTHER (SPECIFY) _______________________________ 96
009 Urban/Rural URBAN ............................................................................. 1
RURAL .............................................................................. 2
010 Outpatient only YES ................................................................................... 1
NO .................................................................................... 2
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Number Question Result

GEOGRAPHIC COORDINATES
COLLECT GEOGRAPHIC COORDINATES INFORMATION FOLLOWING THE INSTRUCTIONS*.
SET DEFAULT SETTINGS FOR GPS:
1. SET COORDINATE FORMAT TO DECIMAL DEGREES (HDDD.DDDDD)
2. SET “DATUM” TO WGS84
3. SET “UNITS” TO METRIC, “NORTH REF” TO MAGNETIC AND “ANGLE” TO DEGREE
MOVE TO MAIN ENTRANCE OF THE BUILDING. STAND WITHIN 30 METERS OF DOOR WHERE ENTRANCE IS IN PLAIN
VIEW TO THE SKY.
1. TURN GPS RECEIVER ON AND WAIT UNTIL SATELLITE PAGE INDICATES "READY TO NAVIGATE" AND
ACCURACY IS AT A RECOMMANDED LEVEL
2. GO TO THE “MENU” PAGE AND SELECT "MARK"
3. HIGHLIGHT THE WAYPOINT NUMBER AND PRESS "ENTER"
4. ENTER FACILITY CODE AND PRESS “ENTER” TO GO BACK TO THE “MARK” PAGE
5. HIGHLIGHT "OK" AND PRESS "ENTER" TO REGISTER THE WAYPOINT
6. GO TO THE MENU PAGE, HIGHLIGHT "WAYPOINT" AND PRESS "ENTER"
7. HIGHLIGHT THE WAYPOINT AND PRESS “ENTER” TO OPEN ITS DETAILED INFORMATION
8. COPY INFORMATION FROM WAYPOINT LIST PAGE IN THE FORM BELOW
BE SURE TO COPY THE WAYPOINT NAME (FACILITY NUMBER) FROM THE WAYPOINT LIST PAGE TO VERIFY THAT
YOU ARE ENTERING THE CORRECT WAYPOINT INFORMATION ON THE DATA FORM
011 Waypoint name
(Facility number)
012 Altitude
Meters
013 Latitude
N/S……………… a
DEGREES/DEC b . c
014 Longitude
E/W……………… a
DEGREES/DEC b . c
*Detailed information is available in the data collector’s guide
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Number Question Result Skip

GENERAL INFORMATION
FACILITY NUMBER INTERVIEWER CODE
FIND THE MANAGER, THE PERSON IN-CHARGE OF THE FACILITY, OR MOST SENIOR HEALTH WORKER RESPONSIBLE
FOR OUTPATIENT SERVICES WHO IS PRESENT AT THE FACILITY. READ THE FOLLOWING GREETING:
Good day! My name is _____________________. We are here on behalf of [IMPLEMENTING AGENCY] conducting
a survey of health facilities to assist the government in knowing more about health services in [COUNTRY].
Now I will read a statement explaining the study.
Your facility was selected to participate in this study. We will be asking you questions about various health
services. Information about your facility may be used by the [MOH], organizations supporting services in your
facility, and researchers, for planning service improvement or for conducting further studies of health services.
Neither your name nor that of any other health worker respondents participating in this study will be included in
the dataset or in any report; however, there is a small chance that any of these respondents may be identified
later. Still, we are asking for your help to ensure that the information we collect is accurate.
You may refuse to answer any question or choose to stop the interview at any time. However, we hope you will
answer the questions, which will benefit the services you provide and the nation.
If there are questions for which someone else is the most appropriate person to provide the information, we
would appreciate if you introduce us to that person to help us collect that information.
At this point, do you have any questions about the study? Do I have your agreement to proceed?
_________________________________________ 2 0 1
INTERVIEWER'S SIGNATURE INDICATING CONSENT OBTAINED DAY MONTH YEAR
015 May I begin the interview?
YES ..................................................... 1
NO ...................................................... 2 5001
016 INTERVIEW START TIME (use the 24 hour-clock :
system)
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2. Core instrument
Indicator Number Question Result Skip

code
MODULE 1: SERVICE AVAILABILITY

SECTION 2: STAFFING
200 I have a few questions on staffing for this
facility. Please tell me how many staff with
each of the following qualifications are
currently assigned to, employed by, or
seconded to this facility. Please count each
staff member only once, on the basis of the
highest technical or professional qualification. A)
For doctors, I would also like to know, of the ASSIGNED/ EMPLOYED/
total number, how many are part-time in this SECONDED (INCLUDING B)
facility. PART TIME) PART TIME
S4 01 Generalist (non-specialist) medical doctors
S4 02 Specialist medical doctors
S4 03 Non-physician clinicians/paramedical
professionals
S4 04 Nursing professionals
S4 05 Midwifery professionals
08 Pharmacists
11 Laboratory technicians (medical and

pathology)
12 Community health workers
SECTION 3: INPATIENT AND OBSERVATION BEDS

S2 301 Excluding any delivery beds, how many # OF OVERNIGHT/
overnight/inpatient beds in total does this INPATIENT BEDS. . . . .
facility have, both for adults and children?
S3 302 Of the overnight/inpatient beds in this facility, # OF DEDICATED
how many are dedicated maternity beds? MATERNITY BEDS. . . . .
THIS DOES NOT INCLUDE DELIVERY BEDS
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MODULE 2: SERVICE READINESS

SECTION 4: INFRASTRUCTURE
This section will focus on questions related to infrastructure.
COMMUNICATIONS
I5 400 Does this facility have a functioning land line
telephone that is available to call outside at all YES ............................................................. 1
times client services are offered? NO ............................................................. 2
CLARIFY THAT IF FACILITY OFFERS 24-HOUR EMERGENCY
SERVICES, THEN THIS REFERS TO 24-HOUR AVAILABILITY.
I5 401 Does this facility have a functioning cellular

telephone or a private cellular phone that is YES ............................................................. 1
supported by the facility? NO ............................................................. 2
I5 402 Does this facility have a functioning short-wave
radio for radio calls? YES ............................................................. 1
NO ............................................................. 2
I6 403 Does this facility have a functioning computer?
YES ............................................................. 1
NO ............................................................. 2
I6 404 Is there access to email or internet within the
facility today? YES ............................................................. 1
NO ............................................................. 2
AMBULANCE/TRANSPORT FOR EMERGENCIES
I7 405 Does this facility have a functional ambulance
or other vehicle for emergency transportation YES ............................................................. 1 407
for clients that is stationed at this facility or NO ............................................................. 2
operates from this facility?
I7 406 Does this facility have access to an ambulance or
other vehicle for emergency transport for clients YES ............................................................. 1 408
that is stationed at another facility or that NO ............................................................. 2 408
operates from another facility in near proximity?
I7 407 Is fuel for the ambulance or other emergency
vehicle available today? YES ............................................................. 1
NO ............................................................. 2
DON’T KNOW .......................................... 98
POWER SUPPLY
I1 408 Does your facility have electricity from any
source (e.g. electricity grid, generator, solar, or YES ............................................................. 1
other) including for stand-alone devices (EPI NO ............................................................. 2 417
cold chain)?
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I1 409 What is the electricity used for in the facility?

ONLY STAND-ALONE ELECTRIC MEDICAL
DEVICES/APPLIANCES (e.g. EPI cold room,
refrigerator, suction apparatus, etc.) ........ 1
ELECTRIC LIGHTING (EXCLUDING
FLASHLIGHTS) AND COMMUNICATIONS ... 2
ELECTRIC LIGHTING, COMMUNICATIONS,
AND 1 TO 2 ELECTRIC MEDICAL DEVICES/
APPLIANCES ............................................... 3
ALL ELECTRICAL NEEDS OF FACILITY ......... 4
410 What is the facility’s main source of electricity?

CENTRAL SUPPLY OF ELECTRICITY (e.g.
national or community grid) ..................... 1
GENERATOR (FUEL OR BATTERY OPERATED
GENERATOR) ............................................ 2
SOLAR SYSTEM ......................................... 3
OTHER ___________________________ 96
(SPECIFY)
411 Other than the main or primary source, does the
facility have a secondary or backup source of NO SECONDARY SOURCE .......................... 0
electricity? CENTRAL SUPPLY OF ELECTRICITY (e.g.
national or community grid) ..................... 1
IF YES: What is the secondary source of GENERATOR (FUEL OR BATTERY OPERATED
electricity? GENERATOR) ............................................ 2
SOLAR SYSTEM ......................................... 3
OTHER ___________________________ 96
(SPECIFY)
I1 412 During the past 7 days, was electricity available
at all times from the main or any backup source ALWAYS AVAILABLE (NO
when the facility was open for services? INTERRUPTIONS) ....................................... 1
OFTEN AVAILABLE (INTERRUPTIONS OF
LESS THAN 2 HOURS PER DAY) ..................2
SOMETIMES AVAILABLE (FREQUENT OR
PROLONGED INTERRUPTIONS OF MORE
THAN 2 HOURS PER DAY) ..........................3
CHECK Q410 AND Q411:
FACILITY HAS A GENERATOR ( “2” CIRCLED FOR FACILITY DOES NOT HAVE A GENERATOR
EITHER QUESTION) (“2” NOT CIRCLED FOR BOTH QUESTIONS)
Q415
413 Is the generator functional?
YES ............................................................. 1
NO ............................................................. 2 415
DON’T KNOW .......................................... 98 415
414 Is there fuel or a charged battery available

today? YES ............................................................. 1
NO ............................................................. 2
DON’T KNOW .......................................... 98
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415 CHECK Q410 AND Q411:

FACILITY HAS A SOLAR SYSTEM ( “3” CIRCLED FACILITY DOES NOT HAVE A SOLAR SYSTEM
FOR EITHER QUESTION) (“3” NOT CIRCLED FOR BOTH QUESTIONS)
Q417
416 Is the solar system functional?

YES, FUNCTIONING .................................... 1
PARTIALLY, BATTERY NEEDS
SERVICING/REPLACEMENT........................ 2
NO, NOT FUNCTIONAL .............................. 3
DON’T KNOW .......................................... 98
BASIC CLIENT AMENITIES
417 On average, how many hours per day is this
facility open? 4 HOURS OR LESS ...................................... 1
5 TO 8 HOURS............................................ 2
9 TO 16 HOURS.......................................... 3
17 TO 23 HOURS........................................ 4
24 HOURS .................................................. 5
I2 418 What is the most commonly used source of
water for the facility at this time? PIPED INTO FACILITY ................................. 1 420
PIPED ONTO FACILITY GROUNDS .............. 2 420
PUBLIC TAP/STANDPIPE ............................ 3
OBSERVE THAT WATER IS AVAILABLE FROM THE SOURCE TUBEWELL/BOREHOLE .............................. 4
OR IN THE FACILITY ON THE DAY OF THE VISIT. E.G. CHECK PROTECTED DUG WELL ............................. 5
THAT THE PIPE IS FUNCTIONING.
UNPROTECTED DUG WELL ........................ 6
PROTECTED SPRING .................................. 7
UNPROTECTED SPRING ............................. 8
RAINWATER COLLECTION ......................... 9
BOTTLED WATER ..................................... 10 420
CART W/SMALL TANK/DRUM ................. 11 420
TANKER TRUCK ........................................ 12 420
SURFACE WATER ..................................... 13
OTHER ___________________________96
(SPECIFY)
DON'T KNOW .......................................... 98 420
NO WATER SOURCE ................................ 00 420
I2 419 Is water available from this source on facility YES, INSIDE THE FACILITY .......................... 1
premises? YES, WITHIN THE GROUND OF THE
FACILITY ..................................................... 2
NO, OUTSIDE THE FACILITY GROUNDS ...... 3
I3 420 Is there a room with auditory and visual privacy AUDITORY PRIVACY ONLY ......................... 1
available for patient consultations? VISUAL PRIVACY ONLY............................... 2
BOTH AUDITORY AND VISUAL PRIVACY .... 3
NO PRIVACY............................................... 4
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I4 421 Is there a toilet (latrine) on premises in FLUSH TOILET ............................................ 1

functioning condition that is accessible for VENTILATED IMPROVED PIT LATRINE
general outpatient client use? IF YES: What type
(VIP) ........................................................... 2
of toilet?
IF MULTIPLE TOILETS ARE AVAILABLE, CONSIDER THE MOST
PIT LATRINE WITH SLAB ............................ 3
MODERN TYPE PIT LATRINE WITHOUT SLAB/OPEN PIT..... 4
COMPOSTING TOILET ................................ 5
OBSERVE THAT THE TOILET (LATRINE) IS ACCESSIBLE BUCKET ...................................................... 6
(UNLOCKED OR KEY AVAILABLE) AND FUNCTIONING
HANGING TOILET/ HANGING LATRINE ...... 7
NO FACILITIES ON PREMISES/BUSH/FIELD 8
INFECTION CONTROL
T1 422 Does this facility have any guidelines on
standard precautions for infection prevention? YES, OBSERVED.......................................... 1
IF YES, ASK TO SEE THE DOCUMENT YES, REPORTED NOT SEEN ........................ 2
NO ............................................................. 3
PROCESSING OF EQUIPMENTS FOR REUSE
423 Please tell me if the following items used for A) AVAILABLE B) FUNCTIONING
processing of equipment for reuse are available
and functional in the facility today.
REPORTED NOT DON’T
IF AVAILABLE, ASK TO SEE IT AND INDICATE IF IT IS OBSERVED YES NO
NOT SEEN AVAILABLE KNOW
FUNCTIONING OR NOT
I8 01 Electric autoclave (pressure & wet heat) 3

1→B 2→B 1 2 8
02
I8 02 Non-electric autoclave 3
1→B 2→B 1 2 8
03
I8 03 Electric dry heat sterilizer 3
1→B 2→B 1 2 8
04
04 Electric boiler or steamer (no pressure) 3
1→B 2→B 1 2 8
05
05 Non-electric pot with cover for boiling/steam 1 2 3
06 06 06
I8 06 Heat source for non-electric equipment 1→B 2→B 3 1 2 8
424
HEALTH CARE WASTE MANAGEMENT
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I9 424 Now I would like to ask you a few questions

about waste management practices for sharps BURN INCINERATOR
waste, such as needles or blades. 2-CHAMBER INDUSTRIAL (800-1000+° C) . 2
1-CHAMBER DRUM/BRICK ........................ 3
How does this facility finally dispose of sharps OPEN BURNING
waste (e.g., filled sharps boxes)? FLAT GROUND - NO PROTECTION ............. 4
PIT OR PROTECTED GROUND .................... 5
PROBE TO ARRIVE AT CORRECT RESPONSE
DUMP WITHOUT BURNING
NOTE: IF ANY OF THE RESPONSES 2-9 TAKE PLACE OUTSIDE
FLAT GROUND - NO PROTECTION ............. 6
THE FACILITY, THEN THE CORRECT RESPONSE TO CIRCLE COVERED PIT OR PIT LATRINE ................... 7
WILL BE IN THE CATEGORY OF "REMOVE OFFSITE"
OPEN-PIT - NO PROTECTION ..................... 8
PROTECTED GROUND OR PIT .................... 9
REMOVE OFFSITE
STORED IN COVERED CONTAINER........... 10
STORED IN OTHER PROTECTED
ENVIRONMENT........................................ 11
STORED UNPROTECTED .......................... 12
OTHER ___________________________96
(SPECIFY)
NEVER HAS SHARP WASTE ...................... 95
I10 425 Now I would like to ask you a few questions
about waste management practices for medical SAME AS FOR SHARPS ITEMS .................... 1
waste other than sharps, such as used BURN INCINERATOR
bandages. 2-CHAMBER INDUSTRIAL (800-1000+° C) . 2
1-CHAMBER DRUM/BRICK ........................ 3
How does this facility finally dispose of medical OPEN BURNING
waste other than sharps boxes? FLAT GROUND - NO PROTECTION ............. 4
PIT OR PROTECTED GROUND .................... 5
PROBE TO ARRIVE AT CORRECT RESPONSE
DUMP WITHOUT BURNING
NOTE: IF ANY OF THE RESPONSES 2-9 TAKE PLACE OUTSIDE FLAT GROUND - NO PROTECTION ............. 6
THE FACILITY, THEN THE CORRECT RESPONSE TO CIRCLE
COVERED PIT OR PIT LATRINE ................... 7
WILL BE IN THE CATEGORY OF "REMOVE OFFSITE"
OPEN-PIT - NO PROTECTION ..................... 8
PROTECTED GROUND OR PIT .................... 9
REMOVE OFFSITE
STORED IN COVERED CONTAINER........... 10
STORED IN OTHER PROTECTED
ENVIRONMENT........................................ 11
STORED UNPROTECTED .......................... 12
OTHER ___________________________96
(SPECIFY)
NEVER HAS SHARP WASTE ...................... 95
426 CHECK Q424 AND Q425:
INCINERATOR USED (EITHER "2" OR "3" INCINERATOR NOT USED (NEITHER "2" NOR
CIRCLED) "3" CIRCLED)
Q430
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I9 427 Is the incinerator functional today?

I10 YES ............................................................. 1
NO ............................................................. 2 430
DON’T KNOW .......................................... 98 430
I9 428 Is fuel for the incinerator available today?
I10 YES ............................................................. 1
NO ............................................................. 2
DON’T KNOW .......................................... 98
SUPERVISION
430 When was the last time this facility received a
supervision visit from the higher level (DHMT or THIS MONTH ............................................. 1
other)? IN THE LAST 3 MONTHS ............................ 2
MORE THAN 3 MONTHS AGO ................... 3 500
DON’T KNOW .......................................... 98 500
431 During the supervision visit, did the supervisor YES NO

assess the following?
01 Pharmacy (e.g. drug stock out, expiry, records,
1 2
etc.)
02 Staffing (e.g. staff available and training) 1 2
03 Data (e.g. completeness, quality, and timely
1 2
reporting)
GENERAL OUTPATIENT SECTION
BASIC EQUIPMENT
500 Please tell me if the following basic equipment A) AVAILABLE B) FUNCTIONING
and supplies used in the provision of client
services are available and functional in this
REPORTED NOT DON’T
facility today. OBSERVED
NOT SEEN AVAILABLE
YES NO
KNOW
ASK TO SEE THE ITEMS
E1 01 Adult weighing scale 3

1→B 2→B 1 2 8
02
E2 02 Child weighing scale- 250 gram gradation 3
E38 1→B 2→B 1 2 8
03
E38 03 Infant weighing scale – 100 gram gradation 3
1→B 2→B 1 2 8
04
E18 04 Measuring tape-height board/stadiometre 3
1→B 2→B 1 2 8
05
E3 05 Thermometer 3
1→B 2→B 1 2 8
06
E4 06 Stethoscope 3
1→B 2→B 1 2 8
07
E5 07 Blood pressure apparatus (may be digital or 3
manual sphygmomanometer with stethoscope) 1→B 2→B 1 2 8
08
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E6 08 Light source (flashlight acceptable) 3

1→B 2→B 1 2 8
09
M27 09 Intravenous infusion kits 1 2 3
10 10 10
E45 10 Oxygen concentrators 3
1→B 2→B 1 2 8
11
E45 11 Oxygen cylinders 3
1→B 2→B 1 2 8
12
E45 12 Central oxygen supply 3
1→B 2→B 1 2 8
13
E45 13 Flowmeter for oxygen therapy (with 3
humidification) 1→B 2→B 1 2 8
14
E45 14 Oxygen delivery apparatus (key connecting 3
tubes and mask/nasal prongs) 1→B 2→B 1 2 8
501
E45 501 At any time during the past 3 months has
oxygen been unavailable for any reason? YES ............................................................. 1
NO .............................................................2
INFECTION CONTROL PRECAUTIONS
600 Please tell me if the following
resources/supplies used for infection control are
available in the general outpatient area of this
facility today. REPORTED NOT
ASK TO SEE THE ITEMS OBSERVED NOT SEEN AVAILABLE
I15 01 Clean running water (piped, bucket with tap, or
1 2 3
pour pitcher)
I15 02 Hand-washing soap/liquid soap 1 2 3
I15 03 Alcohol based hand rub 1 2 3
I16 04 Disposable latex gloves 1 2 3
I12 05 Waste receptacle (pedal bin) with lid and plastic
1 2 3
bin liner
I11 06 Sharps container ("safety box") 1 2 3
I13 07 Environmental disinfectant (e.g., chlorine, alcohol) 1 2 3
I14 08 Disposable syringes with disposable needles 1 2 3
I14 09 Auto-disable syringes 1 2 3
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SECTION 5: AVAILABLE SERVICES

This section will focus on questions related to available services.
A. REPRODUCTIVE, MATERNAL AND NEWBORN HEALTH
FAMILY PLANNING SERVICES
S7 700 Does this facility offer family planning
services? YES ............................................................. 1
NO ............................................................. 2 800
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE FAMILY PLANNING SERVICES ARE PROVIDED. FIND THE
PERSON MOST KNOWLEDGEABLE ABOUT FAMILY PLANNING SERVICES IN THE FACILITY. INTRODUCE YOURSELF,
EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
701 Does this facility provide or prescribe any of
the following modern methods of family
planning: YES NO
S7_01 01 Combined estrogen progesterone oral
1 2
contraceptive pills
S7_02 02 Progestin-only contraceptive pills 1 2
S7_03 03 Combined estrogen progesterone injectable
1 2
contraceptives
S7_04 04 Progestin-only injectable contraceptives 1 2
S7_05 05 Male condoms 1 2
S7_06 06 Female condoms 1 2
S7_07 07 Intrauterine contraceptive device (IUCD) 1 2
S7_08 08 Implants 1 2
S7_09 09 Cycle beads for standard days method 1 2
S7_10 10 Emergency contraceptive pills 1 2
S7_11 11 Male sterilization 1 2
S7_12 12 Female sterilization 1 2
702 Does this facility provide or prescribe any of
the following modern methods of family
planning for unmarried adolescents: YES NO
S12_02 01 Combined estrogen progesterone oral
1 2
S12_03 contraceptive pills
S12_02 02 Male condoms
1 2
S12_04
S12_02 03 Emergency contraceptive pills

1 2
S12_06
S12_02 04 Intrauterine contraceptive device (IUCD)

1 2
S12_07
703 Please tell me if the following documents are YES,

available in the facility today: YES, REPORTED
IF AVAILABLE, ASK TO SEE THE DOCUMENT OBSERVED NOT SEEN NO
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T2 01 National family planning guidelines 1 2 3

T62 02 Any family planning check-lists and/or job-
1 2 3
aids
704 Have you or any provider(s) of family
planning services: YES NO
T3 01 Received any family planning training in the
1 2
last two years?
T16 02 Received any training in adolescent sexual
1 2
and reproductive health in the last two years?
705 Does this facility stock contraceptive
commodities at this service site? YES ............................................................. 1
NO ............................................................. 2 800
706 Are any of the following reproductive health OBSERVED AVAILABLE NOT OBSERVED
medicines and commodities available in this
service site today? REPORTED
AVAILABLE NOT
CHECK TO SEE IF AT LEAST ONE OF EACH AT LEAST ONE AVAILABLE NON BUT NOT AVAILABLE NEVER
MEDICINE/COMMODITY IS VALID (NOT EXPIRED) VALID VALID SEEN TODAY AVAILABLE
M15 01 Combined estrogen progesterone oral

1 2 3 4 5
contraceptive pills
M96 02 Progestin-only contraceptive pills 1 2 3 4 5
M16 03 Combined estrogen progesterone injectable
M97 contraceptives 1 2 3 4 5
M16 04 Progestin-only injectable contraceptives

1 2 3 4 5
M98
M17 05 Male condoms 1 2 3 4 5

M99 06 Female condoms 1 2 3 4 5
M108 07 Implant (e.g. levonorgestrel, etonogestrel) 1 2 3 4 5
M109 08 Emergency contraceptive pills (e.g.
levonorgestrel tablet, ulipristal acetate tablet, 1 2 3 4 5
mifepristone tablet 10-25 mg)
M105 09 Intrauterine contraceptive device (IUCD) 1 2 3 4 5
707 For each of the following items, please check NO STOCK- PRODUCT FACILITY
STOCK-OUT OUT IN NOT RECORD
in the facility records if there has been a OFFERED
IN THE PAST PAST 3 NOT NOT
stock-out in the past 3 months: 3 MONTHS MONTHS INDICATED AVAILABLE
M99_A 01 Female condoms 1 2 3 4 5

M108_A 02 Implant (e.g.levonorgestrel, etonogestrel) 1 2 3 4 5
M109_A 03 Emergency contraceptive pills (e.g.
levonorgestrel tablet, ulipristal acetate tablet, 1 2 3 4 5
mifepristone tablet 10-25 mg
ANTENATAL CARE SERVICES
S8 800 Does this facility offer antenatal care (ANC)
services? YES ............................................................. 1
NO ............................................................. 2 900
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ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE ANTENATAL CARE SERVICES ARE PROVIDED. FIND THE
PERSON MOST KNOWLEDGEABLE ABOUT ANTENATAL CARE SERVICES IN THE FACILITY. INTRODUCE YOURSELF,
801 Do ANC providers provide any of the
following services to pregnant women as part
of routine ANC services? YES NO
S8_01 01 Iron supplementation 1 2
S8_02 02 Folic acid supplementation 1 2
S8_03 03 Intermittent preventive treatment in
1 2
pregnancy (IPTp) for malaria
S8_04 04 Tetanus toxoid immunization 1 2
S8_05 05 Monitoring for hypertensive disorder of
1 2
pregnancy
T4 01 National ANC guidelines 1 2 3
T63 02 Any ANC check-lists and/or job-aids 1 2 3
T19 03 IPTp guidelines, check-lists and/or job-aids
(including wall charts) 1 2 3
ACCEPTABLE IF PART OF ANC GUIDELINES.
803 Have you or any provider(s) of ANC services:

YES NO
T5 01 Received any ANC training in the last two
1 2
years?
T21 02 Received any training in IPTp in the last two
1 2
years?
PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV
S20 900 Does this facility offer services for the
prevention of mother-to-child transmission of YES ............................................................. 1
HIV (PMTCT)? NO ............................................................. 2 1000
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE PMTCT SERVICES ARE PROVIDED. FIND THE PERSON
MOST KNOWLEDGEABLE ABOUT PMTCT SERVICES IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE
OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
901 As part of PMTCT services, please tell me if
this facility provides the following services to
clients: YES NO
S20_01 01 Provide HIV counselling and testing services
1 2
to HIV positive pregnant women for PMTCT
S20_02 02 Provide HIV counselling and testing services
to infants born to HIV positive pregnant 1 2
women for PMTCT
S20_03 03 Provide ARV prophylaxis to HIV positive
1 2
pregnant women for PMTCT
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S20_04 04 Provide ARV prophylaxis to newborns of HIV

1 2
positive pregnant women for PMTCT
S20_05 05 Provide infant and young child feeding
counselling for PMTCT 1 2
S20_06 06 Provide nutritional counselling for HIV

positive pregnant women and their infants for 1 2
PMTCT
S20_07 07 Provide family planning counselling to HIV
positive pregnant women for PMTCT 1 2
902 Please tell me if the following guidelines are YES,

T37 01 National guidelines for PMTCT 1 2 3
T38 02 Guidelines for infant and young child feeding
counselling 1 2 3
903 Have you or any provider(s) of PMTCT

services: YES NO
T39 01 Received any training in PMTCT in the last
two years? 1 2
T40 02 Received any training in infant and young

child feeding in the last two years? 1 2
I24 904 Is the PMTCT service room or area a private

room/area with auditory and visual privacy? AUDITORY PRIVACY ONLY ......................... 1
VISUAL PRIVACY ONLY .............................. 2
NO PRIVACY............................................... 4
OBSTETRIC AND NEWBORN CARE SERVICES
S9 1000 Does this facility offer delivery (including
normal delivery, basic emergency obstetric YES ............................................................. 1
care, and/or comprehensive emergency NO ............................................................. 2 1100
obstetric care) and/or newborn care services?
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE OBSTETRIC AND NEWBORN CARE SERVICES ARE
PROVIDED. FIND THE PERSON MOST KNOWLEDGEABLE ABOUT OBSTETRIC AND NEWBORN CARE SERVICES IN THE
FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
1001 Please tell me if the following interventions
are routinely carried out by providers of
delivery services in this facility: YES NO
S9_13 01 Administration of oxytocin injection
immediately after birth to all women for the 1 2
prevention of post-partum haemorrhage
S9_14 02 Monitoring and management of labour using
1 2
partograph
S9_15 03 Immediate and exclusive breastfeeding 1 2
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S9_16 04 Hygienic cord care (cut with sterile item and

apply disinfectant to tip and stump, and no 1 2
application of other substances)
S9_17 05 Thermal protection (drying baby immediately
1 2
after birth and wrapping)
1002 Please tell me if any of the following
interventions for the management of
complications during and after pregnancy and
childbirth have been carried out in the last 12
months by providers of delivery services as
part of their work in this facility. YES NO
S9_01 01 Parenteral administration of antibiotics (IV or
S9_18 IM) for mothers 1 2
S26_03
S9_02 02 Parenteral administration of oxytocic for

S9_18 treatment of post-partum haemorrhage (IV or 1 2
S26_03 IM)
S9_03 03 Parenteral administration of magnesium
S9_18 sulphate for management of preeclampsia 1 2
S26_03 and eclampsia (IV or IM)
S9_04 04 Assisted vaginal delivery
S9_18 1 2
S26_03
S9_05 05 Manual removal of placenta

S9_18 1 2
S26_03
S9_06 06 Removal of retained products of conception

S9_18 1 2
S26_03
S9_07 07 Neonatal resuscitation with bag and mask

S9_19 1 2
S26_03
S26_01 08 Caesarean section

1 2
S26_03
S26_02 09 Blood transfusion

1 2
S26_03
S9_09 10 Antibiotics for preterm or prolonged PROM

S9_19 (premature rupture of membranes) to 1 2
prevent infection
S9_10 11 Corticosteroids in preterm labour
1 2
S9_19
S9_11 12 KMC (Kangaroo mother care) for

1 2
S9_19 premature/very small babies
S9_12 13 Injectable antibiotics for neonatal sepsis
1 2
S9_19
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1003 Are the following documents available in the YES,

facility today: YES, REPORTED
T6 01 Any national guidelines for essential
childbirth care 1 2 3
T64 02 Any check-lists and/or job-aids for Essential

1 2 3
childbirth care
T66 03 Any national guidelines for essential newborn
1 2 3
care
1004 Have you or any provider(s) of delivery
services: YES NO
T65 01 Received training in newborn resuscitation
using the newborn bag and mask in the last 1 2
two years
T7 02 Apart from newborn resuscitation, received
training in essential childbirth care in the last 1 2
two years
1005 I would like to know if the following basic
A) AVAILABLE B) FUNCTIONING
equipment items are available in this service
area today. For each equipment or item,
please tell me if it is available today and
functioning. REPORTED NOT DON'T
ASK TO SEE THE ITEMS OBSERVED NOT SEEN AVAILABLE YES NO KNOW
E7 01 Examination light (flashlight ok) 3

1→B 2→B 1 2 8
02
E8 02 Delivery pack 3
1→B 2→B 1 2 8
03
E8 03 Cord clamp 3
1→B 2→B 1 2 8
04
E8 04 Episiotomy scissors 3
1→B 2→B 1 2 8
05
E8 05 Scissors or blade to cut cord 3
1→B 2→B 1 2 8
06
E8 06 Suture material with needle 1 2 3
07 07 07
E8 07 Needle holder 3
1→B 2→B 1 2 8
08
E10 08 Manual vacuum extractor 3
1→B 2→B 1 2 8
09
E11 09 Vacuum aspirator or D&C kit 3
1→B 2→B 1 2 8
10
E30 10 Incubator 3
1→B 2→B 1 2 8
11
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12 12 12
E13 12 Blank partograph 1 2 3
13 13 13
E37 13 Delivery bed 3
1→B 2→B 1 2 8
14
E50 14 Resuscitation table (with heat source) (for 3
newborn resuscitation) 1→B 2→B 1 2 8
15
E12 15 Newborn bag and mask size 1 for term babies 3
E43 (for newborn resuscitation) 1→B 2→B 1 2 8
16
E12 16 Newborn bag and mask size 0 for pre-term 3
E43 babies (for newborn resuscitation) 1→B 2→B 1 2 8
17
E9 17 Electric suction pump (for suction apparatus) 3
E43 1→B 2→B 1 2 8
18
E9 18 Suction catheter (for suction apparatus) for 3
E43 suctioning newborn 1→B 2→B 1 2 8
19
E9 19 Suction bulb, single use 3
E43 1→B 2→B 1 2 8
20
E9 20 Suction bulb, sterilizable multi-use 3
E43 1→B 2→B 1 2 8
21
E44 21 Speculum 3
1→B 2→B 1 2 8
22
E51 22 Infant weighting scale 3
1→B 2→B 1 2 8
23
E52 23 Blood pressure apparatus (may be digital or 3
manual sphygmomanometer with 1→B 2→B 24 1 2 8
stethoscope)
I25 24 Clean running water (piped, bucket with tap, 1 2 3
or pour pitcher) 25 25 25
26 26 26
1006 1006 1006
1006 Does this facility stock any medicines for
obstetric care in this service site? YES ............................................................. 1
NO .............................................................2 1009
1007 Are any of the following medicines and
OBSERVED AVAILABLE NOT OBSERVED
commodities available in this service site
today? REPORTED
CHECK TO SEE IF AT LEAST ONE OF EACH AVAILABLE NOT
AT LEAST ONE AVAILABLE NON BUT NOT AVAILABLE NEVER
MEDICINE/COMMODITY IS VALID (NOT EXPIRED) VALID VALID SEEN TODAY AVAILABLE
M21 01 Antibiotic eye ointment for newborn 1 2 3 4 5
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M72 02 Gentamicin injection

M23
1 2 3 4 5
M110
M141
M71 03 Ampicillin powder for injection

1 2 3 4 5
M23
M106 04 Hydralazine injection 1 2 3 4 5

05 Metronidazole injection
1 2 3 4 5
M73
M75 06 Azithromycin cap/tab or oral liquid 1 2 3 4 5

M76 07 Cefixime cap/tab 1 2 3 4 5
M77 08 Benzathine benzylpenicillin powder for
1 2 3 4 5
injection
M79 09 Nifedipine cap/tab (10mg) 1 2 3 4 5
M107 10 Methyldopa tablet 1 2 3 4 5
M70 11 Calcium gluconate injection 1 2 3 4 5
M24 12 Magnesium sulphate injectable 1 2 3 4 5
M26 13 Skin disinfectant 1 2 3 4 5
M27 14 Intravenous solution with infusion set 1 2 3 4 5
M69 15 Sodium chloride injectable solution 1 2 3 4 5
M78 16 Betamethasone injection 1 2 3 4 5
M78 17 Dexamethasone injection
1 2 3 4 5
M129
M22 18 Oxytocin injection 1 2 3 4 5

IF OXYTOCIN IS OBSERVED AVAILABLE IF OXYTOCIN IS NOT OBSERVED AVAILABLE
(Q1007_18 is “1” OR “2”) (Q1007_19 is “3”,”4”,OR” 5”)
Q1009
1008 Is the oxytocin stored in cold storage?
YES ............................................................. 1
NO ............................................................. 2
CESAREAN SECTION
1009 CHECK Q1002_08:
CESAREAN SECTION OFFERED CESAREAN SECTION NOT OFFERED
Q1100
T51 1010 Do you have the national guidelines for
Comprehensive Emergency Obstetric Care YES, OBSERVED.......................................... 1
(CEmOC) available in this facility today? YES, REPORTED NOT SEEN ........................ 2
IF AVAILABLE, ASK TO SEE THE DOCUMENT NO .............................................................3
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T52 1011 Have you or any provider(s) of delivery

service received any training in YES ............................................................. 1
Comprehensive Emergency Obstetric Care NO .............................................................2
(CEmOC) in the last two years?
T53 1012 Does this facility have a health professional
who can perform caesarean section present YES ............................................................. 1
in the facility or on call 24 hours a day NO .............................................................2
(including weekends and on public holidays)?
T54 1013 Does this facility have an anaesthetist (or
doctor with anaesthetics training) present in YES ............................................................. 1
the facility or on call 24 hours a day (including NO .............................................................2
weekends and on public holidays)?
IMMUNIZATION
S10 1100 Does this facility offer immunization services?
YES ............................................................. 1
NO ............................................................. 2 1200
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE IMMUNIZATION SERVICES ARE PROVIDED. FIND THE
PERSON MOST KNOWLEDGEABLE ABOUT IMMUNIZATION SERVICES IN THE FACILITY. INTRODUCE YOURSELF,
1101 Is this facility providing immunization services

today? YES ............................................................. 1
NO ............................................................. 2
1102 Does this facility provide any of the following
BOTH IN
immunization services in the facility only, as THE
outreach at fixed post only, or both? FACILITY IN THE SERVICE
*VACCINES SCHEDULE SHOULD BE SPECIFIED AS PART OF AND AS FACILITY OUTREACH NOT
COUNTRY ADAPTATION OUTREACH ONLY ONLY OFFERED
S10_07 01 Birth doses (e.g. hepB0, BCG, OPV0, …) 1 2 3 4

S10_08 02 Infant vaccines (under 1 year) 1 2 3 4
S10_09 03 Adolescent/adult vaccines (e.g. HPV, tetanus,
1 2 3 4
flu)
S10_10A 1103 How often does this facility offer routine full
S10_10B child immunization services at the facility? DAILY ......................................................... 1
S10_10C WEEKLY ..................................................... 2
S10_10D MONTHLY .................................................. 3
S10_10E
QUARTERLY ............................................... 4
OTHER ___________________________ 96
(SPECIFY)
S10_11A 1104 How often does this facility offer routine full
S10_11B child immunization services as outreach? DAILY ......................................................... 1
S10_11C WEEKLY ..................................................... 2
S10_11D MONTHLY .................................................. 3
S10_11E
QUARTERLY ............................................... 4
OTHER ___________________________ 96
(SPECIFY)
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routine child immunization available in this YES, OBSERVED.......................................... 1
facility today? YES, REPORTED NOT SEEN ........................ 2
IF AVAILABLE, ASK TO SEE THE DOCUMENT NO .............................................................3
*NATIONAL GUIDELINE SHOULD BE SPECIFIED AS PART OF
COUNTRY ADAPTATION
1106 Have you or any provider(s) of immunization

service delivery received any training in any
of the following child immunization services
in the last two years?
YES,
IF YES: Pease specify if it was through formal YES, FORMAL SUPPORTIVE
training or supportive supervision TRAINING SUPERVISION NO TRAINING
T9 01 Immunization service delivery (Immunization
1 2 3
in practice (IIP) or any similar)
T9 02 Vaccine management/handling and cold
1 2 3
chain
T9 03 Data reporting and monitoring of service
delivery (e.g. Data Quality Self-Assessment 1 2 3
(DQS))
T9 04 Disease surveillance and reporting 1 2 3
T9 05 Injection safety and waste management 1 2 3
T9 06 RED (Reaching Every District) 1 2 3
T9 07 Training on new vaccine* prior to
introduction 1 2 3
* NEW VACCINE SHOULD BE SPECIFIED AS PART OF COUNTRY
ADAPTATION
1107 I would like to know if the following items for

immunization are available in this service
area today. For each item, please tell me if it
is available today. REPORTED NOT
I14 01 Auto-disable syringes
1 2 3
I22
I21 02 Sharps container/safety box 1 2 3

E14 03 Vaccine carrier(s)/cold box 1 2 3
E14 04 Set of ice packs for vaccine carriers
1 2 3
(Note: 4-5 ice packs make one set)
E41 05 Immunization cards (or child health booklet) 1 2 3
E42 06 Official immunization tally sheets or
1 2 3
integrated tally sheet
07 Official immunization registers or equivalent 1 2 3
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E15 1108 Does this facility have a refrigerator available

E47 and functioning for the storage of vaccines? AVAILABLE AND FUNCTIONAL ................... 1
AVAILABLE NOT FUNCTIONAL ................... 2
NOTE: FOR A REGRIGERATOR TO BE FUNCTIONAL IT AVAILABLE DON’T KNOW IF
MUST HAVE SUFFICIENT CAPACITY TO ACCOMMODATE FUNCTIONING ........................................... 3
ALL NEEDED VACCINES.
NOT AVAILABLE ......................................... 4 1115
E40 1109 What type of energy source is used for the
E40_A vaccine refrigerator? ELECTRICITY (GRID OR GENERATOR)......... 1
E40_B SOLAR (WITH OR WITHOUT BATTERIES) ... 2
E40_C GAS ............................................................ 3
E40_D
KEROSENE ................................................. 4
E40_E
MIXED (ELECTRIC WITH GAS KEROSENE) .. 5
E40_F
OTHER ..................................................... 96
E40 1110 Does this energy source supply power to the
refrigerator for 24 hours a day and for 7 days YES ............................................................. 1
in the week? NO ............................................................. 2
1111 Which of the following devices for monitoring A) AVAILABLE B) FUNCTIONNING

refrigerator temperature are available and
functioning in the refrigerator today: NOT DON'T
REPORTED
E39 01 Thermometer 3
E47
1→B 2→B 1 2 8
02
E39 02 Continuous temperature recorder/logger 3
1→B 2→B 1 2 8
E47 1112
E49 1112 Is the temperature of the refrigerator

E47 monitored twice daily? YES, LOG OBSERVED .................................. 1
IF YES: PLEASE ASK TO SEE THE LOG USED TO RECORD YES, LOG REPORTED NOT SEEN ................. 2
THE TEMPERATURE NO ............................................................ 3 1115
E49 1113 Has the temperature log been completed for
E47 the last 30 days? YES ............................................................. 1
PLEASE REVIEW LOG AND CHECK FOR COMPLETENESS YES, PARTIALLY .......................................... 2
(TEMPERATURE RECORDED 2 TIMES / DAY DURING THE NO ............................................................. 3 1115
LAST 30 DAYS)
E49 1114 Has the temperature been out of the range 2

E47 o
to 8 C inclusive in the last 30 days? OBSERVED IN RANGE ................................ 1
PLEASE CHECK THE TEMPERATURE RECORD AND VERIFY REPORTED IN RANGE BUT NOT SEEN ...... 2
THE TEMPERATURE FOR THE LAST 30 WORKING DAYS IN OUT OF RANGE ......................................... 3
ORDER TO ANSWER THE QUESTION
RECORD NOT AVAILABLE.......................... 4
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1115 CHECK Q1101 AND Q1108: FACILITY DOES NOT OFFER IMMUNIZATION
FACILITY IS OFFERING IMMUNIZATION SERVICES TODAY (Q1101 = “2”) AND DOES
SERVICES TODAY (Q1101 =“1” ) OR HAS A NOT HAVE A FUNCTIONAL REFRIGERATOR
FUNCTIONNING REFRIGERATOR FOR THE FOR THE STORAGE OF VACCINES (Q1108 =
STORAGE OF VACCINES (Q1108 = “1”) “2”, “3” OR “4”)
Q1117
1116 Are any of the following vaccines available in OBSERVED

NOT OBSERVED
this service site today? AVAILABLE
* THE LIST OF VACCINES BELOW SHOULD BE SPECIFIED AS PER
NATIONAL SCHEDULE DURING COUNTRY ADAPTATION PROCESS
SELECT ONE OF EACH VACCINE AT RANDOM AND CHECK
IF THE VACCINE IS VALID: 1. VIAL MONITOR (VVM) ON REPORTED NOT
THE VACCINE VIAL HAS NOT TURNED AND 2. THE EXPIRY AT LEAST ONE AVAILABLE AVAILABLE AVAILABLE NEVER
DATE HAS NOT PASSED VALID NON VALID BUT NOT SEEN TODAY AVAILABLE
M28 01 Measles vaccine and diluent 1 2 3 4 5

M29 02 DPT-Hib+HepB (pentavalent) 1 2 3 4 5
M30 03 Oral polio vaccine 1 2 3 4 5
M31 04 BCG vaccine and diluent 1 2 3 4 5
M92 05 Rotavirus vaccine 1 2 3 4 5
M93 06 Pneumococcal vaccine 1 2 3 4 5
M142 07 IPV (Inactivated polio vaccine) 1 2 3 4 5
M143 08 HPV (Human papillomavirus vaccine) 1 2 3 4 5
1117 In the past three months were you unable to
give any of the vaccines listed below because
of unavailable stock?
FOR EACH OF THE FOLLOWING ITEMS, PLEASE CHECK IN
THE FACILITY RECORDS IF THERE HAS BEEN A STOCK- PRODUCT
FACILITY
OUT IN THE PAST 3 MONTHS NOT
RECORD
OFFERED
* THE LIST OF VACCINES BELOW SHOULD BE SPECIFIED AS PER YES, STOCK NO STOCK NOT NOT
NATIONAL SCHEDULE DURING COUNTRY ADAPTATION PROCESS OUT OUT INDICATED AVAILABLE
M28_A 01 Measles vaccine and diluent 1 2 3 4 5

M29_A 02 DPT-Hib-HepB (pentavalent) vaccine 1 2 3 4 5
M30_A 03 Oral polio vaccine 1 2 3 4 5
M31_A 04 BCG vaccine and diluent 1 2 3 4 5
M92_A 05 Rotavirus vaccine 1 2 3 4 5
M93_A 06 Pneumococcal vaccine 1 2 3 4 5
M142_A 07 IPV (Inactivated polio vaccine) 1 2 3 4 5
M143_A 08 HPV (Human papillomavirus vaccine) 1 2 3 4 5
B. CHILD AND ADOLESCENT HEALTH
CHILD PREVENTATIVE AND CURATIVE CARE SERVICES
S11 1200 Does this facility offer preventative and
curative care services for children under 5? YES ............................................................. 1
NO ............................................................. 2 1300
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ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE CHILD PREVENTATIVE AND CURATIVE CARE SERVICES ARE
PROVIDED. FIND THE PERSON MOST KNOWLEDGEABLE ABOUT CHILD PREVENTATIVE AND CURATIVE CARE SERVICES
IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING
QUESTIONS.
1201 Please tell me if this facility provides the
following services: YES NO
S11_01 01 Diagnose and/or treat child malnutrition 1 2
S11_02 02 Provide vitamin A supplementation 1 2
S11_03 03 Provide iron supplementation 1 2
S11_04 04 Provide ORS to children with diarrhoea 1 2
S11_04 05 Provide zinc supplementation to children with
1 2
diarrhoea
S11_05 06 Child growth monitoring 1 2
S11_06 07 Treatment of pneumonia 1 2
S11_07 08 Administration of amoxicillin for the
1 2
treatment of pneumonia in children
S11_08 09 Treatment of malaria in children
1 2

T10 01 IMCI guidelines for the diagnosis and
1 2 3
management of childhood illnesses
T11 02 National guidelines for growth monitoring 1 2 3
03 Any check-lists and/or job-aids for IMCI 1 2 3
1203 Have you or any provider(s):
YES NO
T12 01 Of curative care services for sick children
received any training in the Integrated
1 2
Management of Childhood Illnesses (IMCI) in
the last two years?
T13 02 Of growth monitoring services for children
received any training in growth monitoring in 1 2
the last two years?
1204 Please tell me if the following basic
A) AVAILABLE B) FUNCTIONNING
equipment items are available and functional
in this service area today.
ASK TO SEE THE ITEMS REPORTED NOT DON'T
OBSERVED NOT SEEN AVAILABLE YES NO KNOW
E16 01 Length/height measuring equipment 3

1→B 2→B 1 2 8
02
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E17 02 Growth charts 1 2 3

1300 1300 1300
ADOLESCENT HEALTH SERVICES

S12 1300 Does this facility offer adolescent health
services? YES ............................................................. 1
NO ............................................................. 2 1400
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE ADOLESCENT HEALTH SERVICES ARE PROVIDED. FIND
THE PERSON MOST KNOWLEDGEABLE ABOUT ADOLESCENT HEALTH SERVICES IN THE FACILITY. INTRODUCE
YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
service provision to adolescents available in YES, OBSERVED.......................................... 1
this facility today? YES, REPORTED NOT SEEN ........................ 2
IF AVAILABLE, ASK TO SEE THE DOCUMENT NO ............................................................. 3
T15 1302 Have you or any providers of adolescent
health services received any training on the YES ............................................................. 1
provision of adolescent health services in the NO ............................................................. 2
last two years?
C. COMMUNICABLE DISEASES
HIV COUNSELLING & TESTING
S17 1400 Does this facility offer HIV counselling and
testing services? YES ............................................................. 1
NO ............................................................. 2 1500
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE HIV COUNSELLING AND TESTING SERVICES ARE
PROVIDED. FIND THE PERSON MOST KNOWLEDGEABLE ABOUT HIV COUNSELLING AND TESTING SERVICES IN THE
FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
T30 1401 Do you have the national HIV counselling and
testing guidelines available in this facility YES, OBSERVED.......................................... 1
today? YES, REPORTED NOT SEEN ........................ 2
1402 Have you or any provider(s) of HIV/AIDS
counselling and testing services: YES NO
T31 01 Received any training in voluntary counselling
and testing (VCT) in the last two years? 1 2
T17 02 Received any training in HIV/AIDS prevention,

care, and management for adolescents in the 1 2
last two years?
S12_01 1403 Does this facility provide HIV counselling and
testing services to minor adolescents? YES ............................................................. 1
NO ............................................................. 2
I23 1404 Is the HIV testing and counselling service
room or area a private room/area with AUDITORY PRIVACY ONLY ......................... 1
auditory and visual privacy? VISUAL PRIVACY ONLY .............................. 2
NO PRIVACY............................................... 4
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code
D6 1405 Does this facility have HIV rapid test kits (with
valid expiration date) in stock in this service YES, OBSERVED.......................................... 1
site today? YES, REPORTED NOT SEEN ........................ 2
CHECK TO SEE IF VALID (NOT EXPIRED) NO ............................................................. 3
M17 1406 Does this facility have condoms available in
M91 this service site today to give to clients YES, OBSERVED.......................................... 1
receiving services? YES, REPORTED NOT SEEN ........................ 2
IF YES, ASK TO SEE CONDOMS NO ............................................................. 3
1407 Please tell me if the following
resources/supplies used for infection control
are available in this service area today. REPORTED NOT
I15 01 Clean running water (piped, bucket with tap,
1 2 3
or pour pitcher)
I12 05 Waste receptacle (pedal bin) with lid and
1 2 3
plastic bin liner
I13 07 Environmental disinfectant (e.g., chlorine,
1 2 3
alcohol)
HIV TREATMENT
S19 1500 Does this facility offer HIV & AIDS
antiretroviral prescription or antiretroviral YES ............................................................. 1
treatment follow-up services? NO ............................................................. 2 1600
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE HIV TREATMENT SERVICES ARE PROVIDED. FIND THE
PERSON MOST KNOWLEDGEABLE ABOUT HIV TREATMENT SERVICES IN THE FACILITY. INTRODUCE YOURSELF,
1501 Do providers in this facility:
YES NO
S19_01 01 Prescribe ART 1 2
S12_09 02 Prescribe ART to adolescents 1 2
S19_02 1502 Does this facility provide treatment follow-up
services for persons on ART, including YES ............................................................. 1
providing community-based services? NO ............................................................. 2
T35 1503 Do you have the national ART guidelines
available in this facility today? YES, OBSERVED.......................................... 1
IF AVAILABLE, ASK TO SEE THE DOCUMENT YES, REPORTED NOT SEEN ........................ 2
NO ............................................................. 3
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code
T36 1504 Have you or any provider(s) of ART received

any training in ART prescription and YES ............................................................. 1
management in the last two years? NO ............................................................. 2
HIV CARE AND SUPPORT

S18 1600 Does this facility offer HIV & AIDS care and
support services, including treatment of YES ............................................................. 1
opportunistic infections and provisions of NO ............................................................. 2 1700
palliative care?
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE HIV CARE AND SUPPORT SERVICES ARE PROVIDED. FIND
THE PERSON MOST KNOWLEDGEABLE ABOUT HIV CARE AND SUPPORT SERVICES IN THE FACILITY. INTRODUCE
following services for HIV/AIDS clients: YES NO
S18_01 01 Prescribe treatment for any opportunistic
infections or symptoms related to HIV/AIDS?
1 2
This includes treating topical fungal
infections.
S18_02 02 Provide or prescribe palliative care for
patients, such as symptom or pain
1 2
management, or nursing care for the
terminally ill, or severely debilitated clients?
S18_03 03 Provide systemic intravenous treatment of
specific fungal infections such as cryptococcal 1 2
meningitis?
S18_04 04 Provide treatment for Kaposi's sarcoma? 1 2
S18_05 05 Provide nutritional rehabilitation services?
e.g., client education and provision of 1 2
nutritional supplements?
S18_06 06 Prescribe or provide fortified protein
1 2
supplementation (FPS)?
S18_07 07 Care for paediatric HIV/AIDS patients? 1 2
S18_08 08 Prescribe or provide preventive treatment for
1 2
TB (INH + Pyridoxine)?
S18_09 09 Primary preventive treatment for
opportunistic infections, such as co- 1 2
trimoxazole preventive treatment (CPT)?
S18_10 10 Provide or prescribe micronutrient
supplementation, such as vitamins or iron? 1 2
S18_11 11 Family planning counselling for HIV/AIDS

1 2
clients?
S18_12 12 Provide condoms for preventing further
1 2
transmission of HIV?
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code
D14 1602 Do providers in this facility screen or test HIV

clients for TB or have a system for diagnosis YES, OBSERVED.......................................... 1
of TB among HIV positive clients? YES, REPORTED NOT SEEN ........................ 2
IF YES, ASK TO SEE A REGISTER OR RECORD OF HIV- YES, REGISTER NOT MAINTAINED ............. 3
POSITIVE CLIENTS TESTED FOR TB
NO ............................................................. 4
T32 01 National guidelines for the clinical
management of HIV/AIDS 1 2 3
T33 02 Guidelines for palliative care 1 2 3

T34 1604 Have you or any provider(s) of HIV care and
support services received any training in the YES ............................................................. 1
clinical management of HIV/AIDS in the last NO ............................................................. 2
two years?
SEXUALLY TRANSMITTED INFECTIONS

S21 1700 Does this facility offer diagnosis or treatment
of STIs other than HIV? YES ............................................................. 1
NO ............................................................. 2 1800
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE STI SERVICES ARE PROVIDED. FIND THE PERSON MOST
KNOWLEDGEABLE ABOUT STI SERVICES IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE
SURVEY AND ASK THE FOLLOWING QUESTIONS.
S21_01 1701 Do providers in this facility diagnose STIs?
YES ............................................................. 1
NO ............................................................. 2
S21_02 1702 Do providers in this facility prescribe
treatment for STIs? YES ............................................................. 1
NO ............................................................. 2
T41 1703 Do you have the national guidelines for the
diagnosis and treatment of STIs available in YES, OBSERVED.......................................... 1
this facility today? YES, REPORTED NOT SEEN ........................ 2
T42 1704 Have you or any provider(s) of STI services
received any training in STI diagnosis and YES ............................................................. 1
treatment in the last two years? NO ............................................................. 2
TUBERCULOSIS
S16 1800 Does this facility offer diagnosis, treatment
prescription, or treatment follow-up of YES ............................................................. 1
tuberculosis? NO ............................................................. 2 1900
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE TUBERCULOSIS SERVICES ARE PROVIDED. FIND THE
PERSON MOST KNOWLEDGEABLE ABOUT TUBERCULOSIS SERVICES IN THE FACILITY. INTRODUCE YOURSELF,
S16_01 1801 Do providers in this facility diagnose TB?
YES ............................................................. 1
NO ............................................................. 2 1803
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code
1802 Which of the following methods are used at

this facility for diagnosing TB: YES NO
S16_03 01 Clinical symptoms 1 2
S16_02 02 Sputum smear microscopy examination
1 2
S16_04
S16_02 03 Culture
1 2
S16_05
S16_02 04 Rapid test (GeneXpert MTB/RIF)

1 2
S16_06
S16_02 05 Chest X-ray

1 2
S16_07
S16_08 1803 Does this facility prescribe drugs for TB

patients? YES ............................................................. 1
NO ............................................................. 2
S16_09 1804 Does this facility provide drugs to TB

patients? YES ............................................................. 1
NO ............................................................. 2
S16_10 1805 Does this facility manage and provide
treatment follow-up for TB patients? YES ............................................................. 1
NO ............................................................. 2
D13 1806 Do providers in this facility screen or test TB
patients for HIV or have a system for YES, OBSERVED.......................................... 1
diagnosis of HIV among TB patients? YES, REPORTED NOT SEEN ........................ 2
IF YES, ASK TO SEE A REGISTER OR RECORD OF TB YES, REGISTER NOT MAINTAINED ............. 3
CLIENTS TESTED FOR HIV
NO ............................................................. 4
T22 01 Diagnosis and treatment of TB 1 2 3
T23 02 Management of HIV and TB co-infection 1 2 3
T24 03 MDR-TB 1 2 3
T25 04 TB infection control 1 2 3
1808 Have any providers of TB services at this
facility received training in the following
topics in the last two years? YES NO
T26 01 Diagnosis and treatment of TB 1 2
T27 02 Management of HIV and TB co-infection 1 2
T28 03 MDR-TB 1 2
T29 04 TB infection control 1 2
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code
1809 Does this facility stock any medicines for TB

treatment? YES, IN SERVICE SITE.................................. 1
YES, ELSEWHERE (E.G BULK
STORE/PHARMACY)................................... 2 1900
YES, IN BOTH LOCATIONS .......................... 3
NO, TB MEDS NOT STOCKED ..................... 4 1900
1810 Are any of the following medicines available OBSERVED AVAILABLE NOT OBSERVED
in this service site today?
REPORTED
CHECK TO SEE IF AT LEAST ONE OF EACH MEDICINE IS AT LEAST AVAILABLE NOT
VALID (NOT EXPIRED) ONE AVAILABLE BUT NOT AVAILABLE
VALID NON VALID SEEN TODAY NEVER AVAILABLE
M41 01 Ethambutol 1 2 3 4 5
M41 02 Isoniazid 1 2 3 4 5
M41 03 Pyrazinamide 1 2 3 4 5
M41 04 Rifampicin 1 2 3 4 5
M41 05 Isoniazid + Rifampicin (2FDC) 1 2 3 4 5
M41 06 Isoniazid + Ethambutol (EH) (2FDC) 1 2 3 4 5
M41 07 Isoniazid + Rifampicin + Pyrazinamide (RHZ)
1 2 3 4 5
(3FDC)
M41 08 Isoniazid + Rifampicin + Ethambutol (RHE)
1 2 3 4 5
(3FDC)
M41 09 Isoniazid + Rifampicin + Pyrazinamide +
1 2 3 4 5
Ethambutol (4FDC)
10 Streptomycin Injectable 1 2 3 4 5
MALARIA
S15 1900 Does this facility offer diagnosis or treatment
of malaria? YES ............................................................. 1
NO ............................................................. 2 2000
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE MALARIA SERVICES ARE PROVIDED. FIND THE
PERSON MOST KNOWLEDGEABLE ABOUT MALARIA SERVICES IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN
THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
S15_01 1901 Do providers in this facility diagnose malaria?
YES ............................................................. 1
NO ............................................................. 2 1906
1902 Which of the following methods are used at
this facility for diagnosing malaria:
YES NO
S15_05 01 Clinical symptoms 1 2
S15_02 02 Rapid diagnostic testing (RDT)
1 2
S15_06
S15_02 03 Microscopy
S15_07
1 2
96

code
CHECK Q1902_02:
IF FACILITY CONDUCTS MALARIA RDTS: IF FACILITY DOES NOT CONDUCT
MALARIA RDTS: Q1906
D3 1903 Does this facility have malaria rapid

D34 diagnostic test kits (with valid expiration date) YES, OBSERVED.......................................... 1
D36 in stock in this service site today? YES, REPORTED NOT SEEN ........................ 2
CHECK TO SEE IF VALID (NOT EXPIRED) NO ............................................................. 3
D36_A 1904 Has there been a stock-out of malaria RDT
kits in the past 4 weeks? YES ............................................................. 1
NO ............................................................. 2 1906
D36_B 1905 How many days of stock-out?
LESS THAN 7 DAYS ..................................... 1
7 TO 14 DAYS ............................................. 2
MORE THAN 14 DAYS ................................ 3
S15_03 1906 Do providers in this facility prescribe
treatment for malaria? YES ............................................................. 1
NO ............................................................. 2
diagnosis and treatment of malaria available YES, OBSERVED.......................................... 1
in this facility today? YES, REPORTED NOT SEEN ........................ 2
T20 1908 Have you or any provider(s) of malaria
D34 services received any training in malaria YES ............................................................. 1
diagnosis with RDTs in the last two years? NO ............................................................. 2
T20 1909 Have you or any provider(s) of malaria
services received any training in malaria YES ............................................................. 1
treatment in the last two years? NO ............................................................. 2
S15_04 1910 Does this facility provide Intermittent
preventive treatment for malaria? YES ............................................................. 1
NO ............................................................. 2
D. NON-COMMUNICABLE DISEASES
S22 2000 Does this facility offer diagnosis or
S23 management of non-communicable diseases, YES ............................................................. 1
S24 such as diabetes, cardiovascular disease, NO ............................................................. 2 2100
S29 chronic respiratory disease, or cervical
cancer?
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE NON-COMMUNICABLE DISEASE SERVICES ARE
PROVIDED. FIND THE PERSON MOST KNOWLEDGEABLE ABOUT NCD SERVICES IN THE FACILITY. INTRODUCE
S22 2001 Do providers in this facility diagnose and/or
manage diabetes in patients? YES ............................................................. 1
NO ............................................................. 2 2004
diagnosis and management of diabetes YES, OBSERVED.......................................... 1
available in this facility today? YES, REPORTED NOT SEEN ........................ 2
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code
T44 2003 Have you or any provider(s) of diabetes

services received any training in the diagnosis YES ............................................................. 1
and management of diabetes in the last two NO ............................................................. 2
years?
manage cardiovascular diseases such as YES ............................................................. 1
hypertension in patients? NO ............................................................. 2 2007
diagnosis and management of cardiovascular YES, OBSERVED.......................................... 1
diseases available in this facility today? YES, REPORTED NOT SEEN ........................ 2
T46 2006 Have you or any provider(s) of services for
cardiovascular diseases received any training YES ............................................................. 1
in the diagnosis and management of NO ............................................................. 2
cardiovascular diseases such as hypertension
in the last two years?
manage chronic respiratory diseases in YES ............................................................. 1
patients? NO ............................................................. 2 2011
diagnosis and management of chronic YES, OBSERVED.......................................... 1
respiratory disease available in this facility YES, REPORTED NOT SEEN ........................ 2
today? NO ............................................................. 3
IF AVAILABLE, ASK TO SEE THE DOCUMENT
T48 2009 Have you or any provider(s) of chronic

respiratory disease services received any YES ............................................................. 1
training in the diagnosis and management of NO ............................................................. 2
chronic respiratory diseases in the last two
years?
2010 Please tell me if the following basic A) AVAILABLE B) FUNCTIONING

equipment items are available and functional
in this service area today. NOT DON'T
REPORTED
E19 01 Peak flow meters 3

1→B 2→B 02 1 2 8
E20 02 Spacers for inhalers 3

1→B 2→B 2011 1 2 8
S29 2011 Do providers in this facility diagnose cervical

cancer in patients? YES ............................................................. 1
NO ............................................................. 2 2100
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code

cervical cancer prevention and control? YES, OBSERVED.......................................... 1
IF AVAILABLE, ASK TO SEE THE DOCUMENT YES, REPORTED NOT SEEN ........................ 2
NO ............................................................. 3
T61 2013 Have you or any provider(s) received any
training in cervical cancer prevention and YES ............................................................. 1
control? NO ............................................................. 2
2014 Please tell me if the following basic

equipment/items are available in this service A) AVAILABLE B) FUNCTIONING
area today.
REPORTED NOT DON'T
OBSERVED NOT SEEN AVAILABLE YES NO KNOW
D37 01 Acetic acid 1 2 3

02 02 02
E44 02 Speculum 3
1→B 2→B 2100 1 2 8
E. SURGERY
SURGICAL SERVICES
S25 2100 Does this facility offer any surgical services
S28 (including minor surgery such as suturing, YES ............................................................. 1
circumcision, wound debridement, etc.), or NO ............................................................. 2 2200
caesarean section?
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE SURGICAL SERVICES ARE PROVIDED. FIND THE PERSON
MOST KNOWLEDGEABLE ABOUT SURGICAL SERVICES IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN THE
PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
following services: YES NO
S25_01 01 Incision and drainage of abscesses 1 2
S25_02 02 Wound debridement 1 2
S25_03 03 Acute burn management 1 2
S25_04 04 Suturing 1 2
S25_05 05 Closed repair of fracture 1 2
S25_06 06 Cricothyroidotomy 1 2
S25_07 07 Male circumcision 1 2
S25_08 08 Hydrocele reduction 1 2
S25_09 09 Chest tube insertion 1 2
S25_10 10 Closed repair of dislocated joint 1 2
S25_11 11 Biopsy of lymph node or mass or other 1 2
S25_12 12 Removal of foreign body (throat, eye, ear or
1 2
nose)
99
2. Core instrument

code
CHECK Q007:
IF HOSPITAL: IF NOT HOSPITAL:
Q2102
S28_01 13 Tracheostomy 1 2
S28_02 14 Tubal ligation 1 2
S28_03 15 Vasectomy 1 2
S28_04 16 Dilatation & Curettage 1 2
S28_05 17 Obstetric fistula repair 1 2
S28_06 18 Episiotomy, cervical and vaginal laceration 1 2
S28_07 19 Appendectomy 1 2
S28_08 20 Hernia repair (strangulated) 1 2
S28_22 21 Hernia repair (elective) 1 2
S28_09 22 Cystostomy 1 2
S28_10 23 Urethral stricture dilatation 1 2
S28_11 24 Laparotomy (uterine rupture, ectopic
pregnancy, acute abdomen, intestinal 1 2
obstruction, perforation, injuries)
S28_12 25 Congenital hernia repair 1 2
S28_13 26 Neonatal surgery (abdominal wall defect,
colostomy imperforate anus, 1 2
intussusceptions)
S28_14 27 Cleft palate repair 1 2
S28_23 28 Contracture release 1 2
S28_23 29 Skin grafting 1 2
S28_17 30 Open reduction and fixation for fracture 1 2
S28_18 31 Amputation 1 2
S28_19 32 Cataract surgery 1 2
S28_20 33 Club foot repair (casting or open club foot
1 2
release)
S28_21 34 Drainage of osteomyelitis-septic arthritis 1 2
2102 Please tell me if the following surgical A) AVAILABLE B) FUNCTIONING
equipment and supplies are available and
functional in this facility today. NOT DON'T
REPORTED
E29 01 Resuscitator bag and mask- adult 3

1→B 2→B 1 2 8
E27 02
E29 02 Resuscitator bag and mask- paediatric 3
E27 1→B 2→B 03 1 2 8
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code
E21 03 Needle holder 3

1→B 2→B 04 1 2 8
E22 04 Scalpel handle with blades 3

1→B 2→B 05 1 2 8
E23 05 Retractor 3
1→B 2→B 06 1 2 8
E24 06 Surgical scissors 3

1→B 2→B 07 1 2 8
E25 07 Nasogastric tubes 3

1→B 2→B 08 1 2 8
E26 08 Tourniquet 3
1→B 2→B 09 1 2 8
E28 09 Suction pump (manual or electric) with 3

catheter 1→B 2→B 10 1 2 8
10 CHECK Q007 AND Q1002_08:

IF HOSPITAL OR HEALTH FACILITY OFFERS IF NOT HOSPITAL AND CESAREAN SECTION
CESAREAN SECTION: NOT OFFERED:
Q2104
E29 11 Oropharyngeal airway- adult 3
1→B 2→B 12 1 2 8
E29 12 Oropharyngeal airway- paediatric 3

1→B 2→B 13 1 2 8
E29 13 Magills forceps- adult 3

1→B 2→B 14 1 2 8
E29 14 Magills forceps- paediatric 3

1→B 2→B 15 1 2 8
E29 15 Endotracheal tube neonatal – uncuffed size 3

1→B 2→B 1 2 8
below 3 16
E29 16 Endotracheal tube paediatric- uncuffed sizes 3
3.0 to 5.0 1→B 2→B 17 1 2 8
E29 17 Endotracheal tube adult- cuffed sizes 5.5 to 3

9.0 1→B 2→B 18 1 2 8
E29 18 Laryngoscope handle and blade- adult 3

1→B 2→B 19 1 2 8
E29 19 Laryngoscope handle and blade- paediatric 3

1→B 2→B 20 1 2 8
E29 20 Laryngoscope handle and blade- neonatal 3

1→B 2→B 1 2 8
21
E29 21 Anaesthesia machine 3
1→B 2→B 22 1 2 8
101
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code
E29 22 Tubings and connectors (to connect 3

endotracheal tube) 1→B 2→B 23 1 2 8
E29 23 Stylet 3
1→B 2→B 24 1 2 8
E32 24 Spinal needle 3

1→B 2→B 25 1 2 8
E29 25 Newborn bag and mask size 1 for term babies 3

(for newborn resuscitation) 1→B 2→B 26 1 2 8
E48 26 Oxygen concentrators 3

1→B 2→B 27 1 2 8
E48 27 Oxygen cylinders 3

1→B 2→B 28 1 2 8
E48 28 Central oxygen supply 3

1→B 2→B 1 2 8
29
E48 29 Flowmeter for oxygen therapy (with 3
1→B 2→B 1 2 8
humidification) 30
E48 30 Oxygen delivery apparatus (key connecting 3
1→B 2→B 1 2 8
tubes and mask/nasal prongs) 2103
E48 2103 At any time during the past 3 months has
oxygen been unavailable for any reason? YES ............................................................. 1
NO ............................................................. 2
2104 Please tell me if any of the following materials OBSERVED AVAILABLE NOT OBSERVED
or medicines are available in this service site
today. I would like to see those that are
available. REPORTED
AVAILABLE
CHECK TO SEE IF AT LEAST ONE OF EACH AT LEAST AVAILABLE BUT NOT NOT AVAILABLE NEVER
MATERIAL/MEDICINE IS VALID (NOT EXPIRED) ONE VALID NON VALID SEEN TODAY AVAILABLE
M63 01 Suture material (any type) 1 2 3 4 5

M64 03 Ketamine (injection) 1 2 3 4 5
M65 04 Lidocaine 1% or 2% (anaesthesia) 1 2 3 4 5
M148 05 Splints for extremities 1 2 3 4 5
M149 06 Material for cast 1 2 3 4 5
CHECK Q007 AND Q1002_08:
IF HOSPITAL OR HEALTH FACILITY OFFERS IF NOT HOSPITAL AND CESAREAN SECTION
CESAREAN SECTION: NOT OFFERED:
Q2105
M84 07 Thiopental (powder) 1 2 3 4 5
M85 08 Suxamethonium bromide (powder) 1 2 3 4 5
M86 09 Atropine (injection) 1 2 3 4 5
M25 10 Diazepam (injection) 1 2 3 4 5
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code
M87 11 Halothane (inhalation) 1 2 3 4 5

M88 12 Bupivacaine (injection) 1 2 3 4 5
M89 13 Lidocaine 5% (heavy spinal solution) 1 2 3 4 5
M62 14 Epinephrine (injection) 1 2 3 4 5
M90 15 Ephedrine (injection) 1 2 3 4 5
T49 2105 Do you have materials on Integrated
Management of Emergency and Essential YES, OBSERVED.......................................... 1
Surgical care (IMEESC) (e.g. best practices, YES, REPORTED NOT SEEN ........................ 2
protocols, etc.) available in this facility today? NO ............................................................. 3
IF AVAILABLE, ASK TO SEE THE DOCUMENT
T50 2106 Have you or any provider(s) of basic surgical

services received any training in IMEESC in YES ............................................................. 1
the last two years? NO ............................................................. 2
T57 2107 Does this facility have a staff member trained
in surgery, including caesarean section, YES ............................................................. 1
(clinical officer, general physician, or surgeon) NO ............................................................. 2
present in the facility or on call 24 hours a day
T58 2108 Does this facility have a staff member trained
in anaesthesia (nurse, clinical officer, general YES ............................................................. 1
physician, surgeon, or anaesthesiologist) NO ............................................................. 2
present in the facility or on call 24 hours a day
2109 I am interested in knowing if the following
resources/supplies used for infection control
are available in this service area today. REPORTED NOT
I15 01 Clean running water (piped, bucket with tap,
1 2 3
or pour pitcher)
I12 05 Waste receptacle (pedal bin) with lid and
1 2 3
plastic bin liner
I13 07 Environmental disinfectant (e.g., chlorine,
1 2 3
alcohol)
BLOOD TRANSFUSION
S27 2200 Does this facility offer blood transfusion
services? YES ............................................................. 1
NO ............................................................. 2 3000
103
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code
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE BLOOD IS COLLECTED, PROCESSED, TESTED, STORED, OR
HANDLED PRIOR TO TRANSFUSION. FIND THE PERSON MOST KNOWLEDGEABLE ABOUT BLOOD TRANSFUSION
SERVICES IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE
FOLLOWING QUESTIONS.
M66 2201 Have there been any interruptions in blood
availability during the past 3 months? YES ............................................................. 1
NO ............................................................. 2
M67 2202 Does this facility obtain blood from a national
or regional blood centre? YES ............................................................. 1
NO ............................................................. 2
M67 2203 Does this facility obtain ANY blood from
sources other than the national or regional YES ............................................................. 1
blood centre? NO ............................................................. 2
M67 2204 Does any place in this facility do blood
screening for infectious diseases prior to YES ............................................................. 1
transfusion? NO ............................................................. 2 2206
2205 Please tell me if the blood that is transfused

in the facility is "always",
"sometimes", ”rarely”, or "never" screened
for any of the following infectious diseases. ALWAYS SOMETIMES RARELY NEVER
M67 01 HIV 1 2 3 4
M67 02 Syphilis 1 2 3 4
M67 03 Hepatitis B 1 2 3 4
M67 04 Hepatitis C 1 2 3 4
E31 2206 Does this facility have a refrigerator available
and functioning in this service area for the AVAILABLE AND FUNCTIONAL ................... 1
storage of blood? AVAILABLE NOT FUNCTIONAL ................... 2
AVAILABLE DON’T KNOW IF
FUNCTIONING ........................................... 3
NOT AVAILABLE ......................................... 4 2210
E31 2207 Is the temperature of the refrigerator
monitored at least once every 24 hours? YES, LOG OBSERVED .................................. 1
IF YES: PLEASE ASK TO SEE THE LOG USED TO RECORD YES, LOG REPORTED NOT SEEN ................. 2
THE TEMPERATURE NO ............................................................. 3 2210
E31 2208 Has the temperature log been completed for
the last 30 days? YES ............................................................. 1
PLEASE REVIEW LOG AND CHECK FOR COMPLETENESS YES, PARTIALLY .......................................... 2
(TEMPERATURE RECORDED AT LEAST ONCE EVERY 24 NO ............................................................. 3 2210
HOURS DURING THE LAST 30 DAYS)
E31 2209 Has the temperature been out of the range 2

o
to 6 C inclusive in the last 30 days? OBSERVED IN RANGE ................................ 1
PLEASE CHECK THE TEMPERATURE RECORD AND VERIFY REPORTED IN RANGE BUT NOT SEEN ....... 2
THE TEMPERATURE FOR THE LAST 30 WORKING DAYS IN OUT OF RANGE .......................................... 3
ORDER TO ANSWER THE QUESTION
RECORD NOT AVAILABLE........................... 4
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code
T55 2210 Do you have any guidelines on the

appropriate use of blood and safe transfusion YES, OBSERVED.......................................... 1
practices? YES, REPORTED NOT SEEN ........................ 2
T56 2211 Have any provider(s) of blood transfusion
services received any training in the YES ............................................................. 1
appropriate use of blood and safe transfusion NO ............................................................. 2
practices in the last two years?
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code
SECTION 6: DIAGNOSTICS
3000 Does this facility conduct any diagnostic
testing including any rapid diagnostic testing? YES ..........................................................1
NO ...........................................................2 4000
ASK TO BE SHOWN THE MAIN LABORATORY OR LOCATION IN THE FACILITY WHERE MOST TESTING IS DONE TO
START DATA COLLECTION. INTRODUCE YOURSELF AND EXPLAIN THE PURPOSE OF THE SURVEY, THEN ASK THE
FOLLOWING QUESTIONS.
I would like to know if the following diagnostic tests and associated equipment are available today in this facility.
3100 Does this facility offer any of the following
tests on-site? YES (ONSITE) NO
D9 02 Rapid syphilis testing 1 2
D6 03 HIV rapid testing 1 2
D11 04 Urine rapid tests for pregnancy 1 2
D4 05 Urine protein dipstick testing 1 2
D5 06 Urine glucose dipstick testing 1 2
D20 07 Urine ketone dipstick testing 1 2
D7 08 Dry Blood Spot (DBS) collection for HIV viral
1 2
load or EID
3101 I would like to know if the following items for OBSERVED AVAILABLE NOT OBSERVED
rapid diagnostic testing are available or not
available today. REPORTED
CHECK TO SEE IF AT LEAST ONE OF EACH RDT IS VALID AVAILABLE NOT
AT LEAST ONE AVAILABLE BUT NOT AVAILABLE NEVER
(NOT EXPIRED) VALID NON VALID SEEN TODAY AVAILABLE
D3 01 Malaria rapid diagnostic kit

D34 1 2 3 4 5
D36
D9 02 Syphilis rapid test kit 1 2 3 4 5

D6 03 HIV rapid test kit 1 2 3 4 5
D11 04 Urine pregnancy test kit 1 2 3 4 5
D4 05 Dipsticks for urine protein 1 2 3 4 5
D5 06 Dipsticks for urine glucose 1 2 3 4 5
D20 07 Dipsticks for urine ketone bodies 1 2 3 4 5
D7 08 Filter paper for collecting DBS 1 2 3 4 5
CHECK Q3101_01:
IF FACILITY CONDUCTS MALARIA RDTS IF FACILITY DOES NOT CONDUCT
(Q3101_01 = 1, 2, 3, OR 4): MALARIA RDTS (Q3101_01 = 5):
Q3200
D36_A 3102 Has there been a stock-out of malaria RDT
kits in the past 4 weeks? YES ..........................................................1
NO ...........................................................2 3200
106

code
D36_B 3103 How many days of stock-out?

LESS THAN 7 DAYS ..................................1
7 TO 14 DAYS ..........................................2
MORE THAN 14 DAYS .............................3
3200 Does this facility conduct the following tests DON’T
CONDUCT THE
onsite or offsite?
YES, ONSITE YES, OFFSITE TEST
D2 01 Blood glucose tests using a glucometer 1 2 3
D1 02 Haemoglobin testing 1 2 3
D10 03 General microscopy/wet-mounts 1 2 3
D3 04 Malaria smear tests 1 2 3
D6 05 HIV antibody testing by ELISA
1 2 3
D23
3201 I would like to know if the following general

equipment items are available and functional A) AVAILABLE B) FUNCTIONING
today. REPORTED NOT DON'T
OBSERVED YES NO
ASK TO SEE THE ITEMS NOT SEEN AVAILABLE KNOW
D3 01 Light microscope
D10
D35 3
D8 1→B 2→B 1 2 8
02
D31
D32
D33
D3 02 Glass slides and cover slips

D10 3
D35 03
1→B 2→B 1 2 8
D8
D31
D32
03 Refrigerator 3
1→B 2→B 1 2 8
04
D2 04 Glucometer 3
1→B 2→B 1 2 8
05
D2 05 Glucometer test strips (with valid expiration 3
1→B 2→B 1 2 8
date) 06
D1 06 Colorimeter or haemoglobinometer 3
1→B 2→B 1 2 8
07
D1 07 HemoCue 3
1→B 2→B 1 2 8
08
D3 08 Wright-Giemsa stain or other acceptable 3
D35 malaria parasite stain (e.g. Field Stain A and 1→B 2→B 09 1 2 8
B)
D6 09 ELISA washer 3
1→B 2→B 1 2 8
D23 10
D6 10 ELISA reader 3
1→B 2→B 1 2 8
D23 11
107
2. Core instrument

code
D6 11 Incubator 3
1→B 2→B 1 2 8
D23 12
D6 12 Specific assay kit- HIV antibody testing by 3
1→B 2→B 1 2 8
D23 ELISA 3202
T59 3202 Does this facility have an accredited/certified
D35 microscopist? YES ..........................................................1
NO ...........................................................2
3300 CHECK Q1800:
TB SERVICES OFFERED
TB SERVICES NOT OFFERED
Q3400
D8 3301 Does this facility do Ziehl-Neelsen testing for
TB (AFB) onsite or offsite? YES, ONSITE ............................................1
YES, OFFSITE ...........................................2 3303
NO ...........................................................3 3303
3302 I would like to know if the following

equipment items for TB testing are available A) AVAILABLE B) FUNCTIONING
and functional today. REPORTED NOT DON'T
OBSERVED YES NO
D8 01 Fluorescence microscope (FM) 3

1→B 2→B 1 2 8
02
D8 02 Ziehl-Neelsen stain 3
1→B 2→B 1 2 8
03
D8 03 Auramine Rhodamine stain for fluorescent 3
1→B 2→B 1 2 8
microscopy 3303
3303 Does this facility conduct Xpert MTB/RIF
diagnostic testing for TB onsite or offsite? YES, ONSITE ............................................1
YES, OFFSITE ...........................................2 3400
NO ...........................................................3 3400
3304 Please tell me if the following equipment

items for Xpert MTB/RIF diagnostic testing for A) AVAILABLE B) FUNCTIONING
TB are available and functional today. REPORTED NOT DON'T
OBSERVED YES NO
01 GeneXpert 4 module unit with laptop 3

1→B 2→B 1 2 8
02
02 TB rapid test cartridge 3
1→B 2→B 1 2 8
3400
3400 Does this facility conduct liver function /renal
function tests and/or white blood counts YES, ONSITE ............................................1
onsite or offsite? YES, OFFSITE ...........................................2
NO ...........................................................3 3500
3401 Does this facility conduct the following liver DON’T

CONDUCT THE
and renal function tests onsite or offsite?
D19 01 ALT testing 1 2 3
D19 02 Other liver function testing (such as bilirubin) 1 2 3
D18 03 Serum creatinine testing 1 2 3
108

code
D18 04 Other renal function testing (such as urea

1 2 3
nitrogen)
CHECK Q3401 liver function/renal function:
IF ONLY "YES, OFFSITE" OR
IF "YES, ONSITE" CIRCLED FOR ANY TEST
"NO" ARE CIRCLED
Q3403
items and reagents for liver and kidney A) AVAILABLE B) FUNCTIONING
function testing are available and functional
today. REPORTED NOT DON'T
OBSERVED YES NO
D18 01 Biochemistry analyzer 3

1→B 2→B 1 2 8
D19 02
D18 02 Centrifuge 3
1→B 2→B 1 2 8
D19 03
D19 03 Specific assay kit(s)- liver function test 3
1→B 2→B 1 2 8
04
D18 04 Specific assay kit(s)- renal function test 3
1→B 2→B 1 2 8
3403
D15 3403 Does this facility do full blood count and
D25 differential testing onsite or offsite? YES, ONSITE ............................................1
YES, OFFSITE ...........................................2 3405
NO ...........................................................3 3405

items and reagents for full blood count A) AVAILABLE B) FUNCTIONING
testing are available and functional today. REPORTED NOT DON'T
OBSERVED YES NO
D15 01 Haematology analyzer (for full blood count) 3

1→B 2→B 1 2 8
D25 02
D15 02 Stains for full blood count and differential 3
1→B 2→B 1 2 8
D25 3405
D16 3405 Does this facility do CD4 count (absolute and
percentage) testing onsite or offsite? YES, ONSITE ............................................1
YES, OFFSITE ...........................................2 3500
NO ...........................................................3 3500

items for CD4 testing are available and A) AVAILABLE B) FUNCTIONING
functional today.
REPORTED NOT DON'T
ASK TO SEE THE ITEMS OBSERVED YES NO
D16 01 CD4 counter 3

1→B 2→B 1 2 8
02
D16 02 Specific assay kit- CD4 test 3
1→B 2→B 1 2 8
3500
D21 3500 Does this facility conduct blood group
D22 serology onsite or offsite? YES, ONSITE ............................................1
YES, OFFSITE ...........................................2
NO ...........................................................3 3600
109
2. Core instrument

code
3501 Does this facility conduct the following blood DON’T

CONDUCT THE
group serology tests onsite or offsite?
D21 01 ABO blood grouping testing 1 2 3
D21 02 Rhesus blood grouping testing 1 2 3
D22 03 Cross-match testing by direct agglutination 1 2 3
D22 04 Cross-match testing by indirect anti-globulin
testing or other test with equivalent 1 2 3
sensitivity
CHECK Q3501 Blood typing and cross match:
IF ONLY "YES, OFFSITE" OR "NO" ARE CIRCLED
IF "YES, ONSITE" CIRCLED FOR ANY TEST
Q3600
items and reagents for blood typing and cross A) AVAILABLE B) FUNCTIONING
match are available and functional today.
REPORTED NOT DON'T
D21 01 Centrifuge 3
1→B 2→B 1 2 8
D22 02
D22 02 37° C incubator 3
1→B 2→B 1 2 8
03
D22 03 Grouping sera 3
1→B 2→B 1 2 8
3600
3600 CHECK Q007:
IF HOSPITAL: IF NOT HOSPITAL:
Q4000
3601 Does this facility conduct the following tests DON’T
CONDUCT THE
onsite or offsite?
D24 01 Serum electrolyte testing 1 2 3
D32 02 Urine microscopy testing 1 2 3
D29 03 Syphilis serology testing 1 2 3
D31 04 Gram stain testing 1 2 3
D33 05 CSF/ body fluid counts 1 2 3
D30 06 Cryptococcal antigen testing 1 2 3
D17 07 Molecular biological technique for HIV viral
1 2 3
load or HIV early-infant diagnosis (PCR)
items and reagents are available and A) AVAILABLE B) FUNCTIONING
functional today:
REPORTED NOT DON'T
D24 01 Specific assay kit- serum electrolyte test 3

1→B 2→B 1 2 8
02
110

code
D29 02 Specific assay kit- syphilis serology 3

1→B 2→B 1 2 8
03
D31 03 Gram stains 3
1→B 2→B 1 2 8
04
04 White blood counting chamber 3
1→B 2→B 1 2 8
05
D30 05 Specific assay kit- cryptococcal antigen test 3
1→B 2→B 1 2 8
06
D17 06 Assay specific automated system for 3
1→B 2→B 1 2 8
estimating HIV viral load 07
D17 07 Centrifuge 3
1→B 2→B 1 2 8
D24 08
D17 08 Vortex mixer 3
1→B 2→B 1 2 8
09
D17 09 Pipettes 3
1→B 2→B 1 2 8
10
D24 10 Biochemistry analyzer 3
1→B 2→B 1 2 8
3603
3603 Does this facility perform diagnostic x-rays,
ultrasound, or computerized tomography? YES ............................................................ 1
NO ............................................................. 2 4000
3604 Please tell me if the following imaging

equipment items are available and functional A) AVAILABLE B) FUNCTIONING
today.
REPORTED NOT DON'T
E33 01 X-ray machine 3

1→B 2→B 1 2 8
02
E35 02 Ultrasound equipment 3
1→B 2→B 1 2 8
03
E36 03 CT scan 3
1→B 2→B 1 2 8
04
E34 04 ECG 3
1→B 2→B 1 2 8
4000
111
2. Core instrument

code
SECTION 7: MEDICINES AND COMMODITIES

4000 Does this facility stock medicines, vaccines, or
contraceptive commodities? YES ............................................................ 1
NO ............................................................. 2 5000
ASK TO BE SHOWN THE MAIN LOCATION IN THE FACILITY WHERE MEDICINES AND OTHER SUPPLIES ARE STORED.
FIND THE PERSON MOST KNOWLEDGEABLE ABOUT STORAGE AND MANAGEMENT OF MEDICINES AND SUPPLIES
IN THE FACILITY. INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING
QUESTIONS.
I would like to know if the following medicines are available today in this facility. I would also like to observe the
medicines that are available. If any of the medicines I mention is stored in another location in the facility, please
tell me where in the facility it is stored so I can go there to verify.
4001 Are any of the following medicines for the OBSERVED NOT OBSERVED
treatment of infectious diseases available in AVAILABLE
the facility today? AT LEAST AVAILABLE NON REPORTED NOT NEVER
ONE VALID VALID AVAILABLE AVAILABLE AVAILABLE
CHECK TO SEE IF AT LEAST ONE OF EACH MEDICINE IS BUT NOT SEEN TODAY
VALID (NOT EXPIRED)
M43 01 Co-trimoxazole cap/tab (Oral antibiotic) 1 2 3 4 5
M135 02 Fluconazole cap/tab 1 2 3 4 5
M35 03 Albendazole or Mebendazole cap/tab 1 2 3 4 5
M49 04 Metronidazole cap/tab 1 2 3 4 5
M2 05 Amoxicillin cap/tab 1 2 3 4 5
M5 06 Ceftriaxone injection 1 2 3 4 5
M23
M110
M6 07 Ciprofloxacin cap/tab 1 2 3 4 5
4002 Are any of the following medicines for the OBSERVED NOT OBSERVED
management of non-communicable diseases AVAILABLE
available in the facility today? AT LEAST AVAILABLE NON REPORTED NOT NEVER
CHECK TO SEE IF AT LEAST ONE OF EACH MEDICINE IS BUT NOT SEEN TODAY
VALID (NOT EXPIRED)
M50 01 Metformin cap/tab 1 2 3 4 5
M51 02 Insulin regular injection 1 2 3 4 5
M52 03 Glucose 50% injection 1 2 3 4 5
M53 04 ACE inhibitor (e.g. enalapril, lisinopril, 1 2 3 4 5
ramipril, perindopril)
M54 05 Thiazide (e.g. hydrochlorothiazide) 1 2 3 4 5
M55 06 Beta blocker (e.g.bisoprolol, metoprolol, 1 2 3 4 5
carvedilol, atenolol)
M56 07 Calcium channel blocker (e.g. amlodipine) 1 2 3 4 5
M57 08 Aspirin cap/tab 1 2 3 4 5
M59 09 Beclomethasone inhaler 1 2 3 4 5
M60 10 Prednisolone cap/tab 1 2 3 4 5
112

code
M61 11 Hydrocortisone injection 1 2 3 4 5

M62 12 Epinephrine injection 1 2 3 4 5
M114 13 Furosemide cap/tab 1 2 3 4 5
M10 14 Glibenclamide cap/tab 1 2 3 4 5
M115 15 Gliclazide tablet or glipizide tablet 1 2 3 4 5
M116 16 Glyceryl trinitrate sublingual tablet 1 2 3 4 5
M95 17 Ibuprofen tablet 1 2 3 4 5
M44
M118 18 Isosorbide dinitrate tablet 1 2 3 4 5

M11 19 Omeprazole tablet or alternative such as 1 2 3 4 5
pantoprazole, rabeprazole
M38 20 Paracetamol cap/tab (adult oral formulation) 1 2 3 4 5
M44
M13 21 Salbutamol inhaler 1 2 3 4 5

M14 22 Simvastatin tablet or other statin e.g. 1 2 3 4 5
atorvastatin, pravastatin, fluvastatin
M147 23 Spironolactone tablets 1 2 3 4 5
4003 Are any of the following reproductive health OBSERVED NOT OBSERVED
medicines and commodities available in the AVAILABLE
facility today? AT LEAST AVAILABLE NON REPORTED NOT NEVER
CHECK TO SEE IF AT LEAST ONE OF EACH BUT NOT SEEN TODAY
MEDICINE/COMMODITY IS VALID (NOT EXPIRED)
M15 01 Combined estrogen progesterone oral 1 2 3 4 5
contraceptive pills
M96 02 Progestin-only contraceptive pills 1 2 3 4 5
M16 03 Combined estrogen progesterone injectable 1 2 3 4 5
M97 contraceptives
M16 04 Progestin-only injectable contraceptives 1 2 3 4 5
M98
M17 05 Male condoms 1 2 3 4 5

M99 06 Female condoms 1 2 3 4 5
M108 07 Implant (e.g. levonorgestrel, etonogestrel) 1 2 3 4 5
M109 08 Emergency contraceptive pill (e.g. 1 2 3 4 5
levonorgestrel tablet, ulipristal acetate tablet,
M105 09 Intrauterine contraceptive device (IUCD) 1 2 3 4 5
4004 For each of the following items, please check STOCK- NO STOCK- NOT PRODUCT FACILITY
OUT IN OUT IN PAST INDICATED NOT RECORD NOT
in the facility records if there has been a THE PAST 3 MONTHS OFFERED AVAILABLE
stock-out in the past 3 months: 3
MONTHS
M99_A 01 Female condoms 1 2 3 4 5

M108_A 02 Implant (e.g. levonorgestrel, etonogestrel) 1 2 3 4 5
113
2. Core instrument

code
M109_A 03 Emergency contraceptive pill (e.g. 1 2 3 4 5

levonorgestrel tablet, ulipristal acetate tablet,
4005 Are any of the following maternal health OBSERVED NOT OBSERVED
medicines available in the facility today? AVAILABLE
CHECK TO SEE IF AT LEAST ONE OF EACH MEDICINE IS AT LEAST AVAILABLE NON REPORTED NOT NEVER
VALID (NOT EXPIRED)
BUT NOT SEEN TODAY
M18 01 Iron tablets 1 2 3 4 5

M19 02 Folic acid tablets 1 2 3 4 5
M18 03 Iron and folic acid combined tablets 1 2 3 4 5
M19
M20 04 Tetanus toxoid vaccine 1 2 3 4 5

M69 05 Sodium chloride injectable solution 1 2 3 4 5
M70 06 Calcium gluconate injection 1 2 3 4 5
M24 07 Magnesium sulphate injectable 1 2 3 4 5
M71 08 Ampicillin powder for injection 1 2 3 4 5
M23
M72 09 Gentamicin injection 1 2 3 4 5

M23
M110
M141
M106 10 Hydralazine injection 1 2 3 4 5

11 Metronidazole injection 1 2 3 4 5
M73
M74 12 Misoprostol 200µg tablets 1 2 3 4 5

M75 13 Azithromycin cap/tab or oral liquid 1 2 3 4 5
M76 14 Cefixime cap/tab 1 2 3 4 5
M77 15 Benzathine benzylpenicillin powder for 1 2 3 4 5
injection
M78 16 Betamethasone injection 1 2 3 4 5
M78 17 Dexamethasone injection 1 2 3 4 5
M129
M79 18 Nifedipine cap/tab (10mg) 1 2 3 4 5

M107 19 Methyldopa tablet 1 2 3 4 5
M22 20 Oxytocin injection 1 2 3 4 5
114

code
IF OXYTOCIN IS OBSERVED AVAILABLE IF OXYTOCIN IS NOT OBSERVED AVAILABLE

(Q4005_20 is “1” OR “2”) (Q4005_20 is “3”,”4”,OR “5”)
4007
4006 Is the oxytocin stored in cold storage?

YES ............................................................ 1
NO ............................................................. 2
in the facility records if there has been a THE PAST 3 MONTHS OFFERED AVAILABLE
stock-out in the past 3 months: 3
MONTHS
M22_A 01 Oxytocin injection 1 2 3 4 5

M74_A 02 Misoprostol 200µg tablets 1 2 3 4 5
M24_A 03 Magnesium sulphate injection 1 2 3 4 5
M72_A 04 Gentamicin injection 1 2 3 4 5
M80_A 05 Procaine benzylpenicillin injection 1 2 3 4 5
M5_A 06 Ceftriaxone injection 1 2 3 4 5
M78_A 07 Betamethasone injection 1 2 3 4 5
M78_B 08 Dexamethasone injection 1 2 3 4 5
4008 Are any of the following child health OBSERVED NOT OBSERVED
CHECK TO SEE IF AT LEAST ONE OF EACH MEDICINE IS AT LEAST AVAILABLE NON REPORTED NOT NEVER
VALID (NOT EXPIRED)
BUT NOT SEEN TODAY
01 Procaine benzylpenicillin injection 1 2 3 4 5

M80
M110
M32 02 Oral Rehydration Salts (ORS) sachets 1 2 3 4 5

M36 03 Zinc sulphate tablets 1 2 3 4 5
M36 04 Zinc sulphate syrup or dispersible tablets 1 2 3 4 5
M34 05 Vitamin A (retinol) capsules 1 2 3 4 5
M21 06 Antibiotic eye ointment for newborn 1 2 3 4 5
M7 07 Co-trimoxazole syrup/suspension 1 2 3 4 5
M12 08 Paracetamol syrup/suspension 1 2 3 4 5

M33 09 Amoxicillin 250 mg or 500 mg dispersible 1 2 3 4 5
tablet or syrup/suspension
IF AMOXICILLIN DISPERSIBLE TABLETS ARE AMOXICILLIN DISPERSIBLE TABLETS NOT

OBSERVED AVAILABLE (Q4008_09 is “1”) OBSERVED
4011
115
2. Core instrument

code
4009 Is the product stored so that identification

labels and expiry dates and manufacturing YES ............................................................ 1
dates are visible? NO ............................................................. 2
4010 Check the expiry dates of the stored product.

Are they stored in first-to-expire, first-out YES ............................................................ 1
(FEFO) order (i.e. the stock that will expire NO ............................................................. 2
first is the closest to the front)?
CHECK THE EXPIRY DATES OF THE STORED PRODUCT AT
THE FRONT AND AT THE BACK OF THE SHELF. IF THE
PRODUCT AT THE FRONT EXPIRES FIRST, ANSWER
“YES”. IF THE PRODUCT AT THE BACK EXPIRES FIRST,
ANSWER “NO”.
in the facility records if there has been a THE 3 MONTHS OFFERED AVAILABLE
stock-out in the past 3 months: PAST 3
MONTH
S
M33_A 01 Amoxicillin 250mg or 500mg dispersible 1 2 3 4 5

tablet or syrup/suspension
M32_A 02 Oral rehydration salts (ORS) 1 2 3 4 5
M36_A 03 Zinc sulphate tablets 1 2 3 4 5
M36_B 04 Zinc sulphate syrup or dispersible tablets 1 2 3 4 5
malaria treatment? YES ............................................................ 1
NO ............................................................. 2 4016
4013 Are any of the following malaria medicines OBSERVED NOT OBSERVED
and commodities available today in this AVAILABLE
facility? AT LEAST ONE AVAILABLE REPORTED NOT NEVER
VALID NON VALID AVAILABLE AVAILABLE AVAILABLE
M81 01 ACT 1 2 3 4 5
M37
M136 02 Artemisinin monotherapy (oral) 1 2 3 4 5

M82 03 Artesunate rectal or injection dosage forms 1 2 3 4 5
M39 04 SP (Sulfadoxine + Pyrimethamine) 1 2 3 4 5
M40 05 Insecticide treated bed nets for patients and 1 2 3 4 5
their families and households
M40 06 Insecticide treated bed net vouchers for 1 2 3 4 5
patients and their families and households
M138 07 Chloroquine (oral) 1 2 3 4 5
M139 08 Quinine (oral) 1 2 3 4 5
M140 09 Primaquine (oral) 1 2 3 4 5
CHECK Q4013_01:
IF FACILITY STOCKS ACT IF FACILITY DOES NOT STOCK ACT
(Q4013_01 = 1, 2, 3, OR 4): (Q4013_01 = 5):
4016
116

code
M37_A 4014 Has there been a stock-out of ACT in the past

4 weeks? YES ............................................................ 1
NO ............................................................. 2 4016
M37_B 4015 How many days of stock-out?
LESS THAN 7 DAYS .................................... 1
7 TO 14 DAYS ............................................ 2
MORE THAN 14 DAYS ............................... 3
tuberculosis treatment? YES ............................................................ 1
NO ............................................................. 2 4018
4017 Are any of the following TB medicines OBSERVED NOT OBSERVED
available today in this facility? AVAILABLE
CHECK TO SEE IF AT LEAST ONE OF EACH MEDICINE IS AT LEAST ONE AVAILABLE REPORTED NOT NEVER
VALID (NOT EXPIRED)
BUT NOT SEEN TODAY
M41 01 Ethambutol 1 2 3 4 5
M41 02 Isoniazid 1 2 3 4 5
M41 03 Pyrazinamide 1 2 3 4 5
M41 04 Rifampicin 1 2 3 4 5
M41 05 Isoniazid + Rifampicin (2FDC) 1 2 3 4 5
M41 06 Isoniazid + Ethambutol (EH) (2FDC) 1 2 3 4 5
M41 07 Isoniazid + Rifampicin + Pyrazinamide (RHZ) 1 2 3 4 5
(3FDC)
M41 08 Isoniazid + Rifampicin + Ethambutol (RHE) 1 2 3 4 5
(3FDC)
M41 09 Isoniazid + Rifampicin + Pyrazinamide + 1 2 3 4 5
Ethambutol (4FDC)
10 Streptomycin injectable 1 2 3 4 5
4018 Does this facility stock any antiretroviral
medicines? YES ............................................................ 1
NO ............................................................. 2 4020
4019 Are any of the following ARVs available today OBSERVED NOT OBSERVED
in this facility? AVAILABLE
VALID (NOT EXPIRED)
BUT NOT SEEN TODAY
M45 01 Zidovudine (ZDV, AZT) 1 2 3 4 5

M48
M46 02 Zidovudine (ZDV, AZT) syrup 1 2 3 4 5

M45 03 Abacavir (ABC) 1 2 3 4 5
M48
M45 04 Lamivudine (3TC) 1 2 3 4 5

M48
M45 05 Tenofovir Disoproxil Fumarate (TDF) 1 2 3 4 5

M48
117
2. Core instrument

code
M45 06 Nevirapine (NVP) 1 2 3 4 5

M48
M47 07 Nevirapine (NVP) syrup 1 2 3 4 5

M45 08 Efavirenz (EFV) 1 2 3 4 5
M48
M45 09 Emtricitabine (FTC) 1 2 3 4 5

M48
M45 10 Lamivudine + Abacavir (3TC + ABC) 1 2 3 4 5

M48
M45 11 Zidovudine + Lamivudine (AZT + 3TC) 1 2 3 4 5

M48
M45 12 Zidovudine + Lamivudine + Abacavir (AZT + 1 2 3 4 5

M48 3TC + ABC)
M45 13 Zidovudine + Lamivudine + Nevirapine (AZT + 1 2 3 4 5
M48 3TC + NVP)
M45 14 Tenofovir + Emtricitabine (TDF + FTC) 1 2 3 4 5
M48
M45 15 Tenofovir + Lamivudine (TDF + 3TC) 1 2 3 4 5

M48
M45 16 Tenofovir + Lamivudine + Efavirenz (TDF + 1 2 3 4 5

M48 3TC + EFV)
M45 17 Tenofovir + Emtricitabine + Efavirenz (TDF + 1 2 3 4 5
M48 FTC + EFV)
M45 18 Didanosine (DDI) 1 2 3 4 5
19 Lamivudine (3TC) syrup 1 2 3 4 5
M45 20 Stavudine 30 or 40 (D4T) 1 2 3 4 5
21 Stavudine syrup 1 2 3 4 5
22 Efavirenz (EFV) syrup 1 2 3 4 5
M45 23 Delavirdine (DLV) 1 2 3 4 5
M45 24 Enfuvirtide (T-20) 1 2 3 4 5
M45 25 Stavudine + Lamivudine (D4T + 3TC) 1 2 3 4 5
M45 26 Stavudine + Lamivudine + Nevirapine (D4T + 1 2 3 4 5
3TC + NVP)
4020 Does this facility stock any protease inhibitors
for the treatment of HIV/AIDS? YES ............................................................ 1
NO ............................................................. 2 4022
4021 Are any of the following protease inhibitors OBSERVED NOT OBSERVED
available in the facility today? AVAILABLE
VALID (NOT EXPIRED)
BUT NOT SEEN TODAY
M48 01 Lopinavir (LPV) 1 2 3 4 5

02 Indinavir (IDV) 1 2 3 4 5
03 Nelfinavir (NFV) 1 2 3 4 5
118

code
04 Saquinavir (SQV) 1 2 3 4 5
05 Ritonavir (RTV) 1 2 3 4 5
06 Atazanavir (ATV) 1 2 3 4 5
07 Fosamprenavir (FPV) 1 2 3 4 5
08 Tipranavir (TPV) 1 2 3 4 5
09 Darunavir (DRV) 1 2 3 4 5
4022 Are any of the following other medicines and OBSERVED NOT OBSERVED
commodities available in the facility today? AVAILABLE
CHECK TO SEE IF AT LEAST ONE OF EACH AT LEAST ONE AVAILABLE REPORTED NOT NEVER
BUT NOT SEEN TODAY
M27 01 Normal saline IV solution 1 2 3 4 5

M27 02 Ringers lactate IV solution 1 2 3 4 5
M27 03 5% dextrose IV solution 1 2 3 4 5
M42 04 IV treatment for fungal infections 1 2 3 4 5
06 Gowns 1 2 3 4 5
07 Eye protection (goggles, face shields) 1 2 3 4 5
08 Medical (surgical or procedural) masks 1 2 3 4 5
M63 09 Absorbable suture material 1 2 3 4 5
M63 10 Non-absorbable suture material 1 2 3 4 5
M64 11 Ketamine (injection) 1 2 3 4 5
M65 12 Lidocaine 1% or 2% (anaesthesia) 1 2 3 4 5
M25 13 Diazepam (injection) 1 2 3 4 5
CHECK Q007 AND Q1002_08:
IF HOSPITAL OR HEALTH FACILITY OFFERS IF NOT HOSPITAL AND CESAREAN
CESAREAN SECTION NOT OFFERED:
SECTION:
Q4100
M84 14 Thiopental (powder) 1 2 3 4 5

M85 15 Suxamethonium bromide (powder) 1 2 3 4 5
M86 16 Atropine (injection) 1 2 3 4 5
M87 17 Halothane (inhalation) 1 2 3 4 5
M88 18 Bupivacaine (injection) 1 2 3 4 5
M89 19 Lidocaine 5% (heavy spinal solution) 1 2 3 4 5
M62 20 Epinephrine (injection) 1 2 3 4 5
M90 21 Ephedrine (injection) 1 2 3 4 5
4023 Are any of the following mental health and OBSERVED NOT OBSERVED
neurological medicines available in the facility AVAILABLE
119
2. Core instrument

code
today? AT LEAST ONE AVAILABLE REPORTED NOT NEVER
M1 01 Amitriptyline tablet 1 2 3 4 5
M119 02 Carbamazepine tablet 1 2 3 4 5
M120 03 Chlorpromazine injection 1 2 3 4 5
M121 04 Diazepam tablet 1 2 3 4 5
M122 05 Diazepam injection or diazepam rectal tubes 1 2 3 4 5
M94 06 Fluoxetine tablet 1 2 3 4 5
M123 07 Fluphenazine injection 1 2 3 4 5
M124 08 Haloperidol tablet 1 2 3 4 5
M125 09 Lithium tablet 1 2 3 4 5
M126 10 Phenobarbital tablet 1 2 3 4 5
M127 11 Phenytoin tablet 1 2 3 4 5
M128 12 Valproate sodium tablet 1 2 3 4 5
M144 13 Lorazepam injection 1 2 3 4 5
M145 14 Levodopa + carbidopa tablet 1 2 3 4 5
4024 Are any of the following palliative care OBSERVED NOT OBSERVED
CHECK TO SEE IF AT LEAST ONE OF EACH AT LEAST ONE AVAILABLE REPORTED NOT NEVER
BUT NOT SEEN TODAY
M129 01 Dexamethasone injection 1 2 3 4 5

M130 02 Haloperidol injection 1 2 3 4 5
M131 03 Hyoscine butylbromide injection 1 2 3 4 5
M132 04 Lorazepam tablet 1 2 3 4 5
M133 05 Metoclopramide injection 1 2 3 4 5
M83 06 Morphine granules, tablet 1 2 3 4 5
M44
M83 07 Morphine injection 1 2 3 4 5

M44
M134 08 Senna preparation (laxative) 1 2 3 4 5

M146 09 Loperamide tab/cap 1 2 3 4 5
120

code
SUPPLY CHAIN
4100 Who is the principal person responsible for
managing the ordering of medical supplies at NURSE ....................................................... 1
this facility? CLINICAL OFFICER ..................................... 2
PHARMACY TECHNICIAN .......................... 3
PHARMACY ASSISTANT ............................. 4
PHARMACIST............................................. 5
MEDICAL ASSISTANT ................................. 6
OTHER __________________________ 96
(SPECIFY)
4101 Which of the following mechanisms is used to YES NO DON’T
determine this facility’s resupply quantities? KNOW
ASK FOR EACH OF THE BELOW
01 The facility itself (pull distribution system) 1 2 3
02 A higher level facility (push distribution 1 2 3
system)
03 Other ________________________ 1 2 3
(SPECIFY)
4102 How are the facility’s resupply quantities
determined? FORMULA (ANY CALCULATION) ................ 1
DON’T KNOW ............................................ 2
OTHER MEANS .......................................... 3
4103 What is the main source of your routine
pharmaceutical commodity supplies? By this I NATIONAL MEDICAL STORES .................... 1
mean who is the direct supplier to your JOINT MEDICAL STORES ............................ 2
facility? NGO/DONORS........................................... 3
PRIVATE SOURCES .................................... 4
OTHER __________________________ 96
(SPECIFY)
4104 How are your pharmaceutical commodity
supplies from the main supplier of your SUPPLIER DELIVERS TO FACILITY............... 1
routine pharmaceuticals delivered to this FACILITY MUST ARRANGE DELIVERY TO
facility? FACILITY .................................................... 2
OTHER __________________________ 96
(SPECIFY)
4105 Who is responsible for transporting products YES NO

from central medical stores to your facility?
01 Local supplier delivers 1 2
02 Higher level delivers 1 2
03 This facility collects 1 2
04 Other ________________________ 1 2
(SPECIFY)
121
2. Core instrument

code
4106 For the most recent order, how long did it

take between ordering and receiving LESS THAN 2 WEEKS.................................. 1
products? 2 WEEKS TO 1 MONTH.............................. 2
BETWEEN 1 AND 2 MONTHS .................... 3
MORE THAN 2 MONTHS ........................... 4
We have now completed all of the questions in this module of the survey. Thank you for your participation.
122
Number Question Result Skip

SECTION 8: INTERVIEWER'S OBSERVATIONS
5000 INTERVIEW END TIME (use the 24 hour-clock :
system)
5001 RESULT CODES (LAST VISIT):

COMPLETED .............................................. 1
RESPONDENT NOT AVAILABLE .................. 2
REFUSED .................................................... 3
PARTIALLY COMPLETED ............................ 4
OTHER ___________________________96
(SPECIFY)
COMMENTS ABOUT THE RESPONDENT:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
COMMENTS ON SPECIFIC QUESTIONS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
ANY OTHER COMMENTS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
SUPERVISOR'S OBSERVATIONS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
NAME OF SUPERVISOR: ____________________________________ DATE: ______________________
123

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HEALTH FACILITY ASSESSMENT OF SERVICE AVAILABILITY AND READINESS

Service Availability and Readiness

© World Health Organization 2015

Cover photo credit: WHO/Evelyn Hockstein

Project Management Group

Project Advisory Group

CHAPTER 1 | OVERVIEW ....................................................................................................5

CHAPTER 2 | CORE INSTRUMENT ..................................................................................... 65

CHAPTER 3 | INDICATORS INDEX.................................................................................... 125

SARA core instrument

• Section 1: Cover page

• Section 3: Inpatient and observation beds

• Section 5: Available services

• Section 7: Medicines and commodities

• Section 8: Interviewer’s observations

Number Question Result

Date _______________ _________________ _______________ DAY

007 Type of facility* NATIONAL REFERRAL HOSPITAL ...................................... 1

Number Question Result

*Detailed information is available in the data collector’s guide

Number Question Result Skip

Indicator Number Question Result Skip

MODULE 1: SERVICE AVAILABILITY

S4 02 Specialist medical doctors

11 Laboratory technicians (medical and

12 Community health workers

SECTION 3: INPATIENT AND OBSERVATION BEDS

Indicator Number Question Result Skip

MODULE 2: SERVICE READINESS

I5 401 Does this facility have a functioning cellular

Indicator Number Question Result Skip

I1 409 What is the electricity used for in the facility?

410 What is the facility’s main source of electricity?

414 Is there fuel or a charged battery available

Indicator Number Question Result Skip

415 CHECK Q410 AND Q411:

416 Is the solar system functional?

Indicator Number Question Result Skip

I4 421 Is there a toilet (latrine) on premises in FLUSH TOILET ............................................ 1

I8 01 Electric autoclave (pressure & wet heat) 3

HEALTH CARE WASTE MANAGEMENT

Indicator Number Question Result Skip

I9 424 Now I would like to ask you a few questions

Indicator Number Question Result Skip

I9 427 Is the incinerator functional today?

431 During the supervision visit, did the supervisor YES NO

E1 01 Adult weighing scale 3

Indicator Number Question Result Skip

E6 08 Light source (flashlight acceptable) 3

Indicator Number Question Result Skip

SECTION 5: AVAILABLE SERVICES

S12_02 03 Emergency contraceptive pills

S12_02 04 Intrauterine contraceptive device (IUCD)

703 Please tell me if the following documents are YES,

Indicator Number Question Result Skip

T2 01 National family planning guidelines 1 2 3

M15 01 Combined estrogen progesterone oral

M16 04 Progestin-only injectable contraceptives

M17 05 Male condoms 1 2 3 4 5

Date _______ _ _______ DAY