Mis Supervisory Visit Checklist

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Supervisory visit checklist

Sub center Name of co-ordinator


month
incharge Date

Date of previous visit

Action taken since previous visit
1
2
3

Are there special problems from previous visit that need to be followed during the current visit?
1
2
3

Special needs/requirements
1
2
3














Co-ordinator Feedback form
Feedback on the Visit
Improvements noticed since previous visit:
1
2
3
Problems identified during previous visit that need still further improvement
1
2
3
Problems identified during this visit
1
2
3
Recommendations to Staff:
1
2
3
Actions to be taken by supervisor
1
2
3
Problems to be followed at next month/visit
1
2
3
Date of next visit

,

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