CMW Administrative Supervisory Checklist - AAP-Health-MNCH

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CMW Administrative Supervisory Checklist

To be filled by Supervisors/Focal Person AAP/MNCH

Month _______ Year__________


Section I. Basic information of CMW

1.1 Name of CMW

1.2 PNC registration No:

1.3 Union Council of Deployment

1.4 Union Councilwhere currently working

1.5 CMW Contact Number

1.6 CMW Deployment date

1.7 CMW working hours

CMW is working with any other organization? (If Yes No  Org:
1.8
yes, mention the name of organization.)
Complete address (Either residential or official) of
1.9
CMW

1.10 Catchment Area Population

1.11 Name of Health Facility

1.12 Health Facility ID

1.13 CMW sign board displayed Yes  No 

Section II: Please check the appropriate box (Yes’ No’ and Not Available) (Check
physically with stock register)

Functional
Section II-A: Basic Equipment Not Available
Yes No
A.1 BP apparatus
A.2 Stethoscope
A.3 Fetoscope
A.4 Emergency rechargeable light
A.5 Baby weighing machine
A.6 Weighting machine Adult
A.7 Baby Warmer (Optional)
A.8 Sterilizer (Electric 12 X 16)
A.9 Normal delivery set
A.10 Episiotomy set
A.11 Safety box
A.12 Bulb sucker
A.13 Thermometer
A.14 Measuring Tape
A.15 Safe delivery kit (SDK) (Packed)
A.16 Ambo bag with mask (If mask is not
present, then it is incomplete)
A.17 IUCD set
A.18 Glucometer (Optional)
A.19 Hemoglobin meter
A.20 Manual Vacuum Aspiration (MVA) Kit

Section II.B Medicines


B.1Iron and folate
B.2 Vitamin A
B.3Cap: Amoxicillin
B.4 Syp: Amoxicillin (or any other
antibiotics)
B.5 Tab: Mefnamic Acid
B.6 Tab: Paracetamol
B.7 Drops. Paracetamol
B.8 Tab: Metronidazole (200mg and 400
mg)
B.9 Canestine Vaginal Tablet with
Applicator
B.10 Inj. Oxytocin
 If Inj. Oxytocin is cold stored?
B.11Tab. Misoprostol
B.12 Inj. Methergin 0.2mg
B.13 Inj Magnesium Sulphate
B.14 Inj Valium
B.15 Inj Calcium gluconate
B.16 Inj Dexamethasone
B.17 N/S 500 ml, 1000 ml with drip sets

B.18 Ringers Lactate 500 ml with drip sets


B.19 Antiseptic solution (Pyodine, Alcohol)

B.20 Chlorhexidine
Section II.C Family Planning
commodities

C.1 Oral Contraceptive Pills


C.2 Injectable
C.3 IUCD
C.4 Condoms
C.5 Emergency Contraceptive Pill (ECP)
Section II. D Consumables
D.1 Urine dip stick
D.2 Folly’s catheter
D.3 Urine bag
D.4 Syringes
D.5 I/V cannulas
D.6 Adhesive tape
D.7 Gloves
D.8 Face mask
D.9 Apron
D.10 Cotton
D.11Plastic sheet

Section II.E Furniture items

E.1 Examination Couch


E.2 Curtin screen
E.3 Delivery table
E.4 Office table
E.5 Chair
E.6 Client stool
E.7 Almira
Section II. F CMW-MIS tools & Currently used
Registers (Available stock should be Available (Check for last Remarks
enough for 3 months atleast) month)
F.1 Daily Register Y N Y N

F.2 Stock register Y N Y N

F.3 MNCH Cards Y N Y N


F.4 Partograph Charts Y N Y N
F.5 Monthly Report Forms Y N Y N

F.6 Health Education Material Y N Y N

F.7 Family Planning Client cards Y N Y N

F.8 Referral slips Y N Y N

Section III: Please check the appropriate box after Status Remarks
consulting CMW

Section III. A Data

3.1 Is CMW daily register updated? Complete

Timely
3.2 Has CMW kept the copy of monthly report of Yes No
previous month?
3.3 Does the CMW Monthly Report Data tally with the Yes No
Register data?
3.4 Has CMW technical/administrative supervisor Yes No
visited during last three months?
Section III. B Disposal of Waste
3.b.1 Is the Placenta appropriately disposed through Yes No
burial?
3.b.2 Are blade/syringe/sharps burned or buried Yes No
properly?

Section IV. Referrals Status Remarks


Number of referrals from LHWs/community
4.1
workers to CMWin last month
Number of referrals from CMW to health facility
4.2
in last month
List of referral health facilities for referrals with Yes No
4.3
contact numbers is available
4.4 Available mode of transport for referrals Yes No Type:
4.5 Number of referrals of Pregnant women for TT Yes No
Number of newborns referred for BCG and / or Yes No
4.6
OPV
Section V: Community/Service Users Satisfaction (Check, Observe and report by ticking
‘Yes’ or ‘No’)
S. No. Yes No
5.1 CMW responsiveness/attitude
5.2 Provision of quality ANC
5.3 Provision of quality PNC
5.4 Provision of required medicines
5.5 Provision of contraceptives (method opted by client)
Timely Response to the call for delivery (Within 1
5.6
Hour)

Summary of Findings:

 PLEASE GIVE WRITTEN AND VERBAL FEEDBACK TO THE CMW FOR IMPROVEMENT
BASED ON THE ABOVE FINDINGS

Supervisor name and signature

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