PRAVARA INSTITUTE OF MEDICAL SCIENCES

(DEEMED TO BE UNIVERSITY), LONI

DR BVP RURAL MEDICAL COLLEGE

DEPARTMENT OF COMMUNITY MEDICINE

FAMILY ADOPTION PROGRAMME

NAME ____________________________________________________

BATCH____________________________________________________

ROLL NO__________________________________________________

1
हीच अमुची प्रार्थना अन् हेच अमुचे मागणे
माणसाने माणसाशी माणसासम वागणे

2
 Certificate of Completion

This is to certify that

Mr.___________________________________________________________________

of the Batch ________________has successfully completed Family Study &

Community Survey Activities under Department of Community Medicine and has

acquired the requisite competencies.

Batch In charge Head of the Department

3
 Hippocratic Oath
I swear to fulfil, to the best of my ability and judgment, this covenant:
 I will respect the hard-won scientific gains of those physicians in whose steps I walk,
and gladly share such knowledge as is mine with those who are to follow.
 I will apply, for the benefit of the sick, all measures [that] are required, avoiding those
twin traps of overtreatment and therapeutic nihilism.
 I will remember that there is art to medicine as well as science, and that warmth,
sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
 I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the
skills of another are needed for a patient's recovery.
 I will respect the privacy of my patients, for their problems are not disclosed to me that
the world may know. Most especially must I tread with care in matters of life and death.
If it is given me to save a life, all thanks. But it may also be within my power to take a
life; this awesome responsibility must be faced with great humbleness and awareness
of my own frailty. Above all, I must not play at God.
 I will remember that I do not treat a fever chart, a cancerous growth, but a sick human
being, whose illness may affect the person's family and economic stability. My
responsibility includes these related problems, if I am to care adequately for the sick.
 I will prevent disease whenever I can, for prevention is preferable to cure.
 I will remember that I remain a member of society, with special obligations to all my
fellow human beings, those sound of mind and body as well as the infirm.
 If I do not violate this oath, may I enjoy life and art, respected while I live and
remembered with affection thereafter. May I always act so as to preserve the finest
traditions of my calling and may I long experience the joy of healing those who seek my
help.

Signature

4
Maharshi Charak Shapath
To be Added by Printers

5
 Contents
Name of Student:

Batch/Year:

Field Practice Area:

Sr Topic Page Signature

No. No.
 Curriculum, Competencies and Objectives of
Family Adoption Program
 Village Schedule

1. Family 1

2. Family 2

3. Family 3

4. Family 4

5. Family 5

6. Family Study Survey Report

7. Preventive Check UP/ Camp Reports

8. Sanitation Survey

9. Entomological Survey

10. Health Communication Activities

11. Environmental Sustainability Activities

12. Final Report

Student Field Study Evaluation Checklist

6
 CURRICULUM FOR FAMILY ADOPTION PROGRAMME
This program is being introduced with the aim of village outreach program for MBBS students. Every
college may arrange one diagnostic medical camp in the village wherein identification of:

a) Anemia, malnutrition in children, hypertension, diabetes mellitus, ischemic heart diseases,

kidney diseases, any other local problems may be addressed.
b) If required, patients shall be admitted in the hospital.
c) For chronic illness, students shall be involved.
d) Subsidized treatment charges may be provided under govt. schemes or welfare schemes.
 Medical student may be allocated about 5 families and introduced in the first visit.
 Camps may be arranged by Dean and Community Medicine/ P.S.M. department with active
involvement of Associate/ Asst. Professors, social worker and supporting staff.
 Local population may be involved with village leaders.
 Visit by students be made to the visit as mentioned in table below. Annual follow up diagnostic
camp can be continued by the PSM department.
Targets to be achieved by students:

First a) Learning communication skills and inspire confidence amongst families

Professional b) Understand the dynamics of rural set-up of that region
Year c) Screening programs and education about ongoing government sponsored health
related programs
d) Learn to analyze the data collected from their families
e) Identify diseases/ ill-health/ malnutrition of allotted families and try to improve the
standards
Second a) Inspire active participation of community through families allotted
Professional b) Continue active involvement to become the first doctor /reference point of the
Year family by continued active interaction
c) Start compiling the outcome targets achieved
Third Analysis of their involvement and impact on existing socio-politico-economic dynamics
Professional in addition to improvement in health conditions prepare a report to be submitted to
Year department addressing:
1) Improvement in general health
2l Immunization
3) Sanitation
4) De-addiction
5) Whether healthy lifestyles like reading good books, sports/ yoga activities have been
inculcated in the house-holds.
6) Improvement in Anemia, tuberculosis control
7l Sanitation awareness
8) Any other issues
9) Role of the student in supporting family during illness/ medical emergency
10) Social responsibility in the form of environment protection programme in form of
plantation drive (medicinal plants/trees), cleanliness and sanitation drives with the
initiative of the medical student

7
 FAMILY ADOPTION PROGRAM

Year Objective Teaching Assessment

Hours

First MBBS Students should be able to compile the 6 hours Journal, Log book
basic demographic profile of allocated evaluation
family members

Students should be able to report the Family Survey

basic health profile and treatment history 9 hours
Presentation
of allocated family members

Conduct a Health Communication activity 6 hours

Health Education
with Family Members
Activity Evaluation
Report the activities undertaken for
6 hours Logbook Based
environment protection and sustenance
like study of environment of families, tree Certification of
plantation/ herbal plantation activities Activity
conducted in the village
Second Take history and conduct clinical 6 hours Journal/Logbook
MBBS examination of all Based Certification of
family members Family Activity
survey, Community clinics

Organize health check-up and 9 hours Community case

coordinate treatment of adopted family presentation, OSPE,
under overall guidance of mentor in logbook, Journal
Community clinics, Multispecialty camps

Maintain communication & 9 hours Community case

follow up of remedial measures presentation, OSPE,
logbook, Journal
NSS camp environmental Sustenance 6 hours
activity Sanitary Survey, Entomological Report of Activity
Survey Journal/Logbook,
Photographs/Videos

8
Year Objective Teaching Hours Assessment
Third Take history and Family survey,
MBBS conduct clinical 3 hours Community clinics,
examination of all Journal/Logbook
family members

Organize health 3 hours Family survey,

check-up and Community clinics,
coordinate treatment Journal/Logbook
of adopted family
under overall guidance
of mentor

Maintain 3 hours Logbook Based

communication & Certification of
follow up of remedial Activity
measures

NSS camp environmental 3 hours

Sustenance activity Report of Activity
Analyze health trajectory of Journal/Logbook
Family

Year No. of Visits No. of Hours

First 9 27

Second 10 30

Third 7 21

Total 26 78

9
 Competencies and Objectives of Family Study

FIRST YEAR
CM 1.9: Demonstrate the role of effective communication skills in health
 Ist MBBS students will visit five families allotted in the field area and introduce
themselves to the family
 Ist MBBS students will briefly explain the objective of family study to the family
members
CM 1.10: Demonstrate important aspects of doctor-patient relationship
 The student will establish rapport with the family
CM 2.1: Clinico-Socio Cultural and demographic assessment of families
 Student will note the socio demographic profile of the families
 Students will discuss the importance of socio demographic factors on health with
the facilitator
CM 5.2: Conduct nutritional Assessment of Family at Community Level
 Student shall take detailed dietary history of family members unsupervised
 Students will identify members with malnutrition
 Students will discuss nutritional problems in the families with facilitators and
suggest solutions
CM 5.5: Provide nutrition education under supervision in the community
 The student will prepare a pamphlet with bullet points on nutrition in local
language under supervision and share with families
CM 4.2: Organize Health Education Activity in the Community
 The students will plan and arrange a brief health education activity in the
community under supervision at the end of posting
CM 1.2 Identify determinants of Health
 Students must identify the major determinants of Health based on the socio
demographic history
Identify two Causative factors for common diseases in the family

10
 SECOND YEAR
CM 2.2: Socio cultural Factors, family type and its role in health and disease
 Students must know various family types and
 Identify socio cultural factors in the families allotted to them
 Observe and explain the effect of family type, size and socio cultural factors on
health
CM 2.2: Assessment of Socio Economic Status
 Calculate Socio-economic status of Family using various scales unsupervised
 Observe and Explain effect of Socio economic status on health
CM 2.3: Factors Affecting Health Seeking Behaviour and Assessment of Barriers
to Healthcare
 Identify factors affecting health seeking behaviours
 Identify Barriers to Healthcare
 Discuss in group and suggest solutions to improve health seeking behaviour
CM 2.4: Community Behaviour and its impact on Health
 Identify specific community behaviours
 Discuss their pros and cons in relation to health as a group
 Identify methods to improve community behaviours
CM 2.5: Effect of Socio Economic Status on health, Social Security Measures
 Enumerate ways in which socio economic status affects health
 Identify various government schemes that address Social Security, Insurance
and healthcare for families with low SES
CM 3.2: Environment and Sanitation Survey, Entomological Survey
 Conduct Environment Sanitation and Entomological Survey
 Summarize the key findings and discuss as a group
 Explain health implications of Environment
 Identify various vectors that families are susceptible to and suggest preventive
measures
CM 3.5: Describe standards of housing and effect of housing on health
 Observe and describe the housing of allotted families
 Compare with criteria for Healthful housing
 Comment on overcrowding and other key findings and their health effects
Counsel patient and families on prevention of various infections due to
environmental factors

11
 THIRD YEAR
CM 9.1: Identify Vital Events discuss their implications on health
 Enumerate vital events in the families
 Discuss effects of vital events on health
OG 19.2: Counsel in a simulated environment about contraception and puerperal
sterilization
 Take history of contraceptive usage
 Understand socio cultural nuances and council about contraception accordingly
under supervision
 Identify the eligible couples and direct to appropriate referral centres
CM 10.3: Local Customs and practices during pregnancy, child birth lactation and
feeding
 Observe and note practices during pregnancy child birth and lactation & enquire
into their reasons.
 Discuss as a groups the practices and their effects on health
 Counsel under supervision about correct practices
PE 9.4: Elicit, document and present an appropriate nutritional history and
perform a dietary recall
PE 9.5: Calculate age related calorie requirement in health and disease and
identify gap
PE 10.4: Identify children with under nutrition and plan referral
PE 8.4: Elicit history on complementary feeding habits
PE 8.5: Counsel and Educate mothers on best practices in complementary
feeding
PE 18.3: Conduct antenatal examination of women independently and apply the
at-risk approach in antenatal care
PE 18.6: Perform post natal assessment of newborn and mother, provide advice
on breastfeeding, weaning and family planning
CM 8.2: Epidemiological control measures for disease prevention
 Identify risk factors of various diseases in the family
 Suggest primary secondary and tertiary prevention methods
CM 8.3 Identify National Health Programs that can benefit the family
 Identify National Health Programs that can benefit the family

12
  Explain the programmes succinctly to the family under supervision
CM 8.5: Planning, Implementation and Evaluation of Control Measures
 Identify a modifiable risk factor for a disease in the community
 Plan a feasible intervention and implement it in the community
 Evaluate the response to control measure
CM 12.2: Health Problems in Elderly
 Identify 5 common Health Problems in Elderly
 Enumerate causes of health problems
CM 12.3: Prevention of Health problems in elderly
 Suggest preventive measures for health problems
 Encourage participation of elderly in peer group activities
 Link elderly to appropriate services
CM 15.1: Warning signs of common Mental Illnesses and substance abuse
 Identify common mental illnesses and Addictions in community
 Identify Determinants of the same
 Perform IEC activity and advice referral as appropriate
CM 6.2: Collect Classify and Enter Data
 Collect the data in your journals
 Enter and Clean the data
 Code the data in a database
CM 6.3: Apply Elementary statistical methods to analyse and interpret data
 Find frequency and percentage values of variables
 Compare variables as appropriate
 Interpret the data and draw meaningful conclusions
CM 7.9: Demonstrate application of MS Excel
 Enter and code family study data in MS Excel
 Perform simple statistical operations like calculation of mean using formula
functions
 Perform appropriate graphical representation of data using Excel
CM 8.6: Health Education
 Perform a Health Education activity in the Community under supervision
Compile, analyse and present Family Survey report. Comment on community
diagnosis and actions to be taken at individual, family and community level

13
 Village Schedule

Name of Village: Nearest Post Office:

Total Households: Nearest Bus Stop:

Population: Nearest Railway Station:

 Male: Approach to Village:

 Female:
Transport Facilities:
 Children:

Nearest PHC:

Nearest Wellness Centre/Dispensary:

Nearest Maternity Home:

Nearest Tertiary Care Referral Centre :

Community Institutions No. Name

Co-operatives

Library

Youth Association

Women’s Association

Schools

Anganwadi

Religious/Charitable Institutions

Other

Medical Practitioners

 Allopathic
 AYUSH
 Others

14
Sources of Water: Climate:

Type of Drinking Water Supply: Average Rainfall:

Street Lighting: Predominant Religion:

Major Agricultural Products: Predominant Castes:

Cash Commodities: Fairs & Festivals:

Industrial products: Endemic Diseases:

Cottage & Small Industry:

Name of Sarpanch

Name of CHO

Name of ANM

Name of ASHA

Name of Anganwadi Sevika

Village Map

15
FAMILY
DETAILS

16
 Family 1
Demographic Profile

1. Household Unique ID: ____/____/___ 2. Geotag Latitude:

Longitude:
3. Name of the head of Family: 4. Contact no.

5. Family type:: N / J / T / O t h e r _ _ _ _ _ 6. Religion: H / M / J / B / C / S / O t h e r _ _ _ _ _

7. Family income/month (Rs.) 8. Caste Cat: 1. Open 2.OBC 3.SC 4. ST
5.VJNT 6. SBC, 7. Other___________
9. Ration card: Yellow / Orange / White 10. ABHA card:

Family Details:

Name of Age Sex Education Occupation Marital History of

Family Status
Member
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G

Any Significant Family History?

17
 Health Profile
Diet & Nutrition

Type of Diet: Veg / Mixed Frequency of eating non-veg per week:

Name of Family Member Expected Actual Calorie Expected Actual Protein

Calorie Intake Protein Intake Intake
Intake

 Average Monthly Expenditure on Food:

 Is Supplementary nutrition given to children & Pregnant or lactating women?
 Growth Monitoring To Be Done on Charts Provided

Environmental History

House: Katcha / Pucca / Semipucca. Overcrowding: Yes/ No

Water Supply: Continuous/ Intermittent. Source of water: Tap/ Well

/Bore/ Tanker/__________ . Water disinfection methods:
Purifier/Boiling/Chlorination/Other___________

Storage of non-drinking water: Covered/ Open containers.

LPG (gas): Yes / No Kerosene stove/ Smokeless Chullah/ Ordinary Chullah/ Other_______ .

Sanitary latrine: No/ Private/ Public.

Garbage disposal: Door step / Common point / No collection system.

Any other important finding:

18
 History of addiction in family:
Name Addicted to Monthly expenses
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________

Couples in reproductive age group (15-45 YOA)

Name of couple in family Type of Contraception Specify
+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

Pregnant Women:
Name Score ANC registration done in
G__P__L__A__ Private / Govt. / Not done
G__P__L__A__ Private / Govt. / Not done
Consanguineous marriages
Name of couple Relation to husband Birth defect/condition in children
No /Yes____________________
Children
Visits Anganwadi
Age in Immunization Till Date
Initials Regularly & gets Growth
months
THR (Y/N)
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese

6) Any illness in past 3 months in family (), give details:

19
 Condition Name of Since On From Check Up Advice Given Improv
Patient (yrs.) Treat Private/ (Hb/BP/BSL/RFT/Sputum ement
ment Public/ / Other
F/U 1 Significant
F/U 2 report
F/U 3 F/U 1 F/U 2 F/U 3 (Y/N)
(Y/N) PMT Noted)

Anaemia

Malnutritio

n
Hypertensi

on
Diabetes

Ischemic

Heart
Kidney

Disease
Disease
TB

Other

20
 Community Based Assessment Checklist (CBAC) Form for Early Detection of NCDs

Adult Family Member above 35 years

Question Range Circle

any
1. What is your age? (in complete 30-39 years 0
years ) 40-49 years 1
≥ 50 years 2
2. Do you smoke or consume Never 0
smokeless products such as Gutka; or Used to consume
Khaini ? in the past / 1
Sometimes
Daily 2
3. Do you consume Alcohol daily? No 0
Yes 1
4. Measurement of waist (in cm)
Female Male
<80 cm <90 cm 0
80-90 cm 90-100 cm 1
>90 cm >100 cm 2
5. Do you undertake any physical Less than 150
1
activities for min. of 150 minutes in a minutes in a week
week? At least 150
0
minutes in a week
6. Do you have a family history (any No 0
one of your parents or siblings) of Yes
high blood pressure, diabetes and 2
heart disease?
Total Score
A score above 4 indicates that the person may be at risk for these NCDs and needs to be prioritized for
attending the weekly NCD day.

Part B: Early Detection: Ask if patient has any of these symptoms

B1: Women and Men Yes/ No B2: Women only Yes/No

Shortness of breath Lump in the breast
Coughing more than 2 weeks Blood stained discharge from the nipple
Blood in sputum Change in shape and size of breast
History of fits Bleeding between periods
Difficulty in opening mouth Bleeding after menopause
Ulcers /patch /growth in the Bleeding after intercourse
mouth that has not healed in
two weeks
Any change in the tone of your voice Foul smelling vaginal discharge

In case the individual answers Yes to any one of the above-mentioned symptoms, refer the patient
immediately to the nearest facility where a Medical Officer is available.

21
 Preventive Check-up (Examination of Family Members)

1) ANC/PNC

Name Age:
Visit Date Age at Marriage
Individual No. Age of Menarche:
Obstetric Score G___P____L____A____

LMP Past History:

EDD
ANC visits Personal History:

Counselling Family Planning?

Significant
Medical History
General
Examination
Systemic
Examination

Significant Delivery Details:

findings on
Investigation
Significant Post
Natal History

Advice Given

5 Ruled Pages + Set of Growth Charts to be attached

22
 Family 2
Demographic Profile

11. Household Unique ID: ____/____/___ 12. Geotag Latitude:

Longitude:
13. Name of the head of Family: 14. Contact no.

15. Family type:: N / J / T / O t h e r _ _ _ _ _ 16. Religion: H / M / J / B / C / S / O t h e r _ _ _ _ _

17.Family income/month (Rs.) 18. Caste Cat: 1. Open 2.OBC 3.SC 4. ST
5.VJNT 6. SBC, 7. Other___________
19. Ration card: Yellow / Orange / White 20. ABHA card:

Family Details:

Name of Age Sex Education Occupation Marital History of

Family Status
Member
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G

Any Significant Family History?

23
 Health Profile
Diet & Nutrition

Type of Diet: Veg / Mixed Frequency of eating non-veg per week:

Name of Family Member Expected Actual Calorie Expected Actual Protein

Calorie Intake Protein Intake Intake
Intake

 Average Monthly Expenditure on Food:

 Is Supplementary nutrition given to children & Pregnant or lactating women?
 Growth Monitoring To Be Done on Charts Provided

Environmental History

House: Katcha / Pucca / Semipucca. Overcrowding: Yes/ No

Water Supply: Continuous/ Intermittent. Source of water: Tap/ Well

/Bore/ Tanker/__________ . Water disinfection methods:
Purifier/Boiling/Chlorination/Other___________

Storage of non-drinking water: Covered/ Open containers.

LPG (gas): Yes / No Kerosene stove/ Smokeless Chullah/ Ordinary Chullah/ Other_______ .

Sanitary latrine: No/ Private/ Public.

Garbage disposal: Door step / Common point / No collection system.

Any other important finding:

24
History of addiction in family:
Name Addicted to Monthly expenses
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________

Couples in reproductive age group (15-45 YOA)

Name of couple in family Type of Contraception Specify
+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

Pregnant Women:
Name Score ANC registration done in
G__P__L__A__ Private / Govt. / Not done
G__P__L__A__ Private / Govt. / Not done
Consanguineous marriages
Name of couple Relation to husband Birth defect/condition in children
No /Yes____________________
Children
Visits Anganwadi
Age in Immunization Till Date
Initials Regularly & gets Growth
months
THR (Y/N)
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese

25
 Condition Name of Since On From Check Up Advice Given Improv
Patient (yrs.) Treat Private/ (Hb/BP/BSL/RFT/Sputum ement
ment Public/ / Other
F/U 1 Significant
F/U 2 report
F/U 3 F/U 1 F/U 2 F/U 3 (Y/N)
(Y/N) PMT Noted)

Anaemia

Malnutritio

n
Hypertensi

on
Diabetes

Ischemic

Heart
Kidney

Disease
Disease
TB

Other

26
 Community Based Assessment Checklist (CBAC) Form for Early Detection of NCDs

Adult Family Member above 35 years

Question Range Circle

any
1. What is your age? (in complete 30-39 years 0
years ) 40-49 years 1
≥ 50 years 2
2. Do you smoke or consume Never 0
smokeless products such as Gutka; or Used to consume
Khaini ? in the past / 1
Sometimes
Daily 2
3. Do you consume Alcohol daily? No 0
Yes 1
4. Measurement of waist (in cm)
Female Male
<80 cm <90 cm 0
80-90 cm 90-100 cm 1
>90 cm >100 cm 2
5. Do you undertake any physical Less than 150
1
activities for min. of 150 minutes in a minutes in a week
week? At least 150
0
minutes in a week
6. Do you have a family history (any No 0
one of your parents or siblings) of Yes
high blood pressure, diabetes and 2
heart disease?
Total Score
A score above 4 indicates that the person may be at risk for these NCDs and needs to be prioritized for
attending the weekly NCD day.

Part B: Early Detection: Ask if patient has any of these symptoms

B1: Women and Men Yes/ No B2: Women only Yes/No

Shortness of breath Lump in the breast
Coughing more than 2 weeks Blood stained discharge from the nipple
Blood in sputum Change in shape and size of breast
History of fits Bleeding between periods
Difficulty in opening mouth Bleeding after menopause
Ulcers /patch /growth in the Bleeding after intercourse
mouth that has not healed in
two weeks
Any change in the tone of your voice Foul smelling vaginal discharge

In case the individual answers Yes to any one of the above-mentioned symptoms, refer the patient
immediately to the nearest facility where a Medical Officer is available.

27
 Preventive Check-up (Examination of Family Members)

1) ANC/PNC

Name Age:
Visit Date Age at Marriage
Individual No. Age of Menarche:
Obstetric Score G___P____L____A____

LMP Past History:

EDD
ANC visits Personal History:

Counselling Family Planning?

Significant
Medical History
General
Examination
Systemic
Examination

Significant Delivery Details:

findings on
Investigation
Significant Post
Natal History

Advice Given

5 Ruled Pages + Set of Growth Charts to be attached

28
 Family 3
Demographic Profile

21. Household Unique ID: ____/____/___ 22. Geotag Latitude:

Longitude:
23. Name of the head of Family: 24. Contact no.

25. Family type:: N / J / T / O t h e r _ _ _ _ _ 26. Religion: H / M / J / B / C / S / O t h e r _ _ _ _ _

27.Family income/month (Rs.) 28. Caste Cat: 1. Open 2.OBC 3.SC 4. ST
5.VJNT 6. SBC, 7. Other___________
29. Ration card: Yellow / Orange / White 30. ABHA card:

Family Details:

Name of Age Sex Education Occupation Marital History of

Family Status
Member
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G

Any Significant Family History?

29
 Health Profile
Diet & Nutrition

Type of Diet: Veg / Mixed Frequency of eating non-veg per week:

Name of Family Member Expected Actual Calorie Expected Actual Protein

Calorie Intake Protein Intake Intake
Intake

 Average Monthly Expenditure on Food:

 Is Supplementary nutrition given to children & Pregnant or lactating women?
 Growth Monitoring To Be Done on Charts Provided

Environmental History

House: Katcha / Pucca / Semipucca. Overcrowding: Yes/ No

Water Supply: Continuous/ Intermittent. Source of water: Tap/ Well

/Bore/ Tanker/__________ . Water disinfection methods:
Purifier/Boiling/Chlorination/Other___________

Storage of non-drinking water: Covered/ Open containers.

LPG (gas): Yes / No Kerosene stove/ Smokeless Chullah/ Ordinary Chullah/ Other_______ .

Sanitary latrine: No/ Private/ Public.

Garbage disposal: Door step / Common point / No collection system.

Any other important finding:

30
History of addiction in family:
Name Addicted to Monthly expenses
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________

Couples in reproductive age group (15-45 YOA)

Name of couple in family Type of Contraception Specify
+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

Pregnant Women:
Name Score ANC registration done in
G__P__L__A__ Private / Govt. / Not done
G__P__L__A__ Private / Govt. / Not done
Consanguineous marriages
Name of couple Relation to husband Birth defect/condition in children
No /Yes____________________
Children
Visits Anganwadi
Age in Immunization Till Date
Initials Regularly & gets Growth
months
THR (Y/N)
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese

31
 Condition Name of Since On From Check Up Advice Given Improv
Patient (yrs.) Treat Private/ (Hb/BP/BSL/RFT/Sputum ement
ment Public/ / Other
F/U 1 Significant
F/U 2 report
F/U 3 F/U 1 F/U 2 F/U 3 (Y/N)
(Y/N) PMT Noted)

Anaemia

Malnutritio

n
Hypertensi

on
Diabetes

Ischemic

Heart
Kidney

Disease
Disease
TB

Other

32
 Community Based Assessment Checklist (CBAC) Form for Early Detection of NCDs

Adult Family Member above 35 years

Question Range Circle

any
1. What is your age? (in complete 30-39 years 0
years ) 40-49 years 1
≥ 50 years 2
2. Do you smoke or consume Never 0
smokeless products such as Gutka; or Used to consume
Khaini ? in the past / 1
Sometimes
Daily 2
3. Do you consume Alcohol daily? No 0
Yes 1
4. Measurement of waist (in cm)
Female Male
<80 cm <90 cm 0
80-90 cm 90-100 cm 1
>90 cm >100 cm 2
5. Do you undertake any physical Less than 150
1
activities for min. of 150 minutes in a minutes in a week
week? At least 150
0
minutes in a week
6. Do you have a family history (any No 0
one of your parents or siblings) of Yes
high blood pressure, diabetes and 2
heart disease?
Total Score
A score above 4 indicates that the person may be at risk for these NCDs and needs to be prioritized for
attending the weekly NCD day.

Part B: Early Detection: Ask if patient has any of these symptoms

B1: Women and Men Yes/ No B2: Women only Yes/No

Shortness of breath Lump in the breast
Coughing more than 2 weeks Blood stained discharge from the nipple
Blood in sputum Change in shape and size of breast
History of fits Bleeding between periods
Difficulty in opening mouth Bleeding after menopause
Ulcers /patch /growth in the Bleeding after intercourse
mouth that has not healed in
two weeks
Any change in the tone of your voice Foul smelling vaginal discharge

In case the individual answers Yes to any one of the above-mentioned symptoms, refer the patient
immediately to the nearest facility where a Medical Officer is available.

33
 Preventive Check-up (Examination of Family Members)

1) ANC/PNC

Name Age:
Visit Date Age at Marriage
Individual No. Age of Menarche:
Obstetric Score G___P____L____A____

LMP Past History:

EDD
ANC visits Personal History:

Counselling Family Planning?

Significant
Medical History
General
Examination
Systemic
Examination

Significant Delivery Details:

findings on
Investigation
Significant Post
Natal History

Advice Given

5 Ruled Pages + Set of Growth Charts to be attached

34
 Family 4
Demographic Profile

31. Household Unique ID: ____/____/___ 32. Geotag Latitude:

Longitude:
33. Name of the head of Family: 34. Contact no.

35. Family type:: N / J / T / O t h e r _ _ _ _ _ 36. Religion: H / M / J / B / C / S / O t h e r _ _ _ _ _

37.Family income/month (Rs.) 38. Caste Cat: 1. Open 2.OBC 3.SC 4. ST
5.VJNT 6. SBC, 7. Other___________
39. Ration card: Yellow / Orange / White 40. ABHA card:

Family Details:

Name of Age Sex Education Occupation Marital History of

Family Status
Member
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G

Any Significant Family History?

35
 Health Profile
Diet & Nutrition

Type of Diet: Veg / Mixed Frequency of eating non-veg per week:

Name of Family Member Expected Actual Calorie Expected Actual Protein

Calorie Intake Protein Intake Intake
Intake

 Average Monthly Expenditure on Food:

 Is Supplementary nutrition given to children & Pregnant or lactating women?
 Growth Monitoring To Be Done on Charts Provided

Environmental History

House: Katcha / Pucca / Semipucca. Overcrowding: Yes/ No

Water Supply: Continuous/ Intermittent. Source of water: Tap/ Well

/Bore/ Tanker/__________ . Water disinfection methods:
Purifier/Boiling/Chlorination/Other___________

Storage of non-drinking water: Covered/ Open containers.

LPG (gas): Yes / No Kerosene stove/ Smokeless Chullah/ Ordinary Chullah/ Other_______ .

Sanitary latrine: No/ Private/ Public.

Garbage disposal: Door step / Common point / No collection system.

Any other important finding:

36
History of addiction in family:
Name Addicted to Monthly expenses
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________

Couples in reproductive age group (15-45 YOA)

Name of couple in family Type of Contraception Specify
+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

Pregnant Women:
Name Score ANC registration done in
G__P__L__A__ Private / Govt. / Not done
G__P__L__A__ Private / Govt. / Not done
Consanguineous marriages
Name of couple Relation to husband Birth defect/condition in children
No /Yes____________________
Children
Visits Anganwadi
Age in Immunization Till Date
Initials Regularly & gets Growth
months
THR (Y/N)
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese

37
 Condition Name of Since On From Check Up Advice Given Improv
Patient (yrs.) Treat Private/ (Hb/BP/BSL/RFT/Sputum ement
ment Public/ / Other
F/U 1 Significant
F/U 2 report
F/U 3 F/U 1 F/U 2 F/U 3 (Y/N)
(Y/N) PMT Noted)

Anaemia

Malnutritio

n
Hypertensi

on
Diabetes

Ischemic

Heart
Kidney

Disease
Disease
TB

Other

38
 Community Based Assessment Checklist (CBAC) Form for Early Detection of NCDs

Adult Family Member above 35 years

Question Range Circle

any
1. What is your age? (in complete 30-39 years 0
years ) 40-49 years 1
≥ 50 years 2
2. Do you smoke or consume Never 0
smokeless products such as Gutka; or Used to consume
Khaini ? in the past / 1
Sometimes
Daily 2
3. Do you consume Alcohol daily? No 0
Yes 1
4. Measurement of waist (in cm)
Female Male
<80 cm <90 cm 0
80-90 cm 90-100 cm 1
>90 cm >100 cm 2
5. Do you undertake any physical Less than 150
1
activities for min. of 150 minutes in a minutes in a week
week? At least 150
0
minutes in a week
6. Do you have a family history (any No 0
one of your parents or siblings) of Yes
high blood pressure, diabetes and 2
heart disease?
Total Score
A score above 4 indicates that the person may be at risk for these NCDs and needs to be prioritized for
attending the weekly NCD day.

Part B: Early Detection: Ask if patient has any of these symptoms

B1: Women and Men Yes/ No B2: Women only Yes/No

Shortness of breath Lump in the breast
Coughing more than 2 weeks Blood stained discharge from the nipple
Blood in sputum Change in shape and size of breast
History of fits Bleeding between periods
Difficulty in opening mouth Bleeding after menopause
Ulcers /patch /growth in the Bleeding after intercourse
mouth that has not healed in
two weeks
Any change in the tone of your voice Foul smelling vaginal discharge

In case the individual answers Yes to any one of the above-mentioned symptoms, refer the patient
immediately to the nearest facility where a Medical Officer is available.

39
 Preventive Check-up (Examination of Family Members)

1) ANC/PNC

Name Age:
Visit Date Age at Marriage
Individual No. Age of Menarche:
Obstetric Score G___P____L____A____

LMP Past History:

EDD
ANC visits Personal History:

Counselling Family Planning?

Significant
Medical History
General
Examination
Systemic
Examination

Significant Delivery Details:

findings on
Investigation
Significant Post
Natal History

Advice Given

5 Ruled Pages + Set of Growth Charts to be attached

40
 Family 5
Demographic Profile

41. Household Unique ID: ____/____/___ 42. Geotag Latitude:

Longitude:
43. Name of the head of Family: 44. Contact no.

45. Family type:: N / J / T / O t h e r _ _ _ _ _ 46. Religion: H / M / J / B / C / S / O t h e r _ _ _ _ _

47.Family income/month (Rs.) 48. Caste Cat: 1. Open 2.OBC 3.SC 4. ST
5.VJNT 6. SBC, 7. Other___________
49. Ration card: Yellow / Orange / White 50. ABHA card:

Family Details:

Name of Age Sex Education Occupation Marital History of

Family Status
Member
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G
NA / I/ P / S / HS NA/Student/HW/Farmer/…………… U/ M/ D/W /S
/G

Any Significant Family History?

41
 Health Profile
Diet & Nutrition

Type of Diet: Veg / Mixed Frequency of eating non-veg per week:

Name of Family Member Expected Actual Calorie Expected Actual Protein

Calorie Intake Protein Intake Intake
Intake

 Average Monthly Expenditure on Food:

 Is Supplementary nutrition given to children & Pregnant or lactating women?
 Growth Monitoring To Be Done on Charts Provided

Environmental History

House: Katcha / Pucca / Semipucca. Overcrowding: Yes/ No

Water Supply: Continuous/ Intermittent. Source of water: Tap/ Well

/Bore/ Tanker/__________ . Water disinfection methods:
Purifier/Boiling/Chlorination/Other___________

Storage of non-drinking water: Covered/ Open containers.

LPG (gas): Yes / No Kerosene stove/ Smokeless Chullah/ Ordinary Chullah/ Other_______ .

Sanitary latrine: No/ Private/ Public.

Garbage disposal: Door step / Common point / No collection system.

Any other important finding:

42
History of addiction in family:
Name Addicted to Monthly expenses
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________
Smokeless tobacco/ smoke/ Alcohol/
_________

Couples in reproductive age group (15-45 YOA)

Name of couple in family Type of Contraception Specify
+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

+ Not using/Permanent/ Temporary

Pregnant Women:
Name Score ANC registration done in
G__P__L__A__ Private / Govt. / Not done
G__P__L__A__ Private / Govt. / Not done
Consanguineous marriages
Name of couple Relation to husband Birth defect/condition in children
No /Yes____________________
Children
Visits Anganwadi
Age in Immunization Till Date
Initials Regularly & gets Growth
months
THR (Y/N)
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese
Normal/ MAM/
Complete / Partial / Unimmunized
SAM/Overweight/Obese

43
 Condition Name of Since On From Check Up Advice Given Improv
Patient (yrs.) Treat Private/ (Hb/BP/BSL/RFT/Sputum ement
ment Public/ / Other
F/U 1 Significant
F/U 2 report
F/U 3 F/U 1 F/U 2 F/U 3 (Y/N)
(Y/N) PMT Noted)

Anaemia

Malnutritio

n
Hypertensi

on
Diabetes

Ischemic

Heart
Kidney

Disease
Disease
TB

Other

44
 Community Based Assessment Checklist (CBAC) Form for Early Detection of NCDs

Adult Family Member above 35 years

Question Range Circle

any
1. What is your age? (in complete 30-39 years 0
years ) 40-49 years 1
≥ 50 years 2
2. Do you smoke or consume Never 0
smokeless products such as Gutka; or Used to consume
Khaini ? in the past / 1
Sometimes
Daily 2
3. Do you consume Alcohol daily? No 0
Yes 1
4. Measurement of waist (in cm)
Female Male
<80 cm <90 cm 0
80-90 cm 90-100 cm 1
>90 cm >100 cm 2
5. Do you undertake any physical Less than 150
1
activities for min. of 150 minutes in a minutes in a week
week? At least 150
0
minutes in a week
6. Do you have a family history (any No 0
one of your parents or siblings) of Yes
high blood pressure, diabetes and 2
heart disease?
Total Score
A score above 4 indicates that the person may be at risk for these NCDs and needs to be prioritized for
attending the weekly NCD day.

Part B: Early Detection: Ask if patient has any of these symptoms

B1: Women and Men Yes/ No B2: Women only Yes/No

Shortness of breath Lump in the breast
Coughing more than 2 weeks Blood stained discharge from the nipple
Blood in sputum Change in shape and size of breast
History of fits Bleeding between periods
Difficulty in opening mouth Bleeding after menopause
Ulcers /patch /growth in the Bleeding after intercourse
mouth that has not healed in
two weeks
Any change in the tone of your voice Foul smelling vaginal discharge

In case the individual answers Yes to any one of the above-mentioned symptoms, refer the patient
immediately to the nearest facility where a Medical Officer is available.

45
 Preventive Check-up (Examination of Family Members)

1) ANC/PNC

Name Age:
Visit Date Age at Marriage
Individual No. Age of Menarche:
Obstetric Score G___P____L____A____

LMP Past History:

EDD
ANC visits Personal History:

Counselling Family Planning?

Significant
Medical History
General
Examination
Systemic
Examination

Significant Delivery Details:

findings on
Investigation
Significant Post
Natal History

Advice Given

5 Ruled Pages + Set of Growth Charts to be attached

46
Vital Events (in past year)

Date of Visit

Births
 Sex of Child
 Birth History
 Place of Delivery
Marriage:
Age at Marriage
Deaths
 Cause
 Age
 Sex
Migration:
 To
 Reason

47
FAMILY
SURVEY
REPORT

48
 Family Survey Report

Batch: Survey Period:

Area:

Location:

MAP

No. of Families Residing in the Area:

No. of Families Surveyed: %_______

49
Age & Sex wise Distribution:

Age Group Sex Total

Males (%) Females (%)

Total

Mean Age: years (SD= )

Sex Ratio:

Dependency Ratio:

Age Pyramid

50
Family Types

Family Type No. of Households Percentage

Joint

Nuclear

Three Generation

Other Family Types If Any

Comments:

Religion

Religion No. of Households Percentage

Hindu

Muslim

Buddhist

Christian

Total

Comments:

51
Education

Education Frequency Percentage

Not Applicable

Illiterate

Primary

High School

Secondary

Graduate& Above

Total

Comments:

Occupation

Occupation Frequency Percentage

Comments:

52
Socio Economic Status (Modified BG Prasad Scale Year_______)

Class Criteria No. of Families Percentage

(income/capita/month)

II

III

IV

Comments:

Addictions

Addiction to Males Females Total

Alcohol

Tobacco

Others

Comment

Diet

Diet Frequency Percentage

Vegetarian

Mixed

53
Morbidity Profile

Condition Frequency Percentage

Graph

54
Availability of Important Government Documents

Frequency Percentage

ABHA Card

Ration Card

 White
 Yellow
 Orange

Insurance

Other:

Benefit of Government
Programmes/Schemes

1.

2.

3.

4.

Comments:

Eligible Couples

Number of Couples/ Frequency Percentage

Family

Total

Use of Contraceptives

55
Contraceptive Frequency Percentage

Not Used

Terminal Method

 Vasectomy
 Tubectomy

Temporary Contraceptive

 Condoms
 IUCD
 Pills
 Other

Comments

Unmet Needs of Family Planning

Vaccination

No. of children Percentage

Completely Immunized

Partially Immunized

Unimmunized

Total

Comment

56
Environment
Housing Number Percentage

Kaccha

Semi Pucca

Pucca

Comment

Overcrowding

Number Percentage

Present

Absent

Comment

Water

Source Number Percentage

Comment

57
Purification Methods Used

Method Number of Households Percentage

Comment

Waste Disposal Method

Method Number of Households Percentage

Comment

Latrines

Latrines Used Number of Households Percentage

Public

Private

Condition

Clean

Unclean

Comment

58
Cooking

Cooking Fuel Frequency Percentage

Comment

Schools/ Anganwadi Comment

Local self-help groups, community associations and youth organization

Local Businesses & Other Amenities

59
 COMMUNITY DIAGNOSIS
Enumerate the common public health related problems that you could identify in
the community

60
HEALTH
CAMPS

61
 Health CAMP

Date: Place: Batch: No. of Students:

No. of Doctors with Speciality:

Number of Patients Treated:

Condition Frequency Percentage

Anaemia
Malnutrition
Hypertension
Diabetes
IHD
Kidney Disease
TB
Refractory Errors
Cataract
Acute Febrile Illness
Acute Resp.Illness
Urinary Tract Infections
Diarrhoeal Disease
Other
Total

Signature of Incharge

62
 Health CAMP

Date: Place: Batch: No. of Students:

No. of Doctors with Speciality:

Number of Patients Treated:

Condition Frequency Percentage

Anaemia
Malnutrition
Hypertension
Diabetes
IHD
Kidney Disease
TB
Refractory Errors
Cataract
Acute Febrile Illness
Acute Resp.Illness
Urinary Tract Infections
Diarrhoeal Disease
Other
Total

Signature of Incharge

63
 Health CAMP

Date: Place: Batch: No. of Students:

No. of Doctors with Speciality:

Number of Patients Treated:

Condition Frequency Percentage

Anaemia
Malnutrition
Hypertension
Diabetes
IHD
Kidney Disease
TB
Refractory Errors
Cataract
Acute Febrile Illness
Acute Resp.Illness
Urinary Tract Infections
Diarrhoeal Disease
Other
Total

Signature of Incharge

64
SANITARY SURVEY

65
Specific Diagnostic Information for Assessment Risk

No QUESTION YES NO
1 Is there a latrine within 10 m of the well/hand pump?
2 Is the nearest latrine on higher ground?
3 Is there any other source of pollution within 10 m?
4 Are the drainage condition poor causing stagnant water
within 2m?
5 Is the hand pump drainage channel faulty? Is it broken?
Does the Pump/Bucket need cleaning?
6 Is the cement floor (platform) is absent?
7 Is there any ponding on the cement floor around?
8 Are there any cracks on the cement floor around the hand
pump?
9 Is priming of tube well required during dry season?
10 Is the hand pump loose at the point of attachment to base
(which could permit water to enter the casing)? Is the Well
Uncovered?
Total Scores of Risks ………………/10
Contamination risk score: 9-10 = V, High: 6–8=high; 3–5 =
intermediate, 0–2 = low
Number of “YES” to be counted

C. Results and Recommendations

The following important point of risk (serially from the top) were noted 


and the authority advised on remedial action

66
67
ENTOMOLOGICAL
SURVEY

68
69
Findings of Larval Survey

Recommendations given & Actions Taken

Signature of Teacher

70
 HEALTH
COMMUNICATION

71
What advice have you given to the families to overcome these problems?

72
Additional IEC Actives and New initiatives in the Community

73
ENVIRONMENTAL
SUSTAINABILITY
ACTIVITIES

74
Write about Environmental Sustainability Activities undertaken by you and your friends

In First Year

PHOTOGRAPHS

75
Write about Environmental Sustainability Activities undertaken by you and your friends

In Second Year

PHOTOGRAPHS

76
Write about Environmental Sustainability Activities undertaken by you and your friends

In Third Year

PHOTOGRAPHS

77
Name:

Date of Posting Place

To be filled by teacher in charge for batch field postings. Tick (√) to Grade out of 5.

First Year Second Year Third Year

Appearance and General 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Behaviour

Punctuality 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Attitude towards the 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Community

Relationship with other 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

students

Relationship with People in the 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Community

Collection of Data 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Presentation of Data 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Interpretation of Data 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Ability to relate findings to 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Solving Community Health
Problems

Students critique of his own 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

approach

Ability to suggest solutions to 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

problems

Contribution to group 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
Discussion

Performance in Crisis Situation 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Assessment of Survey Report 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Remarks:

Signature of Batch In charge

78
Resources Used

1. GMER 2023
2. Tejinder Singh & Anshu. Community Based Assessment, Assessment in Medical
Education 1st ed.
3. Operational Guidelines for Swatch Swasthya Sarvatra
4. Compendium of Entomological Surveillance NVBDCP
5. Draft NMC QCI Accreditation Framework

79