{"name": "Primary_ISS_Form_ODK", "type": "survey", "title": "FEDERAL MINISTRY OF HEALTH, \nIntegrated Supportive Supervision (ISS) tool for PHCs, \nMobile Version 2018 (Updated November 2019) PUBLIC", "id_string": "Primary_ISS_Form_ODK", "sms_keyword": "Primary_ISS_Form_ODK", "default_language": "English", "version": "2019010801", "style": "pages", "namespaces": "esri=\"http://esri.com/xforms\"\nenk=\"http://enketo.org/xforms\"", "children": [{"name": "start000000", "label": "Start Time", "type": "start"}, {"name": "end00000000", "label": "End Time", "type": "end"}, {"name": "phonenumber", "type": "phonenumber"}, {"name": "username", "type": "username"}, {"name": "email", "type": "email"}, {"name": "timestarted", "label": "Calculate time started", "type": "calculate", "bind": {"calculate": "format-date-time(now(),'%H:%M')"}}, {"name": "GrpInformtn", "label": "Section 1 **General Information**", "type": "group", "children": [{"name": "nRespondent", "label": "1. Name of Respondent", "type": "text", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w2"}}, {"name": "genphonenumb", "label": "i. Phone Number of Respondent", "type": "text", "bind": {"constraint": "regex(.,'[0-9]{11}')", "required": "TRUE"}, "control": {"appearance": "number"}}, {"name": "StateName00", "label": "2. State", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "children": [{"name": "abia", "label": "Abia"}, {"name": "adamawa", "label": "Adamawa"}, {"name": "anambra", "label": "Anambra"}, {"name": "akwa_ibom", "label": "Akwa-Ibom"}, {"name": "bauchi", "label": "Bauchi"}, {"name": "bayelsa", "label": "Bayelsa"}, {"name": "benue", "label": "Benue"}, {"name": "borno", "label": "Borno"}, {"name": "cross_river", "label": "Cross River"}, {"name": "delta", "label": "Delta"}, {"name": "ebonyi", "label": "Ebonyi"}, {"name": "edo", "label": "Edo"}, {"name": "ekiti", "label": "Ekiti"}, {"name": "enugu", "label": "Enugu"}, {"name": "federal_cap", "label": "Federal Capital Territory"}, {"name": "gombe", "label": "Gombe"}, {"name": "imo", "label": "Imo"}, {"name": "jigawa", "label": "Jigawa"}, {"name": "kaduna", "label": "Kaduna"}, {"name": "kano", "label": "Kano"}, {"name": "katsina", "label": "Katsina"}, {"name": "kebbi", "label": "Kebbi"}, {"name": "kogi", "label": "Kogi"}, {"name": "kwara", "label": "Kwara"}, {"name": "lagos", "label": "Lagos"}, {"name": "nasarawa", "label": "Nasarawa"}, {"name": "niger", "label": "Niger"}, {"name": "ogun", "label": "Ogun"}, {"name": "ondo", "label": "Ondo"}, {"name": "osun", "label": "Osun"}, {"name": "oyo", "label": "Oyo"}, {"name": "plateau", "label": "Plateau"}, {"name": "rivers", "label": "Rivers"}, {"name": "sokoto", "label": "Sokoto"}, {"name": "taraba", "label": "Taraba"}, {"name": "yobe", "label": "Yobe"}, {"name": "zamfara", "label": "Zamfara"}]}, {"name": "CalcState00", "label": "Calculate State", "type": "calculate", "bind": {"calculate": "if(${StateName00} = '','',once(now()))"}}, {"name": "LGAName0000", "label": "3. LGA", "type": "select one external", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "choice_filter": "states = ${StateName00}", "query": "LGAs"}, {"name": "LGAName0001", "label": "Calculate LGA", "type": "calculate", "bind": {"calculate": "if(${LGAName0000} = '','',once(now()))"}}, {"name": "WardName000", "label": "4. Ward", "type": "select one external", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "choice_filter": "LGAs = ${LGAName0000} or LGAs = -88", "query": "wards"}, {"name": "CalcWard000", "label": "Calculate Ward", "type": "calculate", "bind": {"calculate": "if(${WardName000} = '','',once(now()))"}}, {"name": "WardName001", "label": "4a. Specify ward", "hint": "Please remember to add facility to master facility list", "type": "text", "bind": {"relevant": "${WardName000} = 'unknown'", "required": "TRUE"}}, {"name": "FaciliName0", "label": "5. Facility", "type": "select one external", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w2"}, "choice_filter": "wards = ${WardName000} or wards = -88", "query": "facilities"}, {"name": "CalcFacilit", "label": "Calculate facility name", "type": "calculate", "bind": {"calculate": "if(${FaciliName0} = '','',once(now()))"}}, {"name": "otheFacName", "label": "Input facility name", "hint": "Please remember to add facility to master facility list", "type": "text", "bind": {"relevant": "${FaciliName0} = 'other_facility'", "required": "TRUE"}}, {"name": "FacilityTyp", "label": "6. Facility Ownership", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "public", "label": "Public"}, {"name": "private", "label": "Private"}, {"name": "fbo", "label": "Faith Based Organization (FBO)"}, {"name": "ngo", "label": "NGO"}]}, {"name": "levelofca00", "label": "6a. Level of Care", "type": "select one", "bind": {"relevant": "${FacilityTyp} = 'public'", "required": "TRUE"}, "children": [{"name": "primary_health_centre", "label": "Primary Health Centre"}, {"name": "health_post", "label": "Health Post"}, {"name": "clinic", "label": "Health Clinic"}]}, {"name": "SurveyLocat", "label": "7. Location", "type": "geopoint", "bind": {"required": "TRUE"}, "control": {"appearance": "w4", "accuracyThreshold": "10"}}, {"name": "FacilityPic", "label": "8. Take a picture of the front of the Facility", "type": "photo", "bind": {"required": "TRUE"}, "control": {"appearance": "new"}}, {"name": "TotalPopul0", "label": "9. Total Catchment Population", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "inpatientBe", "label": "10a. Do you have in-patient beds", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NumberBeds0", "label": "10b. Number of functional in-patient Beds", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${inpatientBe} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "NumBeds1000", "label": "Calculate Number of Beds", "type": "calculate", "bind": {"calculate": "${NumberBeds0} div ${TotalPopul0} * 1000"}}, {"name": "NumbrStaffs", "label": "11 Number of health workers", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "CalcStaffs0", "label": "Calculate qualified staff", "type": "calculate", "bind": {"calculate": "${NumbrStaffs} div ${TotalPopul0} * 2000"}}, {"name": "MedStaff000", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_31", "label": "12. Medical health workers Total (1/4)", "type": "note"}, {"name": "MedstaffN01", "label": "i. Medical Doctor", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN02", "label": "ii. Specialist Consultant", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN03", "label": "iii. Resident Doctor", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN04", "label": "iv. Medical Officer", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN05", "label": "v. Nurse/Midwives (Double qualification)", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN06", "label": "vi. Nurses", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN25", "label": "vii. Mid wife", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN07", "label": "viii. CHO", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "MedStaffa000", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_41", "label": "12. Medical health workers Total (2/4)", "type": "note"}, {"name": "MedstaffN08", "label": "i. CHEW", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN09", "label": "ii. JCHEW", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN10", "label": "iii. Nutrition Officer/Dietician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN11", "label": "iv. Nutrition Assistant", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN12", "label": "v. Environmental Health Officer", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN13", "label": "vi. Environmental Health Technician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN14", "label": "vii. Environmental Health Assistant", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "MedStaffb000", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_50", "label": "12. Medical health workers Total (3/4)", "type": "note"}, {"name": "MedstaffN15", "label": "i. Pharmacist", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN16", "label": "ii. Medical Lab Scientist", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN17", "label": "iii. Lab Technician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN18", "label": "iv. Lab Assistant", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN19", "label": "v. Health Record Technician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN20", "label": "vi. Health Record Officer", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN21", "label": "vii. Health Education Officer", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "MedStaffc000", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_59", "label": "12. Medical health workers Total (4/4)", "type": "note"}, {"name": "MedstaffN22", "label": "i. Health Education Assistant", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN23", "label": "ii. Pharmacy Technician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN24", "label": "iii. Pharmacy Assistant", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN26", "label": "iv. Dental Technician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN27", "label": "v. Xray Technician", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "MedstaffN28", "label": "vi. Specify other", "type": "text"}]}, {"name": "NonMedStaffa", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_67", "label": "13. Non-Medical health workers", "type": "note"}, {"name": "NonMedSta01", "label": "i. Health Attendants", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta02", "label": "ii. Community Volunteers (CHIPS)", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "NonMedStaffb", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_71", "label": "14. Finance and Administrative Staff", "type": "note"}, {"name": "NonMedSta03", "label": "iii. Accountant/Account Clerk", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta04", "label": "iv. Administrative Staff", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta05", "label": "v. Specify other", "type": "text"}]}, {"name": "NonMedStaff", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_76", "label": "15. Maintenance Staff", "type": "note"}, {"name": "NonMedSta06", "label": "i. Head of Maintenance", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta07", "label": "ii. Laundry Department", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta08", "label": "iii. Cleaners", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta09", "label": "iv. Security Guards", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta10", "label": "v. Drivers/Transport Officers", "hint": "how many", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "NonMedSta11", "label": "vi. Electrician", "type": "integer"}, {"name": "NonMedSta12", "label": "vii. Gardeners", "type": "integer"}]}]}, {"name": "GroupGener0", "label": "Section 2 **General Management**", "type": "group", "children": [{"name": "HealthFacMp", "label": "2.1 Health facility catchment area Map", "type": "group", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "HealthMap00", "label": "1. Is the health map available on the notice board?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MapHealthCo", "label": "2. Does the map contain the following?", "type": "select all that apply", "bind": {"relevant": "${HealthMap00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "table-list"}, "children": [{"name": "population_adjusted_yearly", "label": "population adjusted yearly"}, {"name": "other_facilities_within_the_war", "label": "other facilities within the ward"}, {"name": "villages", "label": "villages"}, {"name": "main_roads_foot_path", "label": "main roads/foot path"}, {"name": "natural_barriers_rivers_mountai", "label": "natural barriers (rivers, mountain, etc)"}, {"name": "special_points_landmarks", "label": "special points/landmarks"}, {"name": "distance_in_km_time", "label": "distance in KM/time"}, {"name": "legend_key_for_specific_age_gro", "label": "legend/key for specific age group"}, {"name": "hard_to_reach_areas", "label": "Hard to reach areas"}]}, {"name": "keycoment1a", "label": "2.1 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Actioplan1a", "label": "2.1 Recommended action", "type": "text"}, {"name": "MapScore000", "label": "Calculate Health Facility Catchment Area", "type": "calculate", "bind": {"calculate": "if(${HealthMap00}='yes',1,0)+if(contains(${MapHealthCo},'population_adjusted_yearly'),0.25,0) + if(contains(${MapHealthCo},' other_facilities_within_the_war'),0.25,0) + if(contains(${MapHealthCo},'villages'),0.25,0) + if(contains(${MapHealthCo},' main_roads_foot_path'),0.25,0) + if(contains(${MapHealthCo},' natural_barriers_rivers_mountai'),0.25,0) + if(contains(${MapHealthCo},' special_points_landmarks'),0.25,0) + if(contains(${MapHealthCo},'distance_in_km_time'),0.25,0) + if(contains(${MapHealthCo},'legend_key_for_specific_age_gro'),0.25,0) + if(contains(${MapHealthCo},' hard_to_reach_areas'),0.25,0)"}}]}, {"name": "PropFilling", "label": "2.2 Proper filing system", "type": "group", "children": [{"name": "FilingSys00", "label": "3. Is the filing cabinet/shelf/cupboard available?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FilingCab01", "label": "4. Is the filing cabinet/shelf/cupboard accessible by all staff on duty?", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FileCabAvail", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_97", "label": "Availability of documents in file cabinet", "type": "note"}, {"name": "FollDocumen", "label": "5. Are the following documents available in the file cabinet/shelve/cupboard", "type": "note", "bind": {"relevant": "${FilingSys00} = 'yes'"}}, {"name": "reserved_name_for_field_list_labels_99", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMIS-msf100", "label": "a. HMIS MSF", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISregiste", "label": "b. HMIS Registers", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "weeklySurve", "label": "c. Weekly surveillance reports", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Businesspla", "label": "d. Approved business plans;", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Minutemeetg", "label": "e. Minutes of any facility meetings;", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IndivPatien", "label": "f. Individual Patient/ Client records", "type": "select one", "bind": {"relevant": "${FilingSys00} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "SOPguidelin", "label": "g. Specify others", "type": "text", "bind": {"relevant": "${FilingSys00} = 'yes'"}, "control": {"appearance": "minimal w1"}}, {"name": "HealtUnqSys", "label": "6. Does the health facility use unique registration system for patient?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PatUnqNumbr", "label": "7. Are all the patients assigned/issued a unique number in their hand card", "type": "select one", "bind": {"relevant": "${HealtUnqSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HandCard_53", "type": "group", "bind": {"relevant": "${PatUnqNumbr} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_109", "label": "8. Does hand card contain the following:", "type": "note"}, {"name": "reserved_name_for_field_list_labels_110", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Theage00001", "label": "a. age", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sex_genderr", "label": "b. sex", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "completeAdd", "label": "c. complete address/location", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Appointment", "label": "d. date of appointments", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ActionpOneb", "label": "2.2 Key Comments", "type": "text", "bind": {"relevant": "${HealtUnqSys} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "kcomentTwob", "label": "2.2 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "FilingScore", "label": "Calculate Filing System", "type": "calculate", "bind": {"calculate": "if(${FilingSys00}='yes',1,0)+if(${FilingCab01}='yes',1,0)+if(${HMIS-msf100}='yes',1,0)+if(${HMISregiste}='yes',1,0)+if(${weeklySurve}='yes',1,0)+if(${Businesspla}='yes',1,0)+if(${Minutemeetg}='yes',1,0)+if(${IndivPatien}='yes',1,0)+if(${HealtUnqSys}='yes',1,0)+if(${PatUnqNumbr}='yes',1,0)+if(${Theage00001}='yes',1,0)+if(${sex_genderr}='yes',1,0)+if(${completeAdd}='yes',1,0)+if(${Appointment}='yes',1,0)"}}]}, {"name": "StaffDutRos", "label": "2.3 Staff duty roster", "type": "group", "children": [{"name": "RostAvailab", "label": "9a. Is staff duty roster available?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RostoUpdate", "label": "9b. Is staff duty roster up to date with phone numbers", "type": "select one", "bind": {"relevant": "${RostAvailab} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StaffVisibl", "label": "9c. Is staff duty roster visible for staff and patients (on notice board)?", "type": "select one", "bind": {"relevant": "${RostoUpdate} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActionpTwob", "label": "2.3 Key Comments", "type": "text", "bind": {"relevant": "${RostAvailab} = 'yes'"}, "control": {"appearance": "minimal w2"}}, {"name": "keycomen1bb", "label": "2.3 Recommended action", "type": "text", "bind": {"relevant": "${StaffVisibl} = 'yes'"}, "control": {"appearance": "minimal w2"}}, {"name": "RosterScore", "label": "Calculate Staff Duty Roster", "type": "calculate", "bind": {"calculate": "if(${RostAvailab}='yes',1,0)+if(${RostoUpdate}='yes',1,0)+if(${StaffVisibl}='yes',1,0)"}}]}, {"name": "StandiOrder", "label": "2.4. Does the health facility have a Standing Order? (sighted)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "TechMeeting", "label": "2.5 Monthly Health Facility Meetings", "type": "group", "children": [{"name": "InternMeetg", "label": "10a.Are monthly internal management meeting conducted?", "type": "select one", "bind": {"relevant": "${StandiOrder} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MinuteAvail", "label": "10b.Are the meeting minutes available?", "type": "select one", "bind": {"relevant": "${InternMeetg} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MinuteConta", "label": "10c.Minutes contains the following:", "type": "select all that apply", "bind": {"relevant": "${MinuteAvail} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "date_of_meeting", "label": "date of meeting"}, {"name": "agenda", "label": "agenda"}, {"name": "signed_attendance_list_of_parti", "label": "signed attendance list of participants"}, {"name": "follow_up_on_decisions_taken_in", "label": "follow up on decisions taken in previous meeting"}, {"name": "list_of_action_points_and_recom", "label": "list of action points and recommendations"}, {"name": "monthly_financial_balances_disc", "label": "monthly financial balances discussed"}, {"name": "minutes_signed_by_chairman", "label": "minutes signed by chairman"}, {"name": "responsible_persons_and_timeline", "label": "responsible persons and timeline"}]}, {"name": "GeneralConM", "label": "11a. Are general staff meeting conducted (weekly, monthly, or quarterly)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "minutssAvai", "label": "11b. Are the meeting minutes available?", "type": "select one", "bind": {"relevant": "${GeneralConM} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ContainMinu", "label": "11c. minutes contains the following", "type": "select all that apply", "bind": {"relevant": "${minutssAvai} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "date_of_meeting", "label": "date of meeting"}, {"name": "agenda", "label": "agenda"}, {"name": "signed_attendance_list_of_parti", "label": "signed attendance list of participants"}, {"name": "follow_up_on_decisions_taken_in", "label": "follow up on decisions taken in previous meeting"}, {"name": "list_of_action_points_and_recom", "label": "list of action points and recommendations"}, {"name": "monthly_financial_balances_disc", "label": "monthly financial balances discussed"}, {"name": "minutes_signed_by_chairman", "label": "minutes signed by chairman"}, {"name": "responsible_persons_and_timeline", "label": "responsible persons and timeline"}]}, {"name": "Actionpla1c", "label": "2.5 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "comenttonec", "label": "2.5 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "TechMeetScr", "label": "Calculate Technical Meetings", "type": "calculate", "bind": {"calculate": "if(${StandiOrder}='yes',1,0)+if(${InternMeetg}='yes',1,0)+if(${MinuteAvail}='yes',1,0)+if(contains(${MinuteConta},'date_of_meeting'),0.25,0) + if(contains(${MinuteConta},'agenda'),0.25,0) + if(contains(${MinuteConta},'signed_attendance_list_of_parti'),0.25,0) + if(contains(${MinuteConta},' follow_up_on_decisions_taken_in'),0.25,0) + if(contains(${MinuteConta},' list_of_action_points_and_recom'),0.25,0) + if(contains(${MinuteConta},' monthly_financial_balances_disc'),0.25,0) + if(contains(${MinuteConta},' minutes_signed_by_chairman'),0.25,0) + if(contains(${MinuteConta},' responsible_persons_and_timeline'),0.25,0)+if(${GeneralConM}='yes',1,0)+if(${minutssAvai}='yes',1,0)+if(contains(${ContainMinu},'date_of_meeting'),0.25,0) + if(contains(${ContainMinu},'agenda'),0.25,0) + if(contains(${ContainMinu},'signed_attendance_list_of_parti'),0.25,0) + if(contains(${ContainMinu},' follow_up_on_decisions_taken_in'),0.25,0) + if(contains(${ContainMinu},' list_of_action_points_and_recom'),0.25,0) + if(contains(${ContainMinu},' monthly_financial_balances_disc'),0.25,0) + if(contains(${ContainMinu},' minutes_signed_by_chairman'),0.25,0) + if(contains(${ContainMinu},' responsible_persons_and_timeline'),0.25,0)"}}]}, {"name": "ReferralSy1", "label": "2.6 Referral System", "type": "group", "children": [{"name": "ReferralSys", "label": "12. Is there a referral system in place", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PHCbooklets", "label": "13. Are booklet(s) of PHC referral slips available", "type": "select one", "bind": {"relevant": "${ReferralSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ReturnSlips", "label": "14. Evidence of completed referral available (check for return slip)", "type": "select one", "bind": {"relevant": "${ReferralSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MechanismsR", "label": "15. Mechanisms for referral", "type": "group", "bind": {"relevant": "${ReferralSys} = 'yes'"}, "children": [{"name": "FunctionAmb", "label": "a. Is there a functional ambulance vehicle or other emergency transport system", "type": "select one", "bind": {"relevant": "${ReferralSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NURTWvehicl", "label": "b. Do you have alternative transportation arrangement", "type": "select one", "bind": {"relevant": "${ReferralSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FuntionFacT", "label": "c. Functional facility telephone with at least #500 airtime", "type": "select one", "bind": {"relevant": "${ReferralSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ReferralDir", "label": "d. Referral Directory available", "type": "select one", "bind": {"relevant": "${ReferralSys} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Actionponec", "label": "2.6 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycoment1d", "label": "2.6 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SheetScore0", "label": "Calculate Referral System", "type": "calculate", "bind": {"calculate": "if(${ReferralSys}='yes',1,0)+if(${PHCbooklets}='yes',1,0)+if(${ReturnSlips}='yes',1,0)+if(${FunctionAmb}='yes',1,0)+if(${NURTWvehicl}='yes',1,0)+if(${FuntionFacT}='yes',1,0)+if(${ReferralDir}='yes',1,0)"}}]}, {"name": "NHMISnhmis9", "label": "2.7 NHMIS", "type": "group", "children": [{"name": "NHMISmsfHea", "label": "16. NHMIS Health facility monthly summary form", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe01", "label": "16. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISmsfHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISfacHea", "label": "17. NHMIS health facility daily attendance register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe02", "label": "17. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISfacHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMIgmpHeal", "label": "18. NHMIS health facility daily GMP (growth monitoring) register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe03", "label": "18. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMIgmpHeal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISimmHea", "label": "19. NHMIS health facility Immunization register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe04", "label": "19. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISimmHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMIStalHea", "label": "20. NHMIS health facility Immunization Tally Sheet register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe05", "label": "20. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMIStalHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMIStdfHea", "label": "21. NHMIS health facility Td register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe06", "label": "21. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMIStdfHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISancHea", "label": "22. NHMIS health facility daily ANC register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe07", "label": "22. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISancHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISopdHea", "label": "23. NHMIS health facility daily OPD register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe08", "label": "23. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISopdHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISfprHea", "label": "24. NHMIS health facility daily FP register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe09", "label": "24. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISfprHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISlabHea", "label": "25. NHMIS health facility labour/delivery register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe10", "label": "25. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISlabHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISipcHea", "label": "26. NHMIS health facility IPC register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "n/a", "label": "N/A"}]}, {"name": "HMISforRe11", "label": "26. i. Is the forms / register up to date and completed correctly?", "type": "select one", "bind": {"relevant": "${NHMISipcHea} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISinforma", "label": "27. Is HMIS information displayed graphically?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FivePriorit", "label": "28. Does analysis identify priority health service indicators?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHMISdataAn", "label": "29. Are the NHMIS data analysed and shared with the facility management committee?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FacilityLGA", "label": "30. Did the facility send last month's monthly summary form to the LGA?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "InformRegis", "label": "31. Does the information in the registers correspond with HMIS data sent to LGA? Compare summary sheet (last 3 months) with register for ANC, immunization and FP", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FacParticip", "label": "32. Does the facility participate in LGA monthly M&E review meetings?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISinfodis", "label": "33. Is HMIS information discussed in the facility management meetings", "hint": "Check for minutes of meetings", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISScore00", "label": "Calculate HMIS", "type": "calculate", "bind": {"calculate": "if(${HMISforRe01}='yes',1,0)+if(${HMISforRe02}='yes',1,0)+if(${HMISforRe03}='yes',1,0)+if(${HMISforRe04}='yes',1,0)+if(${HMISforRe05}='yes',1,0)+if(${HMISforRe06}='yes',1,0)+if(${HMISforRe07}='yes',1,0)+if(${HMISforRe08}='yes',1,0)+if(${HMISforRe09}='yes',1,0)+if(${HMISforRe10}='yes',1,0)+if(${HMISforRe11}='yes',1,0)+if(${HMISinforma}='yes',1,0)+if(${FivePriorit}='yes',1,0)+if(${NHMISdataAn}='yes',1,0)+if(${FacilityLGA}='yes',1,0)+if(${InformRegis}='yes',1,0)+if(${FacParticip}='yes',1,0)+if(${HMISinfodis}='yes',1,0)"}}, {"name": "Actionpla1d", "label": "2.7 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycoment1h", "label": "2.7 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "GenerTotal0", "label": "Calculate General Management Total", "type": "calculate", "bind": {"calculate": "${MapScore000}+${FilingScore}+${RosterScore}+${TechMeetScr}+${SheetScore0}+${HMISScore00}"}}]}, {"name": "BiznessPlan", "label": "Section 3 **Business Plan**", "type": "group", "children": [{"name": "BiznessPla1", "label": "1a. Does facility use a business plan?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "QuarterPlan", "label": "1b. Is the quarterly business plan for the quarter under review developed and made accessible?", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BizPlanStak", "label": "2. Was the business plan prepared with key stakeholders?", "type": "select one", "bind": {"relevant": "${QuarterPlan} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BizPlanGeo0", "label": "3. Business plan valid (signed by all authorised signatories) for the quarter", "type": "select one", "bind": {"relevant": "${QuarterPlan} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BizPlaConfo", "label": "4. Business plan contains the following:", "type": "note", "bind": {"relevant": "${BiznessPla1} = 'yes'"}, "control": {"appearance": "field-list"}}, {"name": "NegotiateRt", "label": "i. Negotiated rates for services between the health facility and community", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OutreachStr", "label": "ii. Outreach strategies for (EPI, FP; ANC) services", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFlistPract", "label": "iii. HF list of informal practitioners (eg TBAs, uncertified drug vendors ect)", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StratDealip", "label": "iv. Strategies to deal with issues of the informal practitioners", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PlanCarIndg", "label": "5. Plan for care of the indigents", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AnPrevBuspl", "label": "6. Analysis of prevoius business plan implementation", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MonQuatilIP", "label": "7. Monthly updated Quality Improvement Plan", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PHC_NSHIP01", "label": "8. Check the following", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "ValidBiz001", "label": "a. Is business plan valid and renegotiated for the quarter under review (signed by all authorised signatories)", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ValidBiz002", "label": "b. Business plan analyzes presence of trained and untrained informal practitioners in catchment area", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ValidBiz003", "label": "c. HF has a list of informal practionners transmitted quarterly to the LGA for action, treats this subject in the BP, and suggests a strategy for dealing with informal practitioners", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ValidBiz004", "label": "d. Business plan shows a plan to assure financial accessibility for the population", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ValidBiz005", "label": "e. Business plan shows negotiated rates between HF, committee and community", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ValidBiz006", "label": "f. Business plan shows planning for care for the indigents", "type": "select one", "bind": {"relevant": "${BiznessPla1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Actionpla1j", "label": "3.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycomment2", "label": "3.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "BizPlTotal0", "label": "Calculate Business Plan Total", "type": "calculate", "bind": {"calculate": "if(${BiznessPla1}='yes',1,0)+if(${QuarterPlan}='yes',1,0)+if(${BizPlanStak}='yes',1,0)+if(${BizPlanGeo0}='yes',1,0)+if(${NegotiateRt}='yes',1,0)+if(${OutreachStr}='yes',1,0)+if(${HFlistPract}='yes',1,0)+if(${StratDealip}='yes',1,0)+if(${PlanCarIndg}='yes',1,0)+if(${AnPrevBuspl}='yes',1,0)+if(${MonQuatilIP}='yes',1,0)+if(${ValidBiz001}='yes',1,0)+if(${ValidBiz002}='yes',1,0)+if(${ValidBiz003}='yes',1,0)+if(${ValidBiz004}='yes',1,0)+if(${ValidBiz005}='yes',1,0)+if(${ValidBiz006}='yes',1,0)"}}]}, {"name": "FinanceGrp0", "label": "Section 4 **Finance**", "type": "group", "control": {"appearance": "minimal w1"}, "children": [{"name": "FinanceDocs", "label": "1a. Does the facility have a functional bank account?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Docuavailab", "label": "1.b. Are the following financial and accounting documents available and well kept?", "type": "note"}, {"name": "MontFinance", "label": "i. Monthly financial report correctly filled and signed by the Health Facility Officer in Charge", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MonthBankSt", "label": "ii. Monthly bank statements", "type": "select one", "bind": {"relevant": "${FinanceDocs} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IncomeExpen", "label": "iii. income and expenditure books including imprest and DRF", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Cash_atHand", "label": "iv. Cash at hand", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FinanIndice", "label": "v. Theoretical balance of cash-book corresponds to liquidity in cash (total income for the period under review = total expenditure during the period + total cash at hand + bank balance).", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionplan2", "label": "4.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycomment3", "label": "4.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "FinanTotal0", "label": "Calculate Finance Total", "type": "calculate", "bind": {"calculate": "if(${FinanceDocs}='yes',1,0)+if(${MontFinance}='yes',1,0)+if(${MonthBankSt}='yes',1,0)+if(${IncomeExpen}='yes',1,0)+if(${Cash_atHand}='yes',1,0)+if(${FinanIndice}='yes',1,0)"}}]}, {"name": "CashReceipt", "label": "Section 5 **Cash Receipts for Quarter**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "CostRecover", "label": "1. Cost recovery (User-charges exclude drugs)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "DrugRevenue", "label": "2. Drug revenues", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "CostRecPreP", "label": "3. Cost recovery (pre-payments)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "SalarieGovt", "label": "4. Salaries from Government and other sources", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "PBFSubsidy0", "label": "5. PBF subsidies from fund holders (e.g BHCPF)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "ContribOthr", "label": "6. Contributions from other sources", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "OtherReceip", "label": "7. Other", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "TotalFinanc", "label": "Calculate Cash Receipts for Quarter", "type": "calculate", "bind": {"calculate": "coalesce(${CostRecover},0)+coalesce(${DrugRevenue},0)+coalesce(${CostRecPreP},0)+coalesce(${SalarieGovt},0)+coalesce(${PBFSubsidy0},0)+coalesce(${ContribOthr},0)+coalesce(${OtherReceip},0)"}}]}, {"name": "ExpenQuartr", "label": "Section 6 **Expenditure by Component for Quarter**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "SalariesExp", "label": "1. Salaries", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "DrugMedCons", "label": "2. Drugs and medical consumables", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "CleanCosts0", "label": "3. Cleaning and office costs", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "TranspCosts", "label": "4. Transport costs", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "SocialMarkt", "label": "5. Social marketing", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "InfrasRehab", "label": "6. Infrastructural rehabilitation", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "EquipFurnit", "label": "7. Equipment and furniture", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "CostIndigen", "label": "8. Costs for indigent patients", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "OtherExpens", "label": "9. Other (trainings, etc)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "TotalExpens", "label": "Calculate Total Expenses", "type": "calculate", "bind": {"calculate": "coalesce(${SalariesExp},0)+coalesce(${DrugMedCons},0)+coalesce(${CleanCosts0},0)+coalesce(${TranspCosts},0)+coalesce(${SocialMarkt},0)+coalesce(${InfrasRehab},0)+coalesce(${EquipFurnit},0)+coalesce(${CostIndigen},0)+coalesce(${OtherExpens},0)"}}, {"name": "NetChngCash", "label": "Calculate Net Change Cash", "type": "calculate", "bind": {"calculate": "${TotalFinanc} - ${TotalExpens}"}}]}, {"name": "OpenCashBal", "label": "Section 7 **Opening Cash Balances for Quarter**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "Disclose0000", "label": "The next two sections is about the health facility cash balance or financial balance, is the staff willing to disclose cash balances /finances ?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BankBalOpsQ", "label": "1. Bank balance at the beginning of the quarter (Operations bank account)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Disclose0000} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "BankBalDrug", "label": "2. Bank balance at the beginning of the quarter (Operations Drugs bank account)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Disclose0000} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "CashHandQtr", "label": "3. Cash at hand at the beginning of the quarter", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Disclose0000} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "NetCashAvai", "label": "Calculate Net Cash Available", "type": "calculate", "bind": {"calculate": "coalesce(${BankBalOpsQ},0)+coalesce(${BankBalDrug},0)+coalesce(${CashHandQtr},0)"}}]}, {"name": "ClosCashBal", "label": "Section 8 **Closing Cash Balances for Quarter**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "BankBalEndO", "label": "1. Bank balance at the end of the quarter (operation bank account)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Disclose0000} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "BankBalEndD", "label": "2. Bank balance at the end of the quarter (drugs bank account)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Disclose0000} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "CashHandEnd", "label": "3. Cash at hand at the end of the quarter", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Disclose0000} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "TotCashBalE", "label": "Calculate Total Cash Balance", "type": "calculate", "bind": {"calculate": "coalesce(${BankBalEndO},0)+coalesce(${BankBalEndD},0)+coalesce(${CashHandEnd},0)"}}]}, {"name": "SumFinancia", "label": "Section 9 **Summary of Financials**", "type": "group", "children": [{"name": "TotFinanNot", "label": "1. Total Financing (A) is: \u20a6${TotalFinanc}", "type": "note", "control": {"appearance": "w1"}}, {"name": "TotExpenNot", "label": "2. Total Expenditure (B) is: \u20a6${TotalExpens}", "type": "note", "control": {"appearance": "w1"}}, {"name": "NetChngNote", "label": "3. Net Change in Cash (C = A - B) is: \u20a6${NetChngCash}", "type": "note", "control": {"appearance": "w1"}}, {"name": "NetCashNote", "label": "4. Net Cash Available (D) is: \u20a6${NetCashAvai}", "type": "note", "control": {"appearance": "w1"}}, {"name": "TotCashNote", "label": "5. Total closing Cash Balance (E) is: \u20a6${TotCashBalE}", "hint": "Note: E must equal D", "type": "note", "control": {"appearance": "w1"}}]}, {"name": "IndigenCare", "label": "Section 10 **Care for the Indigents**", "type": "group", "children": [{"name": "Indigentcar", "label": "10.1 Planning for Care of the Indigents expenditures", "type": "group", "children": [{"name": "IndigenExp0", "label": "1. Are there plans to care for Indigents expenditures?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "curative20c", "label": "2. Up to 20% of curative consultations of the previous month: documented quantity in monthly management meetings", "type": "select one", "bind": {"relevant": "${IndigenExp0} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EvidFreeSer", "label": "3. Evidence of Free services to indigents under HUWE (BHCPF)", "type": "select one", "bind": {"relevant": "${IndigenExp0} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "keycommplan", "label": "10.1 Key Comments", "type": "text"}, {"name": "actiplanind", "label": "10.1 Recommended action", "type": "text"}]}, {"name": "indigentmeet", "label": "10.2 Indigent committee monthly meeting", "type": "group", "children": [{"name": "IndgentMont", "label": "4. Are monthly indigent commitee meetings held?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AvailMinute", "label": "5. Are the meeting minutes available", "type": "select one", "bind": {"relevant": "${IndgentMont} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "followminut", "label": "6. Minutes contain the following:", "type": "select all that apply", "bind": {"relevant": "${AvailMinute} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "date_of_meeting", "label": "date of meeting"}, {"name": "agenda", "label": "agenda"}, {"name": "signed_attendance_list_of_parti", "label": "signed attendance list of participants"}, {"name": "follow_up_on_decisions_taken_in", "label": "follow up on decisions taken in previous meeting"}, {"name": "list_of_action_points_and_recom", "label": "list of action points and recommendations"}, {"name": "monthly_financial_balances_disc", "label": "monthly financial balances discussed"}, {"name": "minutes_signed_by_chairman", "label": "minutes signed by chairman"}, {"name": "responsible_persons_and_timeline", "label": "responsible persons and timeline"}]}, {"name": "CareComment", "label": "10.2 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "CareActionp", "label": "10.2 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Indigentpl1", "label": "Calculate Indigents Plan", "type": "calculate", "bind": {"calculate": "if(${IndigenExp0}='yes',1,0)+if(${curative20c}='yes',1,0)+if(${EvidFreeSer}='yes',1,0)+if(${IndgentMont}='yes',1,0)+if(${AvailMinute}='yes',1,0)+if(contains(${followminut},'date_of_meeting'),0.25,0) + if(contains(${followminut},'agenda'),0.25,0) + if(contains(${followminut},'signed_attendance_list_of_parti'),0.25,0) + if(contains(${followminut},' follow_up_on_decisions_taken_in'),0.25,0) + if(contains(${followminut},' list_of_action_points_and_recom'),0.25,0) + if(contains(${followminut},' monthly_financial_balances_disc'),0.25,0) + if(contains(${followminut},' minutes_signed_by_chairman'),0.25,0) + if(contains(${followminut},' responsible_persons_and_timeline'),0.25,0)"}}]}, {"name": "ListIndigen", "label": "10.3 List of Indigent Patients/Sensitization", "type": "group", "children": [{"name": "veryIndigen", "label": "7. Each month an updated list of indigents from every community of the ward is validated", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sharIndigen", "label": "8. Indigent list shared with the LGA and General Hospital", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RepoIndigen", "label": "9. Details of monthly activity plan to educate the indigents in every community on their priviledge available", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "responactiv", "label": "10. Reports of activities carried out in the previous month available.", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ListIndiTot", "label": "Calculate Indigents Sensitization", "type": "calculate", "bind": {"calculate": "if(${veryIndigen}='yes',1,0)+if(${sharIndigen}='yes',1,0)+if(${RepoIndigen}='yes',1,0)+if(${responactiv}='yes',1,0)"}}, {"name": "Actionplan3", "label": "10.3 Key Comments", "type": "text", "bind": {"relevant": "${veryIndigen} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "keycomentt3", "label": "10.3 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "indigents01", "label": "Calculate Community Linkage Total", "type": "calculate", "bind": {"calculate": "${Indigentpl1}+${ListIndiTot}"}}]}, {"name": "HygieneSter", "label": "Section 11 **Hygiene and Sterilization**", "type": "group", "children": [{"name": "sect5p1", "label": "11.1 Fence health facility available and well maintained", "type": "group", "children": [{"name": "FenceAvail0", "label": "1a. Health facility has a fence and is well maintained", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fenceexists", "label": "b. Fence exists, can be closed at night and there are no holes. A gatekeeper is available (except riverine areas)", "type": "select one", "bind": {"relevant": "${FenceAvail0} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FenceTotal1", "label": "Calculate Fence", "type": "calculate", "bind": {"calculate": "if(${FenceAvail0}='yes',1,0)+if(${Fenceexists}='yes',1,0)"}}, {"name": "p1keycommet", "label": "11.1 Key Comments", "type": "text"}, {"name": "p1actionpla", "label": "11.1 Recommended action", "type": "text"}]}, {"name": "GarbageBin0", "label": "11.2. Availability of a garbage bin in the courtyard", "type": "group", "children": [{"name": "garbageBin1", "label": "2. Is the garbage bin available in the courtyard", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BinLidAcces", "label": "3. Bin with lid accessible to clients which is not full", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "garbagebin2", "label": "Calculate Garbage Bin", "type": "calculate", "bind": {"calculate": "if(${garbageBin1}='yes',1,0)+if(${BinLidAcces}='yes',1,0)"}}, {"name": "p2keycommet", "label": "11.2 Key Comments", "type": "text"}, {"name": "p2actionplan", "label": "11.2 Recommended action", "type": "text"}]}, {"name": "Latrines010", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_311", "label": "11.3 Presence on sufficient latrines/toilets", "type": "note"}, {"name": "reserved_name_for_field_list_labels_312", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Latrines000", "label": "4. Are there sufficient and well-maintained latrines/toilets? (except riverine areas)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Latrines001", "label": "5. At least four water closet functional latrines/toilets (either the flushable squatting closet or the sitting closet) two for staff: Male and female, two for patients: Male and female", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Latrines002", "label": "6. Floor without fissures", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Latrines003", "label": "7. Recently cleaned without visible fecal matter", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Latrines004", "label": "8. Door lockable from the inside, ceiling and super structure with roofing, without flies and no smell", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Latrines005", "label": "9. Proof of use of bleach used as a disinfectant (eg jik, hypo, etc)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actioplann3", "label": "11.3 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycoment4a", "label": "11.3 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "LatrinesTot", "label": "Calculate Latrines", "type": "calculate", "bind": {"calculate": "if(${Latrines000}='yes',1,0)+if(${Latrines001}='yes',1,0)+if(${Latrines002}='yes',1,0)+if(${Latrines003}='yes',1,0)+if(${Latrines004}='yes',1,0)+if(${Latrines005}='yes',1,0)"}}]}, {"name": "ShowerAvail", "label": "11.4 *Presence of sufficient showers which are well maintained*", "type": "group", "children": [{"name": "Showers0001", "label": "10. Are there at least two bathing facilities (with floor without fissures, Door lockable from the inside, super structure with roofing)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Showers0002", "label": "11. Bathing facility with running water, or container with at the least 20 L of water", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Showers0003", "label": "12. Is there a plan for evacuation of the waste water in a sanitation pit?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "keycoment4b", "label": "11.4 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Actionpla4a", "label": "11.4 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Showertotal", "label": "Calculate Showers", "type": "calculate", "bind": {"calculate": "if(${Showers0001}='yes',1,0)+if(${Showers0002}='yes',1,0)+if(${Showers0003}='yes',1,0)"}}]}, {"name": "WastePit000", "label": "11.5 Availability of waste pit for health care waste", "type": "group", "children": [{"name": "WastePit010", "label": "13. Is waste pit for health care waste available and according to the norms?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WastePit001", "label": "14. Waste disposal pit minimum 2 meters deep, lined with clay, concrete or brick or plastic, it is fenced and has a bright flag", "type": "select one", "bind": {"relevant": "${WastePit010} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WastePit002", "label": "15. The waste pit is a minimum of 15 meters from the health facility, minimum of 50 meters from a household, and 100 meters from a water source except in cases where the available surface area does not allow for these distances (written support of the LGA health administration is required)", "type": "select one", "bind": {"relevant": "${WastePit010} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WastePit003", "label": "16. Health Care Waste is not visible (covered by at the least 10 cm of soil or lime)", "type": "select one", "bind": {"relevant": "${WastePit010} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WastePit004", "label": "17. The health facility maintains a register indicating the date of the creation of the pit(s), and the location (s)", "type": "select one", "bind": {"relevant": "${WastePit010} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "keycoment4c", "label": "11.5 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Actionpla4b", "label": "11.5 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "WastePitTot", "label": "Calculate Waste Pit", "type": "calculate", "bind": {"calculate": "if(${WastePit010}='yes',1,0)+if(${WastePit001}='yes',1,0)+if(${WastePit002}='yes',1,0)+if(${WastePit003}='yes',1,0)+if(${WastePit004}='yes',1,0)"}}]}, {"name": "cleancourt0", "label": "11.6 Courtyard clean", "type": "group", "children": [{"name": "cleancourt1", "label": "18. Is the courtyard clean?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cleancourt2", "label": "19. No waste or medical waste in the courtyard (sharps, ampoules, plastics, gloves,syringes,needles, used gauze, etc.)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cleancourt3", "label": "Calculate Clean Courtyard", "type": "calculate", "bind": {"calculate": "if(${cleancourt1}='yes',1,0)+if(${cleancourt2}='yes',1,0)"}}, {"name": "p6keycommet", "label": "11.6 Key Comments", "type": "text"}, {"name": "p6actionplt", "label": "11.6 Recommended action", "type": "text"}]}, {"name": "sterilnor00", "label": "11.7 Sterilization according to norms using a pressure sterilizer", "type": "group", "children": [{"name": "sterilnor01", "label": "20. Is sterilizer functional (eg Autoclave)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sterilnor02", "label": "21. Sterilization protocol available and followed (medical personnel present can explain the protocol or demonstrate the process)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sterilnor03", "label": "Calculate Sterilization", "type": "calculate", "bind": {"calculate": "if(${sterilnor01}='yes',1,0)+if(${sterilnor02}='yes',1,0)"}}, {"name": "p7keycommet", "label": "11.7 Key Comments", "type": "text"}, {"name": "p7actionpln", "label": "11.7 Recommended action", "type": "text"}]}, {"name": "hygiencon00", "label": "11.8 Hygienic conditions during wound dressing and injections", "type": "group", "children": [{"name": "hygiencon01", "label": "22. Are hygienic conditions assured during wound dressing and injections", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hygiencon02", "label": "23. Yellow and Red Bins for medical waste with lid and foot pedal, lined with bag and not full", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hygiencon03", "label": "24. Safety box for needles well positioned, and used (and not full)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hygiencon04", "label": "25. Needle cutter available and used", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hygiencon05", "label": "26. Container/bowl with lid containing disinfectant used for putting used instruments", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hygiencon06", "label": "Calculate Hygienic Conditions", "type": "calculate", "bind": {"calculate": "if(${hygiencon01}='yes',1,0)+if(${hygiencon02}='yes',1,0)+if(${hygiencon03}='yes',1,0)+if(${hygiencon04}='yes',1,0)+if(${hygiencon05}='yes',1,0)"}}, {"name": "p8keycommet", "label": "11.8 Key Comments", "type": "text"}, {"name": "p8actionpln", "label": "11.8 Recommended action", "type": "text"}]}, {"name": "WasteDispos", "label": "11.9 Disposal of Health care waste", "type": "group", "children": [{"name": "WasteChk100", "label": "27. Is disposal of Health care waste according to national norms/guidelines?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk001", "label": "28. Waste disposal of non-contaminated waste in Black Bin with lid and foot pedal, lined and not full", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk002", "label": "29. Waste disposal of contaminated HCW in Yellow Bins with lid and foot pedal, lined with cellophene bag and not full", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk003", "label": "30. Waste disposal of organic HCW in Red Bins with lid and foot pedal, lined with cellophene bag and not full", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk004", "label": "31. Protective gear/wear for personnel managing HCW available; boots, plastic shorts, thick plastic/rubber gloves", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk005", "label": "32. Is there a waste management plan", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk006", "label": "33. Is there a waste management focal person,", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk007", "label": "34. Is the waste management focal person trained", "type": "select one", "bind": {"relevant": "${WasteChk006} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk070", "label": "35. What is the frequency of waste disposal daily?", "type": "text", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}}, {"name": "WasteChk008", "label": "36. How often is the facility fumigated?(in weeks)", "type": "integer", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w2"}}, {"name": "WasteChk009", "label": "37. Is there a waste disposal manual (sighted)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk010", "label": "38. Is there an incinerator", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "onsite", "label": "Onsite"}, {"name": "offsite", "label": "Offsite"}, {"name": "no_incinerator", "label": "No Incinerator"}]}, {"name": "WasteChk011", "label": "39. Is there a storage facility for wasted or expired vaccines before final disposal?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteChk012", "label": "40. Is there a storage facility for wasted or expired drugs before final disposal?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WastDispTot", "label": "Calculate Waste Disposal", "type": "calculate", "bind": {"calculate": "if(${WasteChk100}='yes',1,0)+if(${WasteChk001}='yes',1,0)+if(${WasteChk002}='yes',1,0)+if(${WasteChk003}='yes',1,0)+if(${WasteChk004}='yes',1,0)+if(${WasteChk005}='yes',1,0)+if(${WasteChk006}='yes',1,0)+if(${WasteChk007}='yes',1,0)+if(${WasteChk009}='yes',1,0)+if(${WasteChk010}=\"onsite\" or ${WasteChk010}=\"offsite\", 1, 0)+if(${WasteChk011}='yes',1,0)+if(${WasteChk012}='yes',1,0)"}}, {"name": "keycoment4d", "label": "11.9 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Actionpla4c", "label": "11.9 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "infranew", "label": "Infrastructure", "type": "group", "children": [{"name": "Mortuary000", "label": "41. Availability of a room (mortuary) designated to keep corpse for not more than 12 hours", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Availchecki", "label": "42. Availability of check-ins/outs mortuary registers", "type": "select one", "bind": {"relevant": "${Mortuary000} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EnclKitchen", "label": "43. Availability of functional enclosed kitchen space", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infranew001", "label": "Calculate Infrastructure", "type": "calculate", "bind": {"calculate": "if(${Mortuary000}='yes',1,0)+if(${Availchecki}='yes',1,0)+if(${EnclKitchen}='yes',1,0)"}}]}, {"name": "HyMainTot01", "label": "Calculate Hygiene Total", "type": "calculate", "bind": {"calculate": "${FenceTotal1}+${garbagebin2}+${LatrinesTot}+${Showertotal}+${WastePitTot}+${cleancourt3}+${sterilnor03}+${hygiencon06}+${WastDispTot}+${infranew001}"}}]}, {"name": "Consulation", "label": "Section 12 **Curative Consultations**", "type": "group", "children": [{"name": "WaitingArea", "label": "12.1 Waiting area conditions", "type": "group", "control": {"appearance": "minimal w1"}, "children": [{"name": "Waiting0001", "label": "1. Waiting area protected from the sun and rain", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Waiting0002", "label": "2. Availability of chairs", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Waiting0003", "label": "2a. No. of Chairs", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Waiting0002} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "Waiting0004", "label": "3. Availability of benches", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Waiting0005", "label": "4. No. of benches", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${Waiting0004} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "Waiting0006", "label": "5. Sufficient benches and or chairs protected against sun and rain and waiting area is not inside the consultation room", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WaitingK005", "label": "12.1 Key comments", "type": "text"}, {"name": "WaitingA005", "label": "12.1 Recommended action", "type": "text"}]}, {"name": "DrugUnitFee", "label": "12.2 Unit fees of drugs displayed to the public", "type": "group", "control": {"appearance": "minimal w1"}, "children": [{"name": "DrugUnitFes", "label": "6. Are unit fees of drugs displayed to the public?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DrugUnit001", "label": "7. Easily visible in the consultation room waiting area, updated, with (i) unit price per item; (ii) price for a standard treatment of the drug", "type": "select one", "bind": {"relevant": "${DrugUnitFes} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DrugUnit002", "label": "8. Drugs are all generics", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WaitingCad1", "label": "12.3 Waiting card system", "type": "group", "children": [{"name": "WaitingCard", "label": "9. Waiting card system with numbers exists and is being used", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Waitinarea1", "label": "Calculate Waiting Area Condition", "type": "calculate", "bind": {"calculate": "if(${Waiting0001}='yes',1,0)+if(${Waiting0002}='yes',1,0)+if(${Waiting0004}='yes',1,0)+if(${Waiting0006}='yes',1,0)+if(${DrugUnitFes}='yes',1,0)+if(${DrugUnit001}='yes',1,0)+if(${DrugUnit002}='yes',1,0)+if(${WaitingCard}='yes',1,0)"}}]}, {"name": "ConsulRoom1", "label": "12.4 Consultation room in good condition", "type": "group", "children": [{"name": "ConsulRoom2", "label": "10. Walls with durable materials well painted, floor paved with cement without fissures, undamaged ceiling", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRoom3", "label": "11. Consultation room and waiting space separated assuring confidentiality", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRoom4", "label": "12. Windows with curtains", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRoom5", "label": "13. Functional door with functional lock", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRoom6", "label": "14. Running water (tap or water dispenser) with handwashing soap/liquid and clean towel available and used between patients or Hand sanitizer", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ConsulRom01", "label": "12.5 Electricity in consultation room", "type": "group", "children": [{"name": "ConsulRom02", "label": "15. Does consultation room (where emergencies are recieved) have 24/7 light", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRom03", "label": "16. Is there a good light source (e.g Electricity, solar light, rechargeable lamp, or functioning kerosene lamp etc.) present", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRmTot", "label": "Calculate Consultation Room", "type": "calculate", "bind": {"calculate": "if(${ConsulRoom2}='yes',1,0)+if(${ConsulRoom3}='yes',1,0)+if(${ConsulRoom4}='yes',1,0)+if(${ConsulRoom5}='yes',1,0)+if(${ConsulRoom6}='yes',1,0)+if(${ConsulRom02}='yes',1,0)+if(${ConsulRom03}='yes',1,0)"}}]}, {"name": "StaffConsul", "label": "12.6 Consultations by qualified staff", "type": "group", "children": [{"name": "ConsulQuali", "label": "17 Are consultations done by qualified staff (CHEW or above)?", "hint": "Identification of consulting staff in register (names, rank and signature)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulRegis", "label": "18. Can consulting staff be identified in register (names, rank and signature) ?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Consulbeging", "label": "12.7 Consulting staff", "type": "group", "children": [{"name": "ConsulDress", "label": "19. Is consulting staff well dressed?", "hint": "Clean cloths and footwear and name tags", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StaffConsu2", "label": "Calculate Consulting Staff", "type": "calculate", "bind": {"calculate": "if(${ConsulQuali}='yes',1,0)+if(${ConsulRegis}='yes',1,0)+if(${ConsulDress}='yes',1,0)"}}]}, {"name": "RegisterNum", "label": "20. Are registers correctly numbered?", "hint": "Correct numbering and closed at the end of the month", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulAvail", "label": "21. Is there 24/7 service availability?", "hint": "Supervisor verifies entries in register for the last three Sundays", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MalariaProt", "label": "22. Is malaria protocol available on wall and accessible for staff?", "hint": "National protocol for diagnosis and treatment of simple and severe malaria", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MalariaCase", "label": "23. Are simple malaria cases correctly treated?", "hint": "See last five cases of simple malaria on register and review treatment according to protocol (max 5 points all or nothing)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ARIFlowDiag", "label": "24. Is the WHO flow diagram for Acute Respiratory Infection (ARI) put on wall and accessible for staff?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ARIProtocol", "label": "25. Is the Acute Respiratory Infection (ARI) protocol applied?", "hint": "See last three cases of ARI and review treatment according to protocol (all or nothing)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DiarrheaWHO", "label": "26. Is the WHO protocol for diarrhea put on wall and accessible for staff?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DiarrheaPro", "label": "27. Is the Diarrhea protocol applied?", "hint": "See last three cases of Diarrhea and review treatment according to protocol (all or nothing)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConsulPropo", "label": "28. Is the proportion of consultations treated with antibiotics less than 30%", "hint": "See last 100 cases in register, check diagnosis and calculate the rate (< 30 cases) (In case less than 100 cases during the quarter calculate 30% of the cases in the register)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "TreatGuideL", "label": "29. Are treatment guidelines available in consultation room?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "TuberDanger", "label": "30. Is there knowledge among staff of tuberculosis danger signs and criteria for referral?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Tuber000001", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_442", "label": "31. Select any available qualified medical staff, and ask the question on TB signs/symptoms\nAnswer must contain at least 4 of the following signs:", "type": "note"}, {"name": "reserved_name_for_field_list_labels_443", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Tuber000002", "label": "(i) weight loss;", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Tuber000003", "label": "(ii) loss of appetite;", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Tuber000004", "label": "(iii) fever;", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Tuber000005", "label": "(iv) cough of more than 15 days duration;", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Tuber000006", "label": "(v) night sweating", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "FuncStethos", "label": "32. Is stethoscope available?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FuncSte0001", "label": "32b. How many is/are functional", "hint": "Let health worker check BP and review measure", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${FuncStethos} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "FuncSte0002", "label": "33. BP machine (sphygmomanometer) available", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FuncSte0003", "label": "34. How many BP machine (sphygmomanometer) is/are functional", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${FuncSte0002} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "FuncThermos", "label": "35. Is thermometer available?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Thermos0001", "label": "36. Number functional", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${FuncThermos} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "FuncOtoscop", "label": "37. Is an otoscope available and functional?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Otoscop0001", "label": "38. Number functional", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${FuncOtoscop} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "ExamBeds000", "label": "39. Are examination beds available, and with a mattress?", "hint": "Non-torn, plastic cover, specific for the OPD consultations only", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WeighScale0", "label": "40. Is a weighing scale available and functional?", "hint": "Inspect in comparison with known weight of supervisor: after weighing, the balance should return to zero", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal04", "label": "41. Does the facility provide Integrated Management of Childhood Illnesses (IMCI) services?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal05", "label": "42. Do you manage a sick child using the IMCI chart booklet?", "type": "select one", "bind": {"relevant": "${Childheal04} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal06", "label": "43. DO you have at least one trained staff on IMCI", "type": "select one", "bind": {"relevant": "${Childheal04} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IntManChild", "label": "44. Is Integrated Management of Childhood Illnesses strategy applied?", "type": "select one", "bind": {"relevant": "${Childheal04} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IntManCh001", "label": "45. Protocol is available in the consultation room", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IntManCh002", "label": "46. The last three IMCI cases are traced in the register and comply with the IMCI strategy (all three or nothing)", "type": "select one", "bind": {"relevant": "${Childheal04} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DetNutriUn6", "label": "47. Determination of nutritional status of all children under 5 who come for consultation (check five children under five through a random sampling method: take a random number between 1 and 3 and using this sampling interval check five consultations)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DetNutriUn7", "label": "48. Determination of nutritional status of all women with a sick child under 6 months of age (as above)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DetNutriUn8", "label": "49. Screening record of nutritional status available, up to date and properly filled out", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpla4d", "label": "12.1 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycoment5b", "label": "12.1 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "ConsulTot01", "label": "Calculate Consultation", "type": "calculate", "bind": {"calculate": "if(${RegisterNum}='yes',1,0)+if(${ConsulAvail}='yes',1,0)+if(${MalariaProt}='yes',1,0)+if(${MalariaCase}='yes',1,0)+if(${ARIFlowDiag}='yes',1,0)+if(${ARIProtocol}='yes',1,0)+if(${DiarrheaWHO}='yes',1,0)+if(${DiarrheaPro}='yes',1,0)+if(${ConsulPropo}='yes',1,0)+if(${TreatGuideL}='yes',1,0)+if(${TuberDanger}='yes',1,0)+if(${Tuber000002}='yes',1,0)+if(${Tuber000003}='yes',1,0)+if(${Tuber000004}='yes',1,0)+if(${Tuber000005}='yes',1,0)+if(${Tuber000006}='yes',1,0)+if(${FuncStethos}='yes',1,0)+if(${FuncSte0002}='yes',1,0)+if(${FuncThermos}='yes',1,0)+if(${FuncOtoscop}='yes',1,0)+if(${ExamBeds000}='yes',1,0)+if(${WeighScale0}='yes',1,0)+if(${Childheal04}='yes',1,0)+if(${Childheal05}='yes',1,0)+if(${Childheal06}='yes',1,0)+if(${IntManChild}='yes',1,0)+if(${IntManCh001}='yes',1,0)+if(${IntManCh002}='yes',1,0)+if(${DetNutriUn6}='yes',1,0)+if(${DetNutriUn7}='yes',1,0)+if(${DetNutriUn8}='yes',1,0)"}}, {"name": "RevRecordsD", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_471", "label": "12.2 *Direct observation of three consecutive children under five according to the IMCI protocol*(or review of patient records in case of no patients)", "hint": "IMCI (Integrated Management of Childhood Illness)", "type": "note"}, {"name": "reserved_name_for_field_list_labels_472", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "ReviewFever", "label": "50. Ask about fever and IF FEVER ask about (i) since when; (ii) persistent or intermittent", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "ReviewCough", "label": "51.Ask about cough and IF COUGH ask about since when", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "RevDiarrhea", "label": "52. Ask for diarrhea IF DIARRHOEA then ask (i) since when; (ii) how often per day; (iii) consistency - water or mucus or bloody; (iv) vomiting", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "RevGenImprs", "label": "53. GENERAL IMPRESSION: awake or tired?", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "RevRespRate", "label": "54. FIRST - COUNT RESPIRATION RATE (observe before touching child!!!)", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "RevTempMeas", "label": "55. Temperature (measure)", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "RevSkinPinc", "label": "56. Skin pinch (in case of diarrhea) OR chest auscultation (in case of cough)", "hint": "(if question asked to the three children = 3 points, if 2 = 2, if 1 = 1 if not = 0 point)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "0", "label": "0"}, {"name": "1", "label": "1"}, {"name": "2", "label": "2"}, {"name": "3", "label": "3"}]}, {"name": "Actionpla5b", "label": "12.2 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycoment5c", "label": "12.2 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "RevRecords1", "label": "Calculate Direct Observation", "type": "calculate", "bind": {"calculate": "coalesce(${ReviewFever},0)+coalesce(${ReviewFever},0)+coalesce(${ReviewFever},0)+coalesce(${ReviewFever},0)+coalesce(${ReviewFever},0)+coalesce(${ReviewFever},0)+coalesce(${ReviewFever},0)"}}]}, {"name": "ConsulTotal", "label": "Calculate Curative Consultation Total", "type": "calculate", "bind": {"calculate": "${Waitinarea1}+${ConsulRmTot}+${StaffConsu2}+${ConsulTot01}+${RevRecords1}"}}]}, {"name": "FamilyPlann", "label": "Section 13 **Family Planning**", "type": "group", "children": [{"name": "FamilyPla01", "label": "1. Does the facility provide family planning services?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StaffPlanQl", "label": "2. At least one qualified staff trained in Family Planning (check certificate: original or photocopy certified by the LGA)", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ConfidenRom", "label": "3. Confidentiality in consultancy room assured", "hint": "Room with closed doors, curtains at windows or non transparent glass", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PlanMethods", "label": "4. Family planning methods available and visible in demonstration box for potential users", "hint": "Condoms; OCP; Injectable; Implant; IUD; are available in the demonstration box (all five items)\nPenis model available on the desk; box with condoms available with at the least 50 condoms", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StaffCalcul", "label": "5. Staff correctly calculates number of clients expected monthly for oral and injectable contraceptives", "hint": "For example for 10.000 population (target is entire ward catchment pop) = 10.000 * 22.5% * 25%/12 * 4 * 90% (assuming 25% unmet need; 22.5% target population; 90% of oral/inject AC at HC level. Ask any medical personnel involved in care for clients to explain this target calculation. Total number of women of child bearing age (15 - 49) divided by four. Note that each dose is for 3 months (one blister per month for three months or one injection of depoprovera covers three months)", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FPStratPlan", "label": "6. Business plan contains strategy to achieve FP targets", "hint": "Collaboration with public sector, private sector and social marketing, mobile strategies, advocacy among local leaders etc. (explicit mention in the BP)\nInvolvement of HF staff in strategies (explicit mention of this in the BP)", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StockContra", "label": "7. Security Stock of oral and injectable contraceptives in adequate quantity", "hint": "For example for 10.0000 pop 84 doses of oral (3 month cycles) and injectable methods combined. Total number of women of child bearing age (15 - 49) - 22.5% times unmet need 25% divided by 12 (months) times 2 months (min supply) times 90% delivered at health center level => result 84 doses). Note that each dose is for 3 months", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IUDAvailabl", "label": "8. Intra Uterine device (IUD) available and staff trained to use it", "hint": "At least five IUDs and at the least one staff trained to use it (check certificate original or photocopy certified by the LGA)", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImplanAvail", "label": "9. Implant method available and staff trained to use it", "hint": "At least five implants available and staff trained to use it (check certificate original or photcopy certified by the LGA)", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StratTransf", "label": "10. Strategies available for transfer of persons to hospital seeking permanent FP methods", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StratTra001", "label": "11. Is there a worked-out Referral system with strategy to reduce prices and mobile strategy for surgery?", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FPIndivCard", "label": "12. Does the facilty have FP data tools (i.e FP register cards, DRC monthly report, quarterly report)? Are they properly filled", "hint": "Check at least five cards for BP, hepatomegaly, varicose veins, weight (all cards; all elements checked)", "type": "select one", "bind": {"relevant": "${FamilyPla01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FPIndivC001", "label": "13. Does the facility offer counselling and screening for breast and cervical cancer?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FPIndivC002", "label": "14. Does the facility offer education, counselling and management of rape and other gender based violence?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpla5c", "label": "13.0 Key Comments", "type": "text", "bind": {"relevant": "${FamilyPla01} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "keycomment6", "label": "13.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "FPlanTotal0", "label": "Calculate Family Planning Total", "type": "calculate", "bind": {"calculate": "if(${FamilyPla01}='yes',1,0)+if(${StaffPlanQl}='yes',1,0)+if(${ConfidenRom}='yes',1,0)+if(${PlanMethods}='yes',1,0)+if(${StaffCalcul}='yes',1,0)+if(${FPStratPlan}='yes',1,0)+if(${StockContra}='yes',1,0)+if(${IUDAvailabl}='yes',1,0)+if(${ImplanAvail}='yes',1,0)+if(${StratTransf}='yes',1,0)+if(${StratTra001}='yes',1,0)+if(${FPIndivCard}='yes',1,0)+if(${FPIndivC001}='yes',1,0)+if(${FPIndivC002}='yes',1,0)"}}]}, {"name": "Laboratory8", "label": "Section 14 **Laboratory**", "type": "group", "children": [{"name": "MedLabTechA", "label": "1. Medical Laboratory technician available", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LabOpen7Day", "label": "2. Laboratory is open every day of the week", "hint": "Supervisor verifies the last 4 Sundays in laboratory register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LabExamVisi", "label": "3. List of laboratory examinations visible for the public with fees", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ResulRecord", "label": "4. Results recorded correctly in laboratory register and match with results in inpatient sheets or OPD examination cards", "hint": "Supervisor verifies last five results", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ParaDemonst", "label": "5. Availability of parasites demonstrations", "type": "group", "children": [{"name": "ParaDemo001", "label": "6. On plastic paper, in a color book, or put on wall", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ParaDemo002", "label": "7. Blood smear: Vivax, Ovale, Falciparum and Malariae", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ParaDemo003", "label": "8. Stools: Ascaris, entamoeba, ankylostoma and schistosome", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "MicrosAva01", "label": "9. Microscope available and functional", "hint": "functional objectives; immersion oil available, mirror or electricity\nblades, cover glass, GIEMSA available", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MalariaTest", "label": "10. Malaria rapid tests available", "hint": "At the least 20 tests available in the laboratory; non-expired", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CentriAvail", "label": "11. Centrifuge available and functional", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WasteEvacua", "label": "12. Waste evacuation correctly carried out", "hint": "Organic waste in a bin with lid with disinfectant\nSecurity box for sharp objects available and destroyed according to waste disposal guidelines", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PipetteWash", "label": "13. Personnel adequately washes dirty pipettes in containers with disinfectant", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LabEquipPTB", "label": "14. Laboratory equipment for testing for PTB", "hint": "PTB (Pulmonary Tuberculosis Blood Test)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LabEquipP01", "label": "15. Reagents for AFB testing available; stock control car for reagents is available and lists stock; at the least 30 non-recycled slides available for testing", "hint": "AFB (Acid Fast Bacillus)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LabEquipP02", "label": "16. External Quality assurance protocol for PTB testing available and implemented: slides sampled and sent for quality control according to protocol, and latest report, as per protocol, is available and shows results as per cut-off point of the protocol", "hint": "PTB (Pulmonary Tuberculosis Blood Test)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionplan6", "label": "14.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycomment7", "label": "14.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "LaboraTotal", "label": "Calculate Laboratory Total", "type": "calculate", "bind": {"calculate": "if(${MedLabTechA}='yes',1,0)+if(${LabOpen7Day}='yes',1,0)+if(${LabExamVisi}='yes',1,0)+if(${ResulRecord}='yes',1,0)+if(${ParaDemo001}='yes',1,0)+if(${ParaDemo002}='yes',1,0)+if(${ParaDemo003}='yes',1,0)+if(${MicrosAva01}='yes',1,0)+if(${MalariaTest}='yes',1,0)+if(${CentriAvail}='yes',1,0)+if(${WasteEvacua}='yes',1,0)+if(${PipetteWash}='yes',1,0)+if(${LabEquipPTB}='yes',1,0)+if(${LabEquipP01}='yes',1,0)+if(${LabEquipP02}='yes',1,0)"}}]}, {"name": "PatientWard", "label": "Section 15 **In-patient Wards**", "type": "group", "children": [{"name": "GuardDutRos", "label": "1. Guard duty roster clearly visible for staff and followed up", "hint": "Supervisor verifies guard duty's report - names and signatures match", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FurnitAvail", "label": "2. Furniture available and in good state", "hint": "Each bed has a (i) non-torn plastic covered mattress, (ii) mosquito net, (iii) clean sheets, (iv) night table", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PatientComf", "label": "9.1 Patient comfort and hygiene", "type": "group", "children": [{"name": "Patient0001", "label": "3. The wards are clean with disinfectant: no debris on the floor AND OR proof of use of bleach for cleaning the wards (about 12% hypochlorite)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Patient0002", "label": "4. Space between the beds is at the least one meter", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Patient0003", "label": "5. Each ward has access to drinking water", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Patient0004", "label": "6. Each ward has running water or water dispenser with water, soap and a clean towel", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "LightWardAv", "label": "7. Light available in each ward", "hint": "Electricity; solar light or rechargeable battery lamp", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Confidentia", "label": "8. Confidentiality", "hint": "Women in separate ward from men; the inside of the wards are not visible from the outside", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PatientRegs", "label": "9. In patient register available and is well maintained", "hint": "check identity and hospital bed days", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RecFormHosp", "label": "15.1 Recording forms for hospitalizations available and well filled and well stored", "type": "group", "children": [{"name": "RecForm0001", "label": "10. At least 10 blanks; supervisor verifies 5 filled forms", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RecForm0002", "label": "11. Weight, temperature, and eventual laboratory exams recorded", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RecForm0003", "label": "12. Treatment monitoring checked", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Actionplan7", "label": "15.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycomment8", "label": "15.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "TotPatient0", "label": "Calculate In-patient Wards Total", "type": "calculate", "bind": {"calculate": "if(${GuardDutRos}='yes',1,0)+if(${FurnitAvail}='yes',1,0)+if(${Patient0001}='yes',1,0)+if(${Patient0002}='yes',1,0)+if(${Patient0003}='yes',1,0)+if(${Patient0004}='yes',1,0)+if(${LightWardAv}='yes',1,0)+if(${Confidentia}='yes',1,0)+if(${PatientRegs}='yes',1,0)+if(${RecForm0001}='yes',1,0)+if(${RecForm0002}='yes',1,0)+if(${RecForm0003}='yes',1,0)"}}]}, {"name": "EssDrugsMan", "label": "Section 16 **Essential Drugs Management**", "type": "group", "children": [{"name": "PharmaTechn", "label": "1. The Pharmacy Technician is available", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StockCardED", "label": "2. Staff maintains stock cards for ED showing security stock levels", "hint": "Average Monthly Consumption (AMC= six months Consumption divided by six) * 2 (two Average Monthly Consumption)\nSupply in register corresponds with physical supply: random sample of three essential drugs", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFPurchaseP", "label": "16.1 Health facility purchases drugs, equipment and consumables from the Pharmaceutical Council of Nigeria certified distributor, approved by SMOH/SPHCDA", "type": "group", "children": [{"name": "HFPurchas01", "label": "3. Latest Pharmaceutical Council of Nigeria certified distribution center list for the State available", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFPurchas02", "label": "4. Last procurement list is shown which shows the certified distributor that sold the drugs", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFPurchas03", "label": "5. All drugs and medical consumables are (i) NAFDAC certified and (ii) Generic", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PharmaDeliv", "label": "6. Main pharmacy store delivers drugs to health facility dispensary according to requisition", "hint": "Supervisor verifies whether quantity requisitioned equals quantity served\nDrugs to clients are uniquely dispensed through prescriptions. Prescriptions are stored and accessible\nDrugs and medical consumables prescribed, are all in generic form", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DrugsStored", "label": "7. Drugs stored correctly", "hint": "Clean place, well ventilated with all drugs on cupboards, labeled shelves\nDrugs and medical consumables stored in therapeutical and alphabetical order, first expired - first out basis", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OODDrugsAbs", "label": "8. Absence of out of date drugs or drugs with unreadable labels", "hint": "Supervisor verifies randomly three drugs and 2 consumables\nOut of date drugs well separated from stock\nDestruction protocol for out of date drugs available and applied", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionplan8", "label": "16.1 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycomment9", "label": "16.1 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "EssDrugsCal", "label": "Calculate Essential Drugs Management Total", "type": "calculate", "bind": {"calculate": "if(${PharmaTechn}='yes',1,0)+if(${StockCardED}='yes',1,0)+if(${HFPurchas01}='yes',1,0)+if(${HFPurchas02}='yes',1,0)+if(${HFPurchas03}='yes',1,0)+if(${PharmaDeliv}='yes',1,0)+if(${DrugsStored}='yes',1,0)+if(${OODDrugsAbs}='yes',1,0)"}}]}, {"name": "TracerDrugs", "label": "Section 17 **Tracer Drugs (min. stock = Average Monthly Consumption X 2)**", "type": "group", "children": [{"name": "TracerDrugs01", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_563", "hint": "Correctly calculated", "type": "note"}, {"name": "reserved_name_for_field_list_labels_564", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Paracetamol", "label": "1. Paracetamol 500 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Ibuprofen00", "label": "2. Ibuprofen 200 mg caps", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Chlorphenir", "label": "3. Chlorpheniramine 2 mg", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Oxytocin10I", "label": "4. Oxytocin 10IU/ml vial", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Mebendazole", "label": "5. Mebendazole 100 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FerrousSulf", "label": "6. Ferrous Sulfate 325 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Amoxicil500", "label": "7. Amoxicillin 500 mg caps/Dispersable tab 250mg", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Amoxicil125", "label": "8. Amoxicillin 125 mg/5ml suspension", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Cotrimox480", "label": "9. Co-trimoxazol 480 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Cotrimox200", "label": "10. Co-trimoxazol 40mg/200mg - 5ml susp", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Doxycycline", "label": "11. Doxycycline 100 mg caps", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Erythrom250", "label": "12. Erythromycin 250 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Coartemeter", "label": "13. Artemisinin Combination Therapy (ACT)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Sulfadoxine", "label": "14. Sulfadoxine/pyrimethamine 500 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ZincORSSach", "label": "15. Zinc-ORS sachet", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CondomBrand", "label": "16. Condom", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Metronid200", "label": "17. Metronidazol 200 mg tab", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SterileGlov", "label": "18. Sterile gloves", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Chlohexidin", "label": "19. Chlohexidine Gel", "hint": "Min stock = 10; AMC applies only when higher than 10", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "paracetamol_syrup", "label": "20. Paracetamol Syrup", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Erythomycin_syrup", "label": "21. Erythomycin Syrup", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Magnesium_sulphate", "label": "22. Magnesium Sulphate", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IVGivingSet", "label": "23. IV giving set", "hint": "Min stock = 10; AMC applies only when higher than 10", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RingersLact", "label": "24. Ringers lactate 500 ml", "hint": "Min stock = 5L; AMC applies only when higher than 5L", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dextrose500", "label": "25. Dextrose 5% 500 ml", "hint": "Min stock = 5L; AMc applies only when higher than 5L", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Syringe05ml", "label": "26. Syringe 5ml", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Syringe10ml", "label": "27. Syringe 10ml", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ScalpVeinNd", "label": "28. Scalp vein needle/Canular", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionplan9", "label": "17.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "keycoment10", "label": "17.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "TracDrugCal", "label": "Calculate Tracer Drugs Total", "type": "calculate", "bind": {"calculate": "if(${Paracetamol}='yes',1,0)+if(${Ibuprofen00}='yes',1,0)+if(${Chlorphenir}='yes',1,0)+if(${Oxytocin10I}='yes',1,0)+if(${Mebendazole}='yes',1,0)+if(${FerrousSulf}='yes',1,0)+if(${Amoxicil500}='yes',1,0)+if(${Amoxicil125}='yes',1,0)+if(${Cotrimox480}='yes',1,0)+if(${Cotrimox200}='yes',1,0)+if(${Doxycycline}='yes',1,0)+if(${Erythrom250}='yes',1,0)+if(${Coartemeter}='yes',1,0)+if(${Sulfadoxine}='yes',1,0)+if(${ZincORSSach}='yes',1,0)+if(${CondomBrand}='yes',1,0)+if(${Metronid200}='yes',1,0)+if(${SterileGlov}='yes',1,0)+if(${Chlohexidin}='yes',1,0)+if(${paracetamol_syrup}='yes',1,0)+if(${Erythomycin_syrup}='yes',1,0)+if(${Magnesium_sulphate}='yes',1,0)+if(${IVGivingSet}='yes',1,0)+if(${RingersLact}='yes',1,0)+if(${Dextrose500}='yes',1,0)+if(${Syringe05ml}='yes',1,0)+if(${Syringe10ml}='yes',1,0)+if(${ScalpVeinNd}='yes',1,0)"}}]}]}, {"name": "MaternalHe1", "label": "Section 18 **Maternal Health**", "type": "group", "children": [{"name": "Maternity00", "label": "Maternity", "type": "group", "children": [{"name": "Maternity01", "label": "1. Does this facility provide maternal Health Services ?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuffiWaterD", "label": "2. Is there Sufficient water with antiseptic soap and liquid antiseptic in delivery room?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuffiWater1", "label": "3. Is there a functional water source or at the least 20L gallon of water?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DelivLightR", "label": "4. Is there 24 hours Light in the delivery room?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sourceLight", "label": "5. Is the source of light any of the following", "type": "select all that apply", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "nationalgrid", "label": "National Grid"}, {"name": "generator", "label": "Generator"}, {"name": "solarlight", "label": "SolarLight"}, {"name": "rechargeablebattery", "label": "Rechargeable Battery"}, {"name": "kerosenelamp", "label": "Kerosene Lamp"}]}, {"name": "sourcLight1", "label": "calc multiple light source (no export)", "type": "calculate", "bind": {"calculate": "if(contains(${sourceLight},\"nationalgrid\"),2,0) + if(contains(${sourceLight},\"generator\"),1,0) + if(contains(${sourceLight},\"solarlight\"),1,0) + if(contains(${sourceLight},\"rechargeablebattery\"),0.2,0) + if(contains(${sourceLight},\"kerosenelamp\"),0.2,0)"}}, {"name": "sourcLight2", "label": "calc multiple light source (no export)", "type": "calculate", "bind": {"calculate": "if(${sourcLight1}>=3,3,${sourcLight1})"}}, {"name": "MaternWaste", "label": "6. Are wastes from Maternity correctly handled?", "hint": "Bin with lid and lining and safe needle disposal container, specific for the maternity room use only", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "MaterWast01", "label": "7. Are waste bins with lids and lining and safe needle disposal container, specific for the maternity room use only?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PartogAvail", "label": "8. Availability and use of the partograph", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PartogAva01", "label": "9. Are there at the least 10 partograph available for use?", "type": "select one", "bind": {"relevant": "${PartogAvail} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PartogAva02", "label": "10. Verify three randomly selected partographs whether filled according to the norms", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DelivPerson", "label": "11. Deliveries performed by skilled personnel", "hint": "Identification of the skilled provider from names in the register", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SterGlovPre", "label": "12. Availability of at the least 10 pairs of sterile gloves", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ObsBoxAvail", "label": "13. Availability of at the least 2 sterilized obstetrical boxes (delivery kit)", "hint": "Contains at least any of the folllowing (tick as appropriate)", "type": "select all that apply", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "pair_of_scissors", "label": "1 pair of scissors"}, {"name": "pairs_of_forceps", "label": "2 pairs of forceps"}, {"name": "one_needle_holder", "label": "One needle holder"}, {"name": "not_available", "label": "Not Available"}]}, {"name": "ObsBoxAvai1", "label": "Calc multiple for obstetrical boxes (no export)", "type": "calculate", "bind": {"calculate": "if(contains(${ObsBoxAvail},'pair_of_scissors'),1,0) + if(contains(${ObsBoxAvail},'pairs_of_forceps'),1,0) + if(contains(${ObsBoxAvail},'one_needle_holder'),1,0)"}}, {"name": "ObsBoxAvai2", "label": "Calc multiple for obstetrical boxes (no export)", "type": "calculate", "bind": {"calculate": "if(${ObsBoxAvai1} >=2, 2, ${ObsBoxAvai1})"}}, {"name": "EpisiotoBox", "label": "14. Availability of at the least one episiotomy box", "hint": "Contains at least any of the folllowing (tick as appropriate)", "type": "select all that apply", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "one_sterilized_box_with_needle", "label": "One sterilized box with needle holder, needles"}, {"name": "anatomical_plier", "label": "1 anatomical plier"}, {"name": "surgical_plier", "label": "1 surgical plier"}, {"name": "catgut_and_nylon_sutures", "label": "Catgut and nylon sutures"}, {"name": "antiseptic", "label": "Antiseptic"}, {"name": "local_anesthetics", "label": "Local anesthetics"}, {"name": "sterile_swaps", "label": "Sterile swaps"}, {"name": "none", "label": "None"}]}, {"name": "DelivTable0", "label": "15. Delivery table in good state", "hint": "Table in two parts with removable non-torn plasticized mattress and two functional leg supports", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EquipNewBor", "label": "16. Available essential commodity for care of the newborn", "hint": "Tick the available ones", "type": "select all that apply", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "sterile_tying_string_or_clip_fo", "label": "Sterile tying string or clip for umbilical cord"}, {"name": "%_tetracycline_eye_ointment_non", "label": "1% tetracycline eye ointment non-expired"}, {"name": "%_chlorhexidine_gel", "label": "4% chlorhexidine gel"}, {"name": "mva_mucus_extraction", "label": "MVA (Mucus extraction)"}, {"name": "none", "label": "None"}]}, {"name": "PatRoomAdeq", "label": "17. Adequate in-patient rooms", "hint": "Tick the following conditions", "type": "select all that apply", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "mattress_covered_in_impermeable", "label": "Mattress covered in impermeable plastic sheets"}, {"name": "blankets", "label": "Blankets"}, {"name": "mosquito_nets_on_each_occupied", "label": "Mosquito nets on each occupied bed"}, {"name": "none", "label": "None"}]}, {"name": "DelivMaintd", "label": "18.1 *Maternity: Delivery room is well-maintained*", "type": "group", "bind": {"relevant": "${Maternity01} = 'yes'"}, "children": [{"name": "DurableWall", "label": "18. Are the walls and roof in good condition?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BedDoorCurt", "label": "19. Is there a curtain/screen between delivery bed and door", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DelivDisinf", "label": "20. Delivery room smells of disinfectant AND OR should have proof of use of bleach as a disinfectant for cleaning (eg jik, hypo, etc)", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FloorLeveld", "label": "21. Floor should be levelled with cement, without fissures and ceiling not damaged", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FuncWinDoor", "label": "22. Windows with curtains and functional door", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpla10", "label": "18.1 Key Comments", "type": "text", "bind": {"relevant": "${Maternity01} = 'yes'"}, "control": {"appearance": "minimal w2"}}, {"name": "keycoment11", "label": "18.1 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "Default0001", "label": "23. Is there a portable ultrasound machine in this facility?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Default0002", "label": "24. Has any health worker in this facility been trained on ultrasonography?", "type": "select one", "bind": {"relevant": "${Default0001} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Default0003", "label": "25. Has the use of the ultrasound machine enhanced early detection of complications of pregnancy?", "type": "select one", "bind": {"relevant": "${Default0002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Default0004", "label": "26. Do pregnant women from other facilities come for ultrasound scan here?", "type": "select one", "bind": {"relevant": "${Default0003} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Default0005", "label": "27. Is there a functional haemoglobin scale in this facility?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "DeliMaitTot", "label": "Calculate Delivery", "type": "calculate", "bind": {"calculate": "if(${Maternity01}='yes',1,0)+if(${SuffiWaterD}='yes',1,0)+if(${SuffiWater1}='yes',1,0)+if(${DelivLightR}='yes',1,0)+${sourcLight2}+if(${MaternWaste}='yes',1,0)+if(${MaterWast01}='yes',1,0)+if(${PartogAvail}='yes',1,0)+if(${PartogAva01}='yes',1,0)+if(${PartogAva02}='yes',1,0)+if(${DelivPerson}='yes',1,0)+if(${SterGlovPre}='yes',1,0)+${ObsBoxAvai2}+if(${EpisiotoBox}!=\"none\" and ${EpisiotoBox}!=\"\" ,1,0)+if(${DelivTable0}='yes',1,0)+if(contains(${EquipNewBor},'sterile_tying_string_or_clip_fo'),0.5,0) + if(contains(${EquipNewBor},'%_tetracycline_eye_ointment_non'),0.5,0) + if(contains(${EquipNewBor},'%_chlorhexidine_gel'),0.5,0) + if(contains(${EquipNewBor},'mva_mucus_extraction'),0.5,0)+if(contains(${PatRoomAdeq},'mattress_covered_in_impermeable'),1,0) + if(contains(${PatRoomAdeq},' blankets'),1,0) + if(contains(${PatRoomAdeq},'mosquito_nets_on_each_occupied'),1,0)+if(${DurableWall}='yes',1,0)+if(${BedDoorCurt}='yes',1,0)+if(${DelivDisinf}='yes',1,0)+if(${FloorLeveld}='yes',1,0)+if(${FuncWinDoor}='yes',1,0)+if(${Default0001}='yes',1,0)+if(${Default0002}='yes',1,0)+if(${Default0003}='yes',1,0)+if(${Default0004}='yes',1,0)+if(${Default0005}='yes',1,0)"}}, {"name": "Default0006", "label": "Maternity: Referrals", "type": "group", "children": [{"name": "Default0007", "label": "28. Are referrals forms available?", "type": "select one", "bind": {"relevant": "${Maternity01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Default0008", "label": "29. Is there a functional two-way referral system?", "type": "select one", "bind": {"relevant": "${Default0007} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Default0009", "label": "30. Are there specific referral linkages for the health facility?", "hint": "Sight referral slip", "type": "select one", "bind": {"relevant": "${Default0007} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpla11", "label": "18.2 Key comments", "type": "text", "bind": {"relevant": "${Default0007} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "HapiComment", "label": "18.2 Recommended action", "type": "text", "bind": {"relevant": "${Maternity01} = 'yes'"}, "control": {"appearance": "minimal w2"}}, {"name": "DefaulTot02", "label": "Calculate Maternity Referrals", "type": "calculate", "bind": {"calculate": "if(${Default0007}='yes',1,0)+if(${Default0008}='yes',1,0)+if(${Default0009}='yes',1,0)"}}]}, {"name": "HMIS_hms001", "label": "Maternity: Data records", "type": "group", "children": [{"name": "HMIS_hms002", "label": "31. Has e-registration of pregnant women commenced?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMIS_hms003", "label": "32. Has any of the workers been trained on BEmONC, ELSS, LSS, MLSS ?", "hint": "Basic Emergency Obstetric and Newborn Care,\n Expanded Life Saving Skills\nModified Life Saving Skills\nLife Saving Skills", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMIS_hms000", "label": "33. How many of the workers have been trained on BEmONC, ELSS, LSS, MLSS ?", "hint": "Basic Emergency Obstetric and Newborn Care,\n Expanded Life Saving Skills\nModified Life Saving Skills\nLife Saving Skills", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE", "relevant": "${HMIS_hms003} = 'yes'"}, "control": {"appearance": "w1"}}, {"name": "HMIS_hms008", "label": "34. Do this facility provide Post natal care? (confirm from ANC/PNC register)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CalculateHm", "label": "Calculate Maternity Data Records", "type": "calculate", "bind": {"calculate": "if(${HMIS_hms002}='yes',1,0)+if(${HMIS_hms003}='yes',1,0)+if(${HMIS_hms008}='yes',1,0)"}}]}]}, {"name": "Antenatal01", "label": "Antenatal Care", "type": "group", "children": [{"name": "Antenatal02", "label": "1. Business plan contains convincing strategies to effectively conduct ANC for all pregnant women in catchment area", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Antenatal03", "label": "2. Fixed strategy; and strategy for distant villages: catchment area covers entire ward or defined catchment population.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Antenatal04", "label": "3. Weighing scale present, functional and calibrated to zero", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Antenatal05", "label": "4. ANC client cards for HF available and well filled in: last five clients' cards verified", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANCFormFill", "label": "ANC card continuation", "type": "group", "children": [{"name": "ANCFormFil1", "label": "5. All: Examinations Obstetrical done", "type": "select all that apply", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "weight", "label": "Weight"}, {"name": "bp", "label": "BP"}, {"name": "fundal_height_gestational_age", "label": "Fundal height (Gestational age)"}, {"name": "parity", "label": "Parity"}, {"name": "date_of_last_menstruation", "label": "Date of  last menstruation"}, {"name": "fetal_heart_rate", "label": "Fetal heart rate"}, {"name": "presentation", "label": "Presentation"}, {"name": "fetal_movement_recorded", "label": "Fetal movement recorded"}, {"name": "none", "label": "None"}]}, {"name": "ANCFormFil2", "label": "6. All: Laboratory: albuminuria (proteinuria), glucose, etc", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANCFormFil3", "label": "7. ANC clients' card shows the administration of Ferrous Sulphate/Folic Acid, Mebendazole and SP (for the last five clients' cards above)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ANCclient01", "label": "19.1 ANC Register", "type": "group", "children": [{"name": "ANCclient02", "label": "8.ANC register shows administration of Td (Tetanus diphteria) immunization? (check ANC register for past month)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANCclient03", "label": "9. Does the facility provide Intermitent Preventitive Treatment for Malaria?", "hint": "Check the register for IPT, 1, 2, etc", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANCclient04", "label": "10. Are there new ANC cards in stock: (at the least 10)?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ANCregist01", "label": "19.2 ANC register available and well filled in", "type": "group", "children": [{"name": "ANCregist02", "label": "11. Complete identity, state of vaccinations, date of visit, whether high risk pregnancy or not/danger signs", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANCregist03", "label": "12. All columns well filled including the identification of problems if any, and actions taken", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ANCqualifie", "label": "13. ANC conducted by qualified personnel", "hint": "Nurse; midwife CHO or CHEW, verified on ANC cards", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "groupIEC_bc", "label": "19.3 Group IEC/BCC", "type": "group", "children": [{"name": "groupIEC_b1", "label": "14. Group meeting held before FP consultation (check the schedule of health education sessions)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "groupIEC_b2", "label": "15. Existence of updated IEC report with (a) topic, (b) number of participants, (c) leader of activity and (d) date and (e) signature", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "NCDscreenss", "label": "16. Does the facility screen for Non Communicable Diseases?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FacPMTCT001", "label": "17. Does the facility provide PMTCT services (HIV testing services) ?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActionplHap", "label": "19.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "MatComments", "label": "19.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "AntenatCalc", "label": "Calculate Antenatal Care", "type": "calculate", "bind": {"calculate": "if(${Antenatal02}='yes',1,0)+if(${Antenatal03}='yes',1,0)+if(${Antenatal04}='yes',1,0)+if(${Antenatal05}='yes',1,0)+if(contains(${ANCFormFil1},\"weight\"),0.375,0) + if(contains(${ANCFormFil1},\"bp\"),0.375,0) + if(contains(${ANCFormFil1},\"fundal_height_gestational_age\"),0.375,0) + if(contains(${ANCFormFil1},\"parity\"),0.375,0) + if(contains(${ANCFormFil1},\"date_of_last_menstruation\"),0.375,0) + if(contains(${ANCFormFil1},\"fetal_heart_rate\"),0.375,0) + if(contains(${ANCFormFil1},\"presentation\"),0.375,0) + if(contains(${ANCFormFil1},\"fetal_movement_recorded\"),0.375,0)+if(${ANCFormFil2}='yes',1,0)+if(${ANCFormFil3}='yes',1,0)+if(${ANCclient02}='yes',1,0)+if(${ANCclient03}='yes',1,0)+if(${ANCclient04}='yes',1,0)+if(${ANCregist02}='yes',1,0)+if(${ANCregist03}='yes',1,0)+if(${ANCqualifie}='yes',1,0)+if(${groupIEC_b1}='yes',1,0)+if(${groupIEC_b2}='yes',1,0)+if(${NCDscreenss}='yes',1,0)+if(${FacPMTCT001}='yes',1,0)"}}]}, {"name": "MatAntenat1", "label": "Calculate Maternal Health Total", "type": "calculate", "bind": {"calculate": "${DeliMaitTot}+${DefaulTot02}+${CalculateHm}+${AntenatCalc}"}}]}, {"name": "Noenatal001", "label": "Section 19 **Neonatal Health**", "type": "group", "children": [{"name": "Noenatal002", "label": "1. Does the facility provide Neonatal Services?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "within_the_first_three_days", "label": "Within the first three days"}, {"name": "within_the_first_seven_days", "label": "Within the first seven days"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal005", "label": "2. Does the facility provide neonatal resuscitation?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal006", "label": "3. Is there a resuscitation area for the newborn?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal007", "label": "4. Availability of essential equipment", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal008", "label": "5. Are there measuring tapes to measure the newborn's length?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal009", "label": "6. Scale to measure weight (check functionality)", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal010", "label": "7. Aspirator plunged into a non-irritating disinfectant or functional manual/electric aspirator", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal011", "label": "8. Is there a neonatal ambu bag with face masks of sizes 0 and 1?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PengSuctDev", "label": "9. Is there a penguin suction device or a functional electric aspirator?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal013", "label": "10. 4% Chlorhedixidine gel available for cord care- non-expired", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal014", "label": "11. Does the facility mentor mothers on Kangaroo baby Care for low birth weight babies?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal015", "label": "12. Immunization register shows administration of BCG, HPV0 and OPV0? ( check Immunization register)", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal016", "label": "13. Has any of the workers been trained on Emergency Newborn Care Course and LSS ?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal017", "label": "14. Does the facility refer babies suspected to have jaundice?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Noenatal018", "label": "15. Does the facility mentor mothers on early initiation of breast feeding within the first 30mins of delivery?", "type": "select one", "bind": {"relevant": "${Noenatal002} != 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "keycoment12", "label": "20.0 Key Comments", "type": "text", "bind": {"relevant": "${Noenatal002} != 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "ActionNatal", "label": "20.0 Recommended action", "type": "text", "bind": {"relevant": "${Noenatal002} != 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "neonatesCal", "label": "Calculate Neonatal Health Total", "type": "calculate", "bind": {"calculate": "if(${Noenatal002}=\"within_the_first_three_days\" or ${Noenatal002}=\"within_the_first_seven_days\", 2, 0)+if(${Noenatal005}='yes',1,0)+if(${Noenatal006}='yes',1,0)+if(${Noenatal007}='yes',1,0)+if(${Noenatal008}='yes',1,0)+if(${Noenatal009}='yes',1,0)+if(${Noenatal010}='yes',1,0)+if(${Noenatal011}='yes',1,0)+if(${PengSuctDev}='yes',1,0)+if(${Noenatal013}='yes',1,0)+if(${Noenatal014}='yes',1,0)+if(${Noenatal015}='yes',1,0)+if(${Noenatal016}='yes',1,0)+if(${Noenatal017}='yes',1,0)+if(${Noenatal018}='yes',1,0)"}}]}, {"name": "Childheal01", "label": "Section 20 **Child Health - Immunization in EPI tab**", "type": "group", "children": [{"name": "Childheal02", "label": "1. Does the facility offer child health services?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal03", "label": "2. Does the facility offer routine immunization?", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal07", "label": "3. Does the facility conduct routine growth monitoring for children under5? (Sight weighing scale & growth monitoring register)", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal08", "label": "4. Does the facility keep up to date records of Vitamin A?", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal09", "label": "5. Does the facility provide Vitamin A supplement for children 6-59 months?", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal10", "label": "6. Does the facility identify and refer children with danger signs?", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal11", "label": "7. Does the facility assess child nutritional status?", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal12", "label": "8. Does the facility have a fucntional ORT corner?", "hint": "Oral rehydration treatment", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal13", "label": "9. Does the facility have IEC materials for counseling on IMCI and child health? ( sight IEC materials)", "hint": "IMCI (Integrated Management of Childhood Illness)", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal14", "label": "10. Does the facility have a respiratory rate timer?", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Childheal15", "label": "11. Does the facility have a sick child recording form? (Sight form)", "type": "select one", "bind": {"relevant": "${Childheal02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpla12", "label": "21.0 key Comments", "type": "text", "bind": {"relevant": "${Childheal02} = 'yes'"}, "control": {"appearance": "minimal w2"}}, {"name": "ChiComments", "label": "21.0 Recommended action", "type": "text", "bind": {"relevant": "${Childheal02} = 'yes'"}, "control": {"appearance": "minimal w2"}}, {"name": "calculchild", "label": "Calculate Child Health Immunization Total", "type": "calculate", "bind": {"calculate": "if(${Childheal02}='yes',1,0)+if(${Childheal03}='yes',1,0)+if(${Childheal07}='yes',1,0)+if(${Childheal08}='yes',1,0)+if(${Childheal09}='yes',1,0)+if(${Childheal10}='yes',1,0)+if(${Childheal11}='yes',1,0)+if(${Childheal12}='yes',1,0)+if(${Childheal13}='yes',1,0)+if(${Childheal14}='yes',1,0)+if(${Childheal15}='yes',1,0)"}}]}, {"name": "Adolesce001", "label": "Section 21 **Adolescent Health**", "type": "group", "children": [{"name": "Adolesce002", "label": "1. Does the facility provide information, education and counselling on Sexual and Reproductive Health?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce003", "label": "2. Does the facility provide family planning services for sexually active adolescents?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce004", "label": "3. Does the facility provide immunization for Td and HPV?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce005", "label": "4. Does the facility conduct Screening for Hepatitis B, drug use &addiction?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce006", "label": "5. Does the facility conduct referals for Hepatitis B, drug use &addiction?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce007", "label": "6. Does the facility conduct prevention and management of HIV/sexually Transmitted Infections (STIs) Services", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce008", "label": "7. Does the facility provide nutritional services for adolescents?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce009", "label": "8. Does the facility provide youth friendly health services?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Adolesce010", "label": "9. Does the facility provide iron & folic acid supplementation for girls and pregnant adolescents", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActionplChi", "label": "22.0 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "AdoComments", "label": "22. 0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Adocalculat", "label": "Calculate Adolescent Health Total", "type": "calculate", "bind": {"calculate": "if(${Adolesce002}='yes',1,0)+if(${Adolesce003}='yes',1,0)+if(${Adolesce004}='yes',1,0)+if(${Adolesce005}='yes',1,0)+if(${Adolesce006}='yes',1,0)+if(${Adolesce007}='yes',1,0)+if(${Adolesce008}='yes',1,0)+if(${Adolesce009}='yes',1,0)+if(${Adolesce010}='yes',1,0)"}}]}, {"name": "Nutrition01", "label": "Section 22 **Nutrition**", "type": "group", "children": [{"name": "Nutrition02", "label": "1. Does the facility provide nutritional services?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition03", "label": "2. Does the facility provide nutritional counselling?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition04", "label": "3. Is counselling provided to pregnant women", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition05", "label": "4. Is counselling provided to adolescents", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition06", "label": "5. Is IYCF counselling provided to neonates, infants and children's caregivers ?", "hint": "IYCF (Infant and young child feeding)", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition07", "label": "6. Does the facility provide services for the management of moderate acute malnutrition?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition08", "label": "7. Does the facility provide services for the management of severe acute malnutrition?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition09", "label": "8. Is nutrition education being carried out on \nIYCF (ACF, EBF, GMP e.t.c.) on regular basis?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition10", "label": "9. Do you have staff trained on Infant and Young Child Feeding (IYCF)?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition11", "label": "10. Was food demonstration carried out in the health facility in the last one month?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition12", "label": "11. Are the food demonstration utensils e.g. pots, spoons, plates, cooking gas/stove, etc available in the H/F?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition13", "label": "12. Does the facility have Mid-Upper Arm Circumference tape, weighing scale and heightometer", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition14", "label": "13. Does the Health Worker know how to use and interpret MUAC tape measurement? (let Health Worker demonstrate)", "hint": "MUAC (Mid Upper Arm Circumference)", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition15", "label": "14. Does Health Worker monitor growth of children on regular basis? ( sight child growth monitoring card)?", "type": "select one", "bind": {"relevant": "${Nutrition14} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition16", "label": "15. Do Health Worker know how to chart weight appropriately on Child Health Card?", "type": "select one", "bind": {"relevant": "${Nutrition14} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition17", "label": "16. Do Health Worker know how to interpret the growth curve?", "type": "select one", "bind": {"relevant": "${Nutrition14} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition18", "label": "17. are growth monitoring data tools available in Health facility?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition19", "label": "18. does Health Worker know how to record appropriately?", "type": "select one", "bind": {"relevant": "${Nutrition18} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition20", "label": "19. Is weighing carried out on every infant welfare/immunization clinics?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition21", "label": "20. Is any breastfeeding poster pasted on the wall of the Health facility?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition22", "label": "21. Is information on EBF being passed to mothers during clinics?", "hint": "EBF (Exclusive Breast Feeding)", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition23", "label": "22. Does Health facility have salt testing kit?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition24", "label": "23. Does Health worker know how to use it? Let Health worker demonstrate.", "type": "select one", "bind": {"relevant": "${Nutrition23} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition25", "label": "24. Does Health worker carry out salt testing often?", "type": "select one", "bind": {"relevant": "${Nutrition23} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition27", "label": "25. Does the health facility have nutrition data tools ( I.e. GMP,EBF, Screening for malnutrition)", "hint": "GMP (Growth Monitoring and Promotion)\nEBF (Exclusive Breast Feeding)", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition28", "label": "26. Are the data tools properly filled?", "type": "select one", "bind": {"relevant": "${Nutrition27} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition30", "label": "27. Has the Health facility received supportive supervision on Key Nutrition Interventions in the last three months?", "type": "select one", "bind": {"relevant": "${Nutrition02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Nutrition31", "label": "28. Are there any written action points or feedback from previous supervisory visits on nutrition issues.?", "type": "select one", "bind": {"relevant": "${Nutrition30} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActionplNut", "label": "23.0 Key Comments", "type": "text", "bind": {"relevant": "${Nutrition30} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "NutComments", "label": "23.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "NutritTot01", "label": "Calculate Nutrition Total", "type": "calculate", "bind": {"calculate": "if(${Nutrition02}='yes',1,0)+if(${Nutrition03}='yes',1,0)+if(${Nutrition04}='yes',1,0)+if(${Nutrition05}='yes',1,0)+if(${Nutrition06}='yes',1,0)+if(${Nutrition07}='yes',1,0)+if(${Nutrition08}='yes',1,0)+if(${Nutrition09}='yes',1,0)+if(${Nutrition10}='yes',1,0)+if(${Nutrition11}='yes',1,0)+if(${Nutrition12}='yes',1,0)+if(${Nutrition13}='yes',1,0)+if(${Nutrition14}='yes',1,0)+if(${Nutrition15}='yes',1,0)+if(${Nutrition16}='yes',1,0)+if(${Nutrition17}='yes',1,0)+if(${Nutrition18}='yes',1,0)+if(${Nutrition19}='yes',1,0)+if(${Nutrition20}='yes',1,0)+if(${Nutrition21}='yes',1,0)+if(${Nutrition22}='yes',1,0)+if(${Nutrition23}='yes',1,0)+if(${Nutrition24}='yes',1,0)+if(${Nutrition25}='yes',1,0)+if(${Nutrition27}='yes',1,0)+if(${Nutrition28}='yes',1,0)+if(${Nutrition30}='yes',1,0)+if(${Nutrition31}='yes',1,0)"}}]}, {"name": "EPIConsultn", "label": "Section 23 **EPI and Pre-School Consultation**", "type": "group", "children": [{"name": "EPIConsu001", "label": "1. Monthly target population, based on immunization records (Tally sheet, Monitoring chart, etc)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu002", "label": "2. Does the Health facility have a catchment area map in the microplan?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu003", "label": "3. Does the Health facility have an outreach session plan by location?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu004", "label": "4. Does this Health facility have a functional cold chain equipment (i.e., functional refrigerator)?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu005", "label": "5. is there a temperature chart regularly maintained and updated on each of the equipment", "type": "select one", "bind": {"relevant": "${EPIConsu004} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu006", "label": "6. are the vaccines stored properly inside the equipment?", "type": "select one", "bind": {"relevant": "${EPIConsu004} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu007", "label": "7. Does the health facility have an updated vaccine ledger?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu008", "label": "8. Is there a waste disposable system in the Health facility or Plan to dispose waste appropriately", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu009", "label": "9. Has the Health facility received timely funding for RI (in last 3 months)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu010", "label": "10. Is there a functional Village Development committee (VDC)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu011", "label": "11. Is there evidence that the community is involved in organizing RI session", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu012", "label": "12. Does the Health facility Implement all Immunization session plan both outreach and fixed?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu013", "label": "13. Were all session planned for last month conducted?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIConsu014", "label": "14. why were all planned session for last month not conducted?", "type": "select all that apply", "bind": {"relevant": "${EPIConsu013} = 'no'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "non_availbility_of_vaccines_logistics", "label": "non availbility of vaccines/logistics"}, {"name": "no_trained_healthcar_woker", "label": "no trained healthcare woker"}, {"name": "non_avaibility_of_funds", "label": "non avaibility of funds"}, {"name": "competing_programs", "label": "competing programs"}, {"name": "issues_related_with_the_community", "label": "issues related with the community"}, {"name": "other", "label": "Other"}]}, {"name": "EPIConsu014_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../EPIConsu014, 'other')"}}, {"name": "EPIConsu015", "label": "15. How does the health facility receive RI vaccines for sessions?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "delivered", "label": "Delivered"}, {"name": "collected", "label": "Collected"}]}, {"name": "EPIObser001", "label": "Routine Immunization Session", "type": "group", "children": [{"name": "EPIObser002", "label": "16. Is the planned routine immunization session being conducted?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser003", "label": "17. Has the health worker, providing services been formally trained in Routine Immunization ?", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser004", "label": "18. Does the health worker know the expected number of target age children for this particular session?", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser005", "label": "19. Is the health worker using the right diluents for each of vaccine administered (BCG, Measles, YF)", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser006", "label": "20. Does Health Worker give the vaccine correctly i.e. at the correct site, using correct route and with correct dose", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser007", "label": "21. Does Health Worker use only one syringe/needle for each dose of antigen given", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser008", "label": "22. Does Health Worker dispose of used syringes / needle into safety box immediately", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser009", "label": "23. Does health worker tally each vaccine given correctly ?", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser010", "label": "24. Does health worker record on the child health / vaccination card correctly?", "type": "select one", "bind": {"relevant": "${EPIObser002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser018", "label": "Six Key Messages: \n(1) What vaccine(s) was given \n(2) The number of visits a child still needs in order to be fully immunized\n(3) What side effects may occur and how to treat them \n(4) The place and time of the next immunization \n(5) To bring the child for immunization even if he/she is sick \n(6) To take good care of the immunization card and bring it during the next visit", "type": "note"}, {"name": "EPIObser011", "label": "25. Does health worker provide the 6 key messages to parent / caregiver correctly during immunization", "hint": "(see above for the six messages)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser012", "label": "26. Does health worker know definition of AEFI? (Adverse events following immunization)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser013", "label": "27. Has health worker recorded any AEFI in the last 3 months?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser014", "label": "28. Does the Health Facility have AEFI Kits", "hint": "The component of AEFI kit include; adrenaline, paracetamol injection, 2ml syringes, cotton wool, etc.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser015", "label": "29. Are AEFI forms available at the Health Facilities", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser016", "label": "30. Are there any stock out of any of the antigens in the last 3 months?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser017", "label": "31. Are any other products or services being provided together with RI session?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIObser019", "label": "24.1 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "Personnel01", "label": "24.2 Personnel calculates correctly target for fully vaccinated children", "type": "group", "children": [{"name": "Personnel02", "label": "32. Target = population * 4% / 12 : asked from any medical personnel dealing with care for clients", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Personnel03", "label": "33. The target population concerns the ward population (or the defined catchment pop in case ward has more PBF primary contract holders)", "type": "select one", "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPconsulCal", "label": "Calculate Routine Immunization", "type": "calculate", "bind": {"calculate": "if(${EPIConsu001}='yes',1,0)+if(${EPIConsu002}='yes',1,0)+if(${EPIConsu003}='yes',1,0)+if(${EPIConsu004}='yes',1,0)+if(${EPIConsu005}='yes',1,0)+if(${EPIConsu006}='yes',1,0)+if(${EPIConsu007}='yes',1,0)+if(${EPIConsu008}='yes',1,0)+if(${EPIConsu009}='yes',1,0)+if(${EPIConsu010}='yes',1,0)+if(${EPIConsu011}='yes',1,0)+if(${EPIConsu012}='yes',1,0)+if(${EPIConsu013}='yes',1,0)+if(${EPIConsu015}=\"delivered\" or ${EPIConsu015}=\"collected\", 1, 0)+if(${EPIObser002}='yes',1,0)+if(${EPIObser003}='yes',1,0)+if(${EPIObser004}='yes',1,0)+if(${EPIObser005}='yes',1,0)+if(${EPIObser006}='yes',1,0)+if(${EPIObser007}='yes',1,0)+if(${EPIObser008}='yes',1,0)+if(${EPIObser009}='yes',1,0)+if(${EPIObser010}='yes',1,0)+if(${EPIObser011}='yes',1,0)+if(${EPIObser012}='yes',1,0)+if(${EPIObser013}='yes',1,0)+if(${EPIObser014}='yes',1,0)+if(${EPIObser015}='yes',1,0)+if(${EPIObser016}='yes',1,0)+if(${EPIObser017}='yes',1,0)+if(${Personnel02}='yes',1,0)+if(${Personnel03}='yes',1,0)"}}]}, {"name": "EPIFridge00", "label": "24.3 EPI fridge", "type": "group", "children": [{"name": "EPIFridge01", "label": "34. Presence of a fridge - temp form available, filled twice a day including the day of the visit", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIFridge02", "label": "35. Temperature remains between 2 and 8C in register sheet", "type": "select one", "bind": {"relevant": "${EPIFridge01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EPIFridge04", "label": "36. Temperature between 2 and 8C also according to the thermometer", "hint": "Supervisor verifies functionality of thermometer", "type": "select one", "bind": {"relevant": "${EPIFridge01} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ChemTempInd", "label": "37. Chemical Temperature Indicator", "hint": "Presence of a chemical temperature indicator (this is a specific piece of paper different from the thermometer) which shows temperature acc to the norms", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpl019", "label": "24.3 key comments", "type": "text", "bind": {"relevant": "${EPIFridge01} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "EPIcomments", "label": "24.3 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "AppStorVacc", "label": "24.4 Appropriate storage of vaccines", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "FreezeCompt", "label": "38. Freezing compartment: Measles", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FreezeCom01", "label": "39. Non-freezing compartment: BCG, Penta + HepB, TT, thinners", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FreezeCom02", "label": "40. Absence of vaccines which are expired", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FreezeCom03", "label": "41. Readable labels on all vaccines", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "AppStockVac", "label": "24.5 Appropriate stock of vaccines", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "AppStock001", "label": "42. BCG, Penta, Polio, Yellow Fever, HBV, Measles, Tetanus, Hib, IPV, Vit A", "hint": "(All or None)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AppStock002", "label": "43. Presence of stock control cards for all vaccines; concordance paper and physical stock verified", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ColdChainMt", "label": "24.6 Cold Chain maintenance", "type": "group", "children": [{"name": "ColdChain01", "label": "44. If kerosene fridge: stock of at the least 14L Kerosene; if solar fridge: battery not damaged", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ColdChain02", "label": "45. Is there an updated cold chain inventory of all cold chain in the H/F", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ColdChain03", "label": "46. Are there functional refridgerators or cold chain equipment at the LGA/Health Facilty?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ColdChain04", "label": "47. Are all freezers, refridgerators and other cold chain equipment routinely maintained?", "type": "select one", "bind": {"relevant": "${ColdChain03} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ColdChain05", "label": "48. Is pentavalent vaccine stored in the right compartment in the refridgerator?", "type": "select one", "bind": {"relevant": "${ColdChain03} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ColdChain06", "label": "49. Is the pentavalent vaccine kept at the temperature between 2\u00b0c and 8\u00b0c?", "type": "select one", "bind": {"relevant": "${ColdChain03} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActionplEPI", "label": "24.6 Key Comment", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "ColdComment", "label": "24.6 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "ColdPacksFr", "label": "50. Cold packs are well frozen", "hint": "At the least 5", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SyringePres", "label": "51. Syringes available", "hint": "Auto-blocking at least 30; for dilution - at least 3", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SafeDispBox", "label": "52. Waste collection availability of safe disposal box", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "U5StockCard", "label": "53. Stock of U5 growth cards available", "hint": "At the least 10", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImmunRegist", "label": "54. Child immunization register well maintained & Monthly monitoring chart well filled and updated", "hint": "System is capable of identifying drop outs and Fully Vaccinated Children", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImmunRegi01", "label": "55. Are RI data used to monitor defaulters and drop-out children?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImmunRegi02", "label": "56. Are RI data used to update vaccine stock requests to the LGA?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImmunRegi03", "label": "57. Has someone from this facility attended the LGA routine immunization meeting?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImmunRegi04", "label": "58. When was it", "type": "select one", "bind": {"relevant": "${ImmunRegi03} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "last_1_month", "label": "Last 1 Month"}, {"name": "last_2_3_months", "label": "Last 2-3 Months"}, {"name": "more_than_3_months_ago", "label": "More Than 3 Months Ago"}]}, {"name": "ImmunRegi05", "label": "59. Have LGA officials conducted RI supportive supervision visits to this HF?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ImmunRegi06", "label": "60. When was it", "type": "select one", "bind": {"relevant": "${ImmunRegi05} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "last_1_month", "label": "Last 1 Month"}, {"name": "last_2_3_months", "label": "Last 2-3 Months"}, {"name": "more_than_3_months_ago", "label": "More Than 3 Months Ago"}]}, {"name": "LGA_lga0001", "label": "61. Do you have minutes for most recent LGA review meeting? (sight documents)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LGA_lga0002", "label": "62. Was the HFs' RI dashboard reviewed during the LGA-level meeting?", "type": "select one", "bind": {"relevant": "${LGA_lga0001} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LGA_lga0003", "label": "63. Was any issue specific to data quality identified", "type": "select one", "bind": {"relevant": "${LGA_lga0002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LGA_lga0004", "label": "64. If issues specific to data quality were identified, was action taken to address them?", "type": "select one", "bind": {"relevant": "${LGA_lga0003} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes_fully_implemented", "label": "Yes, fully implemented"}, {"name": "yes_partially_implemented", "label": "Yes, partially implemented"}, {"name": "no", "label": "No"}]}, {"name": "WaitAreaCon", "label": "65. Conditions in waiting area for immunization services", "hint": "Sufficient benches and or chairs, protected against sun and rain", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PatNumbWait", "label": "66. Patients receive numbered waiting buttons according to their arrival", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "BabyWeighSc", "label": "67. Baby weighing scale available and in working condition", "hint": "Balance calibrated to zero + pants available, clean and in good condition", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "GroupIECBCC", "label": "24.7 Group IEC/BCC", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "GroupIECBC1", "label": "68. Existence of updated IEC report with (a) topic, (b) number of participants, \u00a9 leader of activity, (d) date and (e) signature", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "GroupIECBC2", "label": "69. Existence of a system to recover drop-outs", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "GroupIECBC3", "label": "70. Schedule, record of appointments, well arranged invidual charts", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CommentIECB", "label": "24.7 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "ActionplBab", "label": "24.7 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "EPIprescCal", "label": "Calculate Vaccine Storage", "type": "calculate", "bind": {"calculate": "if(${EPIFridge01}='yes',1,0)+if(${EPIFridge02}='yes',1,0)+if(${EPIFridge04}='yes',1,0)+if(${ChemTempInd}='yes',1,0)+if(${FreezeCompt}='yes',1,0)+if(${FreezeCom01}='yes',1,0)+if(${FreezeCom02}='yes',1,0)+if(${FreezeCom03}='yes',1,0)+if(${AppStock001}='yes',1,0)+if(${AppStock002}='yes',1,0)+if(${ColdChain01}='yes',1,0)+if(${ColdChain02}='yes',1,0)+if(${ColdChain03}='yes',1,0)+if(${ColdChain04}='yes',1,0)+if(${ColdChain05}='yes',1,0)+if(${ColdChain06}='yes',1,0)+if(${ColdPacksFr}='yes',1,0)+if(${SyringePres}='yes',1,0)+if(${SafeDispBox}='yes',1,0)+if(${U5StockCard}='yes',1,0)+if(${ImmunRegist}='yes',1,0)+if(${ImmunRegi01}='yes',1,0)+if(${ImmunRegi02}='yes',1,0)+if(${ImmunRegi03}='yes',1,0)+if(${ImmunRegi04}=\"last_1_month\",3,0) + if(${ImmunRegi04}=\"last_2_3_months\",2,0) + if(${ImmunRegi04}=\"more_than_3_months_ago\",1,0)+if(${ImmunRegi05}='yes',1,0)+if(${ImmunRegi06}=\"last_1_month\",3,0) + if(${ImmunRegi06}=\"last_2_3_months\",2,0) + if(${ImmunRegi06}=\"more_than_3_months_ago\",1,0)+if(${LGA_lga0001}='yes',1,0)+if(${LGA_lga0002}='yes',1,0)+if(${LGA_lga0003}='yes',1,0)+if(${LGA_lga0004}=\"yes_fully_implemented\", 1, 0) + if(${LGA_lga0004}=\"yes_partially_implemented\", 0.5, 0) + if(${LGA_lga0004}=\"yes_partially_implemented\", 0, 0)+if(${WaitAreaCon}='yes',1,0)+if(${PatNumbWait}='yes',1,0)+if(${BabyWeighSc}='yes',1,0)+if(${GroupIECBC1}='yes',1,0)+if(${GroupIECBC2}='yes',1,0)+if(${GroupIECBC3}='yes',1,0)"}}]}, {"name": "EPIConslTot", "label": "Calculate EPI Total", "type": "calculate", "bind": {"calculate": "${EPconsulCal}+${EPIprescCal}"}}]}, {"name": "SuperSup001", "label": "Section 24 **SUPPORTIVE SUPERVISION(This is specific to LGA)**", "type": "group", "children": [{"name": "SuperSup002", "label": "1. Is there a supportive supervisory plan?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuperSup003", "label": "2. Is supportive supervision being conducted as planned?", "type": "select one", "bind": {"relevant": "${SuperSup002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuperSup004", "label": "3. Are there supervisory report with identified action points?", "type": "select one", "bind": {"relevant": "${SuperSup002} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionplcod", "label": "25.0 Key comments", "type": "text", "bind": {"relevant": "${SuperSup002} = 'no'"}, "control": {"appearance": "minimal w2"}}, {"name": "SuperSup005", "label": "25.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SuperSupTot", "label": "Calculate Supportive Suppervision Total", "type": "calculate", "bind": {"calculate": "if(${SuperSup002}='yes',1,0)+if(${SuperSup003}='yes',1,0)+if(${SuperSup004}='yes',1,0)"}}]}, {"name": "wasteman001", "label": "Section 25 **LGA WASTE MANAGEMENT**", "hint": "This is specific to LGA", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "wasteman002", "label": "1. Does LGA have appropriate waste disposal facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "wasteman003", "label": "2. does the LGA have a waste disposal plan?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionpl005", "label": "26.0 Key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "wasteman005", "label": "26.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "WasteManTot", "label": "Calculate Waste Management Total", "type": "calculate", "bind": {"calculate": "if(${wasteman002}='yes',1,0)+if(${wasteman003}='yes',1,0)"}}]}, {"name": "sec21", "label": "Section 26 **Exit Interview with the Parents / Caregivers**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "SuperSup011", "label": "1.Is the mother / caregiver aware of the importance of Routine Immunization", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuperSup012", "label": "2. Who mobilized the parent / Caregiver to the HF / Immunization site for Immunization", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "traditional_leader", "label": "Traditional Leader"}, {"name": "voluntary_community_mobilizer_v", "label": "Voluntary Community Mobilizer (VCM)"}, {"name": "health_worker", "label": "Health Worker"}, {"name": "ipds_team_member", "label": "IPDs Team member"}, {"name": "field_volunteer_fv", "label": "Field Volunteer (FV)"}, {"name": "religious_leader", "label": "Religious leader"}, {"name": "community_based_organization", "label": "Community Based organization"}, {"name": "traditional_birth_attendant", "label": "Traditional birth Attendant"}, {"name": "others", "label": "Others"}, {"name": "none", "label": "None"}]}, {"name": "SuperSup013", "label": "3. Who decides whether the child receives routine immunization / vaccines in the family (Encircle as appropriate)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "parents", "label": "Parents"}, {"name": "caregiver", "label": "Caregiver"}]}, {"name": "SuperSup014", "label": "4. Is the caregiver aware of what vaccine was given to the child?(confirm from the child health card)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuperSup015", "label": "5. Is the caregiver aware of the next date to come for follow up immunization (confirm from the child health card)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuperSup016", "label": "6. Is the mother / Caregiver satisfied with the immunization services provided at this site.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SuperSup017", "label": "7. Did the child experience any adverse event following immunization during the last vaccination", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Actionplman", "label": "27.0 key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SupComments", "label": "27.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SuperCalcul", "label": "Calculate Caregiver Exit Interview Total", "type": "calculate", "bind": {"calculate": "if(${SuperSup011}='yes',1,0)+if(${SuperSup012}!=\"none\" and ${SuperSup012}!=\"\",1,0)+if(${SuperSup013}!=\"\",1,0)+if(${SuperSup014}='yes',1,0)+if(${SuperSup015}='yes',1,0)+if(${SuperSup016}='yes',1,0)+if(${SuperSup017}='yes',1,0)"}}]}, {"name": "Surveilla01", "label": "Section 27 **Surveillance**", "type": "group", "children": [{"name": "Surveilla02", "label": "Surveillance focal person", "type": "group", "children": [{"name": "SurvelFocal", "label": "1. Is there a surveillance focal person located in the health facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "TrainedFoca", "label": "2. Has the focal person been trained/re-trained in the last 1 year?", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SurvelGuide", "label": "3. Does the focal person have surveillance guideline booklet?", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFPmeaslesY", "label": "4. Does the focal person know the case definiton of AFP, measles, yellow fever, NNT, GWD , CSM,Lassa Fever, cholera and other epidemic prone diseases", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFP3Diffren", "label": "5. Does the surveillance focal person know at least three differentials of AFP and other diseases as written above?", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Stoolcollec", "label": "6. Does the surveillance focal person know the stool collection procedure for AFP?", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActiveCases", "label": "7. Is the focal person aware of the importance of active case search and immediate reporting of AFP, GWD, Measles, NNT etc", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFP6Montths", "label": "8. Has the focal person reported any AFP case in the last six months?", "type": "select one", "bind": {"relevant": "${SurvelFocal} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SurvelComm", "label": "28.0 key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SurvelRecom", "label": "28.0mmended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SurveiTotal", "label": "Calculate Focal Person", "type": "calculate", "bind": {"calculate": "if(${SurvelFocal}='yes',1,0)+if(${TrainedFoca}='yes',1,0)+if(${SurvelGuide}='yes',1,0)+if(${AFPmeaslesY}='yes',1,0)+if(${AFP3Diffren}='yes',1,0)+if(${Stoolcollec}='yes',1,0)+if(${ActiveCases}='yes',1,0)+if(${AFP6Montths}='yes',1,0)"}}]}, {"name": "ActiveCas01", "label": "Active Case Search/Supervision", "type": "group", "children": [{"name": "ActiveCas02", "label": "1. Were ACS/supervisions conducted in the HF in the last three months based on records?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActiveCas03", "label": "2. Were the ACS conducted in the last three months based on prority?", "type": "select one", "bind": {"relevant": "${ActiveCas02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActiveCas04", "label": "3. Were missed priority diseases detected on record review?", "type": "select one", "bind": {"relevant": "${ActiveCas02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActiveCas05", "label": "4. Is there evidence (smart action points with signature and signed register) of ACS/supervision by the State/LGA to the HF in the last three months?", "type": "select one", "bind": {"relevant": "${ActiveCas02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActiveCas06", "label": "5. Is there evidence (smart action points with signature and signed register) of ACS/supervision by partners in the last 3 months?", "type": "select one", "bind": {"relevant": "${ActiveCas02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ActiveComm", "label": "29.0 key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "ActiveRecom", "label": "29.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "ActivCasTot", "label": "Calculate Active Case Search", "type": "calculate", "bind": {"calculate": "if(${ActiveCas02}='yes',1,0)+if(${ActiveCas03}='yes',1,0)+if(${ActiveCas04}='yes',1,0)+if(${ActiveCas05}='yes',1,0)+if(${ActiveCas06}='yes',1,0)"}}]}, {"name": "Feedback001", "label": "Feedback and Logistics", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "Feedback002", "label": "1. Does the focal person receive regular feedback (lab results) on AFP cases and other priority diseases reported?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Feedback003", "label": "2. Is there case definition of priority diseases displayed?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Feedback004", "label": "3. Are posters for priority diseases available?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Feedback005", "label": "4. Are data tools available for reporting surveillance?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Feedback006", "label": "5. Are AFP specimen containers available?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FeedbackComm", "label": "30.0 key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "FeedbackRecom", "label": "30.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "FeebbackTot", "label": "Calculate Feedback and Logistics", "type": "calculate", "bind": {"calculate": "if(${Feedback002}='yes',1,0)+if(${Feedback003}='yes',1,0)+if(${Feedback004}='yes',1,0)+if(${Feedback005}='yes',1,0)+if(${Feedback006}='yes',1,0)"}}]}, {"name": "Clinician01", "label": "Clinicians", "type": "group", "children": [{"name": "Clinician02", "label": "1. Is the clinician familiar with standard case definition of AFP, GWD, NNT, Measles, Yellow Fever and Meningitis", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician03", "label": "2. Does the clinician know the differentials of priority diseases as listed above?", "type": "select one", "bind": {"relevant": "${Clinician02} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician04", "label": "3. Is there a clinic register for the above-mentioned condition?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician05", "label": "4. Does the clinic register contain column for diagnosis/signs and symptoms?", "type": "select one", "bind": {"relevant": "${Clinician04} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician06", "label": "5. Is there any evidence of ACS in the register in the last three months?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician07", "label": "6. Has any of the clinicians seen any AFP case and other priority diseases in the last six months?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician08", "label": "7. Does the clinician receive regular feedback on cases reported?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician09", "label": "8. Is the clinician aware of the importance of timely reporting of priority diseases?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Clinician10", "label": "9. Is the clinician aware of the importance of active case search and the immediate reporting of AFP, GWD, NNT, Measles, Yellow Fever and Meningitis?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClinicComm", "label": "31.0 key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "ClinicRecom", "label": "31.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "CliniciaTot", "label": "Calculate Clinicians", "type": "calculate", "bind": {"calculate": "if(${Clinician02}='yes',1,0)+if(${Clinician03}='yes',1,0)+if(${Clinician04}='yes',1,0)+if(${Clinician05}='yes',1,0)+if(${Clinician06}='yes',1,0)+if(${Clinician07}='yes',1,0)+if(${Clinician08}='yes',1,0)+if(${Clinician09}='yes',1,0)+if(${Clinician10}='yes',1,0)"}}]}, {"name": "AFPsurvel01", "label": "Priority level for AFP surveillance", "type": "group", "children": [{"name": "AFPsurvel02", "label": "1. Is supervision jointly done with Government Staff/partners", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFPsurvel03", "label": "2. When was the last supervisory visit by the DSNO/epidemiologist recorded in supervision logbook", "hint": "see evidence from supervision logbook", "type": "date", "bind": {"constraint": ".<=date(today())", "jr:constraintMsg": "Date should not be later than today", "required": "TRUE"}, "control": {"appearance": "minimal w1"}}, {"name": "AFPsurvel04", "label": "3. When was the facility last supervised by partner organization?", "hint": "see evidence from supervision logbook", "type": "date", "bind": {"constraint": ".<=date(today())", "jr:constraintMsg": "Date should not be later than today", "required": "TRUE"}, "control": {"appearance": "minimal w1"}}, {"name": "AFPsurvel05", "label": "4. Is active case search done by the health facility focal person in the facility every week?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFPsurvel06", "label": "5. Has the health facility surveillance focal person been trained recently?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFPsurvel07", "label": "6. Which of the following does the surveillance focal person/Clinician/ CHEW/JCHEW know the case definition?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFPsurvel09", "label": "7. Has facility reported AFP case in the last 3 years?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AFPsurvel10", "label": "8. Take a Picture of the Updated Case file and save on your phone", "type": "photo", "control": {"appearance": "new"}}, {"name": "Specimen001", "label": "9. does the health facility Focal person know specimen collection procedures?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen002", "label": "10. does the facility have blank AFP surveillance tools?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen005", "label": "11. Are surveillance posters and/or standard case definitions available in the facility and displayed with contact number of DSNO?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen006", "label": "12. Take a Picture of the surveillance poster and save on your phone", "type": "photo", "control": {"appearance": "new"}}, {"name": "NoenatalEmg", "label": "13. How many workers have been trained on Emergency Newborn Care Course and LSS?", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "Specimen007", "label": "14. Number of unreported AFP cases found", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer", "required": "TRUE"}, "control": {"appearance": "w1"}}, {"name": "Specimen008", "label": "15. Are surveillance guidelines available at the facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen009", "label": "16. Is there an updated list of informants (6 month interval)?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen010", "label": "17. When was the last community informants' sensitization?", "type": "date", "bind": {"constraint": ".<=date(today())", "jr:constraintMsg": "Date should not be later than today", "required": "TRUE"}, "control": {"appearance": "minimal w1"}}, {"name": "Specimen011", "label": "18. Is there a log of calls made to the informants in the last one month?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen012", "label": "19. Is the focal person for the nomadic commuity identified and sensitized?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen013", "label": "20. Is there a log of calls made to the Nomadic population focal person?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Specimen014", "label": "21. Does the HF have community informant list of contact numbers", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SurveyCommt", "label": "32.0 Key comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SurveyActio", "label": "32.0 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "SurveCalcut", "label": "Calculate AFP Surveillance", "type": "calculate", "bind": {"calculate": "if(${AFPsurvel02}='yes',1,0)+if(${AFPsurvel05}='yes',1,0)+if(${AFPsurvel06}='yes',1,0)+if(${AFPsurvel07}='yes',1,0)+if(${AFPsurvel09}='yes',1,0)+if(${Specimen001}='yes',1,0)+if(${Specimen002}='yes',1,0)+if(${Specimen005}='yes',1,0)+if(${Specimen008}='yes',1,0)+if(${Specimen009}='yes',1,0)+if(${Specimen011}='yes',1,0)+if(${Specimen012}='yes',1,0)+if(${Specimen013}='yes',1,0)+if(${Specimen014}='yes',1,0)"}}]}, {"name": "SurveTotal1", "label": "Calculate Surveillance Total", "type": "calculate", "bind": {"calculate": "${SurveiTotal}+${ActivCasTot}+${FeebbackTot}+${CliniciaTot}+${SurveCalcut}"}}]}, {"name": "HIVTubercol", "label": "Section 28 **HIV/TB**", "type": "group", "children": [{"name": "HIVCounselR", "label": "1. Well-equipped HIV counseling room ensuring privacy:", "hint": "Plastered and painted wall of solid material\nSmooth cement floor\nCeiling in good condition\nWindows with glass and curtains\nDoors that close", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "IECHIVMater", "label": "2. Availability of IEC/BCC material related to HIV", "hint": "Penis model on the table\nA box of condoms on the table which has at the least 50 condoms\nWall stickers \nPosters (score Yes for any)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PMTCTCounse", "label": "3. Existence of a (HTS) HIV testing service/PMTCT counseling register and lab register according to the norms", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CounselStaf", "label": "4. Staff trained in HIV testing service counseling (certificate original or certified by LGA)", "hint": "At the least one staff trained as a counselor\nAll counseling done by a trained counselor (check certifcicate)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RefSysHIVCl", "label": "5. Referral system and follow up for HIV clients", "hint": "Individual client cards available; planning for CD4 cell counts", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RefSysTuber", "label": "6. Referral system and follow up for TB patients", "hint": "Each Acid Fast Bacillus (AFB)+ PTB patient has a person attached to him/her who supervises DOTS: proof of in register; mobile phone number of such a supervisor is registered\nEach Pulmonary tuberculosis test(PTB) patient has a contact address and/or phone number in both the register and the individual card", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "TBDrugAvail", "label": "7. Availability of anti-tuberculosis drugs (for at least three new clients)", "hint": "Rifampicin-isoniazid-pyrazinamide : cp120+50+300mg\nEtambutol tabs 400 mg", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sec27", "type": "group", "children": [{"name": "Dotsclinic1", "label": "Availability of DOTS clinic", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dotsclinic2", "label": "8. Does the facility have at least one trained personnel on DOTS", "type": "select one", "bind": {"relevant": "${Dotsclinic1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dotsclinic3", "label": "9. Availability of recording and reporting tools (Presumptive register,Specimen Examination form, Treatment register, patient treatment card, stock card, )", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dotsclinic4", "label": "10. Availability of weighing scale?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dotsclinic5", "label": "11. Availability of at least AFB diagnosis", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dotsclinic6", "label": "12. Are all re-treatment cases tested with Mycobacterium tuberculosis/Rifampicin (MTB/Rif) Assay", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Dotsclinic7", "label": "13. Availability of a treatment supporter for every confirmed TB case", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "keycoment15", "label": "33.1 Key Comments", "type": "text", "control": {"appearance": "minimal w2"}}, {"name": "Actionpla15", "label": "33.1 Recommended action", "type": "text", "control": {"appearance": "minimal w2"}}]}, {"name": "HIVTubeCalc", "label": "Calculate HIV Total", "type": "calculate", "bind": {"calculate": "if(${HIVCounselR}='yes',1,0)+if(${IECHIVMater}='yes',1,0)+if(${PMTCTCounse}='yes',1,0)+if(${CounselStaf}='yes',1,0)+if(${RefSysHIVCl}='yes',1,0)+if(${RefSysTuber}='yes',1,0)+if(${TBDrugAvail}='yes',1,0)+if(${Dotsclinic1}='yes',1,0)+if(${Dotsclinic2}='yes',1,0)+if(${Dotsclinic3}='yes',1,0)+if(${Dotsclinic4}='yes',1,0)+if(${Dotsclinic5}='yes',1,0)+if(${Dotsclinic6}='yes',1,0)+if(${Dotsclinic7}='yes',1,0)"}}]}, {"name": "GrandSummat", "label": "Grand Summary Total", "type": "calculate", "bind": {"calculate": "${GenerTotal0}+${BizPlTotal0}+${FinanTotal0}+${indigents01}+${HyMainTot01}+${ConsulTotal}+${FPlanTotal0}+${LaboraTotal}+${TotPatient0}+${EssDrugsCal}+${TracDrugCal}+${MatAntenat1}+${neonatesCal}+${calculchild}+${Adocalculat}+${NutritTot01}+${EPIConslTot}+${SurveTotal1}+${HIVTubeCalc}"}}, {"name": "GranPercent", "label": "Grand Percent Total", "type": "calculate", "bind": {"calculate": "round((${GrandSummat} div 527.25 * 100),2)"}}, {"name": "FormSummary", "label": "Section 34 **Summary**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "GenManageSc", "label": "1. General Management = ${GenerTotal0}", "type": "note", "control": {"appearance": "w2"}}, {"name": "BizPlanScor", "label": "2. Business Plan = ${BizPlTotal0}", "type": "note", "control": {"appearance": "w2"}}, {"name": "FinanceScor", "label": "3. Finance = ${FinanTotal0}", "type": "note", "control": {"appearance": "w2"}}, {"name": "IndigenScor", "label": "4. Community Linkage = ${indigents01}", "type": "note", "control": {"appearance": "w2"}}, {"name": "HygieneScor", "label": "5. Hygiene and Sterilization = ${HyMainTot01}", "type": "note", "control": {"appearance": "w2"}}, {"name": "ConsulScore", "label": "6. Curative Consultation (OPD) = ${ConsulTotal}", "type": "note", "control": {"appearance": "w2"}}, {"name": "FamPlanScor", "label": "7. Family Planning = ${FPlanTotal0}", "type": "note", "control": {"appearance": "w2"}}, {"name": "LaboraScore", "label": "8. Laboratory = ${LaboraTotal}", "type": "note", "control": {"appearance": "w2"}}, {"name": "InPatScore0", "label": "9. Inpatient Wards = ${TotPatient0}", "type": "note", "control": {"appearance": "w2"}}, {"name": "EssenDrugSc", "label": "10. Essential Drugs Management = ${EssDrugsCal}", "type": "note", "control": {"appearance": "w2"}}, {"name": "TraceDrugSc", "label": "11. Tracer Drugs = ${TracDrugCal}", "type": "note", "control": {"appearance": "w2"}}, {"name": "MaternitySc", "label": "12. Maternal Health = ${MatAntenat1}", "type": "note", "control": {"appearance": "w2"}}, {"name": "NeonatalSco", "label": "13. Neonatal Health = ${neonatesCal}", "type": "note"}, {"name": "ChildScore1", "label": "14. Child Health = ${calculchild}", "type": "note"}, {"name": "AdolescScor", "label": "15. Adolescent Health = ${Adocalculat}", "type": "note"}, {"name": "NutritScore", "label": "16. Nutrition = ${NutritTot01}", "type": "note"}, {"name": "EpiScore001", "label": "17. EPI = ${EPIConslTot}", "type": "note"}, {"name": "SurveyScore", "label": "18. Survelliance = ${SurveTotal1}", "type": "note"}, {"name": "HIVTubeScor", "label": "19. HIV/TB = ${HIVTubeCalc}", "type": "note", "control": {"appearance": "w2"}}, {"name": "GrandTotalF", "label": "**Grand Total = ${GrandSummat} out of a Maximum of 527.25 points**", "type": "note", "control": {"appearance": "w2"}}, {"name": "GrandPerNot", "label": "**Percentage score for HF is: ${GranPercent}%**", "type": "note", "control": {"appearance": "w2"}}]}, {"name": "names_of_enumerators", "label": "**Names of Supervisors**", "type": "group", "children": [{"name": "stenumname1", "label": "1st Supervisor name", "hint": "[First-name Last-name]", "type": "text", "bind": {"required": "TRUE"}, "control": {"appearance": "w2"}}, {"name": "stenumeorg1", "label": "1st Supervisor organization", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "fmoh", "label": "FMoH"}, {"name": "nphcda", "label": "NPHCDA"}, {"name": "naca", "label": "NACA"}, {"name": "smoh", "label": "SMoH"}, {"name": "sphcda", "label": "SPHCDA"}, {"name": "soml", "label": "SOML"}, {"name": "lgha", "label": "LGHA"}, {"name": "partners", "label": "Partners"}]}, {"name": "stenumeorg1a", "label": "Specify", "type": "text", "bind": {"relevant": "${stenumeorg1} = 'partners'", "required": "TRUE"}}, {"name": "stenumpnum1", "label": "1st Supervisor phone number", "type": "text", "bind": {"constraint": "regex(.,'^[0-9]{11}$')", "jr:constraintMsg": "Not valid phone number", "required": "TRUE"}, "control": {"appearance": "numbers w1"}}, {"name": "emailaddres", "label": "1st Supervisor email address", "type": "text", "control": {"appearance": "minimal w1"}}, {"name": "ndenumname2", "label": "2nd Supervisor name", "hint": "[First-name Last-name]", "type": "text", "control": {"appearance": "w2"}}, {"name": "ndenumeorg2", "label": "2nd Supervisor organization", "type": "select one", "control": {"appearance": "minimal w1"}, "children": [{"name": "fmoh", "label": "FMoH"}, {"name": "nphcda", "label": "NPHCDA"}, {"name": "naca", "label": "NACA"}, {"name": "smoh", "label": "SMoH"}, {"name": "sphcda", "label": "SPHCDA"}, {"name": "soml", "label": "SOML"}, {"name": "lgha", "label": "LGHA"}, {"name": "partners", "label": "Partners"}]}, {"name": "ndenumeorg2a", "label": "Specify", "type": "text", "bind": {"relevant": "${ndenumeorg2} = 'partners'"}}, {"name": "ndenumpnum2", "label": "2nd Supervisor phone number", "type": "text", "bind": {"constraint": "regex(.,'^[0-9]{11}$')", "jr:constraintMsg": "Not valid phone number"}, "control": {"appearance": "numbers w1"}}, {"name": "rdenumname3", "label": "3rd Supervisor name", "hint": "[First-name Last-name]", "type": "text", "control": {"appearance": "w2"}}, {"name": "rdenumeorg3", "label": "3rd Supervisor organization", "type": "select one", "control": {"appearance": "minimal w1"}, "children": [{"name": "fmoh", "label": "FMoH"}, {"name": "nphcda", "label": "NPHCDA"}, {"name": "naca", "label": "NACA"}, {"name": "smoh", "label": "SMoH"}, {"name": "sphcda", "label": "SPHCDA"}, {"name": "soml", "label": "SOML"}, {"name": "lgha", "label": "LGHA"}, {"name": "partners", "label": "Partners"}]}, {"name": "rdenumeorg3a", "label": "Specify", "type": "text", "bind": {"relevant": "${rdenumeorg3} = 'partners'"}}, {"name": "rdenumpnum3", "label": "3rd Supervisor phone number", "type": "text", "bind": {"constraint": "regex(.,'^[0-9]{11}$')", "jr:constraintMsg": "Not valid phone number"}, "control": {"appearance": "numbers w1"}}, {"name": "thenumname4", "label": "4th Supervisor name", "hint": "[First-name Last-name]", "type": "text", "control": {"appearance": "w2"}}, {"name": "thenumeorg4", "label": "4th Supervisor organization", "type": "select one", "control": {"appearance": "minimal w1"}, "children": [{"name": "fmoh", "label": "FMoH"}, {"name": "nphcda", "label": "NPHCDA"}, {"name": "naca", "label": "NACA"}, {"name": "smoh", "label": "SMoH"}, {"name": "sphcda", "label": "SPHCDA"}, {"name": "soml", "label": "SOML"}, {"name": "lgha", "label": "LGHA"}, {"name": "partners", "label": "Partners"}]}, {"name": "thenumeorg4a", "label": "Specify", "type": "text", "bind": {"relevant": "${thenumeorg4} = 'partners'"}}, {"name": "thenumpnum4", "label": "4th Supervisor phone number", "type": "text", "bind": {"constraint": "regex(.,'^[0-9]{11}$')", "jr:constraintMsg": "Not valid phone number"}, "control": {"appearance": "numbers w1"}}, {"name": "thenumname5", "label": "5th Supervisor name", "hint": "[First-name Last-name]", "type": "text", "control": {"appearance": "w2"}}, {"name": "thenumeorg5", "label": "5th Supervisor organization", "type": "select one", "control": {"appearance": "minimal w1"}, "children": [{"name": "fmoh", "label": "FMoH"}, {"name": "nphcda", "label": "NPHCDA"}, {"name": "naca", "label": "NACA"}, {"name": "smoh", "label": "SMoH"}, {"name": "sphcda", "label": "SPHCDA"}, {"name": "soml", "label": "SOML"}, {"name": "lgha", "label": "LGHA"}, {"name": "partners", "label": "Partners"}]}, {"name": "thenumeorg5a", "label": "Specify", "type": "text", "bind": {"relevant": "${thenumeorg5} = 'partners'"}}, {"name": "thenumpnum5", "label": "5th Supervisor phone number", "type": "text", "bind": {"constraint": "regex(.,'^[0-9]{11}$')", "jr:constraintMsg": "Not valid phone number"}, "control": {"appearance": "numbers w1"}}, {"name": "morepersons", "label": "Are there more persons?", "type": "select one", "control": {"appearance": "minimal w1"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "howmanother", "label": "How many other persons", "type": "integer", "bind": {"constraint": ". >= 0", "jr:constraintMsg": "Must be greater than or equal to zero", "relevant": "${morepersons} = \"yes\""}, "control": {"appearance": "w1"}}]}, {"name": "meta", "type": "group", "control": {"bodyless": true}, "children": [{"name": "instanceID", "type": "calculate", "bind": {"readonly": "true()", "calculate": "concat('uuid:', uuid())"}}, {"name": "instanceName", "type": "calculate", "bind": {"calculate": "concat(${start000000},' ',${timestarted},'_','ISS_PHC','_',${FaciliName0}, '_', jr:choice-name(${StateName00},'${StateName00}'))"}}]}]}