{"name": "BHCPF_WEB", "type": "survey", "title": "QST PHC-BHCPF WEB VERSION", "id_string": "QST_PHC_BHCPF_WEB_VERSION", "sms_keyword": "QST_PHC_BHCPF_WEB_VERSION", "default_language": "English", "version": "2019010801", "choices": {"yes_no": [{"label": "Yes", "name": "yes"}, {"label": "No", "name": "no"}], "enumerator_name": [{"label": "ABBAH ALFRED/08032570090", "name": "abahalfred"}, {"label": "DR ERIC NWOJIJI/08037907240", "name": "dr_eric_nwoji"}, {"label": "EZINNE OGBONNA/07033912035", "name": "ezinne"}, {"label": "NWIGBO OGBONNAYA/08068425607", "name": "nwigbo"}, {"label": "UCHENNA OSCAR NWANKWO/08034146668", "name": "uschenna"}, {"label": "OROKE MOSES/08131985046", "name": "oroke"}, {"label": "CYPRIAN OGBONNA/08037460272", "name": "cyprian"}, {"label": "ACHI NNABUIKE/08160296692", "name": "nnabuike"}, {"label": "NWAKAMA AGOCHUKWU/07030149551", "name": "nwakama"}, {"label": "EMMANUEL ABAH/08037515192", "name": "abahemmanuel"}, {"label": "ERNESTINA OGBA/08036318859", "name": "ernestogba"}, {"label": "PAUL OGAR /08135250294", "name": "paulogar"}, {"label": "CHARITY ANOKE/08068913764", "name": "charityanoke"}, {"label": "TOCHUKWU NWOKWU/08030500054", "name": "tochukwu"}, {"label": "CYNTHIA ELOY/07062831590", "name": "cynthia_"}, {"label": "JUSTINA OLA OKO/08032711127", "name": "justinaola"}, {"label": "AZUENYA UDUMA /07032124846", "name": "azuenye"}, {"label": "PAUL NWACHI/08037605354", "name": "paulnwachi"}, {"label": "NWEGBE PERPETUA/08037977884", "name": "nwegbe"}, {"label": "EMMANUEL ALI/08068271993", "name": "emmanuel"}, {"label": "JOY ORJI/08063450305", "name": "joyorji"}, {"label": "SAMUEL CHINEDU UGURU/08063162757", "name": "samuel"}, {"label": "EUNICE CHUKWU/08067104774", "name": "eunice"}, {"label": "CHINWE ODAH/08143089835", "name": "chinwe"}, {"label": "OKORO ESENI NNACHI/08068281247", "name": "okoro"}, {"label": "JOSEPH EZEUWA/08035450588", "name": "joseph"}, {"label": "KENNETH NWEKE/08107382006", "name": "kenneth"}, {"label": "LEONARD ALEGU/08030886972", "name": "leonard"}], "facility_area": [{"label": "Rural", "name": "rural"}, {"label": "Urban", "name": "urban"}, {"label": "Peri-Urban", "name": "peri-urban"}], "facility_code": [{"label": "General Hospital (GH) \u2013 001", "name": "general_hospital"}, {"label": "Comprehensive Health Centre (CHC) \u2013 002", "name": "com_health_centre"}, {"label": "Primary Health-care Centre (PHC) \u2013 003", "name": "prim_health_centre"}, {"label": "Clinic/Maternity home \u2013 004", "name": "clinic_mat_home"}, {"label": "Health Post \u2013 005", "name": "health_post"}, {"label": "Mobile Clinic \u2013 006", "name": "mobile_clinic"}, {"label": "Dispensary \u2013 007", "name": "dispensary"}], "position_fac": [{"label": "Medical officer", "name": "medical_doctor"}, {"label": "Nurse/Midwife", "name": "nurse_midwife"}, {"label": "Registered nurse", "name": "registered_nurse"}, {"label": "Midwife", "name": "Mid_wife"}, {"label": "Community Health Extension Worker", "name": "chew"}, {"label": "Junior Community Health Extension Worker", "name": "Jchew"}, {"label": "Pharmacist", "name": "pharmacist"}, {"label": "Lab technician", "name": "Lab_technician"}, {"label": "Health records officer", "name": "Health_records_officer"}, {"label": "Environmental health officer", "name": "Environmental_health_officer"}], "facility_own": [{"label": "Government (public)", "name": "government"}, {"label": "Private not-for-profit/NGO", "name": "Private_not-for-profit/NGO"}, {"label": "Private not-for-profit/Faith-based", "name": "private_not-for-profit/Faith-based"}, {"label": "Private for-profit", "name": "private_for-profit"}], "facility_type": [{"label": "Primary health center", "name": "primary_health_center"}, {"label": "Primary health clinic", "name": "primary_health_clinic"}, {"label": "Health post", "name": "health_post"}], "traveling_time": [{"label": "0-10 minutes", "name": "zero_to_ten_minutes"}, {"label": "11-20 minutes", "name": "eleven_to_twenty_minutes"}, {"label": "> 20 minutes", "name": "greater_than_twenty_minutes"}], "emer_trans": [{"label": "Ambulance owned by facility", "name": "ambulance_owned_facility"}, {"label": "Ambulance available on call", "name": "ambulance_on_call"}, {"label": "Official vehicle (not an ambulance) owned by facility", "name": "official_vehicle_on_call"}, {"label": "Official vehicle (not an ambulance) available on call", "name": "official_vehicle_on_call"}, {"label": "Private vehicle (not ambulance) available on call", "name": "official_vehicle_on_call"}, {"label": "Emergency patient transport", "name": "emergency_patient_transport"}, {"label": "No ambulance/vehicle in the facility", "name": "no_vehicle_in_facility"}], "yes_no_na": [{"label": "Yes", "name": "yes"}, {"label": "No", "name": "no"}, {"label": "Not Applicable", "name": "na"}], "purpose_of_last_trip": [{"label": "Transport health worker to another post", "name": "transport_health_worker"}, {"label": "Transport a patient to another health facility", "name": "transport_patient"}, {"label": "Not Applicable", "name": "na"}], "reason_for_delay_of_qip": [{"label": "Delay in submission of QIP by facility", "name": "delay_in _submission"}, {"label": "Headquarters not approving QIP", "name": "hq_not approving_qip"}, {"label": "Not Applicable", "name": "na"}], "state_of_building": [{"label": "Good; does not require renovation", "name": "no_renovation"}, {"label": "Requires light renovation", "name": "light_renovation"}, {"label": "Requires modest renovation", "name": "modest_renovation"}, {"label": "Requires significant renovation", "name": "significant_renovation"}], "state_of_roof": [{"label": "Good; does not require renovation", "name": "no_renovation"}, {"label": "Requires light renovation", "name": "light_renovation"}, {"label": "Requires modest renovation", "name": "modest_renovation"}, {"label": "Requires significant renovation", "name": "significant_renovation"}], "state_of_fence": [{"label": "Good; does not require renovation", "name": "no_renovation"}, {"label": "Requires light renovation", "name": "light_renovation"}, {"label": "Requires modest renovation", "name": "modest_renovation"}, {"label": "Requires significant renovation", "name": "significant_renovation"}, {"label": "No Fence", "name": "no_fence"}], "source_of_power": [{"label": "No power supply", "name": "none"}, {"label": "Electric power grid", "name": "power_grid"}, {"label": "Fuel operated generator", "name": "fuel_gen"}, {"label": "Battery operated generator", "name": "battery_gen"}, {"label": "Solar system", "name": "solar_system"}], "source_of_power_alt": [{"label": "No alternative source of power", "name": "none"}, {"label": "Electric power grid", "name": "power_grid"}, {"label": "Fuel operated generator", "name": "fuel_gen"}, {"label": "Battery operated generator", "name": "battery_gen"}, {"label": "Solar system", "name": "solar_system"}], "source_of_water": [{"label": "Piped into facility", "name": "piped_into_facility"}, {"label": "Piped onto facility grounds", "name": "piped_onto_facility"}, {"label": "Public tap/standpipe", "name": "public_tap"}, {"label": "Borehole", "name": "borehole"}, {"label": "Protected dug well", "name": "protected_dug_well"}, {"label": "Unprotected dug well", "name": "unprotected_dug_well"}, {"label": "Protected spring", "name": "protected_spring"}, {"label": "Unprotected spring", "name": "unprotected_spring"}, {"label": "Rainwater", "name": "rain_water"}, {"label": "Bottled water", "name": "bottled_water"}, {"label": "Cart w/small tank/drum", "name": "cart_w_small_tank_drum"}, {"label": "Tanker Truck", "name": "truck"}, {"label": "Surface water", "name": "surface_water"}, {"label": "Don't know", "name": "dont_know"}], "source_of_water_alt": [{"label": "No alternative source of water", "name": "none"}, {"label": "Piped into facility", "name": "piped_into_facility"}, {"label": "Piped onto facility grounds", "name": "piped_onto_facility"}, {"label": "Public tap/standpipe", "name": "public_tap"}, {"label": "Borehole", "name": "borehole"}, {"label": "Protected dug well", "name": "protected_dug_well"}, {"label": "Unprotected dug well", "name": "unprotected_dug_well"}, {"label": "Protected spring", "name": "protected_spring"}, {"label": "Unprotected spring", "name": "unprotected_spring"}, {"label": "Rainwater", "name": "rain_water"}, {"label": "Bottled water", "name": "bottled_water"}, {"label": "Cart w/small tank/drum", "name": "cart_w_small_tank_drum"}, {"label": "Tanker Truck", "name": "truck"}, {"label": "Surface water", "name": "surface_water"}, {"label": "Don't know", "name": "dont_know"}], "toilet_type": [{"label": "No functioning toilet", "name": "none"}, {"label": "Bush", "name": "bush"}, {"label": "Flush toilet", "name": "flush_toilet"}, {"label": "Flush toilet (but no water)", "name": "flush_toilet_no_water"}, {"label": "VIP latrine", "name": "vip_latrine"}, {"label": "Covered pit latrine (no slab)", "name": "pit_latrine_covered_no_slab"}, {"label": "Covered pit latrine (w/ slab)", "name": "pit_latrine_covered_with_slab"}, {"label": "Uncoverd pit latrine (no slab)", "name": "pit_latrine_uncovered_no_slab"}, {"label": "Uncovered pit latrine (w/ slab)", "name": "pit_latrine_uncovered_with_slab"}, {"label": "Composting toilet", "name": "composting_toilet"}], "waste_disposal": [{"label": "Incinerator", "name": "incinerator"}, {"label": "1 chamber drum/brick", "name": "1_chamber_drum"}, {"label": "Flat ground - no protection", "name": "flat_ground_no_protection"}, {"label": "Flat ground - with protection", "name": "flat_ground_with_protection"}, {"label": "Pit or protected ground", "name": "pit_protected_ground"}, {"label": "Covered pit or pit latrine", "name": "covered_pit"}, {"label": "Open pit - no protection", "name": "open_pit_no_protection"}, {"label": "Protected ground or pit", "name": "protected_ground_pit"}, {"label": "Stored in covered container", "name": "covered_container"}, {"label": "Stored unprotected", "name": "stored_unprotected"}, {"label": "Facility never has sharp waste", "name": "facility_no_sharp_waste"}, {"label": "Waste collection agency", "name": "waste_collection_agency"}], "financial_management_tools": [{"label": "Receipt boks", "name": "receipt_books"}, {"label": "Payment voucher", "name": "payment_voucher"}, {"label": "Cah books", "name": "cash_books"}, {"label": "Check Issue/Register", "name": "check_issue_ledger"}, {"label": "General Ledger/Vote book", "name": "general_legder_vote_book"}, {"label": "Stores Records", "name": "stores_records"}, {"label": "Statement of expenditure", "name": "statement_of_expenditure"}, {"label": "Did not receive any tools", "name": "did_not_receive_tools"}], "last_calendar_year_visit_accounts_person": [{"label": "Weekly", "name": "weekly"}, {"label": "Biweekly (every two weeks)", "name": "biweekly"}, {"label": "Monthly", "name": "monthly"}, {"label": "Quarterly", "name": "quarterly"}, {"label": "Yearly", "name": "yearly"}], "share_financial_info": [{"label": "Hard copy reports", "name": "hard_copy_reports"}, {"label": "During meetings", "name": "during_meeti"}, {"label": "Chalkboard", "name": "chalk_board"}, {"label": "Posters", "name": "posters"}], "gov_level": [{"label": "State government only", "name": "state"}, {"label": "Local government only", "name": "local"}, {"label": "Both state and local government", "name": "state_local"}], "delay_gov_fund": [{"label": "Delay in submission of quality (business/work) implementation plan", "name": "delay_submission_quality"}, {"label": "Delay in receiving authority to incur expenses (AIE) from authorities", "name": "delay_receive_authority"}, {"label": "Unable to provide timely accounts to LGA or state treasury", "name": "unable_provide_timely_account"}, {"label": "Audit issues raised on facility's account", "name": "audit_issues"}, {"label": "Capacity problems at LGA or state treasury", "name": "capacity_problems"}], "alt_sources_fund": [{"label": "Drug revolving", "name": "drug_revolv"}, {"label": "Registration", "name": "registration"}, {"label": "Development partners/NGOs", "name": "dev_partners_ngos"}], "fac_alloc_spent_bizplan": [{"label": "There is no alignment between spending and the plans", "name": "no_alignment"}, {"label": "Less than 60% of allocation spent on QIP", "name": "less_than_60_spent"}, {"label": "\u2265 60% of allocation spent on QIP", "name": "more_than_60_spent"}], "delay_pay_salary": [{"label": "Never", "name": "never"}, {"label": "Seldom (Once in a year)", "name": "seldom"}, {"label": "Often (Once every 3-6 months)", "name": "often"}, {"label": "Always", "name": "always"}], "attendance_sys": [{"label": "No attendance register available", "name": "none"}, {"label": "Attendance register available but not monitored", "name": "avail_no_monitoring"}, {"label": "Attendance register available and verified by the health facility supervisor", "name": "avail_monitored"}], "staff_recruit_procedures": [{"label": "There are no laid down procedures for staff", "name": "none"}, {"label": "Procedures exists but are not documented", "name": "proc_exist_not_monitor"}, {"label": "Documented procedures exists and are implemented", "name": "doc_proc_exist_implemented"}], "cadre": [{"label": "Superintendent", "name": "super_intindent"}, {"label": "Specialist", "name": "specialist"}, {"label": "Medical officer", "name": "medical_officer"}, {"label": "Community Health Officer", "name": "comm_health_officer"}, {"label": "CHEW", "name": "chew"}, {"label": "Junior CHEW", "name": "junior_chew"}, {"label": "Environmental Health Officer", "name": "environ_health_offic"}, {"label": "BSc Nurse", "name": "bsc_nurse"}, {"label": "Registered Nurse", "name": "regist_nurse"}, {"label": "Registered Midwife", "name": "regist_midwife"}, {"label": "Psychiatric Nurse", "name": "psych_nurse"}, {"label": "Dentist", "name": "dentist"}, {"label": "Pharmacist", "name": "pharmacist"}, {"label": "Laboratory Technician / Technologist", "name": "Lab_technician_technologist"}, {"label": "Volunteer (indicate cadre)", "name": "volunteer"}], "gender": [{"label": "Male", "name": "male"}, {"label": "Female", "name": "female"}], "reason_for_absence": [{"label": "Sick / maternity", "name": "sick_maternity"}, {"label": "In training / seminar", "name": "training_seminar"}, {"label": "Official mission", "name": "official_mission"}, {"label": "Approved absence", "name": "approved_absence"}, {"label": "Not his / her shift", "name": "not_his_her_shift"}, {"label": "Doing fieldwork or outreach work", "name": "field_outreach_work"}, {"label": "Not approved absence", "name": "not_approved_absence"}, {"label": "Gone to retreive salary", "name": "retreive_salary"}, {"label": "On strike", "name": "strike"}], "family_plan_services": [{"label": "Counselling services", "name": "couns_services"}, {"label": "Counselling and commodity services", "name": "couns_comm_services"}], "family_plan_commodity": [{"label": "None", "name": "none"}, {"label": "Condoms", "name": "condoms"}, {"label": "Oral pills", "name": "oral_pills"}, {"label": "Injectibles", "name": "injectibles"}, {"label": "Implants", "name": "implants"}, {"label": "IUC", "name": "iuc"}], "araf_for_anc": [{"label": "No antenatal risk assessment form", "name": "none"}, {"label": "Antenatal risk assessment form present but not used regularly for ANC", "name": "araf_present_not_used"}, {"label": "Antenatal risk assessment form present and used regularly for ANC", "name": "araf_present_used"}], "del_room_light": [{"label": "Yes, Electricity and rechargeable lamp", "name": "elect_rech_lamp"}, {"label": "Yes, Only Electricity", "name": "elect_only"}, {"label": "No", "name": "no"}], "partograph_for_delivery": [{"label": "No partograph in the facility", "name": "none"}, {"label": "Partograph is present but not used", "name": "present_unused"}, {"label": "Partograph is present and used for delivery", "name": "present_used"}], "growth_monit_services": [{"label": "The facility does not offer growth monitoring services", "name": "not_offered"}, {"label": "There is no evidence that the facility offers growth monitoring services", "name": "no_evidence"}, {"label": "There is documented evidence that the facility offers growth monitoring services", "name": "docum_evidence"}], "basic_nuti_ass_guide": [{"label": "No measuring tapes available", "name": "no_tapes"}, {"label": "Measuring tapes available but there is no documentation on MUAC", "name": "tapes_avail_no_doc"}, {"label": "Measuring tapes and documentation available for MUAC", "name": "tapes_doc_avail"}], "yes_obs_no": [{"label": "Yes (observed and functional)", "name": "yes_obs"}, {"label": "No", "name": "no"}], "doc_rosters": [{"label": "The facility does not have any duty roster", "name": "no_duty_roster"}, {"label": "The facility has a duty roster but is not followed", "name": "duty_ros_not_foll"}, {"label": "The facility has a duty roster that is being followed", "name": "duty_ros_foll"}], "impl_univ_prec": [{"label": "No appropriate PPE (gloves, aprons, covered footwear, face masks, etc.)/job aids guidelines", "name": "no_ppe"}, {"label": "Appropriate PPE/job aids available but no evidence of implementation", "name": "ppe_unused"}, {"label": "Appropriate PPE/job aids available and visibly in use", "name": "ppe_used"}], "prov_privacy": [{"label": "No privacy/confidentiality provided for clients", "name": "no_privacy"}, {"label": "Provision for privacy/confidentiality is inadequate", "name": "privacy_inadequate"}, {"label": "Privacy/confidentiality is provided for clients and is adequate", "name": "privacy_adequate"}], "staff_manage": [{"label": "Officer-in-Charge", "name": "off_in_charge"}, {"label": "Medical Officer", "name": "med_officer"}, {"label": "Pharmacy Technician", "name": "pharm_tech"}, {"label": "Pharmacy Assistant", "name": "pharm_ass"}, {"label": "Pharmacist", "name": "pharmacist"}, {"label": "CHEW", "name": "chew"}, {"label": "JCHEW", "name": "jchew"}, {"label": "Lab Technician", "name": "lab_tech"}], "fac_resupply_estim": [{"label": "Facility itself (pull mechanism)", "name": "fac_itself"}, {"label": "Higher level facility (push mechanism)", "name": "high_level_fac"}, {"label": "Combination", "name": "combination"}], "supp_health_comm": [{"label": "LGA Store", "name": "lga_store"}, {"label": "NGO/Donors", "name": "ngo_donors"}, {"label": "Open Market", "name": "open_market"}], "means_drugs_supplied": [{"label": "Supplier delivers to facility", "name": "supplier_to_facility"}, {"label": "Facility arranges delivery", "name": "facility_arrange_del"}], "transport_cost_delivery": [{"label": "Supplier", "name": "supplier"}, {"label": "Facility", "name": "facility"}], "record_exp_drugs": [{"label": "No record of expired drugs or losses kept", "name": "no_record"}, {"label": "Record of expired drugs kept but not up to date", "name": "record_not_uptodate"}, {"label": "Record of expired drugs kept are up to date", "name": "records_uptodate"}], "drug_list": [{"label": "No drug price list available", "name": "no_drug_list"}, {"label": "Drug price list present but not displayed", "name": "list_pres_not_displayed"}, {"label": "Drug price list present and displayed", "name": "list_pres_displayed"}], "lab_list": [{"label": "No laboratory price list available", "name": "no_lab_list"}, {"label": "Laboratory price list present but not displayed", "name": "list_pres_not_displayed"}, {"label": "Laboratory price list present and displayed", "name": "list_pres_displayed"}], "phc_lab_services": [{"label": "Heamatology (PCV, Haemoglobin)", "name": "heam_pcv"}, {"label": "Pregnancy test", "name": "preg_test"}, {"label": "Urine dipsticks for sugar and protein", "name": "sugar_protein_test"}, {"label": "Syphillis rapid test", "name": "syph_rap_test"}, {"label": "Malaria diagnostics", "name": "mal_diag"}, {"label": "HIV diagnostics", "name": "hiv_diag"}, {"label": "Dried Blood Spots (DBS) preparation", "name": "dbs_prep"}, {"label": "TB diagnostics", "name": "tb_diag"}, {"label": "venous collection for CD4", "name": "ven_collect_cd4"}], "hmis_forms_reg": [{"label": "No relevant HMIS forms/registers available", "name": "no_form_reg"}, {"label": "Some HMIS forms/registers available but not up to date (month prior to assessment)", "name": "some_form_avail_not_uptodate"}, {"label": "All relevant HMIS forms/registers available and up to date (month prior to assessment)", "name": "all_form_avail_uptodate"}], "hmis_info_display": [{"label": "HMIS information not represented graphically", "name": "not_rep_graph"}, {"label": "HMIS information represented graphically, but not displayed", "name": "rep_graph_not_display"}, {"label": "HMIS information represented graphically and displayed", "name": "rep_graph_display"}], "nhmis_analyed": [{"label": "Not analysed", "name": "not_analyzed"}, {"label": "Analysed", "name": "analyzed"}, {"label": "Analyzed and shared", "name": "analyzed_shared"}, {"label": "Analysed and used for decision (minutes available)", "name": "analyzed_decision"}], "reg_corres_hmis": [{"label": "The information registers does not correspond with the HMIS data sent to LGA", "name": "info_not_corres"}, {"label": "Some of the information in the registers correspond with the HMIS data sent to LGA=", "name": "some_info_corres"}, {"label": "All the information in the register correspond with the HMIS data sent to LGA", "name": "all_info_corres"}], "comm_outreach_serv": [{"label": "No community outreach services occurring", "name": "no_outreach"}, {"label": "Community outreach services are occurring but not scheduled", "name": "outreach_occ_not_scheduled"}, {"label": "Planned community outreach services are occurring", "name": "outreach_plan_occ"}], "pub_health_ser": [{"label": "No publicity of available health services", "name": "no_pub_avail"}, {"label": "There is no evidence of publicity of available health services", "name": "no_evidence_pub"}, {"label": "There is evidence of publicity of available health services", "name": "evidence_pub_avail"}], "local_comm_involv": [{"label": "Outreaches are solely planned and executed by facility", "name": "exec_by_fac_sole"}, {"label": "Outreaches are planned with local community/Facility Management Committee only, execution is solely carried out by facility staff", "name": "plan_w_local_comm"}, {"label": "Outreaches are planned and implemented in collaboration with the local community/Facility Management Committee", "name": "plan_impl_w_loc_fac_man"}], "review_meeting": [{"label": "None exist", "name": "none"}, {"label": "Review meeting does not occur regularly", "name": "not_regular"}, {"label": "Review meetings are held regularly (monthly)", "name": "regular_monthly"}]}, "style": "theme-grid", "namespaces": "esri=\"http://esri.com/xforms\"\nenk=\"http://enketo.org/xforms\"", "children": [{"name": "start000000", "label": "start", "type": "start"}, {"name": "end00000000", "label": "end", "type": "end"}, {"name": "timestarted", "label": "start time", "type": "calculate", "bind": {"calculate": "format-date-time(now(),'%H:%M')"}}, {"name": "qualityscor", "label": "Welcome to the BHCPF Quality Scoring Tool for PHCs\n\n(Facility Assessment Tool)\n\nMarch 2019", "type": "note"}, {"name": "Permiss0001", "label": "Section 1. **Permission**", "type": "group", "children": [{"name": "name1", "type": "calculate", "bind": {"calculate": "1"}}, {"name": "Permiss0002", "label": "${name1}. Do you agree to be interviewed?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "name2", "type": "calculate", "bind": {"calculate": "2"}}, {"name": "Permiss0003", "label": "${name2}. What is your reason for refusal.", "type": "text", "bind": {"relevant": "${Permiss0002}='no'"}}, {"name": "name3", "type": "calculate", "bind": {"calculate": "if(${Permiss0002} = 'no',${name1} + 2,${name1} + 1)"}}, {"name": "Notes000000", "label": "${name3} . NOTES", "type": "text"}]}, {"name": "surv_start", "label": "Start of Survey", "type": "group", "bind": {"relevant": "${Permiss0002}='yes'"}, "children": [{"name": "FaciInf0001", "label": "Section 2. **Facility Information**", "type": "group", "children": [{"name": "StateName00", "label": "1. State", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "itemset": "states.csv"}, {"name": "CalcState00", "type": "calculate", "bind": {"calculate": "if(${StateName00} = '','',once(now()))"}}, {"name": "LGAName0000", "label": "2. Local Government Area", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "itemset": "LGAs.csv", "choice_filter": "states=${StateName00}"}, {"name": "CalcLGA0000", "type": "calculate", "bind": {"calculate": "if(${LGAName0000} = '','',once(now()))"}, "choice_filter": "wards=${WardName001}"}, {"name": "WardName001", "label": "3. Wards", "type": "select one", "bind": {"relevant": "${StateName00} = 'ebonyi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "itemset": "ebonyi_wards.csv", "choice_filter": "LGAs = ${LGAName0000}"}, {"name": "WardName000", "label": "3. Ward", "type": "text", "bind": {"relevant": "${StateName00} != 'ebonyi'", "required": "TRUE"}}, {"name": "CalcWard000", "type": "calculate", "bind": {"calculate": "if(${WardName000} = '','',once(now()))"}}, {"name": "FaciliNamEb", "label": "4. Health Facility Name", "type": "select one", "bind": {"relevant": "${StateName00} = 'ebonyi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w2"}, "itemset": "ebonyi_facilities.csv", "choice_filter": "wards=${WardName001}"}, {"name": "FacilitName", "label": "4. Health Facility Name", "type": "select one", "bind": {"relevant": "${StateName00} != 'ebonyi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w2"}, "itemset": "facilities.csv", "choice_filter": "LGAs = ${LGAName0000} or LGAs = -88"}, {"name": "CalcFacilit", "type": "calculate", "bind": {"calculate": "if(${FacilitName} = '','',once(now()))"}}, {"name": "otherfacili", "label": "Type in facility name", "hint": "Please remember to take necessary steps to add this facility to the master facility list", "type": "text", "bind": {"relevant": "${FacilitName} = 'other_facility'"}}, {"name": "FacilitType", "label": "5. Health Facility Type", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "primary_health_center", "label": "Primary health center"}, {"name": "primary_health_clinic", "label": "Primary health clinic"}, {"name": "health_post", "label": "Health post"}]}, {"name": "FacilitCode", "label": "6. Health Facility Code", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "general_hospital", "label": "General Hospital (GH) \u2013 001"}, {"name": "com_health_centre", "label": "Comprehensive Health Centre (CHC) \u2013 002"}, {"name": "prim_health_centre", "label": "Primary Health-care Centre (PHC) \u2013 003"}, {"name": "clinic_mat_home", "label": "Clinic/Maternity home \u2013 004"}, {"name": "health_post", "label": "Health Post \u2013 005"}, {"name": "mobile_clinic", "label": "Mobile Clinic \u2013 006"}, {"name": "dispensary", "label": "Dispensary \u2013 007"}]}, {"name": "FacilitArea", "label": "7. Is the facility rural or urban?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "rural", "label": "Rural"}, {"name": "urban", "label": "Urban"}, {"name": "peri-urban", "label": "Peri-Urban"}]}, {"name": "ArrivalTime", "label": "8. Arrival time for first visit", "type": "text", "bind": {"required": "TRUE", "calculate": "format-date-time(now(),'%H:%M')"}}, {"name": "Coordinates", "label": "9. Collect the GPS coordinates of this facility.", "type": "geopoint", "control": {"accuracyThreshold": "5", "appearance": "w4"}}]}, {"name": "GenInfo001", "label": "Section 3. **General Information**", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "nRespondent", "label": "1. Name of Respondent", "hint": "[First-name Last-name]", "type": "text", "bind": {"required": "TRUE"}, "control": {"appearance": "multiline w2"}}, {"name": "numbeRespon", "label": "2. Number of Respondent", "type": "text", "bind": {"required": "TRUE", "constraint": "regex(.,'[0-9]{10}')"}, "control": {"appearance": "number"}}, {"name": "iocpersonel", "label": "3. Are you the OIC", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PositOccupi", "label": "4. Which position do you occupy in this facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "medical_doctor", "label": "Medical officer"}, {"name": "nurse_midwife", "label": "Nurse/Midwife"}, {"name": "registered_nurse", "label": "Registered nurse"}, {"name": "Mid_wife", "label": "Midwife"}, {"name": "chew", "label": "Community Health Extension Worker"}, {"name": "Jchew", "label": "Junior Community Health Extension Worker"}, {"name": "pharmacist", "label": "Pharmacist"}, {"name": "Lab_technician", "label": "Lab technician"}, {"name": "Health_records_officer", "label": "Health records officer"}, {"name": "Environmental_health_officer", "label": "Environmental health officer"}, {"name": "other", "label": "Other"}]}, {"name": "PositOccupi_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../PositOccupi, 'other')"}}, {"name": "Facilityown", "label": "5. Who owns this facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "government", "label": "Government (public)"}, {"name": "Private_not-for-profit/NGO", "label": "Private not-for-profit/NGO"}, {"name": "private_not-for-profit/Faith-based", "label": "Private not-for-profit/Faith-based"}, {"name": "private_for-profit", "label": "Private for-profit"}, {"name": "other", "label": "Other"}]}, {"name": "Facilityown_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../Facilityown, 'other')"}}, {"name": "PaySalaryst", "label": "6. Who mainly pays the salaries of staff at this facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "government", "label": "Government (public)"}, {"name": "Private_not-for-profit/NGO", "label": "Private not-for-profit/NGO"}, {"name": "private_not-for-profit/Faith-based", "label": "Private not-for-profit/Faith-based"}, {"name": "private_for-profit", "label": "Private for-profit"}, {"name": "other", "label": "Other"}]}, {"name": "PaySalaryst_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../PaySalaryst, 'other')"}}, {"name": "PaySupplies", "label": "7.Who mainly pays for medical supplies (equipment, drugs, commodities) for this facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "government", "label": "Government (public)"}, {"name": "Private_not-for-profit/NGO", "label": "Private not-for-profit/NGO"}, {"name": "private_not-for-profit/Faith-based", "label": "Private not-for-profit/Faith-based"}, {"name": "private_for-profit", "label": "Private for-profit"}, {"name": "other", "label": "Other"}]}, {"name": "PaySupplies_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../PaySupplies, 'other')"}}, {"name": "PayOprMaint", "label": "8. Who mainly pays for operation & maintenance costs for this facility?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "government", "label": "Government (public)"}, {"name": "Private_not-for-profit/NGO", "label": "Private not-for-profit/NGO"}, {"name": "private_not-for-profit/Faith-based", "label": "Private not-for-profit/Faith-based"}, {"name": "private_for-profit", "label": "Private for-profit"}, {"name": "other", "label": "Other"}]}, {"name": "PayOprMaint_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../PayOprMaint, 'other')"}}, {"name": "FacilitType", "label": "9. What type of health facility is this?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "primary_health_center", "label": "Primary health center"}, {"name": "primary_health_clinic", "label": "Primary health clinic"}, {"name": "health_post", "label": "Health post"}]}, {"name": "NumRoomFaci", "label": "10. How many rooms does this health facility have?", "type": "integer", "bind": {"required": "TRUE", "jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0"}}, {"name": "NumRoomFac1", "label": "11. Take a picture of the waiting area in the health facility if available", "type": "photo"}, {"name": "NumRoomFac2", "label": "12. Take a picture of the consulting room in the health facility if available", "type": "photo"}, {"name": "TravelTime0", "label": "13. What is the traveling time by car, in minutes, to the state capital in the DRY season?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "zero_to_ten_minutes", "label": "0-10 minutes"}, {"name": "eleven_to_twenty_minutes", "label": "11-20 minutes"}, {"name": "greater_than_twenty_minutes", "label": "> 20 minutes"}]}, {"name": "TravelTime1", "label": "14. What is the traveling time by car, in minutes, to the state capital in the RAINY season?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "zero_to_ten_minutes", "label": "0-10 minutes"}, {"name": "eleven_to_twenty_minutes", "label": "11-20 minutes"}, {"name": "greater_than_twenty_minutes", "label": "> 20 minutes"}]}, {"name": "CatchmenAre", "label": "15. Does this facility have a specified catchment area\u2014that is a defined geographic area for which the facility has direct responsibility for serving?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "nuCatchAr", "type": "group", "children": [{"name": "numCatchAre", "label": "16. How many people live in the catchment area for this facility?", "type": "integer", "bind": {"relevant": "${CatchmenAre} = 'yes'", "required": "TRUE", "jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0"}}]}]}, {"name": "AdminSysInf", "label": "Section 4. Administrative System and Infrastructure", "type": "group", "children": [{"name": "AdminSys", "label": "Administrative System", "type": "group", "children": [{"name": "FacServices", "label": "1. Does the health facility offer 24 hour's services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FunctiPhone", "label": "2. Does the facility have a functioning mobile phone with ability to charge?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FunctioComp", "label": "3. Does this facility have a functioning computer?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "InterAccess", "label": "4. Is there access to email or internet within the facility today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "name5", "type": "calculate", "bind": {"calculate": "5"}}, {"name": "EmergTrans1", "label": "${name5}. Does this health facility have arrangements for emergency transport", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "EmergTrans2", "label": "6. What type of arrangements does this health facility have for emergency transport?", "type": "select all that apply", "bind": {"relevant": "${EmergTrans1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "ambulance_owned_facility", "label": "Ambulance owned by facility"}, {"name": "ambulance_on_call", "label": "Ambulance available on call"}, {"name": "official_vehicle_on_call", "label": "Official vehicle (not an ambulance) owned by facility"}, {"name": "official_vehicle_on_call", "label": "Official vehicle (not an ambulance) available on call"}, {"name": "official_vehicle_on_call", "label": "Private vehicle (not ambulance) available on call"}, {"name": "emergency_patient_transport", "label": "Emergency patient transport"}, {"name": "no_vehicle_in_facility", "label": "No ambulance/vehicle in the facility"}]}, {"name": "EmergTrans3", "label": "7. Take a picture of the ambulance vehicle", "type": "photo", "bind": {"relevant": "${EmergTrans1} = 'yes'"}}, {"name": "aDrivercall", "label": "8. Is there a driver on call/available 24 hours?", "type": "select one", "bind": {"relevant": "${EmergTrans1} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FuelVehicle", "label": "9. Is fuel available in the vehicle today?", "type": "select one", "bind": {"relevant": "${EmergTrans1} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "purpVehTrip", "label": "10. What was the purpose of the last trip that the vehicle or ambulance made?", "type": "select one", "bind": {"relevant": "${EmergTrans1} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "transport_health_worker", "label": "Transport health worker to another post"}, {"name": "transport_patient", "label": "Transport a patient to another health facility"}, {"name": "na", "label": "Not Applicable"}]}, {"name": "PayVehicl01", "label": "11. Do patients have to pay to use this vehicle or ambulance?", "type": "select one", "bind": {"relevant": "${EmergTrans1} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PayVehicl02", "label": "How much?", "type": "integer", "bind": {"relevant": "${PayVehicl01} = 'yes'", "required": "TRUE", "jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0"}}, {"name": "name12", "type": "calculate", "bind": {"calculate": "if(${EmergTrans1} = 'yes',${name5} + 7,${name5} + 1)"}}, {"name": "FacGuidli01", "label": "${name12}. Does this facility have any guidelines on standard precautions for infection prevention?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "name13", "type": "calculate", "bind": {"calculate": "if(${EmergTrans1} = 'yes',${name12} + 1,${name5} + 2)"}}, {"name": "FacGuidli02", "label": "${name13}. Does this facility have any guidelines on health care waste management? If yes, ask to see the guidelines.", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "name14", "type": "calculate", "bind": {"relevant": "if(${EmergTrans1} = 'yes',${name13} + 1,${name5} + 3)", "calculate": "if(${EmergTrans1} = 'yes',${name13} + 1,${name5} + 3)"}}, {"name": "TrainWastMa", "label": "${name14}. Have you or any provider(s) received training in health care waste management practices in the past two years?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "name15", "type": "calculate", "bind": {"calculate": "if(${EmergTrans1} = 'yes',${name14} + 1,${name5} + 4)"}}, {"name": "QIPimplplan", "label": "${name15}. Do you have a Quarterly (Business/Work) Implementation Plan? [ask to see the document]", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "QIPsubmitfa", "label": "a. When did the facility submit the Quarterly (Business/Work) Implementation Plan for approval?", "hint": "Answer should be in weeks", "type": "text", "bind": {"relevant": "${QIPimplplan} = 'yes'", "required": "TRUE"}}, {"name": "QIPapproval", "label": "b. When did the facility receive written approval from the relevant authorities for the Quarterly (Business/Work) Implementation Plan?", "hint": "Answer should be in weeks", "type": "text", "bind": {"relevant": "${QIPimplplan} = 'yes'", "required": "TRUE"}}, {"name": "QIPdelayfac", "label": "c. Was there a delay in receiving Quarterly (Business/Work) Implementation Plan approval from the relevant authorities?", "type": "select one", "bind": {"relevant": "${QIPimplplan} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "na", "label": "Not Applicable"}]}, {"name": "DelayReason", "label": "Why was there a delay?", "type": "select one", "bind": {"relevant": "${QIPdelayfac} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "delay_in _submission", "label": "Delay in submission of QIP by facility"}, {"name": "hq_not approving_qip", "label": "Headquarters not approving QIP"}, {"name": "na", "label": "Not Applicable"}, {"name": "other", "label": "Other"}]}, {"name": "DelayReason_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../DelayReason, 'other')"}}, {"name": "faciQIPplan", "label": "16. Does your health facility have a Quality Improvement Plan (QIP)?", "hint": "ask to see the document", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "faQIPcosted", "label": "a. Is the QIP costed?", "type": "select one", "bind": {"relevant": "${faciQIPplan} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "na", "label": "Not Applicable"}]}, {"name": "LGAsup00001", "label": "17. Did the facility/hospital receive a supervision visit from the LGA-PHC in this calendar year?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LGAsup00002", "label": "18. Did they leave a copy or written feedback?", "type": "select one", "bind": {"relevant": "${LGAsup00001} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "LGAsup00003", "label": "19. Did they use a checklist?", "type": "select one", "bind": {"relevant": "${LGAsup00001} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "na", "label": "Not Applicable"}]}]}, {"name": "Infastructu", "label": "Infrastructure", "type": "group", "children": [{"name": "StrucBuild0", "label": "1. What is the current state of the building?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "no_renovation", "label": "Good; does not require renovation"}, {"name": "light_renovation", "label": "Requires light renovation"}, {"name": "modest_renovation", "label": "Requires modest renovation"}, {"name": "significant_renovation", "label": "Requires significant renovation"}]}, {"name": "BuildPic01", "label": "2. Take a picture of the FRONT VIEW of the facility building", "type": "photo"}, {"name": "BuildPic02", "label": "3. Take a picture of the SIDE VIEW of the facility building", "type": "photo"}, {"name": "BuildPic03", "label": "4. Take a picture of the back view of the facility building", "type": "photo"}, {"name": "StrucRoof00", "label": "5. What is the current state of the roof?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "no_renovation", "label": "Good; does not require renovation"}, {"name": "light_renovation", "label": "Requires light renovation"}, {"name": "modest_renovation", "label": "Requires modest renovation"}, {"name": "significant_renovation", "label": "Requires significant renovation"}]}, {"name": "RoofPic01", "label": "6.Take a picture of the roof of the health facility, Take a second picture of the roof of the health facility", "type": "photo"}, {"name": "RoofPic02", "label": "7. Take a picture of the facility ceiling, Take a second picture of the facility ceiling", "type": "photo"}, {"name": "name8", "type": "calculate", "bind": {"calculate": "8"}}, {"name": "StructFence", "label": "${name8}.What is the current state of the fence?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "no_renovation", "label": "Good; does not require renovation"}, {"name": "light_renovation", "label": "Requires light renovation"}, {"name": "modest_renovation", "label": "Requires modest renovation"}, {"name": "significant_renovation", "label": "Requires significant renovation"}, {"name": "no_fence", "label": "No Fence"}]}, {"name": "Fname9", "type": "calculate", "bind": {"calculate": "9"}}, {"name": "FencePic01", "label": "${Fname9}. Take a picture of the fence of the health facility if available", "type": "photo", "bind": {"relevant": "${StructFence} = 'no_fence'"}}, {"name": "FencePic02", "label": "10. Take a second picture of the fence of the health facility if available", "type": "photo", "bind": {"relevant": "${StructFence} = 'no_fence'"}}, {"name": "Fname11", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 2,${name8} + 1)"}}, {"name": "FacState001", "label": "${Fname11}. Are the consulting rooms clean, clearly demarcated with adequate sitting and examination facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname12", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 3,${name8} + 2)"}}, {"name": "InpaToilPic", "label": "${Fname12}. Take a picture of the inpatient toilet in the health facility", "type": "photo"}, {"name": "Fname13", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 4,${name8} + 3)"}}, {"name": "FunToilet07", "label": "${Fname13}. How many of the mentioned (inpatient) toilets/latrines are there?", "type": "integer", "bind": {"required": "TRUE", "jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0"}}, {"name": "Fname14", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 5,${name8} + 4)"}}, {"name": "FunToilet08", "label": "${Fname14}. How many of the mentioned (inpatient) toilets/latrines are currently functioning?", "type": "integer", "bind": {"required": "TRUE", "jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0"}}, {"name": "Fname15", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 6,${name8} + 5)"}}, {"name": "WastDisp001", "label": "${Fname15}. How does this facility finally dispose of sharps waste (e.g., filled sharps boxes)? [state all]", "hint": "should be 2m deep, 15m from facility, 100m from water source and 50m from households", "type": "select all that apply", "bind": {"required": "TRUE"}, "children": [{"name": "incinerator", "label": "Incinerator"}, {"name": "1_chamber_drum", "label": "1 chamber drum/brick"}, {"name": "flat_ground_no_protection", "label": "Flat ground - no protection"}, {"name": "flat_ground_with_protection", "label": "Flat ground - with protection"}, {"name": "pit_protected_ground", "label": "Pit or protected ground"}, {"name": "covered_pit", "label": "Covered pit or pit latrine"}, {"name": "open_pit_no_protection", "label": "Open pit - no protection"}, {"name": "protected_ground_pit", "label": "Protected ground or pit"}, {"name": "covered_container", "label": "Stored in covered container"}, {"name": "stored_unprotected", "label": "Stored unprotected"}, {"name": "facility_no_sharp_waste", "label": "Facility never has sharp waste"}, {"name": "waste_collection_agency", "label": "Waste collection agency"}, {"name": "other", "label": "Other"}]}, {"name": "WastDisp001_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../WastDisp001, 'other')"}}, {"name": "Fname16", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 7,${name8} + 6)"}}, {"name": "WastDisp002", "label": "${Fname16}. How does this facility finally dispose of medical waste other than sharps boxes? [state all]", "type": "select all that apply", "bind": {"required": "TRUE"}, "children": [{"name": "incinerator", "label": "Incinerator"}, {"name": "1_chamber_drum", "label": "1 chamber drum/brick"}, {"name": "flat_ground_no_protection", "label": "Flat ground - no protection"}, {"name": "flat_ground_with_protection", "label": "Flat ground - with protection"}, {"name": "pit_protected_ground", "label": "Pit or protected ground"}, {"name": "covered_pit", "label": "Covered pit or pit latrine"}, {"name": "open_pit_no_protection", "label": "Open pit - no protection"}, {"name": "protected_ground_pit", "label": "Protected ground or pit"}, {"name": "covered_container", "label": "Stored in covered container"}, {"name": "stored_unprotected", "label": "Stored unprotected"}, {"name": "facility_no_sharp_waste", "label": "Facility never has sharp waste"}, {"name": "waste_collection_agency", "label": "Waste collection agency"}, {"name": "other", "label": "Other"}]}, {"name": "WastDisp002_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../WastDisp002, 'other')"}}, {"name": "Fname17", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 8,${name8} + 7)"}}, {"name": "WastDisp003", "label": "${Fname17}. Are black bins for non-contaminated waste available?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname18", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 9,${name8} + 8)"}}, {"name": "WastDisp004", "label": "${Fname18}. Are yellow and red bins for contaminated medical waste available?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname19", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 10,${name8} + 9)"}}, {"name": "WastDisp005", "label": "${Fname19}. Is a security box for sharps available?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname20", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 11,${name8} + 10)"}}, {"name": "WastDisp006", "label": "${Fname20}. Is the incinerator functional today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname21", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 12,${name8} + 11)"}}, {"name": "IncPwrSrc00", "label": "${Fname21}. Is the power source for the incinerator available today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "na", "label": "Not Applicable"}]}, {"name": "Fname22", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 13,${name8} + 12)"}}, {"name": "FacInpWard0", "label": "${Fname22}. Is there an inpatient ward in this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname23", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 14,${name8} + 13)"}}, {"name": "FacInpWard1", "label": "${Fname23}. Are the patient wards appear clean and in good condition?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname24", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 15,${name8} + 14)"}}, {"name": "InPaWardPic", "label": "${Fname24}. Take a picture of the in- patient ward in the facility", "type": "photo"}, {"name": "Fname25", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 16,${name8} + 15)"}}, {"name": "FacInpWard2", "label": "${Fname25}. Is it equipped with in-patient beds?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname26", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 17,${name8} + 16)"}}, {"name": "FacInpWard3", "label": "${Fname26}. How many inpatient beds does the facility have?", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "Fname27", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 18,${name8} + 17)"}}, {"name": "DelRoom0000", "label": "${Fname27}. Is the delivery room is well-maintained? (Clean, delivery couch in good condition, water accessible and well lit)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname28", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 19,${name8} + 18)"}}, {"name": "DelRoomPic", "label": "${Fname28}.Take a picture of the interior of the delivery room, and specifically the delivery couch, in the facility", "type": "photo"}, {"name": "Fname29", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 20,${name8} + 19)"}}, {"name": "MatRoom0000", "label": "${Fname29}. Do you have a maternity waiting room where women can stay prior to giving birth?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname30", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 21,${name8} + 20)"}}, {"name": "StaffAccom0", "label": "${Fname30}. Is there staff accommodation in this facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname31", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 22,${name8} + 21)"}}, {"name": "oncallRm001", "label": "${Fname31}. Is there a call room for staff on call duty?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Fname32", "type": "calculate", "bind": {"calculate": "if(${StructFence} = 'no_fence',${Fname9} + 23,${name8} + 22)"}}, {"name": "oncallRm002", "label": "${Fname32}. Is the on-call room equipped with basic conveniences (bed/couch, bed linen and ventilation)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "FinancSys01", "label": "Section 5. Financial System", "type": "group", "children": [{"name": "FinancSys02", "label": "1. Does this facility have a staff responsible for the financial/accounting system of the facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FinancSys03", "label": "2. Has the facility received financial training by appropriate organization/partner?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FinancBk01", "label": "Financial Bookkeeping", "type": "group", "children": [{"name": "FinTool0001", "label": "3. Which of the following financial management tools do you have?", "type": "select one", "children": [{"name": "receipt_books", "label": "Receipt boks"}, {"name": "payment_voucher", "label": "Payment voucher"}, {"name": "cash_books", "label": "Cah books"}, {"name": "check_issue_ledger", "label": "Check Issue/Register"}, {"name": "general_legder_vote_book", "label": "General Ledger/Vote book"}, {"name": "stores_records", "label": "Stores Records"}, {"name": "statement_of_expenditure", "label": "Statement of expenditure"}, {"name": "did_not_receive_tools", "label": "Did not receive any tools"}, {"name": "other", "label": "Other"}]}, {"name": "FinTool0001_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../FinTool0001, 'other')"}}, {"name": "FinRep00001", "label": "4. Have you submitted the financial report for the last quarter? [ask to see transmittal evidence]", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FinRep00002", "label": "5. Monthly financial report (income and expenditure books) available and correctly filled and signed by the Health Facility Officer in Charge", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FacVisit000", "label": "6. How often was the facility visited by a state/LGA/Ward level accounts person in the last calendar year?", "type": "select one", "children": [{"name": "weekly", "label": "Weekly"}, {"name": "biweekly", "label": "Biweekly (every two weeks)"}, {"name": "monthly", "label": "Monthly"}, {"name": "quarterly", "label": "Quarterly"}, {"name": "yearly", "label": "Yearly"}, {"name": "other", "label": "Other"}]}, {"name": "FacVisit000_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../FacVisit000, 'other')"}}, {"name": "InfoShare01", "label": "7. Does the facility share its financial information with the facility management committee?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "InfoShare02", "label": "8. How does the facility share the information", "type": "select one", "bind": {"relevant": "${InfoShare01} = 'yes'"}, "children": [{"name": "hard_copy_reports", "label": "Hard copy reports"}, {"name": "during_meeti", "label": "During meetings"}, {"name": "chalk_board", "label": "Chalkboard"}, {"name": "posters", "label": "Posters"}, {"name": "other", "label": "Other"}]}, {"name": "InfoShare02_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../InfoShare02, 'other')"}}]}, {"name": "OpFunds0001", "label": "Operational Funds", "type": "group", "children": [{"name": "OpFunds0002", "label": "1. Did the facility receive any non-salary, operational funds from the state/local government in the calendar last year?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OpFunds0003", "label": "2. Which level of government provided funds for non-salary, operational expenses in the last year?", "type": "select one", "children": [{"name": "state", "label": "State government only"}, {"name": "local", "label": "Local government only"}, {"name": "state_local", "label": "Both state and local government"}]}, {"name": "Oname3", "type": "calculate", "bind": {"calculate": "3"}}, {"name": "OpFunds0004", "label": "${Oname3}. Did the facility experience any delay in receipt of non-salary, operational funds from state/local government?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OpFunds0005", "label": "4. Which level of government delayed funding for non-salary, operational expenses in the last year?", "type": "select one", "bind": {"relevant": "${OpFunds0004} = 'yes'"}, "children": [{"name": "state", "label": "State government only"}, {"name": "local", "label": "Local government only"}, {"name": "state_local", "label": "Both state and local government"}]}, {"name": "OpFunds0006", "label": "5. Please indicate the principle reason for the delays", "type": "select one", "bind": {"relevant": "${OpFunds0004} = 'yes'"}, "children": [{"name": "delay_submission_quality", "label": "Delay in submission of quality (business/work) implementation plan"}, {"name": "delay_receive_authority", "label": "Delay in receiving authority to incur expenses (AIE) from authorities"}, {"name": "unable_provide_timely_account", "label": "Unable to provide timely accounts to LGA or state treasury"}, {"name": "audit_issues", "label": "Audit issues raised on facility's account"}, {"name": "capacity_problems", "label": "Capacity problems at LGA or state treasury"}, {"name": "other", "label": "Other"}]}, {"name": "OpFunds0006_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../OpFunds0006, 'other')"}}, {"name": "Oname6", "type": "calculate", "bind": {"calculate": "if(${OpFunds0004} = 'yes', ${Oname3} + 3,${Oname3} + 1)"}}, {"name": "OpFunds0007", "label": "${Oname6}. Does the facility have alternate sources of funding?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OpFunds0008", "label": "a. Which of the following have been alternative sources of funding in the last year?", "type": "select one", "bind": {"relevant": "${OpFunds0007} = 'yes'"}, "children": [{"name": "drug_revolv", "label": "Drug revolving"}, {"name": "registration", "label": "Registration"}, {"name": "dev_partners_ngos", "label": "Development partners/NGOs"}, {"name": "other", "label": "Other"}]}, {"name": "OpFunds0008_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../OpFunds0008, 'other')"}}, {"name": "Oname7", "type": "calculate", "bind": {"calculate": "if(${OpFunds0004} = 'yes',${Oname3} + 4,${Oname3} + 2)"}}, {"name": "OpFunds0009", "label": "${Oname7}. Does this health facility have a bank account?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OpFunds0010", "label": "a. How many active Bank accounts does the facility operate?", "type": "integer", "bind": {"relevant": "${OpFunds0009} = 'yes'", "constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "Oname8", "type": "calculate", "bind": {"calculate": "if(${OpFunds0004} = 'yes',${Oname3} + 5,${Oname3} + 3)"}}, {"name": "OpFunds0011", "label": "${Oname8}. Are user fees/charges displayed at the facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "NHISProc001", "label": "NHIS/Fee-for-service Processing", "type": "group", "children": [{"name": "Oname9", "type": "calculate", "bind": {"calculate": "if(${OpFunds0004} = 'yes',${Oname3} + 6,${Oname3} + 4)"}}, {"name": "NHISProc002", "label": "${Oname9}. Do you have the appropriate NHIS utilization and claim forms?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHISProc003", "label": "a. Does the utilization and claims data correspond and are accurate?", "type": "select one", "bind": {"relevant": "${NHISProc002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHISProc004", "label": "b. The information of the enrollee is complete (including patient identification number, age, gender and contact details) - up to date for the preceding month", "type": "select one", "bind": {"relevant": "${NHISProc002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "NHISProc005", "label": "c. Is there evidence to show that NHIS utilization claims are submitted regularly as required? (assumes monthly submission - cutoff date TBD", "type": "select one", "bind": {"relevant": "${NHISProc002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "QIPBizPlan1", "label": "QIP/Business Plan Financing", "type": "group", "children": [{"name": "Oname10", "type": "calculate", "bind": {"calculate": "if(${OpFunds0004} = 'yes',${Oname3} + 7,${Oname3} + 5)"}}, {"name": "QIPBizPlan2", "label": "${Oname10}. What proportion of facility allocation is spent on QIP and business plan?", "type": "select one", "children": [{"name": "no_alignment", "label": "There is no alignment between spending and the plans"}, {"name": "less_than_60_spent", "label": "Less than 60% of allocation spent on QIP"}, {"name": "more_than_60_spent", "label": "\u2265 60% of allocation spent on QIP"}]}]}, {"name": "ServCost001", "label": "Services and Costs", "type": "group", "children": [{"name": "Servicenote", "label": "Please insert the costs of the health services below", "type": "note", "control": {"appearance": "field-list"}}, {"name": "ServCost002", "label": "1. Registration", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost003", "label": "2. Consultation- 5 years or older", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost004", "label": "3. Consultation- under 5 years of old", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost005", "label": "4. Laboratory: Malaria Test", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost006", "label": "5. Laboratory: Random blood sugar", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost007", "label": "6. Laboratory: Haemoglobin (Hb)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost008", "label": "7. Laboratory: urinalysis", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost009", "label": "8. Laboratory: Other (Specify)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost010", "label": "9. Drugs: Amoxicillin Syrup", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost011", "label": "10. U 5 services (Immunization, Diarrhea treatment,, ARI)", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost012", "label": "a. Immunization", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost013", "label": "b. Diarrhea", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost014", "label": "c. Acute Respiratory Infection", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost015", "label": "11. ANC Visit", "type": "group", "children": [{"name": "ServCost016", "label": "a. Registration", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost017", "label": "b. Drugs", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}]}, {"name": "ServCost018", "label": "12. Normal Delivery", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost019", "label": "13. Family Planning", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost020", "label": "14. Malaria Drugs", "type": "group", "children": [{"name": "ServCost021", "label": "a. Artesunate/Artemisinin combination therapy (ACT)/ Lumefantrine", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost022", "label": "b. Sulfadoxine/Pyramethamine(Fansidar), Chloroquine, Others", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}]}, {"name": "ServCost023", "label": "15. HIV/AIDS", "type": "group", "children": [{"name": "ServCost024", "label": "a. Counselling", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost025", "label": "b. Screening", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost026", "label": "c. ARVs", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}]}, {"name": "ServCost027", "label": "15. TB", "type": "group", "children": [{"name": "ServCost028", "label": "a. Sputum test", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost029", "label": "b. Chest x-ray", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "ServCost030", "label": "c. Treatment/DOTS", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}]}, {"name": "ServCost031", "label": "16. Are the user fees/charges displayed at the facility service charters?", "hint": "Ask to see the boards", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ExemPay0001", "label": "17. In your facility, who is exempted from paying user fees?", "type": "group", "children": [{"name": "ExemPay0002", "label": "a. Patients with chronic diseases", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ExemPay0003", "label": "b. Elderly patients", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ExemPay0004", "label": "c. Very poor people", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ExemPay0005", "label": "d. Facility staff", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ExemPay0006", "label": "e. Relatives of staff", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "WaiverValue", "label": "18. What was the value for Waivers/Exemptions during the last financial year?", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}]}]}, {"name": "HumResMan01", "label": "Section 6. Human Resources Management", "type": "group", "children": [{"name": "HumResMan02", "label": "1. How many health workers are employed in this facility", "hint": "Doctors, nurses, midwives, CHEWs, lab scientist/technician, dentist, pharmacy scientist/technician, environmental officer, and medical record officer", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "HumResMan03", "label": "2. How many non-health workers are employed in this facility", "hint": "Drivers, cleaners, gardeners, security personnel, and health attendants/ward miads", "type": "integer", "bind": {"constraint": ". >=0", "jr:constraintMsg": "Enter a positive integer"}}, {"name": "HumResMan04", "label": "3. Do your staff experience delay in payment of salary?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HumResMan05", "label": "a. How frequently?", "type": "select one", "bind": {"relevant": "${HumResMan04} = 'yes'"}, "children": [{"name": "never", "label": "Never"}, {"name": "seldom", "label": "Seldom (Once in a year)"}, {"name": "often", "label": "Often (Once every 3-6 months)"}, {"name": "always", "label": "Always"}]}, {"name": "HumResMan06", "label": "4. Are there measures (attendance system) against lateness/absenteeism?", "type": "select one", "children": [{"name": "none", "label": "No attendance register available"}, {"name": "avail_no_monitoring", "label": "Attendance register available but not monitored"}, {"name": "avail_monitored", "label": "Attendance register available and verified by the health facility supervisor"}]}, {"name": "HumResMan07", "label": "5. Are there laid down procedures for contract staff recruitment", "type": "select one", "children": [{"name": "none", "label": "There are no laid down procedures for staff"}, {"name": "proc_exist_not_monitor", "label": "Procedures exists but are not documented"}, {"name": "doc_proc_exist_implemented", "label": "Documented procedures exists and are implemented"}]}, {"name": "StaffRos001", "label": "Staff Roster", "type": "group", "children": [{"name": "roster_repeat", "type": "repeat", "children": [{"name": "StaffRos002", "label": "1. Name", "type": "text"}, {"name": "StaffRos003", "label": "2. Cadre", "type": "select one", "children": [{"name": "super_intindent", "label": "Superintendent"}, {"name": "specialist", "label": "Specialist"}, {"name": "medical_officer", "label": "Medical officer"}, {"name": "comm_health_officer", "label": "Community Health Officer"}, {"name": "chew", "label": "CHEW"}, {"name": "junior_chew", "label": "Junior CHEW"}, {"name": "environ_health_offic", "label": "Environmental Health Officer"}, {"name": "bsc_nurse", "label": "BSc Nurse"}, {"name": "regist_nurse", "label": "Registered Nurse"}, {"name": "regist_midwife", "label": "Registered Midwife"}, {"name": "psych_nurse", "label": "Psychiatric Nurse"}, {"name": "dentist", "label": "Dentist"}, {"name": "pharmacist", "label": "Pharmacist"}, {"name": "Lab_technician_technologist", "label": "Laboratory Technician / Technologist"}, {"name": "volunteer", "label": "Volunteer (indicate cadre)"}, {"name": "other", "label": "Other"}]}, {"name": "StaffRos003_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../StaffRos003, 'other')"}}, {"name": "StaffRos004", "label": "3. Gender", "type": "select one", "children": [{"name": "male", "label": "Male"}, {"name": "female", "label": "Female"}]}, {"name": "StaffRos005", "label": "4. Age", "type": "integer"}, {"name": "StaffRos006", "label": "5. Does ${StaffRos002} regularly perform outpatient consultation", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StaffRos007", "label": "6. Is ${StaffRos002} currently in the facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StaffRos008", "label": "7. Reason for absence", "type": "select one", "bind": {"relevant": "${StaffRos007} = 'no'"}, "children": [{"name": "sick_maternity", "label": "Sick / maternity"}, {"name": "training_seminar", "label": "In training / seminar"}, {"name": "official_mission", "label": "Official mission"}, {"name": "approved_absence", "label": "Approved absence"}, {"name": "not_his_her_shift", "label": "Not his / her shift"}, {"name": "field_outreach_work", "label": "Doing fieldwork or outreach work"}, {"name": "not_approved_absence", "label": "Not approved absence"}, {"name": "retreive_salary", "label": "Gone to retreive salary"}, {"name": "strike", "label": "On strike"}, {"name": "other", "label": "Other"}]}, {"name": "StaffRos008_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../StaffRos008, 'other')"}}]}]}]}, {"name": "MatChilSer", "label": "Section 7. Maternal and Child Services", "type": "group", "children": [{"name": "FamPlan0001", "label": "Family Planning", "type": "group", "children": [{"name": "FamPlan0002", "label": "1. Are family planning services offered here?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FamPlan0003", "label": "2. Which type of family planning services are offered here?", "type": "select one", "bind": {"relevant": "${FamPlan0002} = 'yes'"}, "children": [{"name": "couns_services", "label": "Counselling services"}, {"name": "couns_comm_services", "label": "Counselling and commodity services"}]}, {"name": "FamPlan0004", "label": "3. Which family planning methods (commodities) are available today?", "type": "select one", "bind": {"relevant": "${FamPlan0002} = 'yes'"}, "children": [{"name": "none", "label": "None"}, {"name": "condoms", "label": "Condoms"}, {"name": "oral_pills", "label": "Oral pills"}, {"name": "injectibles", "label": "Injectibles"}, {"name": "implants", "label": "Implants"}, {"name": "iuc", "label": "IUC"}]}, {"name": "FamPlan0005", "label": "4. Are FP individual cards available and filled according to the format?", "type": "select one", "bind": {"relevant": "${FamPlan0002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FamPlan0006", "label": "5. How many qualified staff are trained in Family Planning?", "type": "integer", "bind": {"relevant": "${FamPlan0002} = 'yes'"}}]}, {"name": "ANC00000001", "label": "Antenatal Care", "type": "group", "children": [{"name": "ANC00000002", "label": "1. Does this facility provide antenatal care services?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000003", "label": "2. Is Antenatal Risk Assessment form (ARAF) used for ANC?", "type": "select one", "bind": {"relevant": "${ANC00000002} = 'yes'"}, "children": [{"name": "none", "label": "No antenatal risk assessment form"}, {"name": "araf_present_not_used", "label": "Antenatal risk assessment form present but not used regularly for ANC"}, {"name": "araf_present_used", "label": "Antenatal risk assessment form present and used regularly for ANC"}]}, {"name": "ANC00000004", "label": "3. Does this facility provide post-natal care services?", "type": "select one", "bind": {"relevant": "${ANC00000002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ObsCare0001", "label": "Obstetric Care", "type": "group", "children": [{"name": "ObsCare0002", "label": "1. Does this facility provide Basic Emergency Obstetric Care (BEOC)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ObsCare0003", "label": "2. How many staff present are qualified to offer BEOC? Insert number and cadre", "type": "integer", "bind": {"relevant": "${ObsCare0002} = 'yes'"}}, {"name": "ObsCare0004", "label": "3. Do you take deliveries at this facility?", "type": "select one", "bind": {"relevant": "${ObsCare0002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ObsCare0005", "label": "4. How many qualified staff are trained on Live Saving Skills (LSS)?", "type": "integer", "bind": {"relevant": "${ObsCare0002} = 'yes'"}}, {"name": "ObsCare0006", "label": "5. Is there light in delivery room for 24 hours", "type": "select one", "bind": {"relevant": "${ObsCare0002} = 'yes'"}, "children": [{"name": "elect_rech_lamp", "label": "Yes, Electricity and rechargeable lamp"}, {"name": "elect_only", "label": "Yes, Only Electricity"}, {"name": "no", "label": "No"}]}, {"name": "ObsCare0007", "label": "6. Is a partograph used for delivery? (Check via case note audits \u20135 case notes)", "type": "select one", "bind": {"relevant": "${ObsCare0002} = 'yes'"}, "children": [{"name": "none", "label": "No partograph in the facility"}, {"name": "present_unused", "label": "Partograph is present but not used"}, {"name": "present_used", "label": "Partograph is present and used for delivery"}]}, {"name": "ObsCare0008", "label": "7. How many case notes (out of 5 above) are with partographs?", "type": "integer", "bind": {"relevant": "${ObsCare0002} = 'yes'"}}]}, {"name": "ManChilSer0", "label": "Management of Childhood illnesses", "type": "group", "children": [{"name": "ManChilSer1", "label": "1. Does this facility provide routine immunization services?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ManChilSer2", "label": "2. How many staff have been trained on Integrated Management of Childhood Illnesses (IMCI)?", "hint": "by appropriate agency e.g. MOH, Dev partners, certified CBOs and others", "type": "integer", "bind": {"relevant": "${ManChilSer1} = 'yes'"}}, {"name": "ManChilSer3", "label": "3. Do you offer growth monitoring services to all U5 patients?", "type": "select one", "bind": {"relevant": "${ManChilSer1} = 'yes'"}, "children": [{"name": "not_offered", "label": "The facility does not offer growth monitoring services"}, {"name": "no_evidence", "label": "There is no evidence that the facility offers growth monitoring services"}, {"name": "docum_evidence", "label": "There is documented evidence that the facility offers growth monitoring services"}]}, {"name": "ManChilSer4", "label": "4. Does the facility have basic nutritional assessment guide? (MUAC)", "type": "select one", "bind": {"relevant": "${ManChilSer1} = 'yes'"}, "children": [{"name": "no_tapes", "label": "No measuring tapes available"}, {"name": "tapes_avail_no_doc", "label": "Measuring tapes available but there is no documentation on MUAC"}, {"name": "tapes_doc_avail", "label": "Measuring tapes and documentation available for MUAC"}]}]}]}, {"name": "PatMan001", "label": "Section 8. Priority Area: Patient Care Management", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "AvailEqu001", "label": "Available Equipment", "type": "group", "children": [{"name": "AvailEqu002", "label": "1. Adult weighing scale", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu003", "label": "2. Child weighing scale (250g gradation)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu004", "label": "3. Infant weighing scale (100g gradation)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu005", "label": "4. Thermometer", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu006", "label": "5. Stethoscope", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu007", "label": "6. Foetoscope", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu008", "label": "7. Sphygmonometer", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu009", "label": "8. Angle poised lamp", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu010", "label": "9. Centrifuge, manual", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu011", "label": "10. Chart holder", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu012", "label": "11. Cooking pot (A set of 6)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu013", "label": "12. Delivery couch", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu014", "label": "13. Dissecting forceps", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu015", "label": "14. Dressing scissors", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu016", "label": "15. Dressing trolley", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu018", "label": "16. Enema can", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu019", "label": "17. Episiotomy scissors", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu020", "label": "18. Examination couch", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu021", "label": "19. Fire extinguishers", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqucon1", "label": "20. Available Equipment (continued)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "AvailEqu022", "label": "21. Forceps jar", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu023", "label": "22. Growth charts", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu024", "label": "23. Galipot(medium)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu025", "label": "24. Incision and drainage kit", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu026", "label": "25. Instrument cabinet", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu027", "label": "26. Instrument tray", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu028", "label": "27. Fire extinguishers", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu029", "label": "28. Kidney dishes(large)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu030", "label": "29. Kidney dish(medium)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu031", "label": "30. Surgical Knives", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu032", "label": "31. Length measure for babies", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu033", "label": "32. Linen cupboard", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu034", "label": "33. Mackintosh", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu035", "label": "34. Microscope cover slides (pack of 100)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu036", "label": "35. Newborn bag and mask (ambubag)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu037", "label": "36. Oro-pharyngeal airway (set of 7)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu038", "label": "37. Pedal bin", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu039", "label": "38. Perineal sheet", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu040", "label": "39. Autoclave (pressure and wet heat)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu041", "label": "40. Electric boiler or steamer (no pressure)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu042", "label": "41. Electric dry heat sterilizer", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu043", "label": "42. Non-electric pot for boiling/steam or Heat source from non-electric equipment (stove or cooker)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu044", "label": "43. Delivery bed", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu045", "label": "44. Battery \u2013 powered torch", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu046", "label": "45. Partogram", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu047", "label": "46. Sterilizable scissors", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu048", "label": "47. Sterilizable cord ties", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu049", "label": "48. Snellen's chart", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu050", "label": "49. Soap box", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu051", "label": "50. Soap/disinfectant dispenser", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu052", "label": "51. Stainless bedpan", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu053", "label": "52. Stainless ear syringe", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu054", "label": "53. Stitch removal/ suture scissors", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailEqucon2", "label": "54. Available Equipment (continued)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "AvailEqu056", "label": "55. Stool specimen bottles(pack of 100)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu057", "label": "56. Stretcher trolley", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu058", "label": "57. Suction pump", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu059", "label": "58. Suture kit", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu060", "label": "59. Suture needles", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu061", "label": "60. Swivel stool", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu062", "label": "61. Tape dispenser", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu063", "label": "62. Tape measure", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu064", "label": "63. Tenaculum forceps", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu065", "label": "64. Test tube rack", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu066", "label": "65. Theatre gown", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu067", "label": "66. Tissue forceps", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu068", "label": "67. Tongue depressor", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu069", "label": "68. Tourniquet", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu070", "label": "69. Tray test tube", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu071", "label": "70. Tripod stand", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu072", "label": "71. Umbilical cord clamp, pack of 100", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu073", "label": "72. Urinal, female", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu074", "label": "73. Urinary catheter", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu075", "label": "74. Urine dipstick (multstix)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu076", "label": "75. Urine dipstick for sugar and albumin, pack of 100", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu077", "label": "76. Vacuum extractor(manual)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailEqu078", "label": "77. Vaginal speculum (sim) set of 3", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}]}, {"name": "DocRos00001", "label": "73. Are there documented rosters for facility coverage?", "hint": "spot check workers in ANC, OPD and family planning against roster", "type": "select one", "children": [{"name": "no_duty_roster", "label": "The facility does not have any duty roster"}, {"name": "duty_ros_not_foll", "label": "The facility has a duty roster but is not followed"}, {"name": "duty_ros_foll", "label": "The facility has a duty roster that is being followed"}]}, {"name": "RefSys00001", "label": "74. Is there a documented referral and follow up system available for services (E.g. HIV, TB, and chronic illnesses)", "hint": "Cross check referral register, facility copy of form and return/feedback slips.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "RefSys00002", "label": "75. Where does the facility refer its patients to?", "type": "text"}, {"name": "RefSys00003", "label": "76. How many patients did the facility refer to another facility in the prior 3 months?", "hint": "please check the referral register", "type": "integer"}, {"name": "RefSys00004", "label": "77. Using the most common means for transportation, how long does it take for a referred patient to go from your facility to the most commonly used next level for referral during the DRY season?", "type": "select one", "children": [{"name": "zero_to_ten_minutes", "label": "0-10 minutes"}, {"name": "eleven_to_twenty_minutes", "label": "11-20 minutes"}, {"name": "greater_than_twenty_minutes", "label": "> 20 minutes"}]}, {"name": "RefSys00005", "label": "78. Using the most common means for transportation, how long does it take for a referred patient to go from your facility to the most commonly used next level for referral during the RAINY season?", "type": "select one", "children": [{"name": "zero_to_ten_minutes", "label": "0-10 minutes"}, {"name": "eleven_to_twenty_minutes", "label": "11-20 minutes"}, {"name": "greater_than_twenty_minutes", "label": "> 20 minutes"}]}, {"name": "HIVTBser001", "label": "HIV/TB Services", "type": "group", "children": [{"name": "HIVTBser002", "label": "1.Does this facility provide HIV/AIDS prevention and care services?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HIVTBser003", "label": "2. Are staff trained in testing and counseling?", "hint": "by appropriate structure e.g. LGA, development partners, MOH, certified CBOs", "type": "select one", "bind": {"relevant": "${HIVTBser002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HIVTBser004", "label": "3. Does this facility provide STI control services?", "type": "select one", "bind": {"relevant": "${HIVTBser002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HIVTBser005", "label": "4. Does this facility treat TB patients?", "type": "select one", "bind": {"relevant": "${HIVTBser002} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "DisMan001", "label": "Disease Management", "type": "group", "children": [{"name": "DisMan002", "label": "Is there evidence of protocol being implemented in case notes? Randomly select 1 case note each from OPD, ANC and child clinic.", "hint": "Use checklist as appropriate against one consultation.", "type": "note"}, {"name": "malaria0001", "label": "Case Study: Malaria + Anemia", "type": "group", "children": [{"name": "malaria0002", "label": "History Taking", "type": "group", "children": [{"name": "malaria0003", "label": "1. Duration of fever", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0004", "label": "2. Pattern of fever/Presence or history of fever", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0005", "label": "3. Shiver or sweat", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0006", "label": "4. Convulsions", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0007", "label": "5. Vomiting", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0008", "label": "6. Appetite", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0009", "label": "7. Diarrhoea", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0010", "label": "8. Cough", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0011", "label": "9. Severity of cough", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0012", "label": "10. Difficulty in breathing", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0013", "label": "11. Type of cough (productive or dry)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0014", "label": "12. Type of medication given", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0015", "label": "13. Amount of dose given", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0016", "label": "14. Vaccinations", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "malaria0017", "label": "Physical Examination carried out", "type": "group", "children": [{"name": "malaria0018", "label": "15. Hands (palmar pallor)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0019", "label": "16. Tongue", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0020", "label": "17. Eyes, sunken?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0021", "label": "18. Eyes, pale colour?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0022", "label": "19. Responsiveness / general condition", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0023", "label": "20. Skin condition", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0024", "label": "21. Temperature", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0025", "label": "22. Pulse", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0026", "label": "23. Neck stiffness", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0027", "label": "24. Puffy face", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0028", "label": "25. Swelling of the feet", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0029", "label": "26. Abdomen/liver", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0030", "label": "27. Weight", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0031", "label": "28. Respiratory rate", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "malaria0032", "label": "Tests administered", "type": "group", "children": [{"name": "malaria0033", "label": "29. Microscopy/ Blood slide for malaria parasite", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0034", "label": "30. Rapid Diagnostic test", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0035", "label": "31. Hb / Full Blood Count", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "malaria0036", "label": "Diagnosis", "type": "group", "children": [{"name": "malaria0037", "label": "32. Malaria", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0038", "label": "33. Anemia", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0039", "label": "34. Malaria with Anemia", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0040", "label": "35. Severe Malaria", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "malaria0041", "label": "Treatment", "type": "group", "children": [{"name": "malaria0042", "label": "36. Artemizinin combination", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0043", "label": "37. Paracetamol", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0044", "label": "38. Adequate fluids and nutrition", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0045", "label": "39. Chloroquine 1.5 tabs x 1/day x 3 days", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0046", "label": "40. Quinine intramuscular injection", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0047", "label": "41. Artesunate Amodiaquin", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0048", "label": "42. Sulphadoxine Pyrimethamine .5 tab 250 mg tds x 3 days", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "malaria0049", "label": "Was the patient counselled on any of the following (Confirm if documented in the case notes)", "type": "group", "children": [{"name": "malaria0050", "label": "43. Adherence to treatment.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0051", "label": "44. Prompt return if symptoms worsen", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0052", "label": "45. Increased fluid intake", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "ANC00000005", "label": "Case Study: Antenatal Care", "type": "group", "children": [{"name": "ANC00000006", "label": "1. History taken", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000007", "label": "2. Clinical examination conducted", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000008", "label": "3. Estimated date of delivery calculated", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000009", "label": "4. Blood pressure taken", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000010", "label": "5. Maternal height/weight measured", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000011", "label": "6. Haemoglobin test conducted", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000012", "label": "7. Rapid Plasma Reagin performed", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000013", "label": "8. Urine tested", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000014", "label": "9. Rapid ph performed", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000015", "label": "10. Counselled and voluntary testing for HIV", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000016", "label": "11. Tetanus toxoid given", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000017", "label": "12. Iron and folic acid supplementation provided", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000018", "label": "13. Calcium supplementation provided", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000019", "label": "14. Information for emergencies given", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000020", "label": "15. Clinical examination for anaemia", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000021", "label": "16. Urine test for protein", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000022", "label": "17. Uterus measured for excessive growth or poor growth", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000023", "label": "18. Instructions for delivery/transport to institution and recommendations for lactation, and contraception done", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000024", "label": "19. Antenatal card completed and given to woman. Woman told to bring it when in labour", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem001", "label": "Case Study: Post-partum Hemorrhage", "type": "group", "children": [{"name": "PoParHem002", "label": "History Taking", "type": "group", "children": [{"name": "PoParHem003", "label": "1. Were other symptoms reported?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem004", "label": "2. Was the blood loss quantified?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem005", "label": "3. Were the number of pads used indicated?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem006", "label": "4. Was the parity recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem007", "label": "5. Was the duration of labor recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem008", "label": "6. Was the mode of Placenta delivery indicated?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem009", "label": "7. Is there a record of medicines given to speed up delivery during Labor", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem010", "label": "8. Is there a record of history of excessive bleeding after delivery?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem011", "label": "9. Is there a record of history of prolonged menses (Fibroids)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem012", "label": "10. I there a record of excessive (amniotic) fluids during pregnancy?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem013", "label": "11. Confirm record of Attendance of ANC", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem014", "label": "12. Is there a record of multiple pregnancy?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem015", "label": "13. Is there a record of Placenta praevia?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem016", "label": "14. Is there a record of Hypertension?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem017", "label": "Physical examination carried out", "type": "group", "children": [{"name": "PoParHem018", "label": "15. Temperature", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem019", "label": "16. Pulse", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem020", "label": "17. Weight", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem021", "label": "18. Respiratory rate", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem022", "label": "19. Retained placenta", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem023", "label": "20. Blood pressure", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem024", "label": "21. Ruptured uterus", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem025", "label": "22. Laceration / tears of genital tract (cervical / vaginal / vulvoperineal tears)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem026", "label": "23. Uterine palpation", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem027", "label": "24. Genital examination", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem028", "label": "Tests Administered", "type": "group", "children": [{"name": "PoParHem029", "label": "25. Blood for grouping and cross matching", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem030", "label": "26. Hemoglobin level", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem031", "label": "27. Bleeding time", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem032", "label": "28. Clotting time", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem033", "label": "29. Coagulation factors", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem034", "label": "Diagnosis", "type": "group", "children": [{"name": "PoParHem035", "label": "30. Post-partum Hemorrhage", "hint": "It will take some time to get the results. Please make a preliminary diagnosis.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem036", "label": "Which of the following treatments were administered", "type": "group", "children": [{"name": "PoParHem037", "label": "31. IV line", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem038", "label": "32. Blood taken for grouping and cross matching", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem039", "label": "33. The self retaining catheter foley was inserted", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem040", "label": "34. Was a bimanual uterine massage carried out?: this may also provoke contractions", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem041", "label": "35. PuWas an oxytocin drip with dextrose saline given", "hint": "20 units in 500 ml dextrose or normal saline to run at 20 drops per minute for about 2 hours", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem042", "label": "36. Was prostaglandins and misoprostal given?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem043", "label": "37. Was the patient referred?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "Pneum000001", "label": "Case Study: Pneumonia", "type": "group", "children": [{"name": "Pneum000002", "label": "History Taking", "type": "group", "children": [{"name": "Pneum000003", "label": "1. Were other symptoms recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000004", "label": "2. Was the duration of cough recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000005", "label": "3. Was the nature of the cough (sputum production or dry cough) recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000006", "label": "4. Was the presence of blood or colour of sputum recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000007", "label": "5. Was there a record of the presence of chest pain?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000008", "label": "6. Was there a record on presence of difficulty in breathing", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000009", "label": "7. Was there a record of patient's appetite?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000010", "label": "8. Was there a record of fever?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000011", "label": "9. Was there a record on general condition (awake / lethargic", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000012", "label": "10. Was there a record on presence of convulsions?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000013", "label": "11. Was there a record on patient's difficulty in swallowing?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000014", "label": "12. Was the presence of running nose recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000015", "label": "13. Was any medication /treatment received recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000016", "label": "14. Was recent history of Measles recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000017", "label": "15. Was family history of Asthma recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000018", "label": "16.Was the redness of the eyes observed?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Pneum000019", "label": "Physical examination carried out", "type": "group", "children": [{"name": "Pneum000020", "label": "17. Was the respiratory rate counted?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000021", "label": "18. Was the breathing of lower chest wall in-drawing observed?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000022", "label": "19. Breathing, is there wheezing?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000023", "label": "20. Was the chest auscultated?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000024", "label": "21. Was nasal flaring observed?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000025", "label": "22. Was temperature recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000026", "label": "23. Was the throat examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000027", "label": "24. Were the child's ears examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000028", "label": "25. Were the lymph nodes examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Pneum000029", "label": "Tests administered", "type": "group", "children": [{"name": "Pneum000030", "label": "26. Chest X-ray", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000031", "label": "27. Haemogram", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000032", "label": "28. BS for MPS", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Pneum000033", "label": "Diagnosis", "type": "group", "children": [{"name": "Pneum000034", "label": "29. Pneumonia", "hint": "It will take some time to get the results. Please make a preliminary diagnosis.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Pneum000035", "label": "Treatment", "type": "group", "children": [{"name": "Pneum000036", "label": "30. Treat as out-patient.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000037", "label": "31. Was Cortimoxazole 1 tab bd x 5/7 given or administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000038", "label": "32. Was Amoxycillin Dosage 250mg qds x 5 given or administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000039", "label": "33. Was Arthemeter-Lumefantrine 2 tabs x 2/day x given or administered?\n3 days", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000040", "label": "34. Was Artesunate+Amodiaquine 1 tabX 1/day x given or administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000041", "label": "35. Was Paracetamol dose 250 mg qds x 5 days given or administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000042", "label": "36. Were parents asked to bring child in 2 days?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "Pneum000043", "label": "Was the patient counselled on any of the following (Confirm if documented in the case notes)", "type": "group", "children": [{"name": "Pneum000044", "label": "37. Instruct parent on how to administer antibiotics for 5 days.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000045", "label": "38. Guidance on how to feed.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000046", "label": "39. Increase fluid intake.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000047", "label": "40. Instruct parent to return anytime in case the child worsens (or has any danger signs persisting fever, difficulty in breathing, poor feeding convulsions or new symptoms)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "AcuDiarr001", "label": "Case Study: Acute Diarrohea", "type": "group", "children": [{"name": "AcuDiarr002", "label": "History Taking", "type": "group", "children": [{"name": "AcuDiarr003", "label": "1.Were other symptoms recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr004", "label": "2. Was the duration of diarrhoea recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr005", "label": "3.Was the frequency of diarrhoea recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr006", "label": "4. Was the consistency of stool recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr007", "label": "5. Was the presence of blood in stool recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr008", "label": "6. Vomiting", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr009", "label": "7. Was the mother asked if her child is breastfeeding?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr010", "label": "8. Was the mother asked if her child is breastfeeding well?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr011", "label": "9. Was the presence of cough recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr012", "label": "10. Was the mother asked if her child has fever?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr013", "label": "11. Was the general condition of the child recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr014", "label": "12. Was the presence of tears recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr015", "label": "13. Was the mother asked if her baby started taking other food recently?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr016", "label": "14. Was the mother asked how it been given?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr017", "label": "15. Was the mother asked who prepares and feed her child??", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr018", "label": "16. Was the mother asked about her hand washing practice?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr019", "label": "17. Was the mother asked if their family members/neighbours have diarrhoea?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr020", "label": "18. Was the presence of abdominal discomfort/cramps recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr021", "label": "19. Was the date of the last deworming recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr022", "label": "20. Was the medication/treatment received before visiting the health facility recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "AcuDiarr023", "label": "Physical Examination", "type": "group", "children": [{"name": "AcuDiarr024", "label": "21. Was the general health condition (awake/lethargic/tiredness/fatigue) recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr025", "label": "22. Was the temperature recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr026", "label": "23. Was the state of the child's skin recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr027", "label": "24. Was the child offered a drink?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr028", "label": "25. Was the mucous membrane (oral mucosa) examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr029", "label": "26. Was palmar pallor (or other signs of anaemia) examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr030", "label": "27. Was thye stiffness of the neck examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr031", "label": "28. Was the ear/throat examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr032", "label": "29.Was the respiratory rate examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr033", "label": "30. Was the spleen examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr034", "label": "31. Was visible severe wasting examined?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr035", "label": "32. Was the weight of the child recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr036", "label": "33. Sunken eyes", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr037", "label": "34. Was the weight (against a growth chart) recorded?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr038", "label": "35. Was the presence of oedema of both feet (swollen feet) observed?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "AcuDiarr039", "label": "Tests administered", "type": "group", "children": [{"name": "AcuDiarr040", "label": "36. Stool for rota/adeno virus.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr041", "label": "37. Stool for ova and cyst.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "AcuDiarr042", "label": "Diagnosis", "type": "group", "children": [{"name": "AcuDiarr043", "label": "38. Acute diarrhoea with severe dehydration", "hint": "It will take some time to get the results. Please make a preliminary diagnosis.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "AcuDiarr044", "label": "Treatment", "type": "group", "children": [{"name": "AcuDiarr045", "label": "39. Were Oral Rehydration Salts given/administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr046", "label": "40. Was 100ml/kg Ringer's Lactate Solution given or administer?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr047", "label": "41.Was the patient referred immediately?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr048", "label": "42. Was antibiotics given/administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr049", "label": "43. Were vitamin A capsules given or administered?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr050", "label": "44. Were zinc tablets given or administered? (one daily for 10days).", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "AcuDiarr051", "label": "Was the patient counselled on any of the following (Confirm if documented in the case notes)", "type": "group", "children": [{"name": "AcuDiarr052", "label": "45. Education on using (ORS)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr053", "label": "46. Hand-washing education", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr054", "label": "47. Proper cleaning of feeding utensils.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr055", "label": "48. Emphasis on not withholding feeding especially breast feeding", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr056", "label": "49. Giving plenty of oral fluids.", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}]}, {"name": "ImpUniPreca", "label": "51. Is there evidence of implementation of universal precautions?", "type": "select one", "children": [{"name": "no_ppe", "label": "No appropriate PPE (gloves, aprons, covered footwear, face masks, etc.)/job aids guidelines"}, {"name": "ppe_unused", "label": "Appropriate PPE/job aids available but no evidence of implementation"}, {"name": "ppe_used", "label": "Appropriate PPE/job aids available and visibly in use"}]}, {"name": "HandWashFac", "label": "52. Are there handwashing facilities available at all service points?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ProviPivacy", "label": "53. Is privacy/confidentiality provided for clients?", "type": "select one", "children": [{"name": "no_privacy", "label": "No privacy/confidentiality provided for clients"}, {"name": "privacy_inadequate", "label": "Provision for privacy/confidentiality is inadequate"}, {"name": "privacy_adequate", "label": "Privacy/confidentiality is provided for clients and is adequate"}]}, {"name": "TreatMalari", "label": "54. Do you treat malaria at this facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CurTreatmen", "label": "55. Do you offer curative treatment for patients?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "MinDrugComm", "label": "Section 9. Minimum Drugs and Commodities", "type": "group", "children": [{"name": "DrugVacc001", "label": "Availability of Drugs and Vaccines", "type": "group", "children": [{"name": "Drug0000001", "label": "Drugs", "type": "note"}, {"name": "Drug0000002", "label": "1. Oxytocin (injectable)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000003", "label": "2. Misoprostol (cap/tab)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000004", "label": "3. Sodium chloride (Saline Solution)(injectable solution)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000005", "label": "4. Azithromycin (inj/cap/tab or oral liquid)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000006", "label": "5. Calcium gluconate (tablets)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000007", "label": "6. Benzathinebenzylpenicillin powder (for injection)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000008", "label": "7. Magnesium sulfate (inj/tab/cap)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000009", "label": "8. Dexamethasone (injectable)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000010", "label": "9. Ampicillin powder (for injection)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000011", "label": "10. Nifedipine (cap/tab)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000012", "label": "11. Gentamicin (injectable)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000013", "label": "12. Medroxyprogesterone acetate (Depo-Provera)(injectable)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000014", "label": "13. Metronidazole (inj/tab)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000015", "label": "14. Folic Acid Supplements (cap/tab)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000016", "label": "15. Iron supplements (cap/tab)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000017", "label": "16. Amoxicillin (syrup/suspension/dispersible tablet)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000018", "label": "17. Amoxil (syrup/suspension)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000019", "label": "18. Oral Rehydration Salts (ORS sachets)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000020", "label": "19. Ampicillin (powder for injection)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000021", "label": "20. Zinc (tablets)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000022", "label": "21. Zinc tablet (For Diarrhoea)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000023", "label": "22. Anti snake bites serum injection", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000024", "label": "23. Anti tetanus immunoglobulin injection", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000025", "label": "24. Zinc (oral liquid)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000026", "label": "25. Ceftriaxone (powder for injection)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000027", "label": "26. Artemisinin combination therapy (ACT-tablet)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000028", "label": "27. Vitamin A (capsules)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000029", "label": "28. Benzylpenicillin (powder for injection)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000030", "label": "29. Ergometrine tablet", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000031", "label": "30. Ergometrine injection", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000032", "label": "31. Anti Asthma Drugs: Beclomethasone inhaler", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000033", "label": "32. Salbutamol inhaler", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Drug0000034", "label": "33. Salbutamol tablet", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000001", "label": "VACCINES", "type": "note"}, {"name": "Vacc0000002", "label": "1. Measles vaccine injection", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000003", "label": "2. Rabies immunoglobulin injection", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000004", "label": "3. Tetanus vaccine injection", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000005", "label": "4. Polio vaccine (live attenuated)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000006", "label": "5. Diphteria + pertussis + tetanus vaccine", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000007", "label": "6. BCG vaccine and diluent", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000008", "label": "7. Pneumococcal (PCV 10) vaccines", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "Vacc0000009", "label": "8. DTP-HepB-Hib vaccine", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "SupMinDC001", "label": "Supply of Minimum Drugs and Commodities", "type": "group", "children": [{"name": "SupMinDC002", "label": "1. Does the facility have a staff responsible for managing the ordering of medical supplies?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SupMinDC003", "label": "2. Who is responsible?", "type": "select one", "bind": {"relevant": "${SupMinDC002} = 'yes'"}, "children": [{"name": "off_in_charge", "label": "Officer-in-Charge"}, {"name": "med_officer", "label": "Medical Officer"}, {"name": "pharm_tech", "label": "Pharmacy Technician"}, {"name": "pharm_ass", "label": "Pharmacy Assistant"}, {"name": "pharmacist", "label": "Pharmacist"}, {"name": "chew", "label": "CHEW"}, {"name": "jchew", "label": "JCHEW"}, {"name": "lab_tech", "label": "Lab Technician"}]}, {"name": "SupMinDC004", "label": "3. Who determines this facility's resupply quantities?", "type": "select one", "children": [{"name": "off_in_charge", "label": "Officer-in-Charge"}, {"name": "med_officer", "label": "Medical Officer"}, {"name": "pharm_tech", "label": "Pharmacy Technician"}, {"name": "pharm_ass", "label": "Pharmacy Assistant"}, {"name": "pharmacist", "label": "Pharmacist"}, {"name": "chew", "label": "CHEW"}, {"name": "jchew", "label": "JCHEW"}, {"name": "lab_tech", "label": "Lab Technician"}]}, {"name": "SupMinDC005", "label": "4.How are the facility's resupply quantities estimated?", "type": "select one", "children": [{"name": "fac_itself", "label": "Facility itself (pull mechanism)"}, {"name": "high_level_fac", "label": "Higher level facility (push mechanism)"}, {"name": "combination", "label": "Combination"}, {"name": "other", "label": "Other"}]}, {"name": "SupMinDC005_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../SupMinDC005, 'other')"}}, {"name": "SupMinDC006", "label": "5. Who is the direct supplier of health commodities to your facility?", "type": "select one", "children": [{"name": "lga_store", "label": "LGA Store"}, {"name": "ngo_donors", "label": "NGO/Donors"}, {"name": "open_market", "label": "Open Market"}, {"name": "other", "label": "Other"}]}, {"name": "SupMinDC006_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../SupMinDC006, 'other')"}}, {"name": "SupMinDC007", "label": "6. How are the drugs from the main supplier delivered to this facility?", "type": "select one", "children": [{"name": "supplier_to_facility", "label": "Supplier delivers to facility"}, {"name": "facility_arrange_del", "label": "Facility arranges delivery"}, {"name": "other", "label": "Other"}]}, {"name": "SupMinDC007_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../SupMinDC007, 'other')"}}, {"name": "SupMinDC008", "label": "7. Who bears the transportation cost of delivery to facilities", "type": "select one", "children": [{"name": "supplier", "label": "Supplier"}, {"name": "facility", "label": "Facility"}, {"name": "other", "label": "Other"}]}, {"name": "SupMinDC008_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../SupMinDC008, 'other')"}}, {"name": "SupMinDC009", "label": "8. What was the date for the last delivery of essential medicines and/or medical supplies?", "type": "text"}, {"name": "SupMinDC010", "label": "9. What was the date on which the order that corresponded to the last delivery was placed?", "type": "text"}, {"name": "SupMinDC011", "label": "10. Was the last delivery of essential medicines and supplies verified and signed off by the health facility management committee?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SupMinDC012", "label": "11. Was the community informed of the last delivery of essential medicines and supplies?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SupMinDC013", "label": "12. How were they informed?", "type": "select one", "bind": {"relevant": "${SupMinDC012} = 'yes'"}, "children": [{"name": "hard_copy_reports", "label": "Hard copy reports"}, {"name": "during_meeti", "label": "During meetings"}, {"name": "chalk_board", "label": "Chalkboard"}, {"name": "posters", "label": "Posters"}]}]}, {"name": "StocCont001", "label": "Stock Control", "type": "group", "children": [{"name": "StocCont002", "label": "1. Did the facility procure any out-of-stock items in the last quarter (3 months)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StocCont003", "label": "2. In the last quarter, did the facility purchase any essential medicines and medical supplies locally?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StocCont004", "label": "3. Did any essential medicines in the facility expire during the last quarter (3 months)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StocCont005", "label": "4. Are stock control cards present & updated for the latest delivery?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StocCont006", "label": "5. Are up-to-date records of expired drugs or losses kept?", "type": "select one", "children": [{"name": "no_record", "label": "No record of expired drugs or losses kept"}, {"name": "record_not_uptodate", "label": "Record of expired drugs kept but not up to date"}, {"name": "records_uptodate", "label": "Record of expired drugs kept are up to date"}]}, {"name": "StocCont007", "label": "6. Is there proper storage and security (cool, dry place with a lock) for all drugs & consumables in the facility? (Take a picture of the facility medicines storage)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "StocCont008", "label": "7. How many of the staff involved in essential medicines and supplies management have received training on quantification and ordering of such products?", "type": "integer"}, {"name": "StocCont009", "label": "8. In the last fiscal year, how often was the facility visited by a qualified pharmacist for support supervision?", "type": "select one", "children": [{"name": "weekly", "label": "Weekly"}, {"name": "biweekly", "label": "Biweekly (every two weeks)"}, {"name": "monthly", "label": "Monthly"}, {"name": "quarterly", "label": "Quarterly"}, {"name": "yearly", "label": "Yearly"}, {"name": "other", "label": "Other"}]}, {"name": "StocCont009_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../StocCont009, 'other')"}}, {"name": "StocCont010", "label": "9. Are drug price lists displayed?", "type": "select one", "children": [{"name": "no_drug_list", "label": "No drug price list available"}, {"name": "list_pres_not_displayed", "label": "Drug price list present but not displayed"}, {"name": "list_pres_displayed", "label": "Drug price list present and displayed"}]}]}, {"name": "AvailCom001", "label": "Availability of Minimum Commodities", "type": "group", "children": [{"name": "AvailCom002", "label": "1. Disposable syringes with disposable needles", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom003", "label": "2. Vaccine carrier(s)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom004", "label": "3. Auto-disable syringes", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom005", "label": "4. Set of ice packs for vaccine carriers (Note: 4-5 ice packs make one set)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom006", "label": "5. Clean running water (piped, bucket with tap, or pour pitcher)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom007", "label": "6. Hand-washing soap/liquid soap", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom008", "label": "7. Alcohol based hand rub", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom009", "label": "8. Waste receptacle (pedal bin) with lid and plastic bin liner", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom010", "label": "9. Environmental disinfectant (e.g., chlorine, alcohol)", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom011", "label": "10. Sharps container", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom012", "label": "11. Disposable Gloves", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom013", "label": "12. Condoms", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom014", "label": "13. Are vaccines stored at this facility?", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom015", "label": "14. Does the facility have a working refrigerator for the storage of vaccines?", "hint": "Observe functioning", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "FacFridPic", "label": "15. Take a picture of the facility refrigerator", "type": "photo"}, {"name": "VaccBoxPic", "label": "16. Take a picture of the facility vaccine coldchain box", "type": "photo"}, {"name": "AvailCom016", "label": "17. Is there a functional thermometer to maintain a cold chain?", "type": "select one", "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom017", "label": "18. If there is no storage at the facility, are the facility's vaccines stored at another facility (and picked up from when vaccine services are being provided)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AvailCom018", "label": "**About how many weeks' supply of the following medicines is currently available in the facility?**", "type": "group", "children": [{"name": "AvailCom019", "label": "1. Amoxicillin (syrup/suspension/dispersible tablet)", "type": "integer"}, {"name": "AvailCom020", "label": "2. Injectable antibiotics", "type": "integer"}, {"name": "AvailCom021", "label": "3. Chlorhexidine", "type": "integer"}, {"name": "AvailCom022", "label": "4. Magnesium sulfate (injectable)", "type": "integer"}, {"name": "AvailCom023", "label": "5. Misoprostol (cap/tab)", "type": "integer"}, {"name": "AvailCom024", "label": "6. Oxytocin (injectable)", "type": "integer"}, {"name": "AvailCom025", "label": "7. Oral Rehydration Salts (ORS sachets)", "type": "integer"}, {"name": "AvailCom026", "label": "8. Zinc (tablets)", "type": "integer"}, {"name": "AvailCom027", "label": "9. Emergency contraception", "type": "integer"}, {"name": "AvailCom028", "label": "10. Female condoms", "type": "integer"}, {"name": "AvailCom029", "label": "11. Contraceptive implants", "type": "integer"}, {"name": "AvailCom030", "label": "12. Antenatal corticosteroid (ANCs)", "type": "integer"}, {"name": "AvailCom031", "label": "13. Newborn Resuscitation Device", "type": "integer"}]}]}]}, {"name": "Lab00000001", "label": "Section 10. Laboratory", "type": "group", "children": [{"name": "Lab00000002", "label": "9.1 Laboratory is open every day of the week", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Lab00000003", "label": "9.2 Is there a laboratory scientist/technician available at least 5 days a week?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Lab00000004", "label": "9.3 Are laboratory price lists displayed?", "type": "select one", "children": [{"name": "no_lab_list", "label": "No laboratory price list available"}, {"name": "list_pres_not_displayed", "label": "Laboratory price list present but not displayed"}, {"name": "list_pres_displayed", "label": "Laboratory price list present and displayed"}]}, {"name": "Lab00000005", "label": "9.4 The facility offers PHC Laboratory services (According to the essential laboratory services in the tool) (Please tick as appropriate)", "type": "select one", "children": [{"name": "heam_pcv", "label": "Heamatology (PCV, Haemoglobin)"}, {"name": "preg_test", "label": "Pregnancy test"}, {"name": "sugar_protein_test", "label": "Urine dipsticks for sugar and protein"}, {"name": "syph_rap_test", "label": "Syphillis rapid test"}, {"name": "mal_diag", "label": "Malaria diagnostics"}, {"name": "hiv_diag", "label": "HIV diagnostics"}, {"name": "dbs_prep", "label": "Dried Blood Spots (DBS) preparation"}, {"name": "tb_diag", "label": "TB diagnostics"}, {"name": "ven_collect_cd4", "label": "venous collection for CD4"}]}]}, {"name": "HMIS0000001", "label": "Section 11. Health Management Information System", "type": "group", "children": [{"name": "HMISForm001", "label": "**Are relevant HMIS forms/Registers available in the facility?**", "type": "group", "children": [{"name": "HMISForm002", "label": "1. NHMIS Health facility monthly summary form", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm003", "label": "2. NHMIS health facility daily attendance register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm004", "label": "3. NHMIS health facility daily GMP (growth monitoring) register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm005", "label": "4. NHMIS health facility Immunization register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm006", "label": "5. NHMIS health facility Immunization Tally Sheet register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm007", "label": "6. NHMIS health facility TT register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm008", "label": "7. NHMIS health facility daily ANC register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm009", "label": "8. NHMIS health facility daily OPD register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm010", "label": "9. NHMIS health facility daily FP register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm011", "label": "10. NHMIS health facility daily PMTCT ARVs register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm012", "label": "11. NHMIS health facility labour/delivery register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMISForm013", "label": "12. NHMIS health facility IPC register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "HMIS0000002", "label": "13. Are HMIS forms / register up to date and completed correctly?", "type": "select one", "children": [{"name": "no_form_reg", "label": "No relevant HMIS forms/registers available"}, {"name": "some_form_avail_not_uptodate", "label": "Some HMIS forms/registers available but not up to date (month prior to assessment)"}, {"name": "all_form_avail_uptodate", "label": "All relevant HMIS forms/registers available and up to date (month prior to assessment)"}]}, {"name": "HMIS0000003", "label": "14. Is HMIS information displayed graphically?", "type": "select one", "children": [{"name": "not_rep_graph", "label": "HMIS information not represented graphically"}, {"name": "rep_graph_not_display", "label": "HMIS information represented graphically, but not displayed"}, {"name": "rep_graph_display", "label": "HMIS information represented graphically and displayed"}]}, {"name": "HMIS0000004", "label": "15. Are the NHMIS data analysed and shared with the facility management committee?", "type": "select one", "children": [{"name": "not_analyzed", "label": "Not analysed"}, {"name": "analyzed", "label": "Analysed"}, {"name": "analyzed_shared", "label": "Analyzed and shared"}, {"name": "analyzed_decision", "label": "Analysed and used for decision (minutes available)"}]}, {"name": "HMIS0000005", "label": "16. Did the facility send last month's monthly summary form to the LGA?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMIS0000006", "label": "17. 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", "children": [{"name": "info_not_corres", "label": "The information registers does not correspond with the HMIS data sent to LGA"}, {"name": "some_info_corres", "label": "Some of the information in the registers correspond with the HMIS data sent to LGA="}, {"name": "all_info_corres", "label": "All the information in the register correspond with the HMIS data sent to LGA"}]}, {"name": "HMIS0000007", "label": "18. Do you participate in any LGA monthly M&E review meetings?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HMIS0000008", "label": "19. Is HMIS information discussed in the facility management meetings (check for minutes of meetings)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "UtilClinOut", "label": "Section 12. Utilization and Clinical Outcomes", "type": "group", "children": [{"name": "UtilPatt001", "label": "Utilization Pattern", "type": "group", "children": [{"name": "UtilPatt002", "label": "1. How many deliveries have been conducted at this facility during the past 3 months?", "type": "integer"}, {"name": "UtilPatt003", "label": "2. How many general outpatient visits have you had at this facility in the past 3 months?", "type": "integer"}, {"name": "UtilPatt004", "label": "3. How many in-patient bed-days have you had during the past 3 months?", "type": "integer"}, {"name": "UtilPatt005", "label": "4. How many Under-5 visits have you had at this facility in the past 3 months?", "type": "integer"}, {"name": "UtilPatt006", "label": "5. How many immunization visits have you had at this facility in the past 3 months", "type": "integer"}, {"name": "UtilPatt007", "label": "6. Number of ANC attendance in the past 3 months", "type": "integer"}, {"name": "UtilPatt008", "label": "7. Number of PNC attendance in the past 3 months", "type": "integer"}, {"name": "UtilPatt009", "label": "8. Number of pregnant women who had ANC 1st (booking) visit before 20 weeks?", "type": "integer"}, {"name": "UtilPatt010", "label": "9. Number of patients screened for hypertension", "type": "integer"}, {"name": "UtilPatt011", "label": "10. Number of patients screened for diabetes", "type": "integer"}]}, {"name": "ClinOutco01", "label": "Clinical Outcomes", "type": "group", "children": [{"name": "ClinOutco02", "label": "1. Number of deaths (in relation to registered pregnant women) in the past 3 months?", "type": "integer"}, {"name": "ClinOutco03", "label": "2. Number of deliveries resulting in still births in the past 3 months?", "type": "integer"}, {"name": "ClinOutco04", "label": "3. Rate of re-admission of patients", "type": "integer"}, {"name": "ClinOutco05", "label": "4. Infection due to treatment in the health facilities", "type": "integer"}]}]}, {"name": "CommuInvolv", "label": "Section 13. Community Involvement", "type": "group", "children": [{"name": "OutrSer0001", "label": "Outreach Services", "type": "group", "children": [{"name": "OutrSer0002", "label": "1. Does this facility carry out planned community outreach services?", "type": "select one", "children": [{"name": "no_outreach", "label": "No community outreach services occurring"}, {"name": "outreach_occ_not_scheduled", "label": "Community outreach services are occurring but not scheduled"}, {"name": "outreach_plan_occ", "label": "Planned community outreach services are occurring"}]}, {"name": "OutrSer0003", "label": "2. Does the PHC staff conduct outreach to the community?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "OutrSer0004", "label": "3. How often does the PHC staff conduct outreach to the community?", "type": "select one", "bind": {"relevant": "${OutrSer0003} = 'yes'"}, "children": [{"name": "weekly", "label": "Weekly"}, {"name": "biweekly", "label": "Biweekly (every two weeks)"}, {"name": "monthly", "label": "Monthly"}, {"name": "quarterly", "label": "Quarterly"}, {"name": "yearly", "label": "Yearly"}, {"name": "other", "label": "Other"}]}, {"name": "OutrSer0004_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../OutrSer0004, 'other')"}}, {"name": "OutrSer0005", "label": "4. Is there evidence of publicity (poster, flyers, signage, etc.) of available health services?", "type": "select one", "children": [{"name": "no_pub_avail", "label": "No publicity of available health services"}, {"name": "no_evidence_pub", "label": "There is no evidence of publicity of available health services"}, {"name": "evidence_pub_avail", "label": "There is evidence of publicity of available health services"}]}, {"name": "OutrSer0006", "label": "5. Is there evidence that local communities are involved in outreach planning and implementation?", "type": "select one", "children": [{"name": "exec_by_fac_sole", "label": "Outreaches are solely planned and executed by facility"}, {"name": "plan_w_local_comm", "label": "Outreaches are planned with local community/Facility Management Committee only, execution is solely carried out by facility staff"}, {"name": "plan_impl_w_loc_fac_man", "label": "Outreaches are planned and implemented in collaboration with the local community/Facility Management Committee"}]}, {"name": "OutrSer0007", "label": "6. Is there evidence that this facility do hold review meetings with important community members in attendance?", "type": "select one", "children": [{"name": "none", "label": "None exist"}, {"name": "not_regular", "label": "Review meeting does not occur regularly"}, {"name": "regular_monthly", "label": "Review meetings are held regularly (monthly)"}]}]}, {"name": "CommGov0001", "label": "Community Governance", "type": "group", "children": [{"name": "CommGov0002", "label": "7. Is there a Ward Development Committee (WDC)/Village Development Committee (VDC)/Community Development Committee (CDC) in place in this community?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CommGov0003", "label": "8. Has the committee met at least once in the last year?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CommGov0004", "label": "9. How often does the WDC/VDC/CDC meet?", "type": "select one", "children": [{"name": "weekly", "label": "Weekly"}, {"name": "biweekly", "label": "Biweekly (every two weeks)"}, {"name": "monthly", "label": "Monthly"}, {"name": "quarterly", "label": "Quarterly"}, {"name": "yearly", "label": "Yearly"}, {"name": "other", "label": "Other"}]}, {"name": "CommGov0004_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../CommGov0004, 'other')"}}, {"name": "CommGov0005", "label": "10. Did any member of this WDC/VDC/CDC visit the PHC in during the prior 3 months?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "CommGov0006", "label": "11. How many visits were made during the prior 3 months?", "type": "integer", "bind": {"relevant": "${CommGov0005} = 'yes'"}}, {"name": "WDCact00001", "label": "**Which of the following activities did the WDC/VDC/CDC carry out in the last 12months?**", "type": "group", "children": [{"name": "WDCact00002", "label": "1. Supported or helped improve the health facility (e.g. land, supplies, extensions, etc)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00003", "label": "2. Repairs to facility", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00004", "label": "3. Mobilized community to use facility", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00005", "label": "4. Provided transport for home visits", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00006", "label": "5. Gave in-kind contributions", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00007", "label": "6. Improved security (facility)", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00008", "label": "7. Improved water supply", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00009", "label": "8. Improved water quality", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00010", "label": "9. Supported training for CHEWs", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00011", "label": "10. Support to outreach teams", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00012", "label": "11. Provided new infrastructure", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00013", "label": "12. Provided drugs", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00014", "label": "13. Supported environmental sanitation", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "WDCact00015", "label": "14. Other", "type": "text"}]}, {"name": "HFmanCom001", "label": "15. Is there a Health Facility Management Committee in place for the facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFmanCom002", "label": "16. Has the committee met at least once in the last year?", "type": "select one", "bind": {"relevant": "${HFmanCom001} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFmanCom003", "label": "17. How often does the health facility management committee meet?", "type": "select one", "bind": {"relevant": "${HFmanCom002} = 'yes'"}, "children": [{"name": "weekly", "label": "Weekly"}, {"name": "biweekly", "label": "Biweekly (every two weeks)"}, {"name": "monthly", "label": "Monthly"}, {"name": "quarterly", "label": "Quarterly"}, {"name": "yearly", "label": "Yearly"}, {"name": "other", "label": "Other"}]}, {"name": "HFmanCom003_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../HFmanCom003, 'other')"}}, {"name": "HFmanCom004", "label": "18. How many members does the committee currently have?", "type": "integer", "bind": {"relevant": "${HFmanCom001} = 'yes'"}}, {"name": "HFmanCom005", "label": "19. Was the Health Facility/Hospital management committee involved in workplan development?", "type": "select one", "bind": {"relevant": "${HFmanCom001} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFmanCom006", "label": "20. Is the Officer-in-Charge a member of the committee?", "type": "select one", "bind": {"relevant": "${HFmanCom001} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFmanCom007", "label": "21. Are community members represented on the committee?", "type": "select one", "bind": {"relevant": "${HFmanCom001} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "HFmanCom008", "label": "22. How were community representatives selected?", "type": "text", "bind": {"relevant": "${HFmanCom001} = 'yes'"}}, {"name": "HFmanCom009", "label": "23. Are the minutes available for all the meetings?", "type": "select one", "bind": {"relevant": "${HFmanCom001} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SubComm0011", "label": "**Which of these sub committees are in existence & operational?**", "type": "group", "bind": {"relevant": "${HFmanCom001} = 'yes'"}, "children": [{"name": "SubComm0001", "label": "1. Finance Committee", "type": "select one", "bind": {"relevant": "${SubComm0011} = 'yes'"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SubComm0002", "label": "2. Procurement Committee", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SubComm0003", "label": "3. Audit Committee", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "SubComm0004", "label": "4. Quality Assurance Committee", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "ClientView1", "label": "**Client View \u2013 exit interview for 1 adult client**", "type": "group", "children": [{"name": "ClientView2", "label": "1. Is the health facility clean today?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClientView3", "label": "2. Were health staff courteous and respectful today?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClientView4", "label": "3. Did the health workers do a good job of explaining your condition today?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClientView5", "label": "4. Do you trust in the skills and abilities of the health workers of this facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClientView6", "label": "5. Were the health workers in this facility friendly and approachable?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClientView7", "label": "6. Are you confident that the health workers will maintain the confidentiality of your discussions?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ClientView8", "label": "7. How long (in minutes) did you wait in the health facility before being seen for consultation by the health worker?", "type": "integer"}]}]}]}, {"name": "Beginname1", "type": "group", "children": [{"name": "EnumeratorN", "label": "Enumerator(s) name and Phone numbers", "type": "select all that apply", "bind": {"relevant": "${Permiss0002}='yes'"}, "children": [{"name": "abahalfred", "label": "ABBAH ALFRED/08032570090"}, {"name": "dr_eric_nwoji", "label": "DR ERIC NWOJIJI/08037907240"}, {"name": "ezinne", "label": "EZINNE OGBONNA/07033912035"}, {"name": "nwigbo", "label": "NWIGBO OGBONNAYA/08068425607"}, {"name": "uschenna", "label": "UCHENNA OSCAR NWANKWO/08034146668"}, {"name": "oroke", "label": "OROKE MOSES/08131985046"}, {"name": "cyprian", "label": "CYPRIAN OGBONNA/08037460272"}, {"name": "nnabuike", "label": "ACHI NNABUIKE/08160296692"}, {"name": "nwakama", "label": "NWAKAMA AGOCHUKWU/07030149551"}, {"name": "abahemmanuel", "label": "EMMANUEL ABAH/08037515192"}, {"name": "ernestogba", "label": "ERNESTINA OGBA/08036318859"}, {"name": "paulogar", "label": "PAUL OGAR /08135250294"}, {"name": "charityanoke", "label": "CHARITY ANOKE/08068913764"}, {"name": "tochukwu", "label": "TOCHUKWU NWOKWU/08030500054"}, {"name": "cynthia_", "label": "CYNTHIA ELOY/07062831590"}, {"name": "justinaola", "label": "JUSTINA OLA OKO/08032711127"}, {"name": "azuenye", "label": "AZUENYA UDUMA /07032124846"}, {"name": "paulnwachi", "label": "PAUL NWACHI/08037605354"}, {"name": "nwegbe", "label": "NWEGBE PERPETUA/08037977884"}, {"name": "emmanuel", "label": "EMMANUEL ALI/08068271993"}, {"name": "joyorji", "label": "JOY ORJI/08063450305"}, {"name": "samuel", "label": "SAMUEL CHINEDU UGURU/08063162757"}, {"name": "eunice", "label": "EUNICE CHUKWU/08067104774"}, {"name": "chinwe", "label": "CHINWE ODAH/08143089835"}, {"name": "okoro", "label": "OKORO ESENI NNACHI/08068281247"}, {"name": "joseph", "label": "JOSEPH EZEUWA/08035450588"}, {"name": "kenneth", "label": "KENNETH NWEKE/08107382006"}, {"name": "leonard", "label": "LEONARD ALEGU/08030886972"}]}]}, {"name": "TimeDepart", "type": "group", "children": [{"name": "DepartTime0", "label": "Departure time for first visit", "type": "text", "bind": {"required": "TRUE", "calculate": "format-date-time(now(),'%H:%M')"}}]}, {"name": "end_con_giv", "label": "End of Survey", "type": "note", "bind": {"relevant": "${Permiss0002}='yes'"}}, {"name": "end_con_nt_giv", "label": "Consent not given. End of Survey", "type": "note", "bind": {"relevant": "${Permiss0002}='no'"}}, {"name": "meta", "type": "group", "control": {"bodyless": true}, "children": [{"name": "instanceID", "type": "calculate", "bind": {"readonly": "true()", "calculate": "concat('uuid:', uuid())"}}, {"name": "instanceName", "type": "calculate", "bind": {"calculate": "concat(${start000000},' ',${timestarted},'_','ISS_SHF_ODK','_',jr:choice-name(${FacilitName},'${FacilitName}'), '_', jr:choice-name(${StateName00},'${StateName00}'))"}}]}]}