{"name": "QST_PHC_BHCPF_mobile_VERSION_cloned", "type": "survey", "title": "QST PHC-BHCPF Mobile Version", "id_string": "QST_PHC_BHCPF_mobile_VERSION", "sms_keyword": "QST_PHC_BHCPF_mobile_VERSION", "default_language": "English", "version": "2019010801", "style": "pages", "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": "phonenumber", "type": "phonenumber"}, {"name": "username", "type": "username"}, {"name": "email", "type": "email"}, {"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)", "type": "note"}, {"name": "Permiss0001", "label": "#####Section 1. **Permission**", "type": "group", "children": [{"name": "parent6", "label": "1. Do you agree to be interviewed?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent7", "label": "2. What is your reason for refusal.", "type": "text", "bind": {"relevant": "${parent6}='no'", "required": "TRUE"}}, {"name": "Notes000000", "label": "Any additional notes", "type": "text"}]}, {"name": "FaciInf0002", "label": "#####Section 2. **Facility Information**", "type": "group", "children": [{"name": "parent53", "label": "1. State", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "children": [{"name": "abia", "label": "Abia"}, {"name": "adamawa", "label": "Adamawa"}, {"name": "anambra", "label": "Anambra"}, {"name": "akwa_ibom", "label": "Akwa-Ibom"}, {"name": "bauchi", "label": "Bauchi"}, {"name": "bayelsa", "label": "Bayelsa"}, {"name": "benue", "label": "Benue"}, {"name": "borno", "label": "Borno"}, {"name": "cross_river", "label": "Cross River"}, {"name": "delta", "label": "Delta"}, {"name": "ebonyi", "label": "Ebonyi"}, {"name": "edo", "label": "Edo"}, {"name": "ekiti", "label": "Ekiti"}, {"name": "enugu", "label": "Enugu"}, {"name": "federal_cap", "label": "Federal Capital Territory"}, {"name": "gombe", "label": "Gombe"}, {"name": "imo", "label": "Imo"}, {"name": "jigawa", "label": "Jigawa"}, {"name": "kaduna", "label": "Kaduna"}, {"name": "kano", "label": "Kano"}, {"name": "katsina", "label": "Katsina"}, {"name": "kebbi", "label": "Kebbi"}, {"name": "kogi", "label": "Kogi"}, {"name": "kwara", "label": "Kwara"}, {"name": "lagos", "label": "Lagos"}, {"name": "nasarawa", "label": "Nasarawa"}, {"name": "niger", "label": "Niger"}, {"name": "ogun", "label": "Ogun"}, {"name": "ondo", "label": "Ondo"}, {"name": "osun", "label": "Osun"}, {"name": "oyo", "label": "Oyo"}, {"name": "plateau", "label": "Plateau"}, {"name": "rivers", "label": "Rivers"}, {"name": "sokoto", "label": "Sokoto"}, {"name": "taraba", "label": "Taraba"}, {"name": "yobe", "label": "Yobe"}, {"name": "zamfara", "label": "Zamfara"}]}, {"name": "CalcState002", "type": "calculate", "bind": {"calculate": "if(${parent53} = '','',once(now()))"}}, {"name": "parent8", "label": "2. Local Government Area", "type": "select one external", "bind": {"required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "choice_filter": "states=${parent53}", "query": "LGAs"}, {"name": "CalcLGA00002", "type": "calculate", "bind": {"calculate": "if(${parent8} = '','',once(now()))"}}, {"name": "parent9", "label": "3. Wards", "type": "select one external", "bind": {"relevant": "${parent53} = 'kebbi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w1"}, "choice_filter": "LGAs = ${parent8}", "query": "wards"}, {"name": "parent9a", "label": "3. Ward", "type": "text", "bind": {"relevant": "${parent53} != 'kebbi'", "required": "TRUE"}}, {"name": "CalcWard000", "type": "calculate", "bind": {"calculate": "if(${parent9a} = '','',once(now()))"}}, {"name": "parent10", "label": "4. Health Facility Name", "type": "select one external", "bind": {"relevant": "${parent53} = 'kebbi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w2"}, "choice_filter": "wards=${parent9}", "query": "facilities"}, {"name": "parent10a", "label": "4. Health Facility Name", "type": "select one external", "bind": {"relevant": "${parent53} != 'kebbi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w2"}, "choice_filter": "LGAs = ${parent8} or LGAs = -88", "query": "facilities"}, {"name": "CalcFacil022", "type": "calculate", "bind": {"calculate": "if(${parent10} = '','',once(now()))"}}, {"name": "otherfacili2", "label": "4a. Type in facility name", "hint": "Please remember to take necessary steps to add this facility to the master facility list", "type": "text", "bind": {"relevant": "${parent10} = 'other_facility'", "required": "TRUE"}}, {"name": "parent11", "label": "5. Health Facility Type", "type": "select one external", "bind": {"relevant": "${parent53} = 'kebbi'", "required": "TRUE"}, "control": {"appearance": "autocomplete minimal w2"}, "choice_filter": "facilities=${parent10}", "query": "facility"}, {"name": "Calctype022", "type": "calculate", "bind": {"calculate": "if(${parent11} = '','',once(now()))"}}, {"name": "parent11a", "label": "5. Health Facility Type", "type": "select one", "bind": {"relevant": "${parent53} != 'kebbi'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "primary_health_center", "label": "Primary health center"}, {"name": "primary_health_clinic", "label": "Primary health clinic"}, {"name": "health_post", "label": "Health post"}]}, {"name": "parent52", "label": "6. Health Facility Code", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "general_hospital", "label": "General Hospital (GH) \u2013 001"}, {"name": "com_health_centre", "label": "Comprehensive Health Centre (CHC) \u2013 002"}, {"name": "prim_health_centre", "label": "Primary Health-care Centre (PHC) \u2013 003"}, {"name": "clinic_mat_home", "label": "Clinic/Maternity home \u2013 004"}, {"name": "health_post", "label": "Health Post \u2013 005"}, {"name": "mobile_clinic", "label": "Mobile Clinic \u2013 006"}, {"name": "dispensary", "label": "Dispensary \u2013 007"}]}, {"name": "parent12", "label": "7. Is the facility rural or urban?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "rural", "label": "Rural"}, {"name": "urban", "label": "Urban"}, {"name": "peri-urban", "label": "Peri-Urban"}]}, {"name": "parent51", "label": "8. Is the building rented", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent13", "label": "9. Arrival time for first visit", "type": "text", "bind": {"required": "TRUE"}}, {"name": "parent44", "label": "10. Collect the GPS coordinates of this facility.", "type": "geopoint", "bind": {"required": "TRUE"}, "control": {"accuracyThreshold": "5", "appearance": "w4"}}]}, {"name": "surv_start", "label": "#####Start of Survey", "type": "group", "bind": {"relevant": "${parent6}='yes'"}, "children": [{"name": "GenInfo001", "label": "#####Section 3. **General Information**", "type": "group", "children": [{"name": "gen13", "label": "1. Full name of Respondent", "hint": "[First-name Last-name]", "type": "text", "bind": {"required": "TRUE"}, "control": {"appearance": "multiline w2"}}, {"name": "gen14", "label": "2. Phone Number of Respondent", "type": "text", "bind": {"constraint": "regex(.,'[0-9]{11}')", "required": "TRUE"}, "control": {"appearance": "number"}}, {"name": "gen15", "label": "3. Are you the OIC?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "gen16", "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": "gen16_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../gen16, 'other')"}}, {"name": "gen18", "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": "gen18_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../gen18, 'other')"}}, {"name": "gen19", "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": "gen19_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../gen19, 'other')"}}, {"name": "gen20", "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": "gen20_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../gen20, 'other')"}}, {"name": "gen21", "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": "gen21_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../gen21, 'other')"}}, {"name": "gen22", "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": "gen29", "label": "10. How many rooms does this health facility have?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "picgen23", "label": "11. Take a picture of the waiting area in the health facility", "hint": "*If applicable", "type": "photo"}, {"name": "picgen24", "label": "12. Take a picture of the consulting room in the health facility", "hint": "*If applicable", "type": "photo"}, {"name": "gen25", "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": "gen26", "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": "gen27", "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": "gen28", "label": "16. How many people live in the catchment area for this facility?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE", "relevant": "${gen27} = 'yes'"}}]}]}, {"name": "AdminSysInf", "label": "#####Section 4. Administrative System and Infrastructure", "type": "group", "children": [{"name": "AdminSys", "label": "Administrative System", "type": "group", "children": [{"name": "admin13", "label": "1. Does the health facility offer 24 hour's services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin14", "label": "2. Does the facility have a functioning mobile phone with ability to charge?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin15", "label": "3. Does this facility have a functioning computer?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin16", "label": "4. Is there access to email or internet within the facility today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin17", "label": "5. Are there arrangements for emergency transport?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "picadmin27", "label": "6. Take a picture of the ambulance vehicle", "type": "photo", "bind": {"relevant": "${admin17} = 'yes'", "required": "TRUE"}}, {"name": "admina", "label": "6a. What type of arrangements does this health facility have for emergency transport? [state all]", "type": "select all that apply", "bind": {"relevant": "${admin17} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "ambulance_owned_facility", "label": "Ambulance owned by facility"}, {"name": "ambulance_on_call", "label": "Ambulance available on call"}, {"name": "official_vehicle_owned_by_facility", "label": "Official vehicle (not an ambulance) owned by facility"}, {"name": "official_vehicle_on_call", "label": "Official vehicle (not an ambulance) available on call"}, {"name": "official_vehicle_on_call", "label": "Private vehicle (not ambulance) available on call"}, {"name": "emergency_patient_transport", "label": "Emergency patient transport"}, {"name": "no_vehicle_in_facility", "label": "No ambulance/vehicle in the facility"}, {"name": "other", "label": "Other"}]}, {"name": "admina_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../admina, 'other')"}}, {"name": "admin28", "label": "7. Is there a driver on call/available 24 hours?", "type": "select one", "bind": {"relevant": "${admin17} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin29", "label": "8. Is fuel available in the vehicle today?", "type": "select one", "bind": {"relevant": "${admin17} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin30", "label": "9. What was the purpose of the last trip that the vehicle or ambulance made?", "type": "select one", "bind": {"relevant": "${admin17} = '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": "other", "label": "Other"}]}, {"name": "admin30_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../admin30, 'other')"}}, {"name": "admin32", "label": "10. Do patients have to pay to use this vehicle or ambulance?", "type": "select one", "bind": {"relevant": "${admin17} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin33", "label": "10a. How much?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE", "relevant": "${admin32} = 'yes'"}}, {"name": "admin34", "label": "11. 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": "admin35", "label": "12. Does this facility have any guidelines on health care waste management?", "hint": "Please ask to see the guidelines", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin36", "label": "13. 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": "admin37", "label": "14. Do you have a Quarterly (Business/Work) Implementation Plan?", "hint": "Ask to see the document", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin38", "label": "a. When did the facility submit the Quarterly (Business/Work) Implementation Plan for approval?", "type": "date", "bind": {"jr:constraintMsg": "Date should not be later than today", "constraint": ".<=date(today())", "required": "TRUE", "relevant": "${admin37} = 'yes'"}}, {"name": "admin39", "label": "b. When did the facility receive written approval from the relevant authorities for the Quarterly (Business/Work) Implementation Plan?", "type": "date", "bind": {"jr:constraintMsg": "Date should not be lesser than the date QIP was submitted for appoval(previous question)", "constraint": ". >${admin38} and .<=date(today())", "required": "TRUE", "relevant": "${admin37} = 'yes'"}}, {"name": "admin40", "label": "c. Was there a delay in receiving Quarterly (Business/Work) Implementation Plan approval from the relevant authorities?", "type": "select one", "bind": {"relevant": "${admin37} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "na", "label": "Not Applicable"}]}, {"name": "admin41", "label": "d. Why was there a delay?", "type": "select one", "bind": {"relevant": "${admin40} = 'yes'", "required": "TRUE"}, "control": {"appearance": "minimal w1"}, "children": [{"name": "delay_in _submission", "label": "Delay in submission of QIP by facility"}, {"name": "hq_not approving_qip", "label": "Headquarters not approving QIP"}, {"name": "other", "label": "Other"}]}, {"name": "admin41_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../admin41, 'other')"}}, {"name": "admin42", "label": "15. Does your health facility have a Quality Improvement Plan (QIP)?", "hint": "ask to see the document", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin43", "label": "a. Is the QIP costed?", "type": "select one", "bind": {"relevant": "${admin42} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}, {"name": "na", "label": "Not Applicable"}]}, {"name": "admin44", "label": "16. 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": "admin45", "label": "a. Did they leave a copy or written feedback?", "type": "select one", "bind": {"relevant": "${admin44} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "admin46", "label": "b. Did they use a checklist?", "type": "select one", "bind": {"relevant": "${admin44} = '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": "infra13", "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": "picinfra14", "label": "2. Take a picture of the FRONT VIEW of the facility building", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "picinfra15", "label": "3. Take a picture of the SIDE VIEW of the facility building", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "picinfra16", "label": "4. Take a picture of the BACK VIEW of the facility building", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "infra17", "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": "picinfra18", "label": "6.Take a picture of the roof of the health facility", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "picinfra19", "label": "6a. Take a second picture of the roof of the health facility", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "picinfra20", "label": "7. Take a picture of the facility ceiling", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "picinfra21", "label": "7a. Take a second picture of the facility ceiling", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "infra22", "label": "8. 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": "nofence", "label": "No Fence"}]}, {"name": "picinfra23", "label": "a. Take a picture of the fence of the health facility", "type": "photo", "bind": {"relevant": "${infra22} != 'nofence'", "required": "TRUE"}}, {"name": "picinfra24", "label": "b. Take a second picture of the fence of the health facility", "type": "photo", "bind": {"relevant": "${infra22} != 'nofence'", "required": "TRUE"}}, {"name": "infra25", "label": "9. 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": "picinfra26", "label": "10. Take a picture of the consulting room in the health facility", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "infra27", "label": "11. Are the walls free from cracks?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra28", "label": "12. Does the health facility have functional doors with functional locks?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra96", "label": "13. Is there any source of electricity?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra29", "label": "a. What is the main source of power or electricity for this facility?", "type": "select one", "bind": {"relevant": "${infra96} = 'yes'", "required": "TRUE"}, "children": [{"name": "electric_power_grid", "label": "Electric power grid"}, {"name": "fuel_operated_generator________", "label": "Fuel operated generator"}, {"name": "battery_operated_generator", "label": "Battery operated generator"}, {"name": "solar_system", "label": "Solar system"}, {"name": "other_electricity_source", "label": "Other electricity source"}]}, {"name": "infra30", "label": "b. Specify power or electricity source", "hint": "Please remember to take necessary steps to add this facility to the master facility list", "type": "text", "bind": {"relevant": "${infra29} = 'other_electricity_source'", "required": "TRUE"}}, {"name": "infra31", "label": "14. How many hours per day does this facility have electricity from the main source?", "type": "integer", "bind": {"relevant": "${infra96} = 'yes'", "required": "TRUE"}}, {"name": "infra32", "label": "15. Does this facility use any of the following as alternative power sources?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "no_source_of_power_supply", "label": "No source of power supply"}, {"name": "fuel_operated_generator", "label": "Fuel operated generator"}, {"name": "battery_operated_generator", "label": "Battery operated generator"}, {"name": "solar_system", "label": "Solar system"}, {"name": "other_alternative_power_source", "label": "Other alternative power source"}]}, {"name": "infra97", "label": "15a. Specify alternative power source", "type": "text", "bind": {"relevant": "${infra32} = 'other_alternative_power_source'", "required": "TRUE"}}, {"name": "infra33", "label": "16. Is there any form of water?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra34", "label": "a. What is the main source of water for the facility?", "type": "select one", "bind": {"relevant": "${infra33} = 'yes'", "required": "TRUE"}, "children": [{"name": "piped_into_facility", "label": "Piped into facility"}, {"name": "piped_onto_facility_grounds", "label": "Piped onto facility grounds"}, {"name": "public_tap_standpipe", "label": "Public tap/standpipe"}, {"name": "borehole", "label": "Borehole"}, {"name": "protected_dug_well", "label": "Protected dug well"}, {"name": "unprotected_dug_well", "label": "Unprotected dug well"}, {"name": "protected_spring_______________", "label": "Protected spring"}, {"name": "unprotected_spring", "label": "Unprotected spring"}, {"name": "rainwater", "label": "Rainwater"}, {"name": "bottled_water", "label": "Bottled water"}, {"name": "cart_w_small_tank_drum", "label": "Cart w/small tank/drum"}, {"name": "truck", "label": "Truck"}, {"name": "surface_water", "label": "Surface water"}, {"name": "other_source_of_water", "label": "Other source of water"}]}, {"name": "infra98", "label": "b. Specify other water source", "type": "text", "bind": {"relevant": "${infra34} = 'other_source_of_water'", "required": "TRUE"}}, {"name": "infra35", "label": "17. What is the average walking time, in minutes to and from the main source of water? (including waiting time)", "type": "select one", "bind": {"relevant": "${infra33} = 'yes'", "required": "TRUE"}, "children": [{"name": "0_10_minutes", "label": "0-10 minutes"}, {"name": "11_20_minutes", "label": "11-20 minutes"}, {"name": ">_20_minutes", "label": "> 20 minutes"}]}, {"name": "infra36", "label": "18. Is water from this source available within 500 meters of the facility?", "type": "select one", "bind": {"relevant": "${infra33} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra37", "label": "19. Does this facility have any of the following as an alternative source of water supply?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "no_water_source", "label": "No water source"}, {"name": "piped_into_facility", "label": "Piped into facility"}, {"name": "piped_onto_facility_grounds", "label": "Piped onto facility grounds"}, {"name": "public_tap_standpip", "label": "Public tap/standpip"}, {"name": "borehole", "label": "Borehole"}, {"name": "protected_dug_well", "label": "Protected dug well"}, {"name": "unprotected_dug_well", "label": "Unprotected dug well"}, {"name": "protected_spring_______________", "label": "Protected spring"}, {"name": "unprotected_spring_____________", "label": "Unprotected spring"}, {"name": "rainwater", "label": "Rainwater"}, {"name": "bottled_water", "label": "Bottled water"}, {"name": "cart_w_small_tank_drum", "label": "Cart w/small tank/drum"}, {"name": "tanker_truck", "label": "Tanker truck"}, {"name": "surface_water", "label": "Surface water"}, {"name": "other_alternative_water_source", "label": "Other alternative water source"}]}, {"name": "infra99", "label": "a. Specify alternative water source", "type": "text", "bind": {"relevant": "${infra37} = 'other_alternative_water_source'", "required": "TRUE"}}, {"name": "infra38", "label": "b. What is the average walking time, in minutes, to and from the alternative source of water? (including waiting time)", "type": "select one", "bind": {"relevant": "${infra37} != 'no_water_source'", "required": "TRUE"}, "children": [{"name": "0_10_minutes", "label": "0-10 minutes"}, {"name": "11_20_minutes", "label": "11-20 minutes"}, {"name": ">_20_minutes", "label": "> 20 minutes"}]}, {"name": "infra39", "label": "20. Is there a functioning toilet (latrine) for use by patients in the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra39b", "label": "a. Type of open defecation used", "type": "text", "bind": {"relevant": "${infra39}='no'", "required": "TRUE"}}, {"name": "infra40", "label": "21. What type of toilet (latrine) is available for use by outpatients?", "type": "select one", "bind": {"relevant": "${infra39}='yes'", "required": "TRUE"}, "children": [{"name": "no_functioning_toilet", "label": "No functioning toilet"}, {"name": "bush", "label": "Bush"}, {"name": "flush_toilet", "label": "Flush toilet"}, {"name": "flush_toilet_but_no_water", "label": "Flush toilet (but no water)"}, {"name": "vip_latrine", "label": "VIP latrine"}, {"name": "covered_pit_latrine_no_slab____", "label": "Covered pit latrine"}, {"name": "uncovered_pit_latrine_w__slab", "label": "Uncovered pit latrine w/ slab"}, {"name": "other_specify", "label": "Other (specify)"}]}, {"name": "infra41", "label": "22. Other type of toilet(latrine) available", "type": "text", "bind": {"relevant": "${infra40} = 'other_specify'", "required": "TRUE"}}, {"name": "infra95", "label": "23. How many of the mentioned (outpatient) toilets/latrines are there?", "type": "integer", "bind": {"relevant": "${infra39}='yes'", "required": "TRUE"}}, {"name": "infra43", "label": "24. How many of the mentioned (outpatient) toilets/latrines are currently functioning?", "type": "integer", "bind": {"jr:constraintMsg": "Number of functioning toilet cannot be more than available toilets", "constraint": ". <=${infra95}", "required": "TRUE", "relevant": "${infra39}='yes'"}}, {"name": "infra42", "label": "25. Do outpatients and inpatients use the same toilets?", "type": "select one", "bind": {"relevant": "${infra39}='yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra44", "label": "26. What type of toilet (latrine) is available for use by inpatients?", "type": "select one", "bind": {"relevant": "${infra39}='yes'", "required": "TRUE"}, "children": [{"name": "no_functioning_toilet", "label": "No functioning toilet"}, {"name": "bush", "label": "Bush"}, {"name": "flush_toilet", "label": "Flush toilet"}, {"name": "flush_toilet_but_no_water", "label": "Flush toilet (but no water)"}, {"name": "vip_latrine", "label": "VIP latrine"}, {"name": "covered_pit_latrine_no_slab_", "label": "Covered pit latrine"}, {"name": "uncovered_pit_latrine_w__slab", "label": "Uncovered pit latrine w/ slab"}, {"name": "other_specify", "label": "Other (specify)"}]}, {"name": "infra45", "label": "27. Other type of toilet(latrine) available for use by inpatients", "type": "text", "bind": {"relevant": "${infra44} = 'other_specify'", "required": "TRUE"}}, {"name": "picinfra46", "label": "28. Take a picture of the inpatient toilet in the health facility", "type": "photo", "bind": {"relevant": "${infra39}='yes'", "required": "TRUE"}}, {"name": "infra47", "label": "29. How many of the mentioned (inpatient) toilets/latrines are there?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE", "relevant": "${infra39}='yes'"}}, {"name": "infra48", "label": "30. How many of the mentioned (inpatient) toilets/latrines are currently functioning?", "type": "integer", "bind": {"jr:constraintMsg": "Number of functioning toilet cannot be more than available toilets", "constraint": ". <=${infra47}", "required": "TRUE", "relevant": "${infra39}='yes'"}}, {"name": "infra49", "label": "31. Does this facility finally dispose of sharps waste (e.g., filled sharps boxes)?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infraa", "label": "a. How does this facility finally dispose of sharps waste (e.g., filled sharps boxes)? [state all]", "hint": "should be 2m deep, 15m from facility, 100m from water source and 50m from households", "type": "select all that apply", "bind": {"relevant": "${infra49} = 'yes'", "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": "infraa_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../infraa, 'other')"}}, {"name": "infra63", "label": "32. Does this facility finally dispose of medical waste other than sharps boxes?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infrab", "label": "33. How does this facility finally dispose of medical waste other than sharps boxes? [state all]", "hint": "It should be 2m deep, 15m from facility, 100m from water source and 50m from households", "type": "select all that apply", "bind": {"relevant": "${infra63} = 'yes'", "required": "TRUE"}, "children": [{"name": "incinerator", "label": "Incinerator"}, {"name": "1\u2010chamber_drum_brick", "label": "1\u2010chamber drum/brick"}, {"name": "flat_ground_\u2010_no_protection", "label": "Flat ground \u2010 no protection"}, {"name": "flat_ground_with_protection", "label": "Flat ground with protection"}, {"name": "pit_or_protected_ground", "label": "Pit or protected ground"}, {"name": "covered_pit_or_pit_latrine", "label": "Covered pit or pit latrine"}, {"name": "open\u2010pit_\u2010_no_protection_", "label": "Open\u2010pit \u2010 no protection"}, {"name": "protected_ground_or_pit_", "label": "Protected ground or pit"}, {"name": "stored_in_covered_container", "label": "Stored in covered container"}, {"name": "stored_unprotected_____________", "label": "Stored unprotected"}, {"name": "facility_never_has_sharp_waste", "label": "Facility never has sharp waste"}, {"name": "waste_collection_agency", "label": "Waste collection agency"}, {"name": "other", "label": "Other"}]}, {"name": "infrab_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../infrab, 'other')"}}, {"name": "infra78", "label": "34. Are black bins for non-contaminated waste available?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra79", "label": "35. 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": "infra80", "label": "36. Is a security box for sharps available?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra81", "label": "37. Is the incinerator functional today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra82", "label": "38. 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": "infra83", "label": "39. Is there an inpatient ward in this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra94", "label": "40. Is the ward functional?", "type": "select one", "bind": {"relevant": "${infra83} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra84", "label": "41. Does the patient wards appear clean and in good condition?", "type": "select one", "bind": {"relevant": "${infra83} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "picinfra93", "label": "42. Take a picture of the in- patient ward in the facility", "type": "photo", "bind": {"relevant": "${infra83} = 'yes'", "required": "TRUE"}}, {"name": "infra85", "label": "43. Is the facility equipped with in-patient beds?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra86", "label": "44. How many inpatient beds does the facility have?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE", "relevant": "${infra85} = 'yes'"}}, {"name": "infra89", "label": "45. Do you have a maternity waiting room where women can stay prior to giving birth?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra90", "label": "46. Is there staff accommodation in this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra91", "label": "47. Is there a call room for staff on call duty?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "infra92", "label": "48. Is the on-call room equipped with basic conveniences (bed/couch, bed linen and ventilation)?", "type": "select one", "bind": {"relevant": "${infra91} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "FinancSys01", "label": "#####Section 5. Financial System", "type": "group", "children": [{"name": "fin13", "label": "1. Does this facility have a staff responsible for the financial/accounting system of the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin14", "label": "2. Has he/she received financial training by appropriate organization/partner?", "type": "select one", "bind": {"relevant": "${fin13} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "FinancBk01", "label": "Financial Bookkeeping", "type": "group", "children": [{"name": "fina", "label": "1. Which of the following financial management tools do you have?", "type": "select all that apply", "bind": {"required": "TRUE"}, "children": [{"name": "receipt_books", "label": "Receipt books"}, {"name": "payment_voucher", "label": "Payment voucher"}, {"name": "cash_books", "label": "Cash 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": "fina_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../fina, 'other')"}}, {"name": "fin24", "label": "2. Have you submitted the financial report for the last quarter? [ask to see transmittal evidence]", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin25", "label": "3. Monthly financial report (income and expenditure books) available and correctly filled and signed by the Health Facility Officer in Charge", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin26", "label": "4. How often was the facility visited by a state/LGA/Ward level accounts person in the last calendar year?", "type": "select one", "bind": {"required": "TRUE"}, "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": "fin26_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../fin26, 'other')"}}, {"name": "fin27", "label": "5. Does the facility share its financial information with the facility management committee?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin28", "label": "6. How does the facility share the information?", "type": "select one", "bind": {"relevant": "${fin27} = 'yes'", "required": "TRUE"}, "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": "fin28_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../fin28, 'other')"}}]}, {"name": "OpFunds0001", "label": "Operational Funds", "type": "group", "children": [{"name": "fin30", "label": "1. Did the facility receive any non-salary, operational funds from the state/local government in the calendar last year?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin31", "label": "2. Which level of government provided funds for non-salary, operational expenses in the last year?", "type": "select one", "bind": {"relevant": "${fin30} = 'yes'", "required": "TRUE"}, "children": [{"name": "state", "label": "State government only"}, {"name": "local", "label": "Local government only"}, {"name": "state_local", "label": "Both state and local government"}]}, {"name": "fin32", "label": "3. Did the facility experience any delay in receipt of non-salary, operational funds from state/local government?", "type": "select one", "bind": {"relevant": "${fin30} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin47", "label": "4. Which level of government delayed funding for non-salary, operational expenses in the last year?", "type": "select one", "bind": {"relevant": "${fin32} = 'yes'", "required": "TRUE"}, "children": [{"name": "state", "label": "State government only"}, {"name": "local", "label": "Local government only"}, {"name": "state_local", "label": "Both state and local government"}]}, {"name": "fin48", "label": "5. Please indicate the principle reason for the delays", "type": "select one", "bind": {"relevant": "${fin32} = 'yes'", "required": "TRUE"}, "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": "fin48_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../fin48, 'other')"}}, {"name": "fin33", "label": "6. Does the facility have alternate sources of funding?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "finb", "label": "6a. Which of the following have been alternative sources of funding in the last year?", "type": "select all that apply", "bind": {"relevant": "${fin33} = 'yes'", "required": "TRUE"}, "children": [{"name": "drug_revolv", "label": "Drug revolving"}, {"name": "registration", "label": "Registration"}, {"name": "dev_partners_ngos", "label": "Development partners/NGOs"}, {"name": "other", "label": "Other"}]}, {"name": "finb_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../finb, 'other')"}}, {"name": "fin39", "label": "7. Does this health facility have a bank account?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin40", "label": "7a. How many active Bank accounts does the facility operate?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE", "relevant": "${fin39} = 'yes'"}}, {"name": "fin41", "label": "8. Are user fees/charges displayed at the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "NHISProc001", "label": "NHIS/Fee-for-service Processing", "type": "group", "children": [{"name": "fin42", "label": "9. Do you have the appropriate NHIS utilization and claim forms?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin43", "label": "a. Does the utilization and claims data correspond and are accurate?", "type": "select one", "bind": {"relevant": "${fin42} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin44", "label": "b. The information of the enrollee is complete (including patient identification number, age, gender and contact details) - up to date for the preceding month", "type": "select one", "bind": {"relevant": "${fin42} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "fin45", "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": "${fin42} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "QIPBizPlan1", "label": "QIP/Business Plan Financing", "type": "group", "children": [{"name": "fin46", "label": "10. What proportion of facility allocation is spent on QIP and business plan?", "type": "select one", "bind": {"required": "TRUE"}, "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": "ServCost002", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "Servicenote", "label": "Please insert the costs of the health services below", "type": "note"}, {"name": "serv13", "label": "1. Registration", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv14", "label": "2. Consultation- 5 years or older", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv15", "label": "3. Consultation- under 5 years of old", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv16", "label": "4. Laboratory: Malaria Test", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv17", "label": "5. Laboratory: Random blood sugar", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv18", "label": "6. Laboratory: Haemoglobin (Hb)", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv19", "label": "7. Laboratory: urinalysis", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv20", "label": "8. Laboratory: Other (Specify)", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv28", "label": "9. Drugs: Amoxicillin Syrup", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "serv57", "type": "group", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_193", "label": "10. U 5 services (Immunization, Diarrhea treatment, ARI)", "hint": "*Insert service cost", "type": "note"}, {"name": "serv29", "label": "a. Immunization", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv30", "label": "b. Diarrhea", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv31", "label": "c. Acute Respiratory Infection", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "serv58", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_198", "label": "11. ANC Visit", "hint": "*Insert service cost", "type": "note"}, {"name": "serv32", "label": "a. Registration", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv33", "label": "b. Drugs", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "ServCost003", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_202", "hint": "*Insert cost", "type": "note"}, {"name": "serv34", "label": "12. Normal Delivery", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv35", "label": "13. Family Planning", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "serv59", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_206", "label": "14. Malaria Drugs", "hint": "*Insert service cost", "type": "note"}, {"name": "serv60", "label": "a. Artesunate/Artemisinin combination therapy (ACT)/ Lumefantrine", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv61", "label": "b. Sulfadoxine/Pyramethamine(Fansidar), Chloroquine, Others", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "serv62", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_210", "label": "15. HIV/AIDS", "hint": "*Insert service cost", "type": "note"}, {"name": "serv63", "label": "a. Counselling", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv64", "label": "b. Screening", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv41", "label": "c. ARVs", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "serv65", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_215", "label": "16. TB", "hint": "*Insert service cost", "type": "note"}, {"name": "serv41", "label": "a. Sputum test", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv42", "label": "b. Chest x-ray", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv43", "label": "c. Treatment/DOTS", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}, {"name": "serv44", "label": "17. Are the user fees/charges displayed at the facility service charters?", "hint": "Ask to see the boards", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv66", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_221", "label": "18. In your facility, who is exempted from paying user fees?", "type": "note"}, {"name": "reserved_name_for_field_list_labels_222", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv45", "label": "a. Patients with chronic diseases", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv46", "label": "b. Elderly patients", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv47", "label": "c. Very poor people", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv48", "label": "d. Facility staff", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv49", "label": "e. Relatives of staff", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "serv50", "label": "19. What was the value for Waivers/Exemptions during the last financial year?", "type": "integer", "bind": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}]}]}, {"name": "HumResMan01", "label": "#####Section 6. Human Resources Management", "type": "group", "children": [{"name": "serv51", "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": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv52", "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": {"jr:constraintMsg": "Enter a positive integer", "constraint": ". >=0", "required": "TRUE"}}, {"name": "serv53", "label": "3. Do your staff experience delay in payment of salary?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv54", "label": "3a. How frequently?", "type": "select one", "bind": {"relevant": "${serv53} = 'yes'", "required": "TRUE"}, "children": [{"name": "seldom", "label": "Seldom (Once in a year)"}, {"name": "often", "label": "Often (Once every 3-6 months)"}, {"name": "always", "label": "Always"}]}, {"name": "serv55", "label": "4. Are there measures (attendance system) against lateness/absenteeism?", "type": "select one", "bind": {"required": "TRUE"}, "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": "serv56", "label": "5. Are there laid down procedures for contract staff recruitment", "type": "select one", "bind": {"required": "TRUE"}, "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": "roster_inst", "label": "Please allow me to ask you a few questions about each health worker who works in this facility starting with you. Could you give me the name of the employee in the various categories starting with the physicians or medical officers?", "hint": "*Only health workers information should be collected", "type": "note"}, {"name": "staffRos001", "label": "######Staff Roster", "hint": "*Identify the most senior staff in charge present at the time of the survey. Ask to see staff/personnel records if available.\nPlease allow me to ask you a few questions about the employees in this facility.*", "type": "group", "children": [{"name": "sr1", "label": "1. First Name", "type": "text", "bind": {"required": "TRUE"}}, {"name": "sr2", "label": "2. Last Name", "type": "text", "bind": {"required": "TRUE"}}, {"name": "sr3", "label": "3. Cadre", "type": "select one", "bind": {"required": "TRUE"}, "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": "sr3_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../sr3, 'other')"}}, {"name": "sr9", "label": "3a. Volunteer (Specify)", "type": "text", "bind": {"relevant": "${sr3} = 'volunteer'", "required": "TRUE"}}, {"name": "sr4", "label": "4. Gender", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "male", "label": "Male"}, {"name": "female", "label": "Female"}]}, {"name": "sr5", "label": "5. Age", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "sr6", "label": "6. Does ${sr2} regularly perform outpatient consultation", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sr7", "label": "7. Is ${sr2} currently in the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sr8", "label": "8. Reason for absence", "type": "select one", "bind": {"relevant": "${sr7} = 'no'", "required": "TRUE"}, "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": "sr8_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../sr8, 'other')"}}]}, {"name": "staffRos002", "label": "######Staff Roster", "hint": "Add additional health workers on roster", "type": "group", "children": [{"name": "roster_repeat", "type": "repeat", "children": [{"name": "sr10", "label": "1. First Name", "type": "text", "bind": {"required": "TRUE"}}, {"name": "sr11", "label": "2. Last Name", "type": "text", "bind": {"required": "TRUE"}}, {"name": "sr12", "label": "3. Cadre", "type": "select one", "bind": {"required": "TRUE"}, "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": "sr12_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../sr12, 'other')"}}, {"name": "sr18", "label": "3a. Volunteer (Specify)", "type": "text", "bind": {"relevant": "${sr12} = 'volunteer'", "required": "TRUE"}}, {"name": "sr13", "label": "4. Gender", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "male", "label": "Male"}, {"name": "female", "label": "Female"}]}, {"name": "sr14", "label": "5. Age", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "sr15", "label": "6. Does ${sr11} regularly perform outpatient consultation", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sr16", "label": "7. Is ${sr11} currently in the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "sr17", "label": "8. Reason for absence", "type": "select one", "bind": {"relevant": "${sr16} = 'no'", "required": "TRUE"}, "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": "sr17_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../sr17, 'other')"}}]}]}]}, {"name": "MatChilSer", "label": "#####Section 7. Maternal and Child Services", "type": "group", "children": [{"name": "FamPlan0001", "label": "Family Planning", "type": "group", "children": [{"name": "mnch13", "label": "1. Are family planning services offered here?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mnch14", "label": "2. Which type of family planning services are offered here?", "type": "select one", "bind": {"relevant": "${mnch13} = 'yes'", "required": "TRUE"}, "children": [{"name": "couns_services", "label": "Counselling services"}, {"name": "couns_comm_services", "label": "Counselling and commodity services"}]}, {"name": "mncha", "label": "3. Which family planning methods (commodities) are available today?", "type": "select all that apply", "bind": {"relevant": "${mnch13} = 'yes'", "required": "TRUE"}, "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": "mnch21", "label": "4. Are FP individual cards available and filled according to the format?", "type": "select one", "bind": {"relevant": "${mnch13} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mnch22", "label": "5. How many qualified staff are trained in Family Planning?", "type": "integer", "bind": {"relevant": "${mnch13} = 'yes'", "required": "TRUE"}}]}, {"name": "ANC00000001", "label": "Antenatal Care", "type": "group", "children": [{"name": "mnch23", "label": "1. Does this facility provide antenatal care services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mnch24", "label": "2. Is Antenatal Risk Assessment form (ARAF) used for ANC?", "type": "select one", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}, "children": [{"name": "none", "label": "No antenatal risk assessment form"}, {"name": "araf_present_not_used", "label": "Antenatal risk assessment form present but not used regularly for ANC"}, {"name": "araf_present_used", "label": "Antenatal risk assessment form present and used regularly for ANC"}]}, {"name": "mnch25", "label": "3. Does this facility provide post-natal care services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "ObsCare0001", "label": "Obstetric Care", "type": "group", "children": [{"name": "mnch26", "label": "1. Does this facility provide Basic Emergency Obstetric Care (BEOC)?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mnch27", "label": "2. How many staff present are qualified to offer BEOC? Insert number and cadre", "type": "text", "bind": {"relevant": "${mnch26} = 'yes'", "required": "TRUE"}}, {"name": "mnch28", "label": "3. Do you take deliveries at this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mnch29", "label": "4. How many qualified staff are trained on Live Saving Skills (LSS)?", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "mnch37", "label": "5. Is the delivery room is well-maintained? (Clean, delivery couch in good condition, water accessible and well lit)", "type": "select one", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "picmnch38", "label": "6. Take a picture of the interior of the delivery room, and specifically the delivery couch, in the facility", "type": "photo", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "mnch30", "label": "7. Is there light in delivery room for 24 hours", "type": "select one", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}, "children": [{"name": "elect_rech_lamp", "label": "Yes, Electricity and rechargeable lamp"}, {"name": "elect_only", "label": "Yes, Only Electricity"}, {"name": "no", "label": "No"}]}, {"name": "mnch31", "label": "8. Is a partograph used for delivery? (Check via case note audits \u20135 case notes)", "type": "select one", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}, "children": [{"name": "none", "label": "No partograph in the facility"}, {"name": "present_unused", "label": "Partograph is present but not used"}, {"name": "present_used", "label": "Partograph is present and used for delivery"}]}, {"name": "mnch32", "label": "9. How many case notes (out of 5 above) are with partographs?", "type": "integer", "bind": {"relevant": "${mnch31} = 'present_used'", "required": "TRUE"}}]}, {"name": "ManChilSer0", "label": "Management of Childhood illnesses", "type": "group", "children": [{"name": "mnch33", "label": "1. Does this facility provide routine immunization services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mnch34", "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": {"required": "TRUE"}}, {"name": "mnch35", "label": "3. Do you offer growth monitoring services to all U5 patients?", "type": "select one", "bind": {"required": "TRUE"}, "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": "mnch36", "label": "4. Does the facility have basic nutritional assessment guide? (MUAC)", "type": "select one", "bind": {"relevant": "${mnch35} != 'not_offered'", "required": "TRUE"}, "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", "children": [{"name": "AvailEqu001", "label": "Available Equipment (1/6)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "pcm13", "label": "1. Adult weighing scale", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm14", "label": "2. Child weighing scale (250g gradation)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm15", "label": "3. Infant weighing scale (100g gradation)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm16", "label": "4. Thermometer", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm17", "label": "5. Stethoscope", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm18", "label": "6. Foetoscope", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm19", "label": "7. Sphygmonometer", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm20", "label": "8. Angle poised lamp", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm21", "label": "9. Centrifuge, manual", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm22", "label": "10. Chart holder", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailEqu0012", "label": "Available Equipment (2/6)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "pcm23", "label": "11. Cooking pot (A set of 6)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm24", "label": "12. Delivery couch", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm25", "label": "13. Dissecting forceps", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm26", "label": "14. Dressing forceps", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm27", "label": "15. Dressing scissors", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm28", "label": "16. Dressing trolley", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm29", "label": "17. Drip stand", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm30", "label": "18. Enema can", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm31", "label": "19. Episiotomy scissors", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm32", "label": "20. Examination couch", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm33", "label": "21. Fire extinguishers", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm34", "label": "22. Forceps jar", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm35", "label": "23. Growth charts", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm36", "label": "24. Galipot(medium)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm37", "label": "25. Incision and drainage kit", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm38", "label": "26. Instrument cabinet", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailEqu002", "label": "Available Equipment (3/6)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "pcm39", "label": "27. Instrument tray", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm40", "label": "28. Fire extinguishers", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm41", "label": "29. Kidney dishes(large)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm42", "label": "30. Kidney dish(medium)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm43", "label": "31. Surgical Knives", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm44", "label": "32. Length measure for babies", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm45", "label": "33. Linen cupboard", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm46", "label": "34. Mackintosh", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm47", "label": "35. Microscope cover slides (pack of 100)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm48", "label": "36. Newborn bag and mask (ambubag)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm49", "label": "37. Oro-pharyngeal airway (set of 7)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailEqu002g", "label": "Available Equipment (4/6)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "pcm50", "label": "38. Pedal bin", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm51", "label": "39. Perineal sheet", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm52", "label": "40. Autoclave (pressure and wet heat)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm53", "label": "41. Electric boiler or steamer (no pressure)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm54", "label": "42. Electric dry heat sterilizer", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm55", "label": "43. Non-electric pot for boiling/steam or Heat source from non-electric equipment (stove or cooker)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm56", "label": "44. Delivery bed", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm57", "label": "45. Battery \u2013 powered torch", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm58", "label": "46. Partogram", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm59", "label": "47. Sterilizable scissors", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm60", "label": "48. Sterilizable cord ties", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm61", "label": "49. Snellen's chart", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm62", "label": "50. Soap box", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailEqu003", "label": "Available Equipment (5/6)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "pcm63", "label": "51. Soap/disinfectant dispenser", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm64", "label": "52. Stainless bedpan", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm65", "label": "53. Stainless ear syringe", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm66", "label": "54. Stitch removal/ suture scissors", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm67", "label": "55. Stitch removal/suture", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm68", "label": "56. Stool specimen bottles(pack of 100)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm69", "label": "57. Stretcher trolley", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm70", "label": "58. Suction pump", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm71", "label": "59. Suture kit", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm72", "label": "60. Suture needles", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm73", "label": "61. Swivel stool", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm74", "label": "62. Tape dispenser", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm75", "label": "63. Tape measure", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm76", "label": "64. Tenaculum forceps", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm77", "label": "65. Test tube rack", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailEqu002h", "label": "Available Equipment (6/6)", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "pcm78", "label": "66. Theatre gown", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm79", "label": "67. Tissue forceps", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm80", "label": "68. Tongue depressor", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm81", "label": "69. Tourniquet", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm82", "label": "70. Tray test tube", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm83", "label": "71. Tripod stand", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm84", "label": "72. Umbilical cord clamp, pack of 100", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm85", "label": "73. Urinal, female", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm86", "label": "74. Urinary catheter", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm87", "label": "75. Urine dipstick (multstix)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm88", "label": "76. Urine dipstick for sugar and albumin, pack of 100", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm89", "label": "77. Vacuum extractor(manual)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "pcm90", "label": "78. Vaginal speculum (sim) set of 3", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "parent22", "label": "1. Are there documented rosters for facility coverage?", "hint": "spot check workers in ANC, OPD and family planning against roster", "type": "select one", "bind": {"required": "TRUE"}, "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": "parent23", "label": "2. 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", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent24", "label": "3. Where does the facility refer its patients to?", "type": "text", "bind": {"required": "TRUE"}}, {"name": "parent25", "label": "4. How many patients did the facility refer to another facility in the prior 3 months?", "hint": "please check the referral register", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "parent26", "label": "5. 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", "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": "parent27", "label": "6. 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", "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": "HIVTBser001", "label": "HIV/TB Services", "type": "group", "children": [{"name": "parent28", "label": "1.Does this facility provide HIV/AIDS prevention and care services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent29", "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": "${parent28} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent30", "label": "3. Does this facility provide STI control services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent31", "label": "4. Does this facility treat TB patients?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "DisMan001", "label": "Disease Management", "type": "group", "children": [{"name": "parent32", "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", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_401", "label": "History Taking", "type": "note"}, {"name": "reserved_name_for_field_list_labels_402", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma1", "label": "1. Duration of fever", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma2", "label": "2. Pattern of fever/Presence or history of fever", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma3", "label": "3. Shiver or sweat", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma4", "label": "4. Convulsions", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma5", "label": "5. Vomiting", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma6", "label": "6. Appetite", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma7", "label": "7. Diarrhoea", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma8", "label": "8. Cough", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma9", "label": "9. Severity of cough", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma10", "label": "10. Difficulty in breathing", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma11", "label": "11. Type of cough (productive or dry)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma12", "label": "12. Type of medication given", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma13", "label": "13. Amount of dose given", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma14", "label": "14. Vaccinations", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0003", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "malaria0017", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_418", "label": "Physical Examination carried out", "type": "note"}, {"name": "reserved_name_for_field_list_labels_419", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma15", "label": "15. Hands (palmar pallor)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma16", "label": "16. Tongue", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma17", "label": "17. Eyes, sunken?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma18", "label": "18. Eyes, pale colour?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma19", "label": "19. Responsiveness / general condition", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma20", "label": "20. Skin condition", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma21", "label": "21. Temperature", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma22", "label": "22. Pulse", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma23", "label": "23. Neck stiffness", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma24", "label": "24. Puffy face", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma25", "label": "25. Swelling of the feet", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma26", "label": "26. Abdomen/liver", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma27", "label": "27. Weight", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma28", "label": "28. Respiratory rate", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0018", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "malaria0032", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_435", "label": "Tests administered", "type": "note"}, {"name": "reserved_name_for_field_list_labels_436", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma29", "label": "29. Microscopy/ Blood slide for malaria parasite", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma30", "label": "30. Rapid Diagnostic test", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma31", "label": "31. Hb / Full Blood Count", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "malaria0036", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_440", "label": "Diagnosis", "type": "note"}, {"name": "reserved_name_for_field_list_labels_441", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma32", "label": "32. Malaria", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma33", "label": "33. Anemia", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma34", "label": "34. Malaria with Anemia", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma35", "label": "35. Severe Malaria", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0037", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "malaria0041", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_447", "label": "Treatment", "type": "note"}, {"name": "reserved_name_for_field_list_labels_448", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma36", "label": "36. Artemizinin combination", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma37", "label": "37. Paracetamol", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma38", "label": "38. Adequate fluids and nutrition", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma39", "label": "39. Chloroquine 1.5 tabs x 1/day x 3 days", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma40", "label": "40. Quinine intramuscular injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma41", "label": "41. Artesunate Amodiaquin", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma42", "label": "42. Sulphadoxine Pyrimethamine .5 tab 250 mg tds x 3 days", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0042", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "malaria0049", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_457", "label": "Was the patient counselled on any of the following (Confirm if documented in the case notes)", "type": "note"}, {"name": "reserved_name_for_field_list_labels_458", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma43", "label": "43. Adherence to treatment.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma44", "label": "44. Prompt return if symptoms worsen", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csma45", "label": "45. Increased fluid intake", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "malaria0050", "label": "Notes/ Other questions", "type": "text"}]}]}, {"name": "ANC00000005", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_464", "label": "Case Study: Antenatal Care", "type": "note"}, {"name": "reserved_name_for_field_list_labels_465", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc1", "label": "1. History taken", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc2", "label": "2. Clinical examination conducted", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc3", "label": "3. Estimated date of delivery calculated", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc4", "label": "4. Blood pressure taken", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc5", "label": "5. Maternal height/weight measured", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc6", "label": "6. Haemoglobin test conducted", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc7", "label": "7. Rapid Plasma Reagin performed", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc8", "label": "8. Urine tested", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc9", "label": "9. Rapid ph performed", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc10", "label": "10. Counselled and voluntary testing for HIV", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc11", "label": "11. Tetanus toxoid given", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc12", "label": "12. Iron and folic acid supplementation provided", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc13", "label": "13. Calcium supplementation provided", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc14", "label": "14. Information for emergencies given", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc15", "label": "15. Clinical examination for anaemia", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc16", "label": "16. Urine test for protein", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc17", "label": "17. Uterus measured for excessive growth or poor growth", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc18", "label": "18. Instructions for delivery/transport to institution and recommendations for lactation, and contraception done", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csanc19", "label": "19. Antenatal card completed and given to woman. Woman told to bring it when in labour", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ANC00000006", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "PoParHem001", "label": "Case Study: Post-partum Hemorrhage", "type": "group", "children": [{"name": "PoParHem002", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_487", "label": "History Taking", "type": "note"}, {"name": "reserved_name_for_field_list_labels_488", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph1", "label": "1. Were other symptoms reported?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph2", "label": "2. Was the blood loss quantified?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph3", "label": "3. Were the number of pads used indicated?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph4", "label": "4. Was the parity recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph5", "label": "5. Was the duration of labor recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph6", "label": "6. Was the mode of Placenta delivery indicated?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph7", "label": "7. Is there a record of medicines given to speed up delivery during Labor", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph8", "label": "8. Is there a record of history of excessive bleeding after delivery?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph9", "label": "9. Is there a record of history of prolonged menses (Fibroids)?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph10", "label": "10. I there a record of excessive (amniotic) fluids during pregnancy?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph11", "label": "11. Confirm record of Attendance of ANC", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph12", "label": "12. Is there a record of multiple pregnancy?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph13", "label": "13. Is there a record of Placenta praevia?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph14", "label": "14. Is there a record of Hypertension?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem003", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "PoParHem017", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_504", "label": "Physical examination carried out", "type": "note"}, {"name": "reserved_name_for_field_list_labels_505", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph15", "label": "15. Temperature", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph16", "label": "16. Pulse", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph17", "label": "17. Weight", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph18", "label": "18. Respiratory rate", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph19", "label": "19. Retained placenta", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph20", "label": "20. Blood pressure", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph21", "label": "21. Ruptured uterus", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph22", "label": "22. Laceration / tears of genital tract (cervical / vaginal / vulvoperineal tears)", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph23", "label": "23. Uterine palpation", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph24", "label": "24. Genital examination", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem028", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_516", "label": "Tests Administered", "type": "note"}, {"name": "reserved_name_for_field_list_labels_517", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph25", "label": "25. Blood for grouping and cross matching", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph26", "label": "26. Hemoglobin level", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph27", "label": "27. Bleeding time", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph28", "label": "28. Clotting time", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph29", "label": "29. Coagulation factors", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "PoParHem034", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_523", "label": "Diagnosis", "type": "note"}, {"name": "reserved_name_for_field_list_labels_524", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph30", "label": "30. Post-partum Hemorrhage", "hint": "It will take some time to get the results. Please make a preliminary diagnosis.", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem029", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "PoParHem036", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_527", "label": "Which of the following treatments were administered", "type": "note"}, {"name": "reserved_name_for_field_list_labels_528", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph31", "label": "31. IV line", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph32", "label": "32. Blood taken for grouping and cross matching", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph33", "label": "33. The self retaining catheter foley was inserted", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph34", "label": "34. Was a bimanual uterine massage carried out?: this may also provoke contractions", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph35", "label": "35. Was 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", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph36", "label": "36. Was prostaglandins and misoprostal given?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspph37", "label": "37. Was the patient referred?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "PoParHem037", "label": "Notes/ Other questions", "type": "text"}]}]}, {"name": "Pneum000001", "label": "Case Study: Pneumonia", "type": "group", "children": [{"name": "Pneum000002", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_539", "label": "History Taking", "type": "note"}, {"name": "reserved_name_for_field_list_labels_540", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue1", "label": "1. Were other symptoms recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue2", "label": "2. Was the duration of cough recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue3", "label": "3. Was the nature of the cough (sputum production or dry cough) recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue4", "label": "4. Was the presence of blood or colour of sputum recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue5", "label": "5. Was there a record of the presence of chest pain?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue6", "label": "6. Was there a record on presence of difficulty in breathing", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue7", "label": "7. Was there a record of patient's appetite?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue8", "label": "8. Was there a record of fever?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue9", "label": "9. Was there a record on general condition (awake / lethargic", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue10", "label": "10. Was there a record on presence of convulsions?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue11", "label": "11. Was there a record on patient's difficulty in swallowing?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue12", "label": "12. Was the presence of running nose recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue13", "label": "13. Was any medication /treatment received recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue14", "label": "14. Was recent history of Measles recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue15", "label": "15. Was family history of Asthma recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue16", "label": "16.Was the redness of the eyes observed?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000003", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "Pneum000019", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_558", "label": "Physical examination carried out", "type": "note"}, {"name": "reserved_name_for_field_list_labels_559", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue17", "label": "17. Was the respiratory rate counted?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue18", "label": "18. Was the breathing of lower chest wall in-drawing observed?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue19", "label": "19. Breathing, is there wheezing?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue20", "label": "20. Was the chest auscultated?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue21", "label": "21. Was nasal flaring observed?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue22", "label": "22. Was temperature recorded?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue23", "label": "23. Was the throat examined?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue24", "label": "24. Were the child's ears examined?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue25", "label": "25. Were the lymph nodes examined?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000020", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "Pneum000029", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_570", "label": "Tests administered", "type": "note"}, {"name": "reserved_name_for_field_list_labels_571", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue26", "label": "26. Chest X-ray", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue27", "label": "27. Haemogram", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue28", "label": "28. BS for MPS", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000030", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "Pneum000033", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_576", "label": "Diagnosis", "type": "note"}, {"name": "reserved_name_for_field_list_labels_577", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue29", "label": "29. Pneumonia", "hint": "It will take some time to get the results. Please make a preliminary diagnosis.", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000034", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "Pneum000035", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_580", "label": "Treatment", "type": "note"}, {"name": "reserved_name_for_field_list_labels_581", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue30", "label": "30. Treat as out-patient.", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue31", "label": "31. Was Cortimoxazole 1 tab bd x 5/7 given or administered?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue32", "label": "32. Was Amoxycillin Dosage 250mg qds x 5 given or administered?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue33", "label": "33. Was Arthemeter-Lumefantrine 2 tabs x 2/day x given or administered?\n3 days", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue34", "label": "34. Was Artesunate+Amodiaquine 1 tabX 1/day x given or administered?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue35", "label": "35. Was Paracetamol dose 250 mg qds x 5 days given or administered?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue36", "label": "36. Were parents asked to bring child in 2 days?", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000036", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "Pneum000043", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_590", "label": "Was the patient counselled on any of the following (Confirm if documented in the case notes)", "type": "note"}, {"name": "reserved_name_for_field_list_labels_591", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue37", "label": "37. Instruct parent on how to administer antibiotics for 5 days.", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue38", "label": "38. Guidance on how to feed.", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue39", "label": "39. Increase fluid intake.", "type": "select one", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cspnue40", "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", "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "Pneum000044", "label": "Notes/ Other questions", "type": "text"}]}]}, {"name": "AcuDiarr001", "label": "Case Study: Acute Diarrohea", "type": "group", "children": [{"name": "AcuDiarr002", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_599", "label": "History Taking", "type": "note"}, {"name": "reserved_name_for_field_list_labels_600", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad1", "label": "1.Were other symptoms recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad2", "label": "2. Was the duration of diarrhoea recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad3", "label": "3.Was the frequency of diarrhoea recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad4", "label": "4. Was the consistency of stool recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad5", "label": "5. Was the presence of blood in stool recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad6", "label": "6. Vomiting", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad7", "label": "7. Was the mother asked if her child is breastfeeding?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad8", "label": "8. Was the mother asked if her child is breastfeeding well?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad9", "label": "9. Was the presence of cough recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad10", "label": "10. Was the mother asked if her child has fever?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad11", "label": "11. Was the general condition of the child recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad12", "label": "12. Was the presence of tears recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad13", "label": "13. Was the mother asked if her baby started taking other food recently?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad14", "label": "14. Was the mother asked how it been given?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad15", "label": "15. Was the mother asked who prepares and feed her child??", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad16", "label": "16. Was the mother asked about her hand washing practice?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad17", "label": "17. Was the mother asked if their family members/neighbours have diarrhoea?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad18", "label": "18. Was the presence of abdominal discomfort/cramps recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad19", "label": "19. Was the date of the last deworming recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad20", "label": "20. Was the medication/treatment received before visiting the health facility recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr003", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "AcuDiarr023", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_622", "label": "Physical Examination", "type": "note"}, {"name": "reserved_name_for_field_list_labels_623", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad21", "label": "21. Was the general health condition (awake/lethargic/tiredness/fatigue) recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad22", "label": "22. Was the temperature recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad23", "label": "23. Was the state of the child's skin recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad24", "label": "24. Was the child offered a drink?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad25", "label": "25. Was the mucous membrane (oral mucosa) examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad26", "label": "26. Was palmar pallor (or other signs of anaemia) examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad27", "label": "27. Was thye stiffness of the neck examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad28", "label": "28. Was the ear/throat examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad29", "label": "29.Was the respiratory rate examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad30", "label": "30. Was the spleen examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad31", "label": "31. Was visible severe wasting examined?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad32", "label": "32. Was the weight of the child recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad33", "label": "33. Sunken eyes", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad34", "label": "34. Was the weight (against a growth chart) recorded?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad35", "label": "35. Was the presence of oedema of both feet (swollen feet) observed?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr024", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "AcuDiarr039", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_640", "label": "Tests administered", "type": "note"}, {"name": "reserved_name_for_field_list_labels_641", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad36", "label": "36. Stool for rota/adeno virus.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad37", "label": "37. Stool for ova and cyst.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr040", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "AcuDiarr042", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_645", "label": "Diagnosis", "type": "note"}, {"name": "reserved_name_for_field_list_labels_646", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad38", "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", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr043", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "AcuDiarr044", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_649", "label": "Treatment", "type": "note"}, {"name": "reserved_name_for_field_list_labels_650", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad39", "label": "39. Were Oral Rehydration Salts given/administered?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad40", "label": "40. Was 100ml/kg Ringer's Lactate Solution given or administer?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad41", "label": "41.Was the patient referred immediately?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad42", "label": "42. Was antibiotics given/administered?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad43", "label": "43. Were vitamin A capsules given or administered?", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad44", "label": "44. Were zinc tablets given or administered? (one daily for 10days).", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr045", "label": "Notes/ Other questions", "type": "text"}]}, {"name": "AcuDiarr051", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_658", "label": "Was the patient counselled on any of the following (Confirm if documented in the case notes)", "type": "note"}, {"name": "reserved_name_for_field_list_labels_659", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad45", "label": "45. Education on using (ORS)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad46", "label": "46. Hand-washing education", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad47", "label": "47. Proper cleaning of feeding utensils.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad48", "label": "48. Emphasis on not withholding feeding especially breast feeding", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "csad49", "label": "49. Giving plenty of oral fluids.", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "AcuDiarr052", "label": "50. Notes/ Other questions", "type": "text"}]}]}]}, {"name": "parent38", "label": "51. Is there evidence of implementation of universal precautions?", "type": "select one", "bind": {"required": "TRUE"}, "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": "parent39", "label": "52. Are there handwashing facilities available at all service points?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent40", "label": "53. Is privacy/confidentiality provided for clients?", "type": "select one", "bind": {"required": "TRUE"}, "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": "parent41", "label": "54. Do you treat malaria at this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "parent42", "label": "55. Do you offer curative treatment for patients?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "MinDrugComm", "label": "#####Section 9. Minimum Drugs and Commodities", "type": "group", "children": [{"name": "DrugVacc", "label": "Availability of Drugs and Vaccines", "type": "group", "children": [{"name": "Drug", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_676", "label": "Drugs", "type": "note"}, {"name": "reserved_name_for_field_list_labels_677", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc13", "label": "1. Oxytocin (injectable)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc14", "label": "2. Misoprostol (cap/tab)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc15", "label": "3. Sodium chloride (Saline Solution)(injectable solution)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc16", "label": "4. Azithromycin (inj/cap/tab or oral liquid)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc17", "label": "5. Calcium gluconate (tablets)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc18", "label": "6. Benzathinebenzylpenicillin powder (for injection)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc19", "label": "7. Magnesium sulfate (inj/tab/cap)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc20", "label": "8. Dexamethasone (injectable)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc21", "label": "9. Ampicillin powder (for injection)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc22", "label": "10. Nifedipine (cap/tab)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc23", "label": "11. Gentamicin (injectable)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc24", "label": "12. Medroxyprogesterone acetate (Depo-Provera)(injectable)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc25", "label": "13. Metronidazole (inj/tab)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc26", "label": "14. Folic Acid Supplements (cap/tab)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc27", "label": "15. Iron supplements (cap/tab)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc28", "label": "16. Amoxicillin (syrup/suspension/dispersible tablet)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc29", "label": "17. Amoxil (syrup/suspension)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc30", "label": "18. Oral Rehydration Salts (ORS sachets)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc31", "label": "19. Ampicillin (powder for injection)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc32", "label": "20. Zinc (tablets)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc33", "label": "21. Zinc tablet (For Diarrhoea)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc34", "label": "22. Anti snake bites serum injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc35", "label": "23. Anti tetanus immunoglobulin injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc36", "label": "24. Zinc (oral liquid)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc37", "label": "25. Ceftriaxone (powder for injection)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc38", "label": "26. Artemisinin combination therapy (ACT-tablet)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc39", "label": "27. Vitamin A (capsules)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc40", "label": "28. Benzylpenicillin (powder for injection)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc41", "label": "29. Ergometrine tablet", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc42", "label": "30. Ergometrine injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc43", "label": "31. Anti Asthma Drugs: Beclomethasone inhaler", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc44", "label": "32. Salbutamol inhaler", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc45", "label": "33. Salbutamol tablet", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "Vacc", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_711", "label": "VACCINES", "type": "note"}, {"name": "reserved_name_for_field_list_labels_712", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc46", "label": "1. Measles vaccine injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc47", "label": "2. Rabies immunoglobulin injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc48", "label": "3. Tetanus vaccine injection", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc49", "label": "4. Polio vaccine (live attenuated)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc50", "label": "5. Diphteria + pertussis + tetanus vaccine", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc51", "label": "6. BCG vaccine and diluent", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc52", "label": "7. Pneumococcal (PCV 10) vaccines", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdc53", "label": "8. DTP-HepB-Hib vaccine", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}]}, {"name": "SupMin", "label": "Supply of Minimum Drugs and Commodities", "type": "group", "children": [{"name": "mdc54", "label": "1. Does the facility have a staff responsible for managing the ordering of medical supplies?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc55", "label": "2. Who is responsible?", "type": "select one", "bind": {"relevant": "${mdc54} = 'yes'", "required": "TRUE"}, "children": [{"name": "off_in_charge", "label": "Officer-in-Charge"}, {"name": "medical_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": "other", "label": "Other"}]}, {"name": "mdc55_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc55, 'other')"}}, {"name": "mdc56", "label": "3. Who determines this facility's resupply quantities?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "off_in_charge", "label": "Officer-in-Charge"}, {"name": "medical_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": "other", "label": "Other"}]}, {"name": "mdc56_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc56, 'other')"}}, {"name": "mdc57", "label": "4.How are the facility's resupply quantities estimated?", "type": "select one", "bind": {"required": "TRUE"}, "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": "mdc57_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc57, 'other')"}}, {"name": "mdca", "label": "5. Who is the direct supplier of health commodities to your facility?", "type": "select all that apply", "bind": {"required": "TRUE"}, "children": [{"name": "lga_store", "label": "LGA Store"}, {"name": "ngo_donors", "label": "NGO/Donors"}, {"name": "open_market", "label": "Open Market"}, {"name": "other", "label": "Other"}]}, {"name": "mdca_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdca, 'other')"}}, {"name": "mdc63", "label": "6. How are the drugs from the main supplier delivered to this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "supplier_to_facility", "label": "Supplier delivers to facility"}, {"name": "facility_arrange_del", "label": "Facility arranges delivery"}, {"name": "other", "label": "Other"}]}, {"name": "mdc63_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc63, 'other')"}}, {"name": "mdc64", "label": "7. Who bears the transportation cost of delivery to facilities", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "supplier", "label": "Supplier"}, {"name": "facility", "label": "Facility"}, {"name": "other", "label": "Other"}]}, {"name": "mdc64_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc64, 'other')"}}, {"name": "mdc65", "label": "8. What was the date for the last delivery of essential medicines and/or medical supplies?", "type": "date", "bind": {"jr:constraintMsg": "Date should not be later than today", "constraint": ".<=date(today())", "required": "TRUE"}}, {"name": "mdc66", "label": "9. What was the date on which the order that corresponded to the last delivery was placed?", "type": "date", "bind": {"jr:constraintMsg": "Date should not be later than today", "constraint": ".<=date(today())", "required": "TRUE"}}, {"name": "mdc67", "label": "10. Was the last delivery of essential medicines and supplies verified and signed off by the health facility management committee?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc68", "label": "11. Was the community informed of the last delivery of essential medicines and supplies?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc80", "label": "12. How were they informed?", "type": "select one", "bind": {"relevant": "${mdc68} = 'yes'", "required": "TRUE"}, "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": "mdc80_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc80, 'other')"}}]}, {"name": "StocCont", "label": "Stock Control", "type": "group", "children": [{"name": "mdc69", "label": "1. Did the facility procure any out-of-stock items in the last quarter (3 months)?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc70", "label": "2. In the last quarter, did the facility purchase any essential medicines and medical supplies locally?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc71", "label": "3. Did any essential medicines in the facility expire during the last quarter (3 months)?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc72", "label": "4. Are stock control cards present & updated for the latest delivery?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdc73", "label": "5. Are up-to-date records of expired drugs or losses kept?", "type": "select one", "bind": {"required": "TRUE"}, "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": "mdc74", "label": "6. Is there proper storage and security (cool, dry place with a lock) for all drugs & consumables in the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "picmdc75", "label": "6a. Take a picture of the facility medicines storage", "type": "photo", "bind": {"required": "TRUE"}}, {"name": "mdc76", "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", "bind": {"required": "TRUE"}}, {"name": "mdc77", "label": "8. In the last fiscal year, how often was the facility visited by a qualified pharmacist for support supervision?", "type": "select one", "bind": {"required": "TRUE"}, "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": "mdc77_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../mdc77, 'other')"}}, {"name": "mdc79", "label": "9. Are drug price lists displayed?", "type": "select one", "bind": {"required": "TRUE"}, "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": "AvailCom", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_748", "label": "Availability of Minimum Commodities (1/2)", "type": "note"}, {"name": "reserved_name_for_field_list_labels_749", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii13", "label": "1. Disposable syringes with disposable needles", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii14", "label": "2. Vaccine carrier(s)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii15", "label": "3. Auto-disable syringes", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii16", "label": "4. Set of ice packs for vaccine carriers (Note: 4-5 ice packs make one set)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii17", "label": "5. Clean running water (piped, bucket with tap, or pour pitcher)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii18", "label": "6. Hand-washing soap/liquid soap", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii19", "label": "7. Alcohol based hand rub", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii20", "label": "8. Waste receptacle (pedal bin) with lid and plastic bin liner", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii21", "label": "9. Environmental disinfectant (e.g., chlorine, alcohol)", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii22", "label": "10. Sharps container", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii23", "label": "11. Disposable Gloves", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii24", "label": "12. Condoms", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "AvailCom2", "label": "Availability of Minimum Commodities (2/2)", "type": "group", "children": [{"name": "mdcii25", "label": "13. Are vaccines stored at this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii26", "label": "14. Does the facility have a working refrigerator for the storage of vaccines?", "hint": "Observe functioning", "type": "select one", "bind": {"relevant": "${mdcii25} = 'yes_obs'", "required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "picmdcii54", "label": "15. Take a picture of the facility refrigerator", "type": "photo", "bind": {"relevant": "${mdcii26} = 'yes_obs'", "required": "TRUE"}}, {"name": "picmdcii54b", "label": "16. Take a picture of the facility vaccine coldchain box", "type": "photo"}, {"name": "mdcii27", "label": "17. Is there a functional thermometer to maintain a cold chain?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}, {"name": "mdcii28", "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", "bind": {"relevant": "${mdcii25} = 'no'", "required": "TRUE"}, "children": [{"name": "yes_obs", "label": "Yes (observed and functional)"}, {"name": "no", "label": "No"}]}]}, {"name": "SupplyWeeks", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "mdciia", "label": "**About how many weeks' supply of the following medicines is currently available in the facility?**", "type": "note"}, {"name": "mdcii29", "label": "1. Amoxicillin (syrup/suspension/dispersible tablet)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii30", "label": "2. Injectable antibiotics", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii31", "label": "3. Chlorhexidine", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii32", "label": "4. Magnesium sulfate (injectable)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii33", "label": "5. Misoprostol (cap/tab)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii34", "label": "6. Oxytocin (injectable)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii35", "label": "7. Oral Rehydration Salts (ORS sachets)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii55", "label": "8. Zinc (tablets)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii36", "label": "9. Emergency contraception", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii37", "label": "10. Female condoms", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii38", "label": "11. Contraceptive implants", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii39", "label": "12. Antenatal corticosteroid (ANCs)", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "mdcii40", "label": "13. Newborn Resuscitation Device", "type": "integer", "bind": {"required": "TRUE"}}]}]}, {"name": "Lab00000001", "label": "#####Section 10. Laboratory", "type": "group", "children": [{"name": "mdcii56", "label": "1. Is there a laboratory?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdcii41", "label": "2. Laboratory is open every day of the week", "type": "select one", "bind": {"relevant": "${mdcii56} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdcii42", "label": "3. Is there a laboratory scientist/technician available at least 5 days a week?", "type": "select one", "bind": {"relevant": "${mdcii56} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "mdcii43", "label": "4. Are laboratory price lists displayed?", "type": "select one", "bind": {"relevant": "${mdcii56} = 'yes'", "required": "TRUE"}, "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": "mdciib", "label": "5. The facility offers PHC Laboratory services (According to the essential laboratory services in the tool) (Please tick as appropriate)", "type": "select all that apply", "bind": {"relevant": "${mdcii56} = 'yes'", "required": "TRUE"}, "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": "HMIS", "label": "######Section 11. Health Management Information System", "type": "group", "children": [{"name": "HMISForm", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_795", "label": "**Are relevant HMIS forms/Registers available in the facility?**", "type": "note"}, {"name": "reserved_name_for_field_list_labels_796", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis13", "label": "1. NHMIS Health facility monthly summary form", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis14", "label": "2. NHMIS health facility daily attendance register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis15", "label": "3. NHMIS health facility daily GMP (growth monitoring) register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis16", "label": "4. NHMIS health facility Immunization register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis17", "label": "5. NHMIS health facility Immunization Tally Sheet register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis18", "label": "6. NHMIS health facility TT register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis19", "label": "7. NHMIS health facility daily ANC register", "type": "select one", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis20", "label": "8. NHMIS health facility daily OPD register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis21", "label": "9. NHMIS health facility daily FP register", "type": "select one", "bind": {"relevant": "${mnch13} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis22", "label": "10. NHMIS health facility daily PMTCT ARVs register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis23", "label": "11. NHMIS health facility labour/delivery register", "type": "select one", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis24", "label": "12. NHMIS health facility IPC register", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "hmis25", "label": "13. Are HMIS forms / register up to date and completed correctly?", "type": "select one", "bind": {"required": "TRUE"}, "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": "hmis26", "label": "14. Is HMIS information displayed graphically?", "type": "select one", "bind": {"required": "TRUE"}, "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": "hmis27", "label": "15. Are the NHMIS data analysed and shared with the facility management committee?", "type": "select one", "bind": {"required": "TRUE"}, "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": "hmis28", "label": "16. Did the facility send last month's monthly summary form to the LGA?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis29", "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", "bind": {"required": "TRUE"}, "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": "hmis30", "label": "18. Do you participate in any LGA monthly M&E review meetings?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hmis31", "label": "19. Is HMIS information discussed in the facility management meetings (check for minutes of meetings)", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "UtilClinOut", "label": "#####Section 12. Utilization and Clinical Outcomes", "type": "group", "children": [{"name": "UtilPatt001", "type": "group", "bind": {"relevant": "${mnch28} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_818", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt002", "label": "1. How many deliveries have been conducted at this facility during the past 3 months?", "type": "note", "bind": {"relevant": "${mnch28} = 'yes'"}}, {"name": "hmis32", "label": "a. Month 1", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "hmis33", "label": "b. Month 2", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "hmis34", "label": "c. Month 3", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "hmis35", "label": "d. Total", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}]}, {"name": "UtilPatt00122", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_825", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt003", "label": "2. How many general outpatient visits have you had at this facility in the past 3 months?", "type": "note"}, {"name": "hmis36", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis37", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis38", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis39", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "UtilPatt00123", "type": "group", "bind": {"relevant": "${admin13} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_832", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt004", "label": "3. How many in-patient bed-days have you had during the past 3 months?", "type": "note", "bind": {"relevant": "${admin13} = 'yes'"}}, {"name": "hmis40", "label": "a. Month 1", "type": "integer", "bind": {"relevant": "${admin13} = 'yes'", "required": "TRUE"}}, {"name": "hmis41", "label": "b. Month 2", "type": "integer", "bind": {"relevant": "${admin13} = 'yes'", "required": "TRUE"}}, {"name": "hmis42", "label": "c. Month 3", "type": "integer", "bind": {"relevant": "${admin13} = 'yes'", "required": "TRUE"}}, {"name": "hmis43", "label": "d. Total", "type": "integer", "bind": {"relevant": "${admin13} = 'yes'", "required": "TRUE"}}]}, {"name": "UtilPatt00124", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_839", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt005", "label": "4. How many Under-5 visits have you had at this facility in the past 3 months?", "type": "note"}, {"name": "hmis44", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis45", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis46", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis47", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "UtilPatt00125", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_846", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt006", "label": "5. How many immunization visits have you had at this facility in the past 3 months", "type": "note"}, {"name": "hmis48", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis49", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis50", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis51", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "UtilPatt00126", "type": "group", "bind": {"relevant": "${mnch23} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_853", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt007", "label": "6. Number of ANC attendance in the past 3 months", "type": "note", "bind": {"relevant": "${mnch23} = 'yes'"}}, {"name": "hmis52", "label": "a. Month 1", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}, {"name": "hmis53", "label": "b. Month 2", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}, {"name": "hmis54", "label": "c. Month 3", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}, {"name": "hmis55", "label": "d. Total", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}]}, {"name": "UtilPatt00127", "type": "group", "bind": {"relevant": "${mnch25} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_860", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt008", "label": "7. Number of PNC attendance in the past 3 months", "type": "note", "bind": {"relevant": "${mnch25} = 'yes'"}}, {"name": "hmis56", "label": "a. Month 1", "type": "integer", "bind": {"relevant": "${mnch25} = 'yes'", "required": "TRUE"}}, {"name": "hmis57", "label": "b. Month 2", "type": "integer", "bind": {"relevant": "${mnch25} = 'yes'", "required": "TRUE"}}, {"name": "hmis58", "label": "c. Month 3", "type": "integer", "bind": {"relevant": "${mnch25} = 'yes'", "required": "TRUE"}}, {"name": "hmis59", "label": "d. Total", "type": "integer", "bind": {"relevant": "${mnch25} = 'yes'", "required": "TRUE"}}]}, {"name": "UtilPatt00128", "type": "group", "bind": {"relevant": "${mnch23} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_867", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt009", "label": "8. Number of pregnant women who had ANC 1st (booking) visit before 20 weeks?", "type": "note", "bind": {"relevant": "${mnch23} = 'yes'"}}, {"name": "hmis60", "label": "a. Month 1", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}, {"name": "hmis61", "label": "b. Month 2", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}, {"name": "hmis62", "label": "c. Month 3", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}, {"name": "hmis63", "label": "d. Total", "type": "integer", "bind": {"relevant": "${mnch23} = 'yes'", "required": "TRUE"}}]}, {"name": "UtilPatt00129", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_874", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt010", "label": "9. Number of patients screened for hypertension", "type": "note"}, {"name": "hmis64", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis65", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis66", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis67", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "UtilPatt001220", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_881", "label": "Utilization Pattern", "type": "note"}, {"name": "UtilPatt011", "label": "10. Number of patients screened for diabetes", "type": "note"}, {"name": "hmis68", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis69", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis70", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis71", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}]}, {"name": "ClinOutco01", "type": "group", "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_888", "label": "Clinical Outcomes", "type": "note"}, {"name": "ClinOutco02", "label": "11. Number of deaths (in relation to registered pregnant women) in the past 3 months?", "type": "note"}, {"name": "hmis72", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis73", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis74", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis75", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "ClinOutco03", "label": "12. Number of deliveries resulting in still births in the past 3 months?", "type": "note", "bind": {"relevant": "${mnch28} = 'yes'"}}, {"name": "hmis76", "label": "a. Month 1", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "hmis77", "label": "b. Month 2", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "hmis78", "label": "c. Month 3", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "hmis79", "label": "d. Total", "type": "integer", "bind": {"relevant": "${mnch28} = 'yes'", "required": "TRUE"}}, {"name": "ClinOutco04", "label": "13. Rate of re-admission of patients", "type": "note"}, {"name": "hmis80", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis81", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis82", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis83", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "ClinOutco05", "label": "14. Infection due to treatment in the health facilities", "type": "note"}, {"name": "hmis84", "label": "a. Month 1", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis85", "label": "b. Month 2", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis86", "label": "c. Month 3", "type": "integer", "bind": {"required": "TRUE"}}, {"name": "hmis87", "label": "d. Total", "type": "integer", "bind": {"required": "TRUE"}}]}]}, {"name": "CommuInvolv", "label": "#####Section 13. Community Involvement", "type": "group", "children": [{"name": "OutrSer", "label": "Outreach Services", "type": "group", "children": [{"name": "ci13", "label": "1. Does this facility carry out planned community outreach services?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "no_outreach", "label": "No community outreach services occurring"}, {"name": "outreach_occ_not_scheduled", "label": "Community outreach services are occurring but not scheduled"}, {"name": "outreach_plan_occ", "label": "Planned community outreach services are occurring"}]}, {"name": "ci14", "label": "2. Does the PHC staff conduct outreach to the community?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci16", "label": "3. How often does the PHC staff conduct outreach to the community?", "type": "select one", "bind": {"relevant": "${ci14} = 'yes'", "required": "TRUE"}, "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": "ci16_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../ci16, 'other')"}}, {"name": "ci18", "label": "4. Is there evidence of publicity (poster, flyers, signage, etc.) of available health services?", "type": "select one", "bind": {"required": "TRUE"}, "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": "ci19", "label": "5. Is there evidence that local communities are involved in outreach planning and implementation?", "type": "select one", "bind": {"required": "TRUE"}, "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": "ci20", "label": "6. Is there evidence that this facility do hold review meetings with important community members in attendance?", "type": "select one", "bind": {"required": "TRUE"}, "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": "CommGov", "label": "Community Governance", "type": "group", "children": [{"name": "ci21", "label": "1. Is there a Ward Development Committee (WDC)/Village Development Committee (VDC)/Community Development Committee (CDC) in place in this community?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci22", "label": "2. Has the committee met at least once in the last year?", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci23", "label": "3. How often does the WDC/VDC/CDC meet?", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "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": "ci23_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../ci23, 'other')"}}, {"name": "ci24", "label": "4. Did any member of this WDC/VDC/CDC visit the PHC during the prior 3 months?", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci60", "label": "5. How many visits were made during the prior 3 months?", "type": "integer", "bind": {"relevant": "${ci24} = 'yes'", "required": "TRUE"}}, {"name": "cia", "label": "**Which of the following activities did the WDC/VDC/CDC carry out in the last 12months?**", "type": "group", "children": [{"name": "ci25", "label": "6. Supported or helped improve the health facility", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci26", "label": "7. Repairs to facility", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci27", "label": "8. Mobilized community to use facility", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci28", "label": "9. Provided transport for home visits", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci29", "label": "10. Gave in-kind contributions", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci30", "label": "11. Improved security (facility)", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci31", "label": "12. Improved water supply", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci32", "label": "13. Improved water quality", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci33", "label": "14. Supported training for CHEWs", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci34", "label": "15. Support to outreach teams", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci35", "label": "16. Provided new infrastructure", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci36", "label": "17. Provided drugs", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci37", "label": "18. Supported environmental sanitation", "type": "select one", "bind": {"relevant": "${ci21} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci38", "label": "19. Other", "type": "text", "bind": {"relevant": "${ci21} = 'yes'"}}]}, {"name": "ci39", "label": "1. Is there a Health Facility Management Committee in place for the facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci40", "label": "2. Has the committee met at least once in the last year?", "type": "select one", "bind": {"relevant": "${ci39} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci41", "label": "3. How often does the health facility management committee meet?", "type": "select one", "bind": {"relevant": "${ci40} = 'yes'", "required": "TRUE"}, "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": "ci41_other", "label": "Specify other.", "type": "text", "bind": {"relevant": "selected(../ci41, 'other')"}}, {"name": "ci42", "label": "4. How many members does the committee currently have?", "type": "integer", "bind": {"relevant": "${ci39} = 'yes'", "required": "TRUE"}}, {"name": "ci43", "label": "5. Was the Health Facility/Hospital management committee involved in workplan development?", "type": "select one", "bind": {"relevant": "${ci39} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci44", "label": "6. Is the Officer-in-Charge a member of the committee?", "type": "select one", "bind": {"relevant": "${ci39} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci45", "label": "7. Are community members represented on the committee?", "type": "select one", "bind": {"relevant": "${ci39} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci46", "label": "8. How were community representatives selected?", "type": "text", "bind": {"relevant": "${ci45} = 'yes'", "required": "TRUE"}}, {"name": "ci47", "label": "9. Are the minutes available for all the meetings?", "type": "select one", "bind": {"relevant": "${ci39} = 'yes'", "required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "cib", "type": "group", "bind": {"relevant": "${ci39} = 'yes'"}, "control": {"appearance": "field-list"}, "children": [{"name": "generated_table_list_label_951", "label": "**Which of these sub committees are in existence & operational?**", "type": "note"}, {"name": "reserved_name_for_field_list_labels_952", "label": " ", "type": "select one", "control": {"appearance": "label"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci48", "label": "1. Finance Committee", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci49", "label": "2. Procurement Committee", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci50", "label": "3. Audit Committee", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci51", "label": "4. Quality Assurance Committee", "type": "select one", "bind": {"required": "TRUE"}, "control": {"appearance": "list-nolabel"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}]}, {"name": "ClientView", "label": "**Client View \u2013 exit interview for 1 adult client**", "type": "group", "children": [{"name": "ci52", "label": "1. Is the health facility clean today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci53", "label": "2. Were health staff courteous and respectful today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci54", "label": "3. Did the health workers do a good job of explaining your condition today?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci55", "label": "4. Do you trust in the skills and abilities of the health workers of this facility?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci56", "label": "5. Were the health workers in this facility friendly and approachable?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci57", "label": "6. Are you confident that the health workers will maintain the confidentiality of your discussions?", "type": "select one", "bind": {"required": "TRUE"}, "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ci58", "label": "7. How long (in minutes) did you wait in the health facility before being seen for consultation by the health worker?", "hint": "*In minutes", "type": "integer", "bind": {"required": "TRUE"}}]}]}, {"name": "Beginname1", "type": "group", "children": [{"name": "EnumeratorN", "label": "Enumerator name(s)", "type": "text", "bind": {"relevant": "${parent6}='yes'", "required": "TRUE"}}, {"name": "Enumeratorphone", "label": "Enumerator (s) Phone Number", "type": "text", "bind": {"constraint": "regex(.,'[0-9]{11}')", "required": "TRUE", "relevant": "${parent6}='yes'"}, "control": {"appearance": "number"}}, {"name": "EnumeratorMail", "label": "Enumerator(s) email address", "type": "text", "bind": {"constraint": "regex(., '[A-Za-z0-9._%+-]+@[A-Za-z0-9-]+[.][A-Za-z]{2,4}')", "required": "TRUE", "relevant": "${parent6}='yes'"}}, {"name": "EndNotes", "label": "Any additional comment", "type": "text"}]}]}, {"name": "TimeDepart", "type": "group", "children": [{"name": "parent50", "label": "Departure time for first visit", "type": "text", "bind": {"required": "TRUE"}}]}, {"name": "end_con_giv", "label": "End of Survey", "type": "note", "bind": {"relevant": "${parent6}='yes'"}}, {"name": "end_con_nt_giv", "label": "Consent not given. End of Survey", "type": "note", "bind": {"relevant": "${parent6}='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_Mobile','_',${parent10}, '_', jr:choice-name(${parent53},'${parent53}'))"}}]}]}