Ministry of Health & Family Welfare

Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (Delivery Point) - FORM No - I

Name of State: Odisha Name of District: Anugul Number of Blocks:

Total Number of 2019-20
Deliveries Points Reporting Month Reporting Year
Reported

Type of Facility
FRUs DHs SDH CHC PHC

Number of Facilities
Reported-

Birth-6 weeks
Delivery points
Male Female
Number of deliveries in the facility in the reporting month
Number of live births in the facility in the reporting month
Total Number of new born Screened in Current Reporting Month

Cumulative number of Children born in the facility in the year ________ From ________ To
(reporting month)_____________
Cumulative number of newborn screened in the year ________ From ________
To (reporting month)_____________

Total Number of Children identified with Defect at Birth

Sl No Defect at Birth: 0 0

1 Neural tube defect

2 Down’s Syndrome

3 Cleft Lip & Palate

4 Club foot

5 Developmental dysplasia of the hip

6 Congenital cataract

7 Congenital deafness

8 Congenital heart diseases

9 Retinopathy of Prematurity (Only at DH)

Microcephaly

Macrocephaly
Primary care Secondary Care Tertiary Care
Total Children Refered (PHC/CHC) (DH/SDH/SNCU) (DEIC)/MC
Male
Neural tube defect
Female
Male
Down’s Syndrome
Female
Male
Cleft Lip & Palate
Female
Male
Club foot
Female

Developmental dysplasia Male

of the hip Female
Male
Congenital cataract
Female
Male
Congenital deafness
Female
 Male
Congenital Heart diseases
Female
Male
Retinopathy of Prematurity
Female
NAME Report prepared by Report verified by
Signature

Designation

Date
stry of Health & Family Welfare
Government of India
ya Bal Swasthya Karyakram (RBSK)
TING FORMAT (Delivery Point) - FORM No - I

2019-20

SHC

Birth-6 weeks
Total
0
0
0

Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
 0
0
0
0
Report verified by
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (ASHA,HBNC) - FORM No - II

Name of State: Odisha Name of District Name of Block

Number of ASHAs Reporting Month Reporting Year
Birth-6 weeks
ASHA, HBNC
Male Female

Total number of deliveries reported in catchment area of ASHA in the reporting

month

Total number of New borns to be visited in the current month

Number of newborn visited by the ASHA in HBNC visit in the month

Cumulative Number of deliveries in the year ________ From ________ To _____________

Cumulative Number of Children screened for defects at birth during HBNC visits in the year
________ From ________ To _____________

Total Number of Children identified with Defect at Birth by ASHA

Defects at Birth:
Sl No 0 0
1 Neural tube defect
2 Down’s Syndrome
3 Cleft Lip & Palate
4 Club foot
5 Developmental dysplasia of the hip
Developmental Delay identified as per revised MCP card
6
Age of child No of children visited in current month 0 0
6.1 At 3 months
6.2 At 6 months
6.3 At 9 months
6.4 At 12 months
6.5 At 15 months

Secondary Care Tertiary Care (DEIC)

Total Children Refered Primary care (PHC/CHC)
(DH/SDH/SNCU) /MC

Male
Neural tube defect
Female

Male
Down’s Syndrome
Female

Male
Cleft Lip & Palate
Female

Male
Club foot
Female

Developmental Male
dysplasia
of the hip
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (MHT) - FORM No - III

State: Odisha District Name of Block MHT Team Code Reporting Month Reporting Year 2019-20

6 weeks to 3 years (MHT) 3-6 years enrolled in Govt and Govt aided schools (MHT) 6-18 years enrolled in Govt and Govt aided schools (MHT)

Target : Target :
Target : Total Percentage of Found positive No. of children No. of children Percentage of
No. of children No. of children Total Percentage of total Found positive for Total No. of children Found positive
children to be total children for selected screened in No. of children Referred for this screened in total children Referred for
screened in screened Referred for this children to be children screened selected health children to be screened for selected
screened in screened till this health conditions current screened cumulative current current screened till this this current
current month cumulative till current month/year screened in till this month conditions in current screened in cumulative till health conditions
complete year month in current month/year by till current month month/year month/year by month month/year
/Yearby M.H.T. current month complete year by (Cumulative) month complete year by current month in current month
by M.H.T. (Cumulative) month/year M.H.T. M.H.T. (Cumulative)
M.H.T. M.H.T.

Male 0 #DIV/0! 0 0 #DIV/0! 0 0 #DIV/0! 0

Female 0 #DIV/0! 0 0 #DIV/0! 0 0 #DIV/0! 0
Total 0 0 0 #DIV/0! 0 0 0 0 0 #DIV/0! 0 0 0 0 0 #DIV/0! 0 0
Screening details at AWCs Composition of Mobile Health Team
Doctors Pharmacist ANM/ Staff nurse Total

Cumulative gap
Annual plan : Total
Total AWC/School including carry Total Number of
AWC/School visit
visit planned in this forward from MHT Details MHT
Total visit to conducted this Male Female Male Female Male Female Doctors Pharmacist ANM/SN
month by Mobile previous month
be planned in this month by Mobile
Health Teams of the current
year Health Teams
year

Visit 1 Approved 0 0 0
AWCs
Visit 2 In-place 0 0 0
Govt and Govt aided schools Trained 0 0 0
Functional
0 0 0
6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total Number of Children Screened

Number of Children screened in Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition
Remarks by MHT Team
……………………………….
Male Female Total Male Female Total Male Female Total Male Female Total
(Reporting Month)

0 0 0 0 0 0
Defects at Birth: Total 0 0 0 0 0 0 0 0 0 0 0 0 Defect at Birth
Neural tube defect 0 0 0 0 0 0
Down’s Syndrome 0 0 0 0 0 0
Cleft Lip & Palate 0 0 0 0 0 0
Club foot 0 0 0 0 0 0
Developmental dysplasia of the hip 0 0 0 0 0 0
Congenital cataract 0 0 0 0 0 0

Congenital deafness 0 0 0 0 0 0
Congenital heart diseases 0 0 0 0 0 0

Retinopathy of Prematurity 0 0 0 0 0 0

Microcephaly 0 0 0 0 0 0

Macrocephaly 0 0 0 0 0 0

Deficiencies:Total 0 0 0 0 0 0 0 0 0 0 0 0 Deficiencies
Severe Anaemia 0 0 0 0 0 0

Vitamin A deficiency (Bitot spot) 0 0 0 0 0 0

Vitamin D Deficiency, (Rickets) 0 0 0 0 0 0

A) SAM 0 0 0 0 0 0

B) Severe Thinning 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (MHT) - FORM No - III
C) Obesity 0 0 0 0 0 0

Goitre 0 0 0 0 0 0

Severe Stunting 0 0 0 0 0 0

Vitamin B complex deficiency. 0 0 0 0 0 0

Childhood Diseases:Total 0 0 0 0 0 0 0 0 0 0 0 0 Childhood Diseases
Skin conditions 0 0 0 0 0 0
Otitis Media 0 0 0 0 0 0
Rheumatic heart disease 0 0 0 0
Reactive airway disease 0 0 0 0 0 0
Dental Conditions 0 0 0 0 0 0
Convulsive disorders 0 0 0 0 0 0

Childhood leprosy Disease 0 0 0 0 0 0

Childhood T.B. 0 0 0 0 0 0
Childhood Extra Pulmonary T. B. 0 0 0 0 0 0

Developmental Delays
including Disabilities:Total 0 0 0 0 0 0 0 0 0 0 0 0 Developmental Delays including Disabilities

Vision impairment 0 0 0 0 0 0
Hearing Impairment 0 0 0 0 0 0

Neuro motor impairment 0 0 0 0 0 0

Motor delay 0 0 0 0 0 0

Cognitive delay 0 0 0 0 0 0
Language delay 0 0 0 0 0 0
Behaviour disorder (Autism) 0 0 0 0 0 0

Learning disorder 0 0 0 0

Attention deficit hyperactivity disorder 0 0 0 0

Others 0 0 0 0
Adolescent Health:Total 0 0 0 0 0 0 0 0 0 0 0 0 Adolescent Health
Growing up concerns 0 0 0 0
Substance abuse 0 0 0 0
Feel depressed 0 0 0 0

Delay in menstruation cycles

0 0 0 0

Irregular periods 0 0 0 0

Pain or burning sensation while urinating 0 0 0 0

Discharge/ foul smelling discharge from

0 0 0
the genitor-urinary area 0
Pain during menstruation 0 0 0 0

6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total Number of Children Refered at

Total Children Refered with Heatlth

Conditions Secondary Care Secondary Care Secondary Care
Secondary Refer Children for Health Conditions at facility
Primary care Tertiary Care Primary care Tertiary Care Primary care Tertiary Care Primary care Care Tertiary Care
(DH/SDH/ (DH/SDH/ (DH/SDH/
(PHC/CHC) (DEIC)/MC (PHC/CHC) (DEIC)/MC (PHC/CHC) (DEIC)/MC (PHC/CHC) (DH/SDH/ (DEIC)/MC
SNCU) SNCU) SNCU)
SNCU)

Neural tube defect

Male 0 0 0
Female 0 0 0
Down’s Syndrome
Male 0 0 0
Female 0 0 0
Cleft Lip & Palate
Male 0 0 0
Female 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (MHT) - FORM No - III
Club foot
Male 0 0 0
Female 0 0 0
Developmental dysplasia Male 0 0 0
of the hip Female 0 0 0
Congenital cataract
Male 0 0 0
Female 0 0 0
Congenital deafness
Male 0 0 0
Female 0 0 0
Congenital heart diseases
Male 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (MHT) - FORM No - III
Congenital heart diseases
Female 0 0 0
Retinopathy of Prematurity
Male 0 0 0
Female 0 0 0
Microcephaly
Male 0 0 0
Female 0 0 0
Macrocephaly
Male 0 0 0
Female 0 0 0
Severe Anaemia
Male 0 0 0
Female 0 0 0
Vitamin A deficiency Male 0 0 0
(Bitot spot) Female 0 0 0
Vitamin D Deficiency, Male 0 0 0
(Rickets) Female 0 0 0
Male 0 0 0
A)SAM Female 0 0 0
Male 0 0 0
B)Severe Thinning Female 0 0 0
Male 0 0 0
C)Obesity Female 0 0 0
Male 0 0 0
Goitre Female 0 0 0
Male 0 0 0
Severe Stunting Female 0 0 0
Male 0 0 0
Vitamin B complex deficiency. Female 0 0 0
Male 0 0 0
Skin conditions Female 0 0 0
Male 0 0 0
Ottis Media Female 0 0 0
Male 0 0 0
Rheumatic Heart Disease Female 0 0 0
Male 0 0 0
Reactive Airway Disease Female 0 0 0
Male 0 0 0
Dental Conditions Female 0 0 0
Male 0 0 0
Convulsive Disorders Female 0 0 0
Male 0 0 0
Childhood leprosy Disease Female 0 0 0
Male 0 0 0
Childhood T.B. Female 0 0 0
Male 0 0 0
Childhood Extra Pulmonary T. B. Female 0 0 0
Male 0 0 0
Vision impairment Female 0 0 0
Male 0 0 0
Hearing Impairment Female 0 0 0
Male 0 0 0
Neuro motor impairment Female 0 0 0
Male 0 0 0
Motor delay Female 0 0 0
Male 0 0 0
Cognitive delay Female 0 0 0
Male 0 0 0
Language delay Female 0 0 0
Behaviour disorder Male 0 0 0
(Autism)
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (MHT) - FORM No - III
Behaviour disorder
(Autism) Female 0 0 0
Learning disorder Male 0 0 0
Female 0 0 0
Attention deficit hyperactivity Male 0 0 0
disorder
Female 0 0 0
Others Male 0 0 0
Female 0 0 0
Growing up concerns Male 0 0 0
Female 0 0 0
Substance abuse Male 0 0 0
Female 0 0 0
Feel depressed Male 0 0 0
Female 0 0 0
Delay in menstruation cycles Male 0 0 0
Female 0 0 0
Irregular periods Male 0 0 0
Female 0 0 0
Pain or burning sensation while Male 0 0 0
urinating
Female 0 0 0
Discharge/ foul smelling discharge Male 0 0 0
from the
genitor-urinary area
Female 0 0 0

Male 0 0 0
Pain during menstruation
Female 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Defects at Birth
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Deficiencies
Female 0 0 0 0 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0 0 0 0 0
Childhood Diseases
Female 0 0 0 0 0 0 0 0 0 0 0 0

Male 0 0 0 0 0 0 0 0 0 0 0 0
Developmental Delays

Female 0 0 0 0 0 0 0 0 0 0 0 0

Male 0 0 0 0 0 0 0 0 0 0 0 0
Adolescent Health

Female 0 0 0 0 0 0 0 0 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20
6 weeks to 3 years (MHT) 3-6 years years enrolled in Govt and Govt aided schools (MHT) 6-18 years enrolled in Govt and Govt aided schools (MHT)
Target : No. of No. of children Percentage of Found positive for Referred for this Target : No. of No. of children Percentage of Found Referred for this Target : No. of No. of children Percentage of Found positive for Referred for this
children screened total children selected health current children screened total children positive for current children screened total children selected health current month/year
Total children to screened in cumulative till screened till this conditions in month/year Total children screened in cumulative till screened till selected month/year Total children screened in cumulative till screened till this conditions in
be screened in current current month month current to be current current month this month health to be current current month month current month
complete year by month (Cumulative) month/year screened in month/year by (Cumulative) conditions screened in month/year (Cumulative)
M.H.T. /Yearby complete M.H.T. in current complete by M.H.T.
M.H.T. year by month year by
M.H.T. M.H.T.

Male 0 #DIV/0! 0 0 0 #DIV/0! 0 0 0 #DIV/0! 0 0

Female 0 #DIV/0! 0 0 0 #DIV/0! 0 0 0 #DIV/0! 0 0

Total
0 0 0 #DIV/0! 0 0 0 0 0 #DIV/0! 0 0 0 0 0 #DIV/0! 0 0
Screening details at AWCs DEIC and MHT Information
Annual plan Total AWC/School Total AWC/School Cumulative gap Doctors Pharmacist ANM/ Staff nurse Remarks by State RBSK Team
: visit planned in visit conducted including carry
this month by this month by forward from
Total visit to Mobile Health Mobile Health previous month of
be planned Teams Teams the current year
in this year Total MHT
Male Female Total Male Female Total Male Female Total

Number Number Number Number Approved 0 0

0
Visit 1 In-place 0 0 0
AWC
Visit 2 Trained 0 0 0
Govt and Govt aided schools Operational 0 0 0
Birth-6 weeks 6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total children
Number of Children screened in the year
ASHA, HBNC Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition
: Current Reporting Month (From)
__________ (To) End of Rerpoting
Month _____________ Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Defects at Birth: Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Defect at Birth
Neural tube defect 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Down’s Syndrome 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cleft Lip & Palate 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Club foot 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Developmental dysplasia of the hip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Congenital cataract 0 0 0 0 0 0 0 0 0 0 0 0
Congenital deafness 0 0 0 0 0 0 0 0 0 0 0 0
Congenital heart diseases 0 0 0 0 0 0 0 0 0 0 0 0
Retinopathy of Prematurity 0 0 0 0 0 0 0 0 0 0 0 0
Microcephaly 0 0 0 0 0 0 0 0 0 0 0 0
Macrocephaly 0 0 0 0 0 0 0 0 0 0 0 0
Deficiencies:Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Deficiencies
Severe Anaemia 0 0 0 0 0 0 0 0 0
Vitamin A deficiency (Bitot spot) 0 0 0 0 0 0 0 0 0
Vitamin D Deficiency, (Rickets) 0 0 0 0 0 0 0 0 0
A) SAM 0 0 0 0 0 0 0 0 0
B) Severe Thinning 0 0 0
C) Obesity 0 0 0 0 0 0 0 0 0
Goitre 0 0 0 0 0 0 0 0 0 0 0 0
Severe Stunting 0 0 0 0 0 0 0 0 0
Vitamin B complex deficiency. 0 0 0 0 0 0 0 0 0 0 0 0
Childhood Diseases:Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Childhood Diseases
Skin conditions 0 0 0 0 0 0 0 0 0 0 0 0
Otitis Media 0 0 0 0 0 0 0 0 0
Rheumatic heart disease 0 0 0
Reactive airway disease 0 0 0 0 0 0 0 0 0 0 0 0
Dental Conditions 0 0 0 0 0 0 0 0 0
Convulsive disorders 0 0 0 0 0 0 0 0 0 0 0 0
Childhood leprosy Disease 0 0 0 0 0 0 0 0 0 0 0 0
Childhood T.B. 0 0 0 0 0 0 0 0 0 0 0 0
Childhood Extra Pulmonary T. B. 0 0 0 0 0 0 0 0 0 0 0 0

Pages 11 of 30
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Developmental Delays including Developmental Delays including

Disabilities:Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Disabilities

Vision impairment 0 0 0 0 0 0 0 0 0 0 0 0
Hearing Impairment 0 0 0 0 0 0 0 0 0 0 0 0
Neuro motor impairment 0 0 0 0 0 0 0 0 0 0 0 0
Motor delay 0 0 0 0 0 0 0 0 0
Cognitive delay 0 0 0 0 0 0 0 0 0
Language delay 0 0 0 0 0 0 0 0 0
Behaviour disorder (Autism) 0 0 0 0 0 0 0 0 0
Learning disorder 0 0 0
Attention deficit hyperactivity disorder 0 0 0
Others 0 0 0 0 0 0
Adolescent Health:Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Adolescent Health
Growing up concerns 0 0 0 0 0 0 0
Substance abuse 0 0 0 0 0 0 0
Feel depressed 0 0 0 0 0 0 0
Delay in menstruation cycles 0 0 0 0 0 0 0
Irregular periods 0 0 0 0 0 0 0
Pain or burning sensation while urinating 0 0 0 0 0 0 0

Discharge/ foul smelling discharge from the

genitor-urinary area
0 0 0 0 0 0 0
Pain during menstruation 0 0 0 0 0 0 0
Birth-6 weeks 6 weeks to 3 years 3 years to 6 years 6 years to 18 years Total Children Referred from Facilities

ASHA, HBNC Refered Children with Health Condition Refered Children with Health Condition Refered Children with Health Condition Refered Children with Health Condition
Refer Children for Health Conditions
Total Children Refered at other facility
Secondary
Primary Secondary Care Secondary Care Primary Primary Secondary Care
Secondary Care Tertiary Care Primary care Tertiary Care Primary care Tertiary Care Care Tertiary Care Tertiary Care
care (DH/SDH/ (DH/SDH/ care care (DH/SDH/
(DH/SDH/MC) (DEIC) (PHC/CHC) (DEIC)/MC (PHC/CHC) (DEIC)/MC (DH/SDH/ (DEIC)/MC (DEIC)/MC
(PHC/CHC) SNCU) SNCU) (PHC/CHC) (PHC/CHC) SNCU)
SNCU)
Neural tube defect
Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Down’s Syndrome
Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Cleft Lip & Palate
Male 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Club foot Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
Developmental dysplasia
of the hip Male 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Congenital cataract
Male 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0 0 0 0
Congenital deafness
Male 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0
0 0 0
Congenital heart diseases
Male 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0
0 0 0
Retinopathy of
Prematurity Male 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0
0 0 0
Microcephaly
Male 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0
0 0 0
Macrocephaly
Male 0 0 0 0 0 0 0 0 0
0 0 0
Female 0 0 0 0 0 0 0 0 0
0 0 0

Pages 12 of 30
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20
Severe Anaemia
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Vitamin A deficiency
(Bitot spot) 0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Vitamin D Deficiency,
(Rickets) 0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
A)SAM
0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0
Female 0 0 0
B)Severe Thinning
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
C)Obesity
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Goitre
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Severe Stunting
0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Vitamin B complex
deficiency. 0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Skin conditions
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Ottis Media
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Rheumatic Heart Disease
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Reactive Airway Disease
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Dental Conditions
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Convulsive Disorders
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Childhood leprosy Disease
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Childhood T.B.
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Childhood Extra
Pulmonary T. B. 0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0

Pages 13 of 30
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20
Vision impairment
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Hearing Impairment
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Neuro motor impairment
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Motor delay
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Cognitive delay
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Language delay
0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Behaviour disorder
(Autism) 0 0 0 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0 0 0 0
Female 0 0 0
Learning disorder
0 0 0 0 0 0
Male 0 0 0

0 0 0 0 0 0
Female 0 0 0
Attention deficit
hyperactivity disorder 0 0 0 0 0 0
Male 0 0 0
0 0 0 0 0 0
Female 0 0 0
Others
0 0 0 0 0 0
Male 0 0 0

0 0 0 0 0 0
Female 0 0 0

Pages 14 of 30
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20
Growing up concerns
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Substance abuse
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Feel depressed
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Delay in menstruation
cycles 0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Irregular periods
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Pain or burning sensation
while urinating 0 0 0
Male 0 0 0

0 0 0
Female 0 0 0
Discharge/ foul smelling
discharge from the 0 0 0
genitor-urinary area Male 0 0 0

0 0 0
Female 0 0 0
Pain during menstruation
0 0 0
Male 0 0 0

0 0 0
Female 0 0 0

Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Defects at Birth

Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Deficiencies

Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Childhood Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Diseases
Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Developmental Delays

Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Male 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Grand Total

Female 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Report prepared by Report verified by Block/ District / State Nodal person
Name
Signature
Designation
Date

Pages 15 of 30
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Number of children with selected health conditions

Referal Managed
Identified through screening Secondary Care Confirmed Waiting for service access
S.No Health Condition Details Primary care (PHC/CHC) (DH/Medical) Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

Neural tube
6 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0
1
0 0
Defect
3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

Down
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
2
Syndrome
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

Cleft Lip
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
3
& Palate
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
4 Club foot
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

Developmental dysplasia
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
5
of the hip
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
6 Congenital cataract
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
7 Congenital Deafness
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
8 Congenital Heart Diseases
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
9 Retinopathy of Prematurity
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Number of children with selected health conditions

Referal Managed
Identified through screening Secondary Care Confirmed Waiting for service access
S.No Health Condition Details Primary care (PHC/CHC) (DH/Medical) Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
10 Severe Anaemia 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
11 Vitamin A deficiency (Bitot spot) 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
12 Vitamin D Deficiency, (Rickets) 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
13 6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
A) SAM 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
B) Severe 3- 6 Yrs
Thinning

6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
C) Obesity 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Number of children with selected health conditions

Referal Managed
Identified through screening Secondary Care Confirmed Waiting for service access
S.No Health Condition Details Primary care (PHC/CHC) (DH/Medical) Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

6 Weeks- 3 Yrs
0 0 0 0 0 0 0 0 0 0
14 Goitre 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
15 Skin conditions 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
16 Otitis Media 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
17 Rheumatic heart disease 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
18 Reactive airway disease 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
19
Dental 3- 6 Yrs
Conditions

6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
20 Convulsive disorders 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
21
Vision 3- 6 Yrs
impairment

6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
22
Hearing 3- 6 Yrs
Impairment

6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
23 Neuro motor impairment 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
24 Motor delay 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
25 Cognitive delay 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
26 Language delay 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Number of children with selected health conditions

Referal Managed
Identified through screening Secondary Care Confirmed Waiting for service access
S.No Health Condition Details Primary care (PHC/CHC) (DH/Medical) Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female
26 Language delay

6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0
27 Behaviour disorder (Autism) 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
28 Learning disorder
6-18 yrs
0 0 0 0 0 0 0 0 0 0
Attention deficit hyperactivity
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
29
disorder
6-18 yrs
0 0 0 0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0
30 Others
6-18 yrs
0 0 0 0 0 0 0 0 0 0
31 Growing up concerns 6-18 yrs
0 0 0 0 0 0 0 0 0 0
32 Substance abuse 6-18 yrs
0 0 0 0 0 0 0 0 0 0
33 Feel depressed 6-18 yrs
0 0 0 0 0 0 0 0 0 0
34 Delay in menstruation cycles 6-18 yrs
0 0 0 0 0 0 0 0 0 0
35 Irregular periods 6-18 yrs 0 0 0 0 0 0 0 0 0 0
0 0
Pain or burning sensation while
0 0 0 0 0 0 0 0
36
urinating 6-18 yrs

Discharge/ foul smelling

37 discharge from the 6-18 yrs 0 0
genitor-urinary area
0 0 0 0 0 0 0 0
38 Pain during menstruation 6-18 yrs
0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0
39 Childhood leprosy Disease 3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Number of children with selected health conditions

Referal Managed
Identified through screening Secondary Care Confirmed Waiting for service access
S.No Health Condition Details Primary care (PHC/CHC) (DH/Medical) Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

6 Weeks- 3 Years
0 0 0 0 0 0 0 0
40 Childhood T.B. 3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0
40.1 Childhood Extra Pulmonary T. B. 3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0
41 6 Weeks- 3 Years
0 0 0 0 0 0 0 0
Severe Stunting
3- 6 Yrs
0 0 0 0 0 0 0 0
Birth-6 weeks

6 Weeks- 3 Years
0 0 0 0 0 0 0 0
42 Microcephaly
3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0
Birth-6 weeks

6 Weeks- 3 Years
0 0 0 0 0 0 0 0
43 Macrocephaly
3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0
44 Vitamin B complex deficiency 3- 6 Yrs
0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Defect at Birth
3- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6-18 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Deficiency 3- 6 Yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Childhood Diseases 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Developmental Delays including
Disabilities 3- 6 Yrs
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Adolescent Health 6-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Weeks- 3 Years
Total Children identified 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6-18 yrs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Report prepared by Report verified by Block/ District / State Nodal person
Name
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: Odisha No of Reported Districts: No of Blocks : Reporting Month Reporting Year 2019-20

Number of children with selected health conditions

Referal Managed
Identified through screening Secondary Care Confirmed Waiting for service access
S.No Health Condition Details Primary care (PHC/CHC) (DH/Medical) Tertiary Care (DEIC) District TB programme District Leprosy programme Medical Surgery Early Intervention AFHC counselling

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

Signature
Designation
Date
 Seco
Note : Mandatory for Secondary Tertiary Care support to children under A 5.2
Name of State/UT Odisha
Details of the Child

Name of Gender Age in Date of RBSK UID MCTS ID if Name of Address Phone
the child completed Birth available/Appl the number
Sl NO year and icable Father of
month index
child
 Secondary tertiary care of children supported under RBSK, wrt A 5.2

FY year
Preliminary identified with health condition Preliminary identification Confirm

District Block Health Condition Identified by date of Health Condition

identified with RBSK Mobile Preliminary confirmed
Health Team identification
Number < Write Date>

Select Select
Preliminary identification Confirmed Type of Health condition managed Medically
management
1) Medical,
Name of Type of Date of 2) Surgery, Name of Type of Date of Amount
the facility confirmation 3) Early the facility management disbursed
facility < Write Date> Intervention, facility < Write Date>
 Health condition managed Surgically Health condition managed Early Interventio

Name of the Details of Surgery Type of Date of Amount Name of Type of

facility facility managem disbursed the facility
ent facility
< Write
Date>

Select
h condition managed Early Intervention Health Condition Health Condition Health Condition referred -
referred - TB referred - Leprosy AFHC

Date of Amount Name of Type of Name of Type of Name of the Type of

management disbursed the facility the facility facility facility
< Write Date> facility facility