COLLEGE OF NURSING, DHAMTARI

BASELINE SURVEY FORM OF COMMUNITY ASSESSMENT

1.Name of the area rural/urban – Urben Area

2.Name of the Health Centre - Primary Health Center Bhatgao
3. Name of the Head of the family – Buddeswar Dewangan
Address – Village – Bhatgao , Post – Bhatgao , Dist – Dhamtari (C.G.)

4. Type of family .1 Single (√) .2 Joint

: …………………………………..……..…
5. Religion :1 Hindu …(√)……….. (Specially the sub cast) : Kosta……
2 Muslim: ……………………………………………..
3 Christian: ………………………...…………………
4 Any other:…………………………………………...

6.Housing Condition :
6.1 Type of house :
1) Pucca 2) Semi Pucca 3) Kutcha (√)
6.2 Rooms :
1) Number -2
2) Adequate / Inadequate(√)
6.3 Occupancy
1) Tenant 2) Owner (√) 3) Monthly Rent
6.4 Ventilation:
1) Adequate 2) Inadequate (√) 3) No ventilation
6.5 Lighting
1) Electricity(√) 2) Gas lamp 3) Oil Lamp
6.6 Source of water supply (Drinking/Washing purpose) :
1) Tap/hand pump (√) 2) Well (√) 3) Open tank
6.7 Kitchen
1) Separate 2) Corner of the room(√) 3) Veranda
6.8 Cooking Fuel :1) Chulha (√) 2) Cooking gas 3) Sigri
6.9 Breeding area of Insects &Rodents: 1) Present 2) Absent (√)
6.10 Are the cattle and poultry housed hygienically?
1) Separate 2) Within house
6.11 System of waste disposal:
1) Composing 2) Burning (√) 3) Burying
6.12 Disposal of sewage water:
1. Drainage (Open/Closed system)(√) 2) Soak pit 3) Kitchen garden
6.13 Lavatory:
1) Own latrine 2) Public latrine 3) Open air defecation (√)
7.Family Composition :
RELATIO

-TIONOCCUPA
EDUCA-

INCOM
S.NO NAME AGE SEX NSHIP
OF THE

E
HEAD
1. Mr.Buddeswar 48yr M Self 3rd Bidhi 3200
Dewangan class Maker

2. Mrs. Dhanseer 43yr F Wife 1st -

class

3. Umeshwari 18yr F Daughter 8th Bidhi 2300

class Maker

4. Hemin 15yr F Daughter 9th Student

class

5. Ghanshyam 7yr M Son 1st Student

class

7. A Total Income of family 7.B EDUCATION STATUS NUMBER

a)Below 1000 a) Not literate -
b) 1001-5000 (√) b)Primary education - 2
c) 5001-10000 c)Middle school - 2
d) 10001 and above d)High school - 0

8. Transport and communication media

8.1 Transport 8.2 Communications

a) Transport ………… a) Mobile …(√)……………
b) Owns Tempo/Tractor ………… b) Television ………………
c) Uses B T S / KSRTC ………… c) Radio ………………
d) Use Private buses ……(√)…… d) Newspaper/magazine …………
e) Train ………… e) Post and above …(√)……………

8.3 Languages : 8.4 Language Known :

a) Mother Tongue ………… a) Chhattisgarhi read/write/speak(√)
b) Chhattisgarhi …(√)……… b) English read/write/speak
c) Hindi ………… c) Hindi read(√)/write(√)/speak
d) Specify others ………… d) Specify others ………. Read/write

9.Dietary pattern :
 Food Available Food Used Traditional Ideal Unhygienic

Rice √ √
Ragi
Jawar
Wheat
Vegetables √ √
Fish √ √
Meat √ √
Egg √ √
Milk and
Milk Products
Pulse √ √
Tubers

10.Statement of expenditure of the family :

S.No. Item Amount Spent (Approx). % of total expenditure

1. Food 1000 18.18%
2. Clothing 1000 18.18%
3. Housing (Rent)
4. Medicine 700 12.72%
5. Children Education 200 3.6%
6 Recreation (Movies
etc)
7 Smoking and /
Liquor
8 Debt
9 Savings 2600 47.27%
10 Other (Specify)

11.It there any case of fever (If yes, write name, age, treatment with remarks) :
a) With rigors ?
b) With cough ?
c) With rash
S.No. Name Age Disease Treatment Remarks
11.1
11.2
11.3
12. Does any one have any skin Disease (e.g. itching, patch, rash)

S.No. Name Age Disease Treatment Remark

13. Does any one have cough for more than 2 weeks .

S.No. Name Age Disease Treatment Remarks

1
2
3
14.Does any one have any other illness ?

S.No. Name Age Disease Treatment Remarks

1 Mr.Buddeswar 48yr Hypertension, Tab.Telvas40 & B.P. 140/90
Blurred Vision ciprofloxine eye mm/hg
drop

2 Mrs. Dhanseer 43yr Paralysis Left

Hand
3

15.Is any woman pregnant, if yes, writes the following remarks .

a) Specify gravid
b) Has she been registered
c) Is she getting iron and folic acid
d) Has she had tetanus toxoid
S.No. Name 15.1 15.2 15.3 15.4

16.Have there been any (within year) _ Vital statistics.

16.1 Birth ?

S.No. Date of Birth Sex Parents Name Remarks

16.2 Death ?

S.No. Date of Death Sex Parents Name Remarks

1
2
3

16.3 Marriages ?

S.No. Date of Marriage Sex Parents Name Remarks

Bride
 Bridegroom

17.Are the any children below five years who have not received immunization(Specify name,
age and reason for not being immunized in remarks)

1.1 BCG vaccination

1.2 DPT vaccination
1.3 Poliomyelitis vaccination
1.4 Measles vaccination
1.5 Vitamin A Solution

S.No. Name Age Sex 17.1 17.2 17.3 17.4 17.5

1 2 3
1
2
3
4

Remarks ………………………………

18. Is there any eligible couple :(If so list them on priority)

S.No Name Age Sex I (Priority) II (Priority) PS SS EM
.
1. Buddeswar / 48 M Permanent
Dhanseer 43 F family
planning
(TT Done)
2.
3.
PS : Primary sterility SS :
Secondary sterility EM : Early
menopause
18.1 Using contraceptive method ? If yes, specify. (TT Done)

18.2 Intendings to undergo 18.2.1 Vasectomy

18.2.1 Tubal ligation
18.3Not interested to adopt FP Method (state the reason)

19. Is there any child 0-5 years in family who shows signs of Malnutrition ?
19.1Kwashiorkor
19.2Marasmus
19.3Vitamin A deficiency
19.4Anemia
19.5Rickets

S.No. Name Age Sex 19.1 19.2 19.3 19.4 19.5

1
2
3
 4
5

Remarks : …………………………………

20.Is The Sullage Water Being Disposed Of Hygienically?

20.1 Drain (√) 20.2 Soakpit 20.3 Kitchen Garde

If no state
reasons…………………………………………………………………………………………………
………………..
21.IS THE RUBBISH BEING DISPOSED HYGIENICALLY? If yes,tick any one/all.

21.1 Composing (√) 21.2 Burning (√) 21.3Burying

If no state reasons……………………………………………………………………………………

22.IF THE EXCRETA BEING DISPOSED OFF HYGIENICALLY? Yes(√)/No

If no state reasons…………………………………………………………………………………….

23.ARE THE CATTLE AND POULTRY HOUSED HYGIENICALLY?Yes /No

23.1 Separate 23.2 Within house

State
reasons………………………………………………………………………………………………

24.IS THERE A WELL OR HANDPUMP?

24.1 Is it maintain in good order. Yes (√)/No if no state reasons.

24.2 When was the well chlorinated? (Date)- State reasons for not chlorinating-No Govt. supply.

25. WHETHER HOUSE IS KEPT CLEAN? Yes(√)/No.if no state reasons

26. WHEN WAS THE HOUSE LAST SPRAYED? (Date)- if no state reasons.-no.any
information

27. IS THERE ANY BREEDING PLACE OF INSECTS AND RODENTS? Yes(√)/No.

28. ARE THERE ANY STRAY DOGS IN THE VICINITY. Yes/No(√).if yes write approximate
no. of dogs.

29. Are official health agencies services adequate ? Yes/No √

If no state reason – No any information

Note : In addition to the above, students are expected to obtain following information
by observation and other methods.

1. Description of the community location, topography, climate, history etc. Type of

Government, no. of schools, no. of health care agencies, Balwadi or ICDS centers, places of
worship (e.g. Temple) and any other relevant information related to health.
2. List of target couple with details on priority basis.
3. Maintain record of Road to Health Card “for knowing the degree of malnutrition for under –
5s where or necessary and use-Nutritional Assessment Form promptly.
4. Use problem solving approach / construct good nursing care plan by using “PRONE” format
taught to you in recent community Nursing Process Lectures.
5. Remarks can be written in separate sheets quoting code no.
6. (eg. 12.2 no sensation found on the patches needs referral and follow us services)

Date of Survey : 10-01-2019 Name of Signature of student