eeilhangeylarshunath

Wsing,

School
Subjed-Communitu
Health Nwnsing

opic- National and

nteynational Health
1gencies5
Qubnitted to
ubmitted. by)
ubtted
Vaishali Singh
( Miss Manisha
BSC Nuung yea PG tuto
PR181102 O (YPs.0.N)
leenthamnenayshunah
School of Nuysi
d.
pubjedt- Communihy Health NbysM
OPrc-Hstonianl deulopmat
Communih Heal,Communiy
Mealh Nwsing Bye-indepenee
amd post- Independence.
gubrittedl by. Subittao to
Vauisthali Singh Hias Ha a
BSC usuing
PG tutoOr
PMRI8110Y TPS 0N)
 eenlhonkey layshvna
CHool o Nuysing
prohatoMon-
N ssignrent
Five Jean M
Submitted bup Submitted to
Vaishali Singh Miss Man@sha
yea PG tutDY
BSC Muounng H
PNRI8)102 4 Ps.0.N
 NURSING
PARSAVNATH SCHOOL OF
CLASS TEACHING PERFORMA

NO:LBIL024.
AME OF THE STUDENT..VaushaliSingh.PNR
Mec.oppl.ec.paogcmme
AAuIsLno-TOPICLisl. day.
ASS
SUBJECT.OhuuLLAHcaltlaTIME20de3pbATE:,2.419|2

Rt Mn MIAALXA khyo
EACHER EVALUATOR:
OBTAINED MARKS
S.NO CRITERIA MARKS ALLOTED
Preparation of the class room
Personal appearance
3
Introduction of topic
Language,voice,clarity,fluency
10
Mastery ofthe topic
Group participation 10
A.V Aids
Conclusion
3
9 Time management 3
10 Bibliography
11 Feedback of class
TOTAL MARK 50

Positive points:

Point to improve:
 plbe

-12 km-
3HARTET TS

+12 km - ToEIRT
* k******** > E*********

NANRER PARSVIATHSCNOLOFNURSIN
AIAItR

TMU
AMAAa,MK

SURVEY REPORT OF VILLAGE

CHABI

SUBMITTED BY SUBMITTED TO

VATSHALI SINGH Htss Nise Mem

BSC AlURSTNGH YHur Ptuta
PIRI8 NO24
(TRS0-N)
 T
RlHANKER PARSVNATH SCHOOL OF NURSING,
AMROHA, U.P

TMU

DERARTYENT OF COMMUNITY HEALTH NURSING

FAMILY FOLDER
ASSESSMENT
BASELINE `URVEY FORM FOR COMMUNITY
1. Name of the area Rural/Urban ..RuAa * *
****

Name of the Health Centre koth.a.0moha.

Name of the Head of the Family ..UAmdua. Singh
Type of Family: 4:1 Single *********
...4.2 Joint...

Religion: 5.1 Hindu HndiuL.. (Specify the subcaste).

5.2 Muslim ***

5.3 Christian
5.4 Any other

6. HOUSING CONDITION:
6.1 Type of house:
Semi Pucca 3) Kutcha
YPucca 2)
6.2 RoomsS:

1) Number Adequate 3) Inadequate

6.3 Occupancy:
1) Tenant Owner 3) Monthly Rent

6.4 Ventilation:
2) Inadequate 3) No Ventilation
Adequate
6.5 Lighting:
2) Gas Lamp 3) Oil Lamnp
Electricity
6.6 Water Supply:

Tap/Handpump 2) Well 3) Open Tank

6.7 Kitchen:
Separate 2) Corner of the room 3 Veranda

Dranage:
6.8
Adequate 2) Inadequate 3) No Drainage

6.9 Vatory
O w n Latrine 2) Public Latrine 3) Open Air Defecation
 ERTHANKER PARSVNATH SCHOOL OF NURSING,
AMROHA, U.P
TMU

DEPARTMENT OF COMMUNITY IEALTH NURSING

FAMILY FOLDER
BASELINE SURVEY FORM FOR
Name of the area
COMMUNITY ASSESSMENT
Rural/Urban .Rumal.
Name of the Health *******

Centre
Name of the Head
of the
.Chabi ..mMAhd
. Family . aMtHQY.
Type of Family: 4:1
5. Single ***
********.*
4 . Z Joint......J
Religion: 5.1 Hindu
5.2
..

(Specify the subcaste)... *******

Muslim ******'*****°**
5.3 Christian * ********* *****
. .

5.4 Any other

6. HOUSING CONDITION:
************

6.1
Type of hous
Pucca 2) Semi Púcca
6.2 Rooms: 3) Kutcha
1) Number
6.3 Adequate 3) Inadequate
Occupancy:
1) Tenant
2 Owner
6.4 3) Monthly Rent
Ventilation:
Adequate 2) Inadequate
6.5 Lighting: 3) No Ventilation

Electricity 2) Gas Lamp

3)
6.6 Water Supply: Oil Lamp

Tap/Handpump 2) Well
3)
6.7 Kitchen: Open Tank
Separate 2) Coner of the
6.8 Drainage: room
3) Verandaa
Adequate 2)
6.9 Vatory Inadequate 3) No Drainage
1)Own Latrine
2) Public Latrine 3)
Open Air Defecation
 EERTHANKER PARSVNATH SCHOOL OF NURSINGG,
AMROHA, U.P

TMU

DEPARTMENTOF COMMUNITYHEALTH NURSING

FAMHLY FOLDER
BASELINE SURVEY FORM FOR COMMUNITY ASSESSMENT

Name of the area Rural/Urban .Rua ***********

Name of the Health Centre Chak. ***** *******

Name of the Head of the Family .Ajcuh. ngh

A Type of Family: 4:1 Single 4.2 Joint....
* * * * * * * * * * * * * * * * * * * * * *
* * * * * * * *

5. Religion: 5.1 Hindu (Specify the subcaste).. .oHh..

5.2 Muslim
5.3 Christian
5.4 Any other

6. HOUSING CONDITION:
6.1 Type of
house:
Pucca 2) Semi Pucca 3) Kutcha
6.2 Rooms
1) Number 2 Adequate 3) Inadequate
6.3 Occupancy:
1) Tenant 2 Owner 3) Monthly Rent

6.4 Ventilation:

Adequate 2) Inadequate 3) No Ventilation

6.5 Lighting:
Electricity 2) Gas Lanp 3) Oil Lamp
.6 Water Supply:
Tap/Handpunp 2) Well Open Tank

6.7 Kitchen:
Separate 2) Corpcr of the room 3) Veranda

6.8 Drainage
Adequate 2) Inadequate 3) No Drainage

Vatory
6.9
1) wn Latrine 2) Public Latrine 3) Open Air Defecation
 1.

L
ORADA AD
CMMUNI
HEALYE NURSING
DEPA M ENT OF
PROCEDUET EVALUATON Date:.oJ12Jx.

* * * ' * *

Name Student:....Maishal...Stngh.
ofthe Procedure:..Anetónculal..Examau.rtKD

Name of the
AR...
* * * * * *

Name of the PHC/CHC/SC/AREA..

N o . . . R U . . A A L . L A . .

ame of the Client/Patient/House

Age. H....yrs, Sex:...f.ema.le..

***

'***
Diagnosis if any:... ***

Address.cliak....flmsLe.h....Koo.el.
'********

* * ° ' * * *

MAX.MARKS: 100
SCORE
3 2 1
.NO ITEM FOR EVALUATION 5 4
PLANNING & ORGANIZATION

Submission of written copy in time

2 Quality of the Content

3 Preparation of articles& the family/pt

4 Self Appearance/personal safety
5 Selection of Site/place for procedure

PROCEDURE DEMONSTRATION
students
6 Prior information to teachers&
Rapport with family/client/students

8 Following Bag technique

9 Application of Aseptic technique 1
10 Application of Nursing Principles/skills
11 Clarity of explanation
demonstrated
12 Accuracy of the procedure
13
Involvement of the students/family

14 Recording of the Procedure/result

Care of the articles after procedure
15
Level of Confidence
16
17 Application of Principles of Teaching 5
KNOWLEDGE

18 Adequacy of Knowledge

19 Purpose of the Procedure

20 Methods of the procedure
- - - TOTAL SCORE:

stdent Signature of the Evaluator/CI

Sierkae
 hnnniARIIZTD MAHA F**

RADA AD NURSING
C M M U N I U E A L Y H

DIPAM ENT
OP 1/.k/R.J..

EVALUATON
Daie:.
Date:

ROCEDUEI
Student:..ashalu.s1mgh.
Name ofthe (/
Name of the Procedure:. ag..eehhuQLl....
PHC/CHC/SC/AREA...Ghakl.

Name of the
Name of the Client/Patient/House No..
Age.6.a.. rs, Sex:....la.le...

***

Diagnosis
d d r eif any:..
* ' * * * ' ' * * " "

A ss . . L h a . k a . . m o l h . . Ko.e.9... ****
* * * * * * * "

MAX.MARKS: 100

5432 1 SCORE
ITEM FOR EVALUATION
S.NO
PLANNING & ORGANIZATION

tiine
Submission of written copy in

Quality of the Content

Preparation of articles & the family/pt

Self Appearance/personal safety
Selection of Site/place for procedure
5
**

PROCEDURE DEMONSTRATION
students
6 Prior information to teachers &
Rapport with family/client/students
7
8 Following Bag technique
9 Application of Aseptic technique
10 Application of Nursing Principles/skills
11 Clarity of explanation
demonstrated
12 Accuracy of the procedure

13 Involvement of the students/family

14 Recording of the Procedure/result

Care of the articles after procedure
15
Level of Conlidence
16
17 Application of Principles of Teaching
IKNOVWLEDGE *******************

18 Adequacy of Fnowledge
19 Purpose of the Procedure

20 Methods of the procedure

*** **********"******* ~*~- TOTAL SCORE:

Sigrki
ignaturo o th Evaluator/CI
 n NTIDOTN
COLL R C E
DTHANKER MAHAVERR
i

RADAAD
DEPA M 2NT OT C MMUNrUEALYH NURSING
ROCEDUEI EVALUATIQN Daie:
Yl/.R/F/.
Name of the Student:.
Vaishaln.S h. * * * * * * ' ******

Name of the
Procedure:....L1aM..A2KA.1.s *****" ****' ' ' * * * ' ' * ' .

Name of the
PHC/CHC/SC/AREA... h.A2..: * *****'''".

Name of the Client/Patient/Housc No.... MeLMa..l2.MA...

"****'******'*****

Age..2.k.s, Sex..exnal...
Diagnosis if any:..
Address:..kacuh.. m.nh.e
*****'****

MAX.MARKS: 100
S.NO ITEM FOR EVALUATION 54 3 2 1 SCORE
PLANNING & ORGANIZATION
Submission of written copy in time
2 Quality of the Content
Preparation of articles & the family/pt
Self Appearance/personal safety
5 Selection of Site/place for procedure
PROCEDUREDEMONSTRATION - - - =

6 Prior information to teachers & students

7 Rapport with family/client/students
8 Following Bag technique
9 Application of Aseptic technique
10 Application of Nursing Principles/skills
11 Clarity of explanation
12 Accuracy of the procedure demonstrated
13 Involvement of the students/family
14 Recording of the Procedure/result
15 Care of the articles after procedure
16 Level of Confidence

17 Application of Principles of Teaching

KNOWLEDGE
18 Adequaty of Knowledge
19 Purpose of the Procedure

20 Methods of the procedure

******

TOTAL SCORE:
7P
Sign t u r Signature oi the'evaluator/C!
TEFRTHANK \MAHAVE FD C o U tCD

OF NURSING,
TEERTHANKER MAHAVEER COLLEGE
MORADABAD

DEPARTMENT OF COMMUNITY HEALTH

NURSINNG
FORM Date.
HEALTII TALK EVALUATION Max. Marks: 100

Name of the Student Vaishol. Ssngh.

anguage Hind
opic allotted by Supervisor/leae. er..oeAt eec
' ' * ' ' ' ' ' ' ' ' ' ' * ' ' ' ' ' ' ' * ' ' ' * * * ' ' * * ' ' * "

Selceted by the sudent

Sndliiduol.Healh . odurotiou
Audience/Group
Ward/ Ficki eld.. ....

Name of the Supervisor/Teacher

MsSSmita.ma..

Yes No
PLANNING (5marks) (0marks)
H a s she/he submitted plan in time?
2 Hasshowshown initiative and interet?
SUBJECT
3 Does she/he select a proper topic/ sub topic?
4 ls the matter adequate?
5 Isthe matter relevant to the group?
6 lsthe knowledgeup to date?
7 Is thematter reliable?
PRESENTATION

8 Isthe introduction of the healthtalkinteresting?

9 Is the method adopted by the student appropriate?
10 Does shecommunicate theideacorrectly?
11Is thelanguage used appreciable?
12 Is the speech and manners satisfactory?
13 Is she effective as a health educator?
14 Is the conclusion of the health talk adequate?
PARTICIPATION AND RESPONSE
positive?
15 Is the responseof the participants/group is
16 Does she/he involve participants/group?
17 Is the doubts of the participants/group is cleared?
VISUAL AIDS

18 Are they effectively prepared by applying principles?

Planning, simplicity,clarity)
19 Has she/he used visual aids correctly?
(Placement, handling, explanation)
20 Has she/he used visual aids at therighttime?
REMARKS: Total Marks obtained:.....
.. * ***''' '**'**** *

Signature of the student SignatureortueSupervisor/CI

 OF NURSING,
EERTHANKER MAHAVEER COLLEGE
MORADABAD
DEPARTMENT OF COMMUNITYHEALTH NURSING D a t e : . .* * * * *

HEALTH TALK EVALUATION FORM Max. Marks: 100

Name of the Student Maishali Sing..

Language ..HINDT... ' ' '

to onmion
puuealution.Rlestid
Topic allotted by Supervisor/Tcacher:.Eeauly.
Selected by the student
%.chllduun (chabi)
Audicnce Group aup.of peaple
Ward/ Field .eld...
MSB NLsha. Mam
***'''''**' ''***'**

Name of the Supervisor/ Teacher

Yes No
PLANNING (5marks) (0 marks)
|1 Has she/he submitted plan in time?
2 Has show shown initiative and interest'
SUBJECT
3 Does she/he select a proper topic / sub topic?
4 Is the matter adequate?
5 I s the matter relevanttothe group?
6 Is the knowledgeup to date?
7 Is the matter reliable?
PRESENTATION

8Istheintroduction ofthe health talk intercsting?

9 Is the method adopted bythcstudent appropriatc?
L10 Does she communicate the idea correctly?
I1|Is the language used appreciable?
12 Is the speech and manners satisfactory?
13Is she effectiveas a health educator?
| 14 Is the conclusion of the health talk adequate?
PARTICIPATION AND RESPONSE

15 Is the response of the participants/group is positivec?

16 Does she/he involve participants/group?
17 Is the doubts of the participants/group is cleared?
VISUAL AIDS
18 Are they effectively preparcd by applying principles?
(Planning, simplicity, clarity)
19 Has she/he used visual aids correctly?
(Placcmcnt,handling, explanation)
20 Has she/he used visual aids at the right time?

REMARKS: Total Marks obtained.

Bnatuy)
SignatyN student Signature dtus supervisor/Cl
Vey apoe
 NURSING
COLLEGE OF
MAHAVEER
EERTHANKER
FAMILY
HEALTH
CARE PLA
EVALUATION C R I T E R I A
FOR
**

i*****

ame of the student:.

ashal.Singii

Name of the Village/Area: . ...aah. ***

***

Pamily NolAddress:....caah..d. M.k..k.oad..

Obtained
Max. Marks
S. No. Contents Marks

Introduction and objective

2, Subjective Data

3. Objective Data
Assessment of family members
(Physical, mental and social)
10
Health nceds identified& Nursing diagrnosis
Planning for family health nursing care

( Including short and long ternm plan )

with
Implementation of home nursing care plan 10
7
scicntilic rationalc.
Ilealth education planning and implementation 10
8.

, Planing tor diet

10. Drugs study and home care

Evaluation
Outeome of family health care
Self-learning as a nurse

12. Specitie procedures 10

13 Writing care plan systematically

Total
100

Siglaur Student

Signature of the ev'aluator