Supervision of Public Health Inspector on Office Maintenance

Supervised on Supervisor
Date: DD / MM / YYYY Name :

Time Started: HM : MM am/pm Designation :

1. General Information
1.1. RDHS area
1.2. MOH area
1.3. Name of the local authority (Pradeshiya
Sabha/Municipality area/Urban Council)

1.4. PHI area

1.5. Name of the PHI
1.6. Date appointed to this station
1.7. Date of first appointment

2. Transport facilities

Yes Personal Departmental

2.1. Available
No Date obtained

2.2. Is it in working condition (if applicable) Yes No

3. Uniform (dressed according to circular) Yes No

Reason/Explanation, if 'NO':

4. Area Information
4.1 Extent (in sq. km.) .............................km2
4.2 Population (based on RG's data)
4.2.1 Urban
4.2.2 Rural
4.2.3 Estate
4.3 Number of Houses

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 4.4 Number of PHMM areas
4.5 Number of GN divisions
4.6 No. of Estates
4.7 No. of Schools Government: Private: Other (e.g. piriven)
Semi Government:

Private:
4.8 No. of Pre‐Schools Government:

4.9 Special care institutions Private:

(childrens' homes, elderly homes) Government:

4.10 No. of Hospitals Government: Private:

4.11 No. of GPs
4.12 No. of Pharmacies
4.13 No. of MCH clinics
Household
4.14 No. of Water schemes
Community Supply schemes
4.15 No. of Food establishments
Large Scale Medium Scale Small scale
4.16 No. of Workplaces
Informal Sector Govt. Offices
4.17 No. of Slaughter Houses
4.18 No. of Community organizations
4.19 No. of NGOs

5. Office Comments
5.1 Office location Govt. Pvt.
5.1 Office located within PHI area Yes No
5.2 Designation Sign Board
Yes No Comments
5.2.1. Available
5.2.2. According to Dept. Instructions

5.3 Maintenance
Yes No Comments
5.3.1. Neat and Tidy
5.3.2. Index available and marked
correctly
5.3.3. Registers, Books and Files kept
convenient for easy access

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 Availability Size (3'x2')
6. Boards Comments
Yes No Yes No
6.1 Administration & Statistics
6.2 Epidemiology
6.3 Environmental & Occupational
Health
6.5 School Health
6.6 Miscellaneous

A. Administration & Statistics

a. Area Map
Yes No Comments
i. A3 paper sized

ii. Drawn in Black colour lines

iii. Has a standard legend

iv. Boundary lines are corresponding to GN Divisions

v. PHMM areas marked with Green interrupted lines

vi. Locations of the following marked;

Yes No

‐ Office of PHI & Offices of PHMM

‐ Hospitals, Health Centres & Clinics
‐ Schools & other Government Institutions
‐ Important Private Institutions
‐ Religious Places
‐ Highways & Sub Roads
‐ Irrigation Schemes
‐ Any other Important & Relevant Places

vii. Use of Standard colours and codes

viii. Direction of North indicated

b. Administration Form
(according to Revised H‐795)
c. Public Health Statistics Form
(according to Revised H‐796)

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 B. Epidemiology (each in A‐4 size papers)
a. Spot Maps Available Updated
Yes No Yes No
i. For current cases of communicable Ds.
(during last 4 weeks)
ii. For cumulative cases of Communicable Ds.
for the year
b. Line Graphs (2) ‐ for last TWO years Current Yr
For selected 5 most prominent
Communicable Diseases. Previous Yr

Current Yr
c. Bar Charts for any other
(eg; NCDs)
Previous Yr

C. Environmental Health (each in A‐4 size papers)

a. Food Safety

Available Updated
Comments
Yes No Yes No

Current Yr
i. Bar Charts (2) for Food
handling establishments
Previous Yr

ii. Bar Charts for Food sampling (by month)

b. Map showing Common drinking water sources

c. Occupational Health

Available Updated
Comments
Yes No Yes No
i. Bar Charts for Workplaces (according to
their categories)
ii. Bar Charts of data on Workplace Inspection
(quarterly)

Previous Yr1
d. Bar Chart (2) showing solid waste
disposable methods
Previous Yr2

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 D. School Health (each in A‐4 size paper)

Yes No Comments

a. SMI coverage (% to be indicated quartely in a

table)
b. Bar Charts (2) for SMI, with;
Current
RED ‐ Number of children to be examined
BLACK ‐ Number examined Year
BLUE ‐ Number with defects Previous
YELLOW ‐ Number of defects
Year
GREEN ‐ Number corrected

Current
c. Bar Charts (2) showing 4 most prominent Year
defects detected
(Quarterly) Previous
Year

d. Bar Charts (2) showing immunization of Current

School Children, (aTd) with; Year
RED ‐ Target
BLACK ‐ No. Immunized Previous
Year
e. Bar Charts (2) for School Sanitary Survey,
with; Current
RED ‐ Number of Schools Year
BLACK ‐ Survey Completed
YELLOW ‐ Adequate Sanitary Latrines Previous
BLUE ‐ Safe Water Supply
Year
GREEN ‐ Disposal of Garbage

f. Number of schools without health hazardous sites

E. Miscellaneous (Any other activity displayed) Any Remarks

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 Available Satisfactory
7. Registers Yes No Yes No Any Remarks

7.1 Sanitation and Basic Information Register

7.2 Latrine Construction Register

7.3 Infectious Diseases Register

7.4 TB Register

7.5 Non‐communicable Diseases (NCD) and

Disabled Persons Register

7.6 Notices and Prosecutions Register

7.7 Trades and Industries Register

7.8 Food Analysis Register

7.9 Building Construction Register

7.10 Environmental Pollution and Public

Complaints Register

7.11 Meat Inspection Register

7.12 Consumable Stores Register

7.13 Inward Register

7.14 Outward Register

7.15 Immunization Register

7.16 Occupational Health and Safety Register

7.17 Common Sources of Drinking Water

Register (Gen. Circular No 01‐23/2007 of 01.10.2009)
7.18 Health Education and Health Promotion
Activities Register
7.19 Disaster Preparedness and Response
Register

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 Available Satisfactory
8. Books & Reports Comments
Yes No Yes No
8.1 Pocket Note Book (H‐253)

8.2 Summary of Activities

8.3 Monthly Report (H‐631)

8.4 Visitors Book

Available Updated
9. Files Comments
Yes No Yes No
9.1 Department Instructions and Circulars

9.2 Correspondence

9.3 Inventory File

9.4 Food Handling Establishments (H‐800)

9.5 Tuberculosis (TB) File (H‐816 A)

9.6 Health Survey File
(List of Beneficiaries of Latrine Construction)
9.7 Public Complaints File

9.8 Programme Files

9.8.1 Monthly Advance Programmes

9.8.2 Annual Latrine Construction Programmes

9.8.3 Environmental & Occupational Health
Programmes
9.8.4 School Health Programmes

9.8.5 Health Promotion Programmes

9.8.6 Food Safety & Hygiene Programmes

9.8.7 Vector Control Programmes

9.8.8 Rabies Control Programmes

9.8.9 Disaster Preparedness Plan

9.8.10 Any other Special Activities or Projects

9.8.11 Supervisory Reports

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 10. In‐Service Training received within last 5 years
Yes No

i. School Health

ii. Food Safety

iii. Life Skills

iv. Adolescent Health

v. Environmental Health

vi. Occupational Health and Safety

vii. Disease Surveillance &
Outbreak Management
viii. Non‐Communicable Diseases

ix. Legal procedures

x. any other (Specify)

11. Participation at the area local conference during

last quarter Yes No

12. Participation at other meetings during last quarter Yes No

Environmental Committees

School Health Advisory Committees

Other (specify)

13. Availability of Advance Programmes Yes No

i. Monthly advance programme planned according to

annual programme
ii. Worked according to monthly advance programme
(cross check with the Diary)

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 14. Performance Indications for the last two years and quarterly in current year

Previous 2 Current year

years Comments
Q1 Q2 Q3 Q4
1. % of schools with sanitary survey
conducted
2. SMI coverage

3. % of students covered at SMI

4. % of aTd coverage among school

children
5. % of reported communicable diseases
timely investigated (within 7days of receipt)
6. % of specially investigated diseases

7. No. of food handling establishments

inspected

8. No. of water quality sampling done

9. % of public complaints attended

10. % of workplace inspections done

15. What was the feedback of the PHI about the supervision?

16. Issues identified by the PHI for his work performance

17. Ideas of the PHI & Opinion for more effective service delivery

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 18. Details of previous supervisions

a. Date of previous supervision

b. Designation of the supervisor

c. Recommendations made were implemented Yes No

d. Reasons/Details on not implemented recommendations:

19. Recommendations of this supervision

A. Strengths B. To be Strengthened

i. i.

ii. ii.

iii. iii.

iv. iv.

v. v.

C. Tentative Date for next supervision DD / MM / YYYY

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 20. Action plan for problem solving
Identified Underlying Suggestive
Responsibility Time frame
problem/deficiency cause/causes solutions

Signature of the Supervisor : .................................................. Completed at: HM : MM am/pm

Signature of the PHI : ............................................................

21. Recommendations of the Head of the Institution

Signature of the Head

of the Institution ...........................................................

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