Application for Review of Protocol by the Ethical Review Committee

Date: 29/04/2022
Name of the Protocol : Assessing the Impact of Non-Communicable Diseases on Quality of Life Among
the Elderly in Rural and Urban Odisha: A Comparative StudyinKhordha district

Name of the PI : Rajesh Dhar

Designation : Student

Names of Co-PIs/Co-Is : NA

Designation : NA

[If the protocol is being submitted by a student, name of his/her faculty mentor]:
Ms. Prasansha Das

Names of Other Key Personnel: NA

Suggested start date: 05/05/2022Anticipated end date: 28/07/2022
Regular Review: Expedited Review:
Type of Protocol: Medical Research Socio-behavioral Research 
Enrollment number (Total subjects to be included with rationale and power analysis) 457
Abstract of the protocol in 200 words.
Background:The global shift in demographics towards an older population has become a defining feature of the 21st
century, with significant implications for healthcare systems worldwide. In India, the state of Odisha is experiencing a
similar demographic transition, resulting in a growing elderly population that faces numerous health challenges,
predominantly from non-communicable diseases (NCDs). NCDs such as diabetes, hypertension, cardiovascular diseases,
and chronic respiratory conditions are the leading causes of morbidity and mortality among the elderly. These diseases
not only lead to a healthcare burden but also significantly affect the quality of life (QoL) of the elderly population.
Quality of Life, a multi-dimensional concept that includes physical, psychological, social, and environmental domains,
serves as a critical indicator of the overall well-being and functional abilities of individuals. In Odisha, where diverse
socio-economic conditions exist between rural and urban areas, it is crucial to explore how these settings differentially
impact the QoL among the elderly living with NCDs. Rural areas, often characterized by limited access to healthcare
services and lower socio-economic conditions, might present different challenges compared to urban settings, which
typically have better healthcare infrastructure but might also deal with issues like overcrowding and pollution.
This study aims to assess and compare the impact of NCDs on the Quality of Life among the elderly populations in rural
and urban Odisha. Understanding these impacts can help in tailoring public health policies and interventions that address
the specific needs of these communities, thereby improving their health outcomes and quality of life. By focusing on the
comparative analysis, the study seeks to highlight the nuances between the two settings and provide a foundation for
resource allocation that is sensitive to the contextual needs of the elderly in Odisha..
Objective:
Methods:Anticipated outcome:
Attach the following documents and send to Member Secretary:
1. Protocol
2. Data collection instruments
3. Consent form
4. Funding source-Self
5. Any other supporting document (Approval letterfrom CDM & PHO, Gajapati, Odisha)

______________________________________________ __29/04/2022____________________
Signature of the PI Date
 Research Protocol

Title:
Introduction & rationale:

As the global population ages, the burden of non-communicable diseases (NCDs) in the elderly has become a significant
public health challenge. In India, this challenge is pronounced due to the rapid demographic transition towards an aging
population, compounded by socio-economic diversity and varying levels of healthcare access across different regions.
Odisha, a state in eastern India, exemplifies these challenges. It is home to a growing elderly population that is increasingly
affected by NCDs such as diabetes, hypertension, cardiovascular diseases, and chronic respiratory disorders. These diseases
are leading causes of disability and mortality among the elderly and significantly impair their quality of life (QoL).

Quality of Life encompasses a broad range of human experiences related to overall well-being, including physical health,
psychological state, level of independence, social relationships, personal beliefs, and their relationship to salient features of
the environment. For the elderly, who are often at a vulnerable phase of life, QoL is a particularly salient measure of the
impact of chronic health conditions on their daily lives and long-term well-being.

Given the rural-urban divide in Odisha, which manifests in disparities in healthcare infrastructure, accessibility, and socio-
economic conditions, it becomes essential to explore how these differences impact the QoL among the elderly with NCDs.
Rural areas might struggle with healthcare access and poverty, which can exacerbate the impact of NCDs on elderly
residents' lives. In contrast, urban areas, despite better healthcare facilities, grapple with problems such as urban sprawl,
pollution, and often, social isolation, which can also affect the elderly's QoL.

This study aims to comprehensively assess the impact of non-communicable diseases on the quality of life among the
elderly in Odisha, comparing and contrasting these effects in rural versus urban settings.

The global burden of non-communicable diseases (NCDs) in the elderly has become a significant public health
challenge as the population ages (1). In India, this challenge is particularly pronounced due to the rapid
demographic transition towards an aging population, compounded by socio-economic diversity and varying
levels of healthcare access across different regions (2). Odisha, a state in eastern India, exemplifies these
challenges, being home to a growing elderly population increasingly affected by NCDs such as diabetes,
hypertension, cardiovascular diseases, and chronic respiratory disorders (3). Quality of Life encompasses a broad
range of human experiences related to overall well-being, including physical health, psychological state, level of
independence, social relationships, personal beliefs, and their relationship to salient features of the environment
(4). For the elderly, who are often at a vulnerable phase of life, QoL is a particularly salient measure of the
impact of chronic health conditions on their daily lives and long-term well-being.The burden of non-
communicable diseases (NCDs) in the elderly has become a significant public health challenge globally (5). In
India, this challenge is pronounced due to the rapid demographic transition towards an aging population,
compounded by socio-economic diversity and varying levels of healthcare access across different regions (3).
Odisha, a state in eastern India, exemplifies these challenges. It is home to a growing elderly population that is
increasingly affected by NCDs such as diabetes, hypertension, cardiovascular diseases, and chronic respiratory
disorders. These diseases are leading causes of disability and mortality among the elderly and significantly
impair their quality of life (QoL).Given the rural-urban divide in Odisha, which manifests in disparities in
healthcare infrastructure, accessibility, and socio-economic conditions (6). it becomes essential to explore how
these differences impact the QoL among the elderly with NCDs.Rural areas might struggle with healthcare
access and poverty, exacerbating the impact of NCDs on elderly residents' lives. In contrast, urban areas, despite
better healthcare facilities, grapple with problems such as urban sprawl, pollution, and often, social isolation,
which can also affect the elderly's QoL (7).
This study aims to comprehensively assess the impact of non-communicable diseases on the quality of life
among the elderly in Odisha, comparing and contrasting these effects in rural versus urban settings.

Objectives:
General Objective: Assessing the Impact of Non-Communicable Diseases on Quality of Life Among the Elderly
in Rural and Urban Odisha: A Comparative Study in Khordha district.
Specific Objectives:
1. To compare the prevalence of non-communicable diseases such as hypertension, diabetes, cardiovascular
diseases, and chronic respiratory conditions among the elderly population in rural and urban Odisha.
2. To assess the effect of these non-communicable diseases on the Quality of Life of the elderly in rural
versus urban settings of Odisha, utilizing validated quality of life instruments.

Research Questions:
1. What are the common non-communicable diseases affecting the elderly in rural and urban areas of
Odisha?
2. How do these diseases affect the day-to-day life and overall well-being of elderly people living in rural
versus urban areas of Odisha?

Methodology:
Study: The study will be a community based study.
Study setting: The study participants will be Elderly individuals aged 60 and above residing in selected rural and
urban areas of Odisha.
Study population: The study population would be elderly individuals (aged 60 years and above) residing in both rural
and urban areas of Khordha district, Odisha, who have been diagnosed with at least one non-communicable disease
(NCD).

Eligibility criteria:
 Age: 60 years and above
 Residence: Residing in either rural or urban areas of Khordha district, Odisha
 Diagnosis: Diagnosed with at least one non-communicable disease (NCD)
Inclusion Criteria:
 Individuals aged 60 years and above at the time of the study
 Residents of either rural or urban areas of Khordha district, Odisha
 Diagnosed with at least one NCD (e.g., diabetes, hypertension, cardiovascular diseases, chronic respiratory
disorders)
 Cognitively capable of understanding and responding to the study questionnaire or interview
 Providing informed consent to participate in the study.
 Exclusion Criteria:
 Individuals with severe cognitive impairment or mental disorders that may impair their ability to participate in
the study
 Individuals residing in long-term care facilities or institutionalized settings
 Individuals who are terminally ill or have a life expectancy of less than one year
 Individuals unwilling to provide informed consent or participate in the study.

Sampling frame:
The sampling frame could include a list of elderly residents (aged 60 years and above) from both rural and urban areas of
Khordha district, Odisha, who have been diagnosed with at least one NCD. This list can be obtained from local healthcare
facilities, community organizations, or government databases.

Sample size:

 Study Design: Cross-sectional (investigating prevalence of infection and foot care practices)
 Confidence Level: 95%
 Expected Prevalence (hypothetical): 30% (infection rate among diabetics)
 Margin of Error: 3%

Sample Size Calculation:

We can use the following formula for calculating sample size in prevalence studies:
n = (Z^2 * p * (1 - p)) / (d^2)

Where:
 n = Sample size
 Z = Z-statistic corresponding to the confidence level (1.96 for 95% confidence)
 p = Expected prevalence (0.3 in this case)
 d = Margin of error (0.05 in this case)
Calculation:
n = (1.96 ^ 2 * 0.3 * (1 - 0.3)) / (0.05 ^ 2) n = (3.8416 * 0.3 * 0.7) / 0.0025 n ≈ 385.03

Sampling strategy: Stratified Random Sampling:

1. Divide the study population into two strata: rural and urban areas of Khordha district.
2. Within each stratum (rural and urban), create a sampling frame by obtaining a list of elderly individuals
(aged 60 years and above) diagnosed with at least one NCD.
3. Randomly select participants from each stratum (rural and urban) using simple random sampling or
systematic random sampling techniques.

This stratified random sampling approach ensures that both rural and urban populations are adequately
represented in the sample, allowing for meaningful comparisons between the two strata.
-------------------------------------------------------------------------------------------

Ethical considerations:The consent form and proposal will be released only to the IRB-Ethical Committee
AIPH University for the approval to commence the research study. The participants will be asked to sign the
consent form if they agree to participate in the study. Confidentiality, privacy, anonymity will be maintained
throughout the study. The place of data collection where privacy will be maximal. Respondent will be given right
to participate in the study or discontinue at any time. This study will do good for the women who delivered
recently, community and society rather than any harm.
Data Collection: Data collection will be done within the time period of May 2022 to June 2022 by the primary
investigator at the residence of study participants. Prior to data collection informed consent will be taken either
through written consent or verbal consent. Enough care will be taken to ensure the privacy and confidentiality of
the study participants and their households.
Data Collection tool: Data will be collected through a structured interview schedule. The structured
questionnaire is developed in both English and Odia language. The duration for interview for participants will be
20-30 minutes per participant.
The interview schedule has questions covering the following domains:
1. Sociodemographic and economic characteristics
2. Out-of-pocket expenditure for antenatal care
3. Out-of-pocket expenditure for delivery care
4. Hardship financing

Data Storage: All the data including the consent form will be stored with the principal investigator and will be
kept securely for a minimum of 5 years. The identifiers and data will be stored separately to ensure anonymity.
Data entry and analysis:Data will be collected using printed questionnaire. After data entry and data cleaning,
analysis will be done according to specific objectives. Analysis will be done by SPSS 20 version software.

Anticipated Outcome:
 Estimation of out-of-pocket expenditure during antenatal and delivery care.
 Factors affecting out-of-pocket expenditure during antenatal and delivery care
 Assessment of Financial Hardship to meet the out-of-pocket expenditure for antenatal and delivery care

References:
1. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-
communicable diseases worldwide: an analysis of burden of disease and life expectancy. The Lancet. 2012
Jul;380(9838):219–29.

2. Raymo JM. The second demographic transition in Japan: a review of the evidence. China popul dev stud. 2022
Sep;6(3):267–87.

3. Sethi RK, Senapati SK, Selim AM, Acharya AP, Mishra C, Das M, et al. Molecular epidemiology of lumpy skin disease
outbreak in Odisha, India. Vet Res Commun. 2022 Sep;46(3):711–7.

4. Valles-Colomer M, Falony G, Darzi Y, Tigchelaar EF, Wang J, Tito RY, et al. The neuroactive potential of the human
gut microbiota in quality of life and depression. Nat Microbiol. 2019 Feb 4;4(4):623–32.

5. Manderson L, Jewett S. Risk, lifestyle and non-communicable diseases of poverty. Global Health. 2023 Mar 2;19(1):13.

6. Brookes K, Cappellina B. Political behaviour in France: the impact of the rural–urban divide. Fr Polit. 2023
Mar;21(1):104–24.

7. Zhang L, Shu X, Zhang L. Urban Sprawl and Its Multidimensional and Multiscale Measurement. Land. 2023 Mar
7;12(3):630.

Participant Information Sheet

Namaskar, I am Saujanya Kar, Master of Public Health (MPH) student of Asian Institute of Public Health
University, Bhubaneswar, Odisha. As a part of my course I am expected to do a study and my topic of study is
“Out-of-pocket expenditure on antenatal and delivery care and hardship financing in Gajapati District, Odisha”.
This study is being done under the supervision ofDr. Pradeep Kumar Panda, Dean and Professor of the Asian
Institute of Public Health University. If this information sheet contains any word or information that you do not
understand, please feel free to clarify these. You may also ask any question or doubt related to this study.
Purpose of the study:
The government has introduced many schemes to provide free health care for delivery. All the same, households
seem to be spending a lot of money for antenatal care and delivery care. In this survey we want to find out the
expenditure that households incur during antenatal care and delivery care services in the Gajapati district. We
also want to learn about how households meet the expenditure for antenatal care and delivery care and to find out
the proportion of households experiencing severe financial hardship due to health expenditure related to antenatal
and delivery care.
This study is being conducted in the Gajapati district and you have been chosen through a random process of
selection based on the eligibility criteria for participating in this study. A total of 457 participants will be
included and interviewed in this study.
Procedure:
The survey will take approximately 20-30 minutes of your time. You will be asked a few questions related to the
most recent delivery in your household and the out-of-pocket expenditure incurred during antenatal care and
delivery care. I may contact you again if I have any clarifications related to the information collected during the
present interview.
Risk and discomfort:
Participating in this study imposes no risk to your health. However, you will be asked some questions which
could be personal in nature.
Benefits:
There may not be any direct benefit for you from this study. But the information provided by you may prove to
be of great importance with respect to understanding about the expenditure pattern for antenatal care and delivery
care. As this is an important public health issue this study may contribute to policies that help to reduce the
spending related to child delivery for the urban and rural population in society.
Confidentiality:
You will be interviewed in private. The information collected will not be shared with anyone not involved in the
study. At no stage will your identity be revealed. All hard copies of filled interview schedules and consent forms
will be kept under the custody of principal investigator and will be destroyed when they are deemed no longer
needed or after five year of dissertation report submission, whichever comes first.
Voluntary participation:
Your participation in this study is voluntary and you have the right to withdraw your participation at any time
during the interview without any explanation. Refusal to participate will not involve any penalty or loss of
benefits to which you are otherwise entitled.

Contact information
Dr. Saujanya Kar Dr. Pradeep K Panda
Mobile no: 8018015389 , 9810906140
Email Id-drsaujanyakar86@gmail.com
 CERTIFICATE OF CONSENT
I have read all the provided information, or it has been read to me and I understand the content of the information
sheet.The nature of the study and my involvement has been explained and all my questions regarding the study
have been answered satisfactorily. By signing / providing thumb impression on this consent form, I indicate that I
understand what will be expected from me and that I am willing to participate in this study. I have also been
informed who should be contacted for further clarifications. I know that I can withdraw my participation at any
time during the interview without any explanation.
I give my consent to share the contents of the interview schedule.

Name of the interviewer Name of the study participant

Dr.Saujanya Kar

Date of consent:

Signature of the interviewer Signature/thumb impression of the study participant

If the participant is illiterate:

Name of witness: _____________________________________

Signature of the witness:

 ଅଂଶଗ୍ରହଣକାରୀସୂଚନାପତ୍ର

ନମସ୍କାର, ମୁଁସୌଜନ୍ୟାକର,ଏସିଆନଇନଷ୍ଟିଚ୍ୟୁଟ୍ଅଫ୍ପବ୍ଲିକ୍ହେଲଥ୍ୟୁନିଭରସିଟିରଜନସ୍ୱାସ୍ଥ୍ୟଭୁ ବନେଶ୍ୱର, ଓଡିଶା (ଏମପିଚ) ଛାତ୍ରୀ|

ମୋପାଠ୍ୟକ୍ରମରଏକଅଂଶଭାବରେମୁଁଏକଅଧ୍ୟୟନକରିବିବୋଲିଆଶାକରାଯାଉଛିଏବଂମୋରଅଧ୍ୟୟନରବିଷୟହେଉଛି
“ଓଡ଼ିଶାରଗଜପତିଜିଲ୍ଲାରେଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଏବଂପ୍ରସବକାଳୀନଯତ୍ନଏବଂକଷ୍ଟଆର୍ଥିକସହାୟତାଏବଂମୁକାବିଲାପାଇଁପକେଟଖର୍ଚ୍ଚରଆକଳନ” |
ଏସିଆନ୍ଇନଷ୍ଟିଚ୍ୟୁଟ୍ଅଫ୍ପବ୍ଲିକ୍ହେଲଥ୍ୟୁନିଭର୍ସିଟିରପ୍ରଫେସରଡକ୍ଟରପ୍ରଦିପକୁମାରପଣ୍ଡାଙ୍କତତ୍ତ୍ୱାବଧାନରେଏହିଅଧ୍ୟୟନକରାଯାଉଛି |
ଯଦିଏହିସୂଚନାପତ୍ରରେଯେକୌଣସିଶବ୍ଦକିମ୍ବାସୂଚନାଧାରଣକରେଯାହାକୁଆପଣବୁଝିପାରୁ ନାହାନ୍ତି, ଦୟାକରିଏହାକୁସ୍ପଷ୍ଟକରିବାକୁମୁକ୍ତମନଦିଅନ୍ତୁ |

ଅଧ୍ୟୟନରଉଦ୍ଦେଶ୍ୟ:

ପ୍ରସବପାଇଁମାଗଣାସ୍ୱାସ୍ଥ୍ୟସେବାଯୋଗାଇବାପାଇଁସରକାରଅନେକଯୋଜନାପ୍ରଣୟନକରିଛନ୍ତି | ସମାନଭାବରେ,
ପରିବାରମାନେଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଏବଂପ୍ରସବକାଳୀନଯତ୍ନପାଇଁବହୁଅର୍ଥଖର୍ଚ୍ଚକରୁ ଥିବାପରିମନେହୁଏ |
ଏହିସର୍ବେକ୍ଷଣରେଆମେଜାଣିବାକୁଚାହୁଁଛୁଯେଗଜପତିଜିଲ୍ଲାରେଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ ,ପ୍ରସବକାଳୀନଯତ୍ନସେବାରେପରିବାରମାନେକେତେଖର୍ଚ୍ଚକରନ୍ତି |
ଆମେମଧ୍ୟଜାଣିବାକୁଚାହୁଁଛୁଯେପରିବାରମାନେଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଏବଂପ୍ରସବକାଳୀନଯତ୍ନପାଇଁଖର୍ଚ୍ଚକିପରିପୂରଣକରନ୍ତିଏବଂଗର୍ଭାବସ୍ଥାକାଳୀନଏବଂପ୍ର
ସବକାଳୀନଯତ୍ନସମ୍ବନ୍ଧୀୟସ୍ୱାସ୍ଥ୍ୟଖର୍ଚ୍ଚହେତୁ ଗୁରୁ ତରଅସୁବିଧାରସମ୍ମୁଖୀନହେଉଥିବାପରିବାରଗୁଡିକରଅନୁପାତଜାଣିବା |
ଏହିଅଧ୍ୟୟନଗଜପତିଜିଲ୍ଲାରେଚାଲିଛିଏବଂଏହିଅଧ୍ୟୟନରେଅଂଶଗ୍ରହଣକରିବାରଯୋଗ୍ୟତାମାନଦଣ୍ଡଉପରେଆଧାରକରିଆପଣଏକମନୋନୀତପ୍ରକ୍ରିୟାମା
ଧ୍ୟମରେମନୋନୀତହୋଇଛନ୍ତି |ଏହିଅଧ୍ୟୟନରେସମୁଦାୟ 457 ଅଂଶଗ୍ରହଣକାରୀଙ୍କୁଅନ୍ତର୍ଭୁ କ୍ତକରାଯିବଏବଂସାକ୍ଷାତକାରଦିଆଯିବ |

ପ୍ରଣାଳୀ:

ସର୍ଭେଆପଣଙ୍କସମୟରପ୍ରାୟ 20-30 ମିନିଟ୍ନେବ |

ତୁ ମଘରରସଦ୍ୟତମପ୍ରସବଏବଂଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଏବଂପ୍ରସବକାଳୀନଯତ୍ନସମୟରେପକେଟଖର୍ଚ୍ଚସହିତଜଡିତକିଛିପ୍ରଶ୍ନତୁ ମକୁପଚରାଯିବ |
ବର୍ତ୍ତମାନରସାକ୍ଷାତକାରସମୟରେସଂଗୃହିତସୂଚନାସହିତମୋରଯଦିକୌଣସିସ୍ପଷ୍ଟୀକରଣଅଛିତେବେମୁଁପୁନର୍ବାରଆପଣଙ୍କସହିତଯୋଗାଯୋଗକରିପାରିବି
|

ବିପଦଏବଂଅସୁବିଧା:

ଏହିଅଧ୍ୟୟନରେଅଂଶଗ୍ରହଣକରିବାଆପଣଙ୍କସ୍ୱାସ୍ଥ୍ୟପାଇଁକୌଣସିବିପଦସୃଷ୍ଟିକରେନାହିଁ |ତଥାପି,
ଆପଣଙ୍କୁକିଛିପ୍ରଶ୍ନପଚରାଯିବଯାହାପ୍ରକୃତିରବ୍ୟକ୍ତିଗତହୋଇପାରେ |

ଉପକାରିତା:

ଏହିଅଧ୍ୟୟନରୁ ଆପଣଙ୍କପାଇଁକୌଣସିପ୍ରତ୍ୟକ୍ଷଲାଭହୋଇପାରେନାହିଁ |
କିନ୍ତୁ ତୁ ମଦ୍ୱାରାପ୍ରଦାନକରାଯାଇଥିବାସୂଚନାଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଏବଂପ୍ରସବକାଳୀନଯତ୍ନପାଇଁଖର୍ଚ୍ଚଢାଞ୍ଚାବିଷୟରେବୁଝିବାସହିତମହତ୍ଵପୁର୍ଣପ୍ରମାଣିତହୋ
ଇପାରେ |ଯେହେତୁ ଏହାଏକଗୁରୁ ତ୍ୱପୂର୍ଣ୍ଣଜନସ୍ୱାସ୍ଥ୍ୟସମସ୍ୟା,
ଏହିଅଧ୍ୟୟନନୀତିରେସହାୟକହୋଇପାରେଯାହାସମାଜରସହରାଞ୍ଚଳତଥାଗ୍ରାମାଞ୍ଚଳରଜନସଂଖ୍ୟାପାଇଁଶିଶୁପ୍ରସବସହଜଡିତଖର୍ଚ୍ଚହ୍ରାସକରିବାରେସାହାଯ୍ୟ
କରିଥାଏ |

ଗୋପନୀୟତା:

ବ୍ୟକ୍ତିଗତଭାବରେଆପଣଙ୍କୁସାକ୍ଷାତକାରଦିଆଯିବ |ସଂଗୃହିତସୂଚନାଅଧ୍ୟୟନରେଜଡିତନଥିବାବ୍ୟକ୍ତିଙ୍କସହଅଂଶୀଦାରହେବନାହିଁ |
କୌଣସିପର୍ଯ୍ୟାୟରେତୁ ମରପରିଚୟପ୍ରକାଶପାଇବନାହିଁ |
ଭରପୂରସାକ୍ଷାତକାରକାର୍ଯ୍ୟସୂଚୀଏବଂସମ୍ମତିଫର୍ମଗୁଡିକରସମସ୍ତହାର୍ଡକପିଗୁଡିକମୁଖ୍ୟଅନୁସନ୍ଧାନକାରୀଙ୍କଅଧୀନରେରଖାଯିବଏବଂଯେତେବେଳେସେଗୁ
ଡିକଆଉଆବଶ୍ୟକନୁହେଁବୋଲିବିବେଚନାକରାଯିବକିମ୍ବାଡିସର୍ଟେସନ୍ରିପୋର୍ଟଦାଖଲହେବାରପାଞ୍ଚବର୍ଷପରେ, ଯାହାପ୍ରଥମେଆସିବ |

ସ୍ବେଛାକୃତଅଂଶଗ୍ରହଣ:

ଏହିଅଧ୍ୟୟନରେଆପଣଙ୍କରଅଂଶଗ୍ରହଣସ୍ୱେଚ୍ଛାକୃତଅଟେଏବଂକୌଣସିବ୍ୟାଖ୍ୟାବିନାସାକ୍ଷାତକାରସମୟରେଯେକୌଣସିସମୟରେଆପଣଙ୍କରଅଂଶଗ୍ରହଣ
ପ୍ରତ୍ୟାହାରକରିବାରଅଧିକାରଅଛି |
ଅଂଶଗ୍ରହଣକରିବାକୁମନାକରିବାଦ୍ୱାରାକୌଣସିଦଣ୍ଡକିମ୍ବାଲାଭନଷ୍ଟହେବନାହିଁଯେଉଁଥିରେଆପଣଅନ୍ୟଥାହକଦାରଅଟନ୍ତି|

ଯୋଗାଯୋଗସୁଚନା
ଡ। ସୌଜନ୍ୟାକର ଡ। ପ୍ରଦିପକୁମାରପଣ୍ଡାଙ୍କ
ମୋବାଇଲ୍ନଂ: ୮୦୧୮୦୧୫୩୮୯, ୯୮୧୦୯୦୬୨୪୦
drsaujanyakar86@gmail.com କୁଇମେଲ୍କରନ୍ତୁ |
 ସ୍ୱୀକୃତିପତ୍ର

ମୁଁ , ପ୍ରଦାନକରାଯାଇଥିବାସମସ୍ତସୂଚନାପତ୍ରପଡିଛିକିମ୍ବାଏହାମୋତେପଢ଼ାଯାଇଛିଏବଂମୁଁସୂଚନାପତ୍ରରବିଷୟବସ୍ତୁବୁଝିପାରୁ ଛି |
ଅଧ୍ୟୟନରପ୍ରକୃତିଏବଂମୋରଯୋଗଦାନକୁବ୍ୟାଖ୍ୟାକରାଯାଇଛିଏବଂଅଧ୍ୟୟନସମ୍ବନ୍ଧୀୟମୋରସମସ୍ତପ୍ରଶ୍ନସନ୍ତୋଷଜନକଭାବରେଉତ୍ତରଦିଆଯାଇଛି |
ଏହିସମ୍ମତିପତ୍ରରେଦସ୍ତଖତକରି /ଆଙ୍ଗୁଠିଛାପପ୍ରଦାନକରି,
ମୁଁସୂଚାଉଛିଯେମୋଠାରୁ ଯାହାଆଶାକରାଯାଏମୁଁବୁଝିପାରୁ ଛିଏବଂମୁଁଏହିଅଧ୍ୟୟନରେଭାଗନେବାକୁଇଚ୍ଛୁକ |
ଅଧିକସ୍ପଷ୍ଟୀକରଣପାଇଁକାହାସହିତଯୋଗାଯୋଗକରାଯିବାଉଚିତ୍ତାହାମଧ୍ୟମୋତେସୂଚିତକରାଯାଇଛି |
ମୁଁଜାଣେଯେକୌଣସିବ୍ୟାଖ୍ୟାବିନାସାକ୍ଷାତକାରସମୟରେମୁଁମୋରଅଂଶଗ୍ରହଣକୁପ୍ରତ୍ୟାହାରକରିପାରିବି |

ସାକ୍ଷାତକାରକାର୍ଯ୍ୟସୂଚୀରବିଷୟବସ୍ତୁଅଂଶୀଦାରକରିବାକୁମୁଁମୋରସମ୍ମତିପ୍ରଦାନକରେ |

ସାକ୍ଷାତକାରରନାମ ଅଧ୍ୟୟନରଅଂଶଗ୍ରହଣକାରୀଙ୍କନାମ |
ଡ। ସୌଜନ୍ୟାକର

ସମ୍ମତିରତାରିଖ:

ସାକ୍ଷାତକାରରଦସ୍ତଖତ ଅଧ୍ୟୟନଅଂଶଗ୍ରହଣକାରୀଙ୍କଦସ୍ତଖତ / ଆଙ୍ଗୁଠିଛାପ

ଯଦିଅଂଶଗ୍ରହଣକାରୀଅଶିକ୍ଷିତ:

ସାକ୍ଷୀରନାମ:

ସାକ୍ଷୀଙ୍କଦସ୍ତଖତ:
 Interview Schedule
Out-of-pocket expenditure on antenatal and delivery care and hardship financing in Gajapati District,
Odisha.
Women aged 15-49 years who delivered in the 1 year preceding the date of survey

IDENTIFICATION

District GAJAPATI

Block (Tribal =1, Non tribal =2)

Area (Rural =1 & Urban=2)

Villages (Serial Number)

Participant Serial Number (Actual)

Date / / 2022

In the next section I will be asking you some details regarding yourself and your family/household.

Section I
Individual /Household characteristics

Sl no. Question Response and code

1. What is your age as completed on

your last birthday?
1Hindu
2. What is your religion? 2Muslim
3Christian
4Others ( specify)
1 Scheduled caste
3. Which of these castes do you belong 2 Scheduled tribe
to? 3 OBC
4 General
1 No formal education
4. What is your highest education 2 Primary level
attained? 3 Upper primary level
4 High school level
5 Higher Secondary
6 Graduate
7 Others (specify)
 1 Professional
5. What is your current occupation? 2 Clerical
3 Self employed
4 Home maker
5 Unemployed
6 Manual labourer/Unskilled
7 Other (specify)
1 No formal education
6. What is your husband/partner’s 2 Primary level
highest educational status? 3 Upper primary level
4 High school level
5 Higher Secondary
6 Graduate
7 Others (specify)
1 Professional
7. What is your husband/partner’s 2 Clerical
current occupation? 3 Self employed
4 Home maker
5 Unemployed
6 Manual labourer/Unskilled
7 Other (specify)
1 Mud
8. Type of floor 2 Cow dung
3 Cement
4 Others (specify)
1 Tiles
9. Type of wall
2 Bricks
3 Cement
4 Iron sheet
5 Others (specify )
1 Tiles
10. Type of roof 2 Bricks
3 Cement
4Iron sheet
5Others (specify)
1 Kutcha
11. Type of house 2 Semi-pucca
3 Pucca
1 BPL
12. What is the type of ration card that 2 APL
you hold? 3 Others (specify)
1 Nuclear Familly
13. Type of family
2 Joint Family
|
Household Income Monthly Rs.
14.
Don’t Know 99998
 Does your household have: Yes No
15. Electricity 1 2
Mattress 1 2
Pressure cooker 1 2
Chair 1 2
Cot/Bed 1 2
Table 1 2
Electric fan 1 2
Radio/Transistor 1 2
B & W Television 1 2
Color Television 1 2
Sewing machine 1 2
Mobile telephone 1 2
Internet 1 2
Computer 1 2
Refrigerator1 2
Air Conditioner/Cooler1 2
Washing machine 1 2
Watch/clock 1 2
Bicycle 1 2
Motor cycle/Scooter 1 2
Animal-drawn cart 1 2
Car 1 2
Water pump 1 2
Thresher 1 2
Tractor 1 2

In the next section I will ask you some details about the antenatal care and the expenses related to it. Please tell
me as much as you can remember. I will give you some options which may help you to remember the various
kinds of expenses you had to manage.

Section II Antenatal care

Did you get a card (Mother & Child 1Yes

16. Protection/any other similar card) at the time
of registration? 2 No

17. How many months were you pregnant when

you first registered your pregnancy? __________

18. Where did you receive Antenatal care for 1 Government Health Facility (SHC, PHC, CHC, Rural
last pregnancy? Hospital, Urban Health Centre/Urban Health Post/Urban
Family Welfare Centre, Government Hospital or
Dispensary, Anganwadi Centre/ICDS Centre, Ayush
Hospital, NGO/Trust Hospital/Clinic)
2 Accredited Private Hospital
3 Private Health Facility (Private Hospital/Clinic)
4 Other (own home, parents’ home, other home, other)
19. While availing the ANC service did you 1 Yes
travel to healthcare facility? 2 No
If yes what is the distance (in kms) from __________ kms
home to facility?
20. Number of times antenatal checkups 1 Once
received during pregnancy associated with 2 Two times
this birth? 3 Three times
If yes 4 Four times
21. During antenatal period, were you 1 Yes
hospitalize?
2 No
22. If yes, for how many days you were 1 One day
hospitalized? 2 Two days
3 More than two days
23. Can you provide me details on the amount paid on the following, if any for
ANC 1
Direct Medical Expenditure
1Room Rent __________
2Consultation Charges ______
3Medicines & Supplies (prescribed
from the facility) __________
4 Laboratory & Diagnostic
Service__________
5 Blood Transfusion (including
expenditure for arranging blood)
__________
Direct Non-medical Expenditure
1Transportation (hiring vehicle to
and from the
facility)_____________________
2Expenses on food during stay in
facility___________________
3Tips for getting
services____________________
4 Other (including all expenditure
that the women could not classify
under the specific categories)
Indirect Costs
1Wages lost during hospital stay by
the patient __________
2 Wages lost during hospital stay by
the patient
accompaniers __________
ANC 2
Direct Medical Expenditure
1 Room Rent __________
2 Consultation Charges _______
3 Medicines & Supplies
(prescribed from the facility)
__________
4 Laboratory & Diagnostic
Service__________
5 Blood Transfusion (including
expenditure for arranging blood)
__________
Direct Non-medical Expenditure
1 Transportation (hiring vehicle to
and from the
facility)_____________________
2 Expenses on food during stay in
facility___________________
3 Tips for getting
services_______________
4 Other (including all expenditure
that the women could not classify
under the specific categories)
Indirect Costs
1 Wages lost during hospital stay
by the patient __________
2 Wages lost during hospital stay
by the patient
accompaniers __________
ANC 3
Direct Medical Expenditure
1 Room Rent __________
2 Consultation Charges _______
3 Medicines & Supplies
(prescribed from the facility)
__________
4 Laboratory & Diagnostic
Service__________
5 Blood Transfusion (including
expenditure for arranging blood)
__________
Direct Non-medical
Expenditure
1 Transportation (hiring vehicle
to and from the
facility)____________________
_ _
2 Expenses on food during stay in
facility________________
3 Tips for getting services______
4 Other (including all expenditure
that the women could not classify
under the specific categories)
Indirect Costs
1 Wages lost during hospital stay
by the patient__________
2 Wages lost during hospital stay
by the patient
accompaniers __________
ANC 4
Direct Medical Expenditure
1 Room Rent __________
2 Consultation Charges _______
3 Medicines & Supplies
(prescribed from the facility)
__________
4 Laboratory & Diagnostic
Service__________
5 Blood Transfusion (including
expenditure for arranging blood)
__________
Direct Non-medical
Expenditure
1 Transportation (hiring vehicle
to and from the
facility)____________________
2 Expenses on food during stay
in facility_______________
3 Tips for getting
services__________________
4 Other (including all
expenditure that the women
could not classify under the
specific categories)
Indirect Costs
1 Wages lost during hospital stay
by the patient _________
2 Wages lost during hospital stay
by the patient
accompaniers __________
 24. Why did you not go for any ANC? 1Not necessary
2 Too far/no transport
3 Not customary
4 Poor Quality Service
5 Cost too much
6 Family did not allow
7 Lack of knowledge
8 No time to go
9 Not Applicable
10 Other
25. Total cost incurred on antenatal checkups Rs. __________
from all sources

26. Out of the total health expenditure incurred 1 Government schemes Amount Rs. __________
due to antenatal care above, did you get any
reimbursement from the following? 2 Personal insurance Amount Rs. __________

In the next section I will ask you some details about the natal/delivery care and the expenses related to it. Please
tell me as much as you can remember. I will give you some options which may help you to remember the various
kinds of expenses you had to manage.
Section III – Delivery care

34 Where did you give birth to 1 Public Health Facility

27. (NAME)? 2 Private Health Facility
3 Home

Was the delivery normal or 1 Normal

28. caesarean?
2 Caesarean

Were there any complications 1 Yes

29. during the recent delivery?
2 No

30. What was the main mode of 1 Government ambulance

transportation used by you to 2 Other ambulance
reach the health facility for 3 Jeep/Car
delivery? 4 Motorcycle/Scooter
5 Bus/Train
6 Tempo/Auto/Tractor
7 Cart
8 On foot
9 Others
(Specify)
31. Who arranged the transportation 1 Doctor
to take you to the health facility 2 ANM
for delivery? 3 Health Worker
4 ASHA
5 PRI member
6 NGO
7 CBO
8 Husband
9 Mother in law
10 Mother
11 Relatives/Friends
12 Self
13 Other
(Specify)

32. What is the distance(in Kms) __________Kms

from home to health care
facility where delivery took
place?

33. How many days after delivery Days

did you receive the financial Don’t Know 99998
assistance under JSY?

34. Was (NAME) delivered by 1 Yes

caesarean section, that is, did
they cut your belly open to take 2 No
the baby out?

35. Out of the following 1Free Delivery _________

entitlements for pregnant
women under JSSK, about
which you are aware of?
JSSK
2Free Caesarean section _________
3Free drugs and consumables _________
4Free diagnostics (Blood, Urine tests and USG) __
5Free Diet during stay in health institution (up to 3 days for 6normal
delivery and 7 days for C-Section) _________
6Free provision of blood _________
7Free transport from home to health institution, between health
institutions in case of referrals and drop back home _________
8Exemption from all kinds of user charges (Also covers antenatal
and postnatal period complications) _________

36. What were the reasons for not 1 Not necessary

going to health facility for 2 Too far/no transport
delivery? 3 Not customary
4Poor Quality Service
5 Cost too much
6 Family did not allow
7 Lack of knowledge
8No time to go
9 Not Applicable
10 Other
37. Who conducted your last
delivery?
38. How long did you stay in the
hospital after delivery
39. Can you provide me details on
the amount paid on the
following, if any
40. Out of the total health
expenditure incurred due to
delivery care above, did you get
any reimbursement from the
following?
41. Are you aware of SUMAN
Grievance redressal toll free
number?
Section-IV Hardship financing
42. How the out of pocket cost was met?(Multiple choice is
possible)
1 Doctor
2 ANM/Nurse/Midwife/LHV
3 Dai
4 Friends
5 Other health personnel
6 Other
___________________________
Direct Medical Expenditure
1 Room Rent _______________
2 Consultation Charges _______________
3 Medicines& Supplies (prescribed from the
facility)____________________
4 Laboratory & Diagnostic Services ____________
5.Surgery cost if any__________________
6. Blood Transfusion (including expenditure for arranging
blood)__________________
7. Newborn Care__________________
Direct Non-medical Expenditure
1 Transportation (hiring vehicle to and from the
facility)_____________________
2 Expenses on food during stay in facility___________________
3 Tips for getting services________________
4 Other (including all expenditure that the women could not classify
under the specific categories) _______________
Indirect Costs
1 Wages lost during hospital stay by the patient ________________
2 Wages lost during hospital stay by the patient
accompaniers________________
1 Government schemes Amount Rs. __________
2 Personal insurance Amount Rs. __________
1 Yes
2 No
1 Bank account/Savings
2 Borrowed from friends/relatives
3 Borrowed from money lenders
4 Selling property
5 Selling Jewellery
6 Insurance
7 Others
(Specify)
43. If borrowed /taken money from friends/relatives/ money lenders, ___________________
what is the interest rate?
44. Did you receive any financial assistance for delivery care? 1 Yes

2 No
45. Did you get assistance for ANC /delivery from any of the 1 Janani Suraksha Yojana
following schemes? 2 Janani Sishu Suraksha Karyakram
(Multiple choice is possible) 3 Mamata scheme
4 SAMPurNA ( SishuAbom Matru
Mrityuhara Purna Nirakaran
Abhijan)
5. Pradhan Mantri
SurakshitMatritvaAbhiyan
(PMSMA)
5 Other Govt. Schemes
6 Others
(Specify)

Thankyou foryourparticipationin thestudy!!!

 ସାକ୍ଷାତକାରକାର୍ଯ୍ୟସୂଚୀ
ଓଡ଼ିଶାରଗଜପତିଜିଲ୍ଲାରେଗର୍ଭାବସ୍ଥାକାଳୀନଏବଂପ୍ରସବକାଳୀନଯତ୍ନଏବଂକଷ୍ଟଆର୍ଥିକସହାୟତାପାଇଁପକେଟରୁ ବାହାରଖର୍ଚ୍ଚ
୧୫-୪୯ବର୍ଷବୟସରମହିଳାମାନେ, ଯେଉଁମାନେସର୍ଭେତାରିଖର୧ବର୍ଷରେପ୍ରସବକରିଥିଲେ |
IDENTIFICATION

District GAJAPATI

Block (Tribal =1, Non tribal =2)

Area (Rural =1 & Urban=2)

Villages (Serial Number)

Participant Serial Number (Actual)

Date / / 2022

ପରବର୍ତ୍ତୀବିଭାଗରେମୁଁଆପଣଙ୍କୁଏବଂଆପଣଙ୍କପରିବାର / ଘରସମ୍ବନ୍ଧୀୟକିଛିବିବରଣୀପଚାରିବି |

ବିଭାଗ I
ବ୍ୟକ୍ତିଗତ / ଘରରବିଶିଷ୍ଟତାଗୁଡିକ |

କ୍ରମିକ ପ୍ରଶ୍ନ ଉତ୍ତରଏବଂକୋଡ୍

ନଂବର

୧ ଆପଣଙ୍କରଶେଷଜନ୍ମଦିନରେତୁ ମରବୟସକେତେ
?
1 ହିନ୍ଦୁ
୨ ଆପଣଙ୍କରଧର୍ମକ’ଣ? 2 ମୁସଲମାନ
3 ଖ୍ରୀଷ୍ଟିଆନ
4 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )
1 ଅନୁସୂଚିତଜାତି
୩ ଆପଣକେଉଁଜାତିରଅଟନ୍ତି? 2 ଅନୁସୂଚିତଜନଜାତି
3 ଓବିସି/ଅନ୍ୟପଛୁଆଜାତି
4 ସାଧାରଣଜାତି
1 କୌଣସିଆନୁଷ୍ଠାନିକଶିକ୍ଷାନାହିଁ |
୪ ଆପଣଙ୍କରସର୍ବୋଚ୍ଚଶିକ୍ଷାକ’ଣପ୍ରାପ୍ତହୋଇଛି? 2 ପ୍ରାଥମିକସ୍ତର
3 ଉପରପ୍ରାଥମିକସ୍ତର |
4 ଉଚ୍ଚବିଦ୍ୟାଳୟସ୍ତର |
5 ଉଚ୍ଚମାଧ୍ୟମିକ |
6 ସ୍ନାତକ
7 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )
 1 ବୃତ୍ତିଗତ
୫ ଆପଣଙ୍କରସାମ୍ପ୍ରତିକବୃତ୍ତିକ’ଣ? 2 କିରାଣୀବର୍ଗୀୟ
3 ସ୍ବରୋଜଗାରୀ
4 ଗୃହିଣୀ
5 ବେରୋଜଗାରୀ
6 ଶାରୀରିକଶ୍ରମିକ/ଅଣକୁଶଳ
7 ଅନ୍ୟାନ୍ୟ (ଉଲେଖକରନ୍ତୁ )
1 କୌଣସିଆନୁଷ୍ଠାନିକଶିକ୍ଷାନାହିଁ |
୬ ଆପଣଙ୍କରସ୍ୱାମୀ / 2 ପ୍ରାଥମିକସ୍ତର
ସାଥୀଙ୍କସର୍ବୋଚ୍ଚଶିକ୍ଷାଗତସ୍ଥିତିକ’ଣ? 3 ଉପରପ୍ରାଥମିକସ୍ତର |
4 ଉଚ୍ଚବିଦ୍ୟାଳୟସ୍ତର |
5 ଉଚ୍ଚମାଧ୍ୟମିକ |
6 ସ୍ନାତକ
7 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )

1 ବୃତ୍ତିଗତ
୭ ଆପଣଙ୍କରସ୍ୱାମୀ / ସାଥୀଙ୍କସାମ୍ପ୍ରତିକବୃତ୍ତିକ’ଣ? 2 କିରାଣୀବର୍ଗୀୟ
3 ସ୍ବରୋଜଗାରୀ
4 ଗୃହିଣୀ
5 ବେରୋଜଗାରୀ
6 ଶାରୀରିକଶ୍ରମିକ/ଅଣକୁଶଳ
7 ଅନ୍ୟାନ୍ୟ (ଉଲେଖକରନ୍ତୁ )
1 କାଦୁଅ
୮ ଚଟାଣରପ୍ରକାର 2 ଗାଈଗୋବର
3 ସିମେଣ୍ଟ |
4 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )
1 ଟାଇଲ୍ସ
୯ କାନ୍ଥରପ୍ରକାର
2 ଇଟା

3 ସିମେଣ୍ଟ

4 ଲୁ ହାସିଟ୍
5 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )
1 ଟାଇଲ୍ସ
୧୦ ଛାତରପ୍ରକାର
2 ଇଟା
3 ସିମେଣ୍ଟ
4 ଲୁ ହାସିଟ୍
5 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )
1 କଚ୍ଚା
୧୧ ଘରରପ୍ରକାର 2 ଅର୍ଦ୍ଧପକ୍କା
3 ପକ୍କା
 1 ଦାରିଦ୍ରସୀମାରେଖାତଳେ |
୧୨ ଆପଣଧାରଣକରିଥିବାରାସନକାର୍ଡରପ୍ରକାରକ’ଣ
2 ଦାରିଦ୍ରସୀମାରେଖାଉପରେ
? 3 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )
1 ଐକିକପରିବାର
୧୩ ପରିବାରରପ୍ରକାର
2 ଯୌଥପରିବାର
ଘରରଆୟ ମାସିକଟଙ୍କା.
୧୪
ଜାଣନାହିଁ99998

ଆପଣଙ୍କଘରରଅଛିକି: Yes No ବିଦ୍ୟୁତ୍1 2

୧୫
ଗଦା 1 2
ପ୍ରେସରକୁକର 1 2 ଚେୟାର୍ 1 2
ଖଟ / ଶଯ୍ୟା 1 2
ସାରଣୀ 1 2
ଇଲେକ୍ଟ୍ରିକ୍ପଙ୍ଖା 1 2
ରେଡିଓ / ଟ୍ରାନଜିଷ୍ଟର 12
କଳାଏବଂଧଳାଟେଲିଭିଜନ 1 2
ରଙ୍ଗୀନଟେଲିଭିଜନ 1 2
ସିଲେଇଯନ୍ତ୍ର 1 2
ମୋବାଇଲ୍ଟେଲିଫୋନ୍ 1 2
ଇଣ୍ଟରନେଟ୍ 1 2
କମ୍ପ୍ୟୁଟର 1 2
ରେଫ୍ରି ଜରେଟର 1 2
ଶିତତାପନିୟନ୍ତ୍ରଣକାରିଯନ୍ତ୍ର /କୁଲର୍1 2
ଲୁ ଗାସଫାଯନ୍ତ୍ର 1 2
ଘଡି/ ଘଣ୍ଟା 1 2
ସାଇକେଲ 1 2
ମୋଟରଚକ୍ର / ସ୍କୁଟର | 1 2
ପଶୁ-ଚାଳିତକାର୍ଟ | 1 2
କାର୍1 2
ପାଣିପମ୍ପ 1 2
ଶସ୍ୟଅମଳକାରୀଯନ୍ତ୍ର 1 2
ଟ୍ରାକ୍ଟର 1 2

ପରବର୍ତ୍ତୀବିଭାଗରେମୁଁଆପଣଙ୍କୁଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଏବଂଏହାସହିତଜଡିତଖର୍ଚ୍ଚବିଷୟରେକିଛିବିବରଣୀପଚାରିବି|
ଦୟାକରିମୋତେଯେତିକିମନେରଖିବେତାହାକୁହନ୍ତୁ |
ମୁଁଆପଣଙ୍କୁକିଛିବିକଳ୍ପଦେବିଯାହାଆପଣଙ୍କୁପରିଚାଳନାକରିବାକୁଥିବାବିଭିନ୍ନପ୍ରକାରରଖର୍ଚ୍ଚମନେରଖିବାରେସାହାଯ୍ୟକରିପାରେ
 ବିଭାଗ II ଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ |

ପଞ୍ଜୀକରଣସମୟରେଆପଣଏକକାର୍ଡପାଇଛକି (ମାଏବଂଶିଶୁସୁରକ୍ଷା 1: ହଁ 2:ନା

୧
/ଅନ୍ୟକୌଣସିସମାନକାର୍ଡ)?
୬

ଯେତେବେଳେଆପଣପ୍ରଥମେତୁ ମରଗର୍ଭଧାରଣକୁପଞ୍ଜୀକୃତକଲେ,ଆପଣକେତେ
୧ __________
ମାସଗର୍ଭବତୀଥିଲେ?
୭

ଗତଗର୍ଭଧାରଣପାଇଁଆପଣକେଉଁଠାରେଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନଗ୍ରହଣକଲେ? 1 ସରକାରୀସ୍ୱାସ୍ଥ୍ୟସୁବିଧାସରକାରୀସ୍ୱାସ୍ଥ୍ୟସୁବିଧା
୧
(ଉପସ୍ୱାସ୍ଥ୍ୟକେନ୍ଦ୍ର,ପ୍ରାଥମିକସ୍ୱାସ୍ଥ୍ୟକେନ୍ଦ୍ର,ଗୋଷ୍ଠୀସ୍ୱାସ୍ଥ୍ୟକେ
୮
ନ୍ଦ୍ର, ଗ୍ରାମୀଣଡାକ୍ତରଖାନା,
ସହରୀସ୍ୱାସ୍ଥ୍ୟକେନ୍ଦ୍ର/ସହରୀସ୍ୱାସ୍ଥ୍ୟପୋଷ୍ଟ/ସହରୀପରିବାର
କଲ୍ୟାଣକେନ୍ଦ୍ର,
ସରକାରୀଡାକ୍ତରଖାନାକିମ୍ବାଡିସପେନସାରି,
ଅଙ୍ଗନୱାଡିକେନ୍ଦ୍ର ,
/ଆଇସିଡିଏସକେନ୍ଦ୍ର,ଆୟୁଷଡାକ୍ତରଖାନା,ଏନଜିଓ /
ଟ୍ରଷ୍ଟହସ୍ପିଟାଲ / କ୍ଲିନିକ୍ |

2 ସ୍ୱୀକୃତିପ୍ରାପ୍ତଘରୋଇହସ୍ପିଟାଲ
3 ଘରୋଇସ୍ୱାସ୍ଥ୍ୟସୁବିଧା (ଘରୋଇହସ୍ପିଟାଲ / କ୍ଲିନିକ୍)
4 ଅନ୍ୟାନ୍ୟ/ଅନ୍ୟ (ନିଜଘର, ପିତାମାତାଙ୍କଘର,
ଅନ୍ୟଘର, ଅନ୍ୟାନ୍ୟ)

ଗର୍ଭାବସ୍ଥାକାଳୀନସେବାପାଇବାବେଳେଆପଣସ୍ୱାସ୍ଥ୍ୟସେବାପାଇଁଯାତ୍ରାକରିଥିଲେକି 1 ହଁ
୧ ? 2 ନା
୯ ଯଦିହଁଘରୁ ସୁବିଧାପର୍ଯ୍ୟନ୍ତଦୂରତା (କିମିରେ) କ’ଣ? __________କି.ମି.

୨ ଏହିଜନ୍ମସହିତଜଡିତଗର୍ଭାବସ୍ଥାରେକେତେଥରଗର୍ଭାବସ୍ଥାକାଳୀନଯାଞ୍ଚଗ୍ରହଣକଲ? 1 ଥରେ
୦ ଯଦିହଁ, କେତେଥର ? 2 ଦୁଇଥର
3 ତିନିଥର
4 ଚାରିଥର
୨ ଗର୍ଭାବସ୍ଥାକାଳୀନଅବସ୍ଥାରେ, ଆପଣଡାକ୍ତରଖାନାରେଭର୍ତ୍ତିହୋଇଥିଲେକି? 1 ହଁ
୧
2 ନା
୨ ଯଦିହଁ, ଆପଣକେତେଦିନହସ୍ପିଟାଲରେଭର୍ତ୍ତିହୋଇଥିଲେ? 1 ଦିନେ
୨ 2 ଦୁଇଦିନ
3 ଦୁଇଦିନରୁ ଅଧିକ |
୨୩ Can you provide me details on the amount paid on the following, if any
for ନିମ୍ନଲିଖିତରେଦିଆଯାଇଥିବାରାଶିବିଷୟରେଆପଣମୋତେବିବରଣୀପ୍ରଦାନକରିପାରିବେକିକି, ଯଦିକିଛିପାଇଁ?

ଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ୧ ଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ୨ ଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ୩ ଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ୪

ସିଧାସଳଖଚିକିତ୍ସାଖର୍ଚ୍ଚ ସିଧାସଳଖଚିକିତ୍ସାଖର୍ଚ୍ଚ ସିଧାସଳଖଚିକିତ୍ସାଖର୍ଚ୍ଚ ସିଧାସଳଖଚିକିତ୍ସାଖର୍ଚ୍ଚ

1 କୋଠରୀଭଡା____________ 1 କୋଠରୀଭଡା____________ 1 କୋଠରୀଭଡା____________ 1 କୋଠରୀଭଡା____________
2 ପରାମର୍ଶବ୍ୟୟ ___________ 2 ପରାମର୍ଶବ୍ୟୟ ___________ 2 ପରାମର୍ଶବ୍ୟୟ ___________ 2 ପରାମର୍ଶବ୍ୟୟ ___________
3 ଔଷଧଏବଂଯୋଗାଣ(ସୁବିଧାରୁ ନିର୍ଦ୍ଧେଶିତ)__ 3 ଔଷଧଏବଂଯୋଗାଣ(ସୁବିଧାରୁ ନିର୍ଦ୍ଧେଶିତ)_ 3 ଔଷଧଏବଂଯୋଗାଣ(ସୁବିଧାରୁ ନିର୍ଦ୍ଧେଶିତ)_ 3 ଔଷଧଏବଂଯୋଗାଣ(ସୁବିଧାରୁ ନିର୍ଦ୍ଧେଶିତ)
___________ ____________ ____________ _____________
4 4 4 4
ପରୀକ୍ଷାଗାରଏବଂନିଦାନସେବାଗୁଡିକ______ ପରୀକ୍ଷାଗାରଏବଂନିଦାନସେବାଗୁଡିକ_____ ପରୀକ୍ଷାଗାରଏବଂନିଦାନସେବାଗୁଡିକ____ ପରୀକ୍ଷାଗାରଏବଂନିଦାନସେବାଗୁଡିକ___
_______ ________ _________ __________
5 5 5 5
ରକ୍ତଦାନ(ରକ୍ତଅନ୍ତରଭରଣପାଇଁଖର୍ଚ୍ଚଅନ୍ତର୍ଭୁ କ୍ତ)_ ରକ୍ତଦାନ(ରକ୍ତଅନ୍ତରଭରଣପାଇଁଖର୍ଚ୍ଚଅନ୍ତର୍ଭୁ କ୍ତ) ରକ୍ତଦାନ(ରକ୍ତଅନ୍ତରଭରଣପାଇଁଖର୍ଚ୍ଚଅନ୍ତର୍ଭୁ କ୍ତ) ରକ୍ତଦାନ(ରକ୍ତଅନ୍ତରଭରଣପାଇଁଖର୍ଚ୍ଚଅନ୍ତର୍ଭୁ କ୍ତ
____________ _____________ _____________ )_____________
ସିଧାସଳଖଅଣ-ଚିକିତ୍ସାଖର୍ଚ୍ଚ ସିଧାସଳଖଅଣ-ଚିକିତ୍ସାଖର୍ଚ୍ଚ ସିଧାସଳଖଅଣ-ଚିକିତ୍ସାଖର୍ଚ୍ଚ ସିଧାସଳଖଅଣ-ଚିକିତ୍ସାଖର୍ଚ୍ଚ
1 1 1 1
ପରିବହନସୁବିଧାପାଇଁଯାନବାହାନକୁନିଯୁକ୍ତି___ ପରିବହନସୁବିଧାପାଇଁଯାନବାହାନକୁନିଯୁକ୍ତି__ ପରିବହନସୁବିଧାପାଇଁଯାନବାହାନକୁନିଯୁକ୍ତି__ ପରିବହନସୁବିଧାପାଇଁଯାନବାହାନକୁନିଯୁକ୍ତି_
___________ ____________ ____________ _____________
2 ସୁବିଧାରେରହିବାସମୟରେଖାଦ୍ୟଉପରେଖର୍ଚ୍ଚ 2 2 2
___________ ସୁବିଧାରେରହିବାସମୟରେଖାଦ୍ୟଉପରେଖର୍ଚ୍ଚ ସୁବିଧାରେରହିବାସମୟରେଖାଦ୍ୟଉପରେଖର୍ଚ୍ଚ ସୁବିଧାରେରହିବାସମୟରେଖାଦ୍ୟଉପରେଖ
3 ସେବାପାଇବାପାଇଁଟିପ୍ସ_________ ___________ ___________ ର୍ଚ୍ଚ ___________
4)ଅନ୍ୟାନ୍ୟ 3 ସେବାପାଇବାପାଇଁଟିପ୍ସ_________ 3 ସେବାପାଇବାପାଇଁଟିପ୍ସ_________ 3 ସେବାପାଇବାପାଇଁଟିପ୍ସ_______
(ସମସ୍ତଖର୍ଚ୍ଚଅନ୍ତର୍ଭୂ କ୍ତକରିଯାହାମହିଳାମାନେନିର୍ଦ୍ଦି 4)ଅନ୍ୟାନ୍ୟ 4)ଅନ୍ୟାନ୍ୟ 4)ଅନ୍ୟାନ୍ୟ
ଷ୍ଟବର୍ଗଅଧୀନରେଶ୍ରେଣୀଭୁ କ୍ତକରିପାରିବେନାହିଁ) (ସମସ୍ତଖର୍ଚ୍ଚଅନ୍ତର୍ଭୂ କ୍ତକରିଯାହାମହିଳାମାନେନି (ସମସ୍ତଖର୍ଚ୍ଚଅନ୍ତର୍ଭୂ କ୍ତକରିଯାହାମହିଳାମାନେନି (ସମସ୍ତଖର୍ଚ୍ଚଅନ୍ତର୍ଭୂ କ୍ତକରିଯାହାମହିଳାମାନେ
___________ ର୍ଦ୍ଦିଷ୍ଟବର୍ଗଅଧୀନରେଶ୍ରେଣୀଭୁ କ୍ତକରିପାରିବେନା ର୍ଦ୍ଦିଷ୍ଟବର୍ଗଅଧୀନରେଶ୍ରେଣୀଭୁ କ୍ତକରିପାରିବେନା ନିର୍ଦ୍ଦିଷ୍ଟବର୍ଗଅଧୀନରେଶ୍ରେଣୀଭୁ କ୍ତକରିପାରି
ପରୋକ୍ଷଖର୍ଚ୍ଚ ହିଁ) ___________ ହିଁ) _______ ବେନାହିଁ) _______
1 ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀରମ ପରୋକ୍ଷଖର୍ଚ୍ଚ ପରୋକ୍ଷଖର୍ଚ୍ଚ ପରୋକ୍ଷଖର୍ଚ୍ଚ
ଜୁରୀକ୍ଷତି________________ 1 ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀର 1 ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀର 1 ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀ
2 ମଜୁରୀକ୍ଷତି________________ ମଜୁରୀକ୍ଷତି________________ ରମଜୁରୀକ୍ଷତି________________
ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀସାଙ୍ଗରେଯା 2 2 2
ଇଥିବାବ୍ୟକ୍ତିଙ୍କରମଜୁରୀକ୍ଷତି_____________ ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀସାଙ୍ଗରେ ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀସାଙ୍ଗରେ ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀସାଙ୍ଗ
________ ଯାଇଥିବାବ୍ୟକ୍ତିଙ୍କରମଜୁରୀକ୍ଷତି___________ ଯାଇଥିବାବ୍ୟକ୍ତିଙ୍କରମଜୁରୀକ୍ଷତି_________ ରେଯାଇଥିବାବ୍ୟକ୍ତିଙ୍କରମଜୁରୀକ୍ଷତି_______
__________ __________ ______________
 ୨ ଆପଣକାହିଁକିକୌଣସିଗର୍ଭାବସ୍ଥାକାଳୀନଯାଞ୍ଚପାଇଁଯାଇନାହାଁନ୍ତି? 1 ଆବଶ୍ୟକନୁହେଁ |
୪ 2 ବହୁତଦୂର / ପରିବହନନାହିଁ
3 ପ୍ରଥାନୁହେଁ |
4 ଖରାପଗୁଣବତ୍ତାସେବା |
5 ଅତ୍ୟଧିକମୂଲ୍ୟ
6 ପରିବାରଅନୁମତିଦେଲାନାହିଁ
7 ଜ୍ଞାନରଅଭାବ |
8 ଯିବାକୁସମୟନାହିଁ |
9 ଅପ୍ରଜୁଯ୍ୟ
10 ଅନ୍ୟ
୨ ସମସ୍ତଉତ୍ସରୁ ଗର୍ଭାବସ୍ଥାକାଳୀନଯାଞ୍ଚରେଉପରେମୋଟଖର୍ଚ୍ଚ ଟଙ୍କା. __________
୫

୨ ଉପରୋକ୍ତଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନହେତୁ ହୋଇଥିବାମୋଟସ୍ୱାସ୍ଥ୍ୟଖର୍ଚ୍ଚମଧ୍ୟ 1 ସରକାରୀଯୋଜନାଗୁଡିକଟଙ୍କା. __________

୬ ରୁ , ଆପଣନିମ୍ନରୁ କୌଣସିପରିଶୋଧପାଇଛନ୍ତିକି?
2 ବ୍ୟକ୍ତିଗତବୀମାଟଙ୍କା __________

ପରବର୍ତ୍ତୀବିଭାଗରେମୁଁଆପଣଙ୍କୁପ୍ରସବକାଳୀନଯତ୍ନଏବଂଏହାସହିତଜଡିତଖର୍ଚ୍ଚବିଷୟରେକିଛିବିବରଣୀପଚାରିବି |
ଦୟାକରିମୋତେଯେତିକିମନେରଖିବେତାହାକୁହନ୍ତୁ |ଦୟାକରିମୋତେଯେତିକିମନେରଖିବେତାହାକୁହନ୍ତୁ |
ମୁଁଆପଣଙ୍କୁକିଛିବିକଳ୍ପଦେବିଯାହାଆପଣଙ୍କୁପରିଚାଳନାକରିବାକୁଥିବାବିଭିନ୍ନପ୍ରକାରରଖର୍ଚ୍ଚମନେରଖିବାରେସାହାଯ୍ୟକରିପାରେ |

ବିଭାଗ II - ପ୍ରସବକାଳୀନଯତ୍ନ

34 ଆପଣକେଉଁଠାରେଜନ୍ମଦେଇଛନ୍ତି(ନାମ)? 1 ଜନସ୍ୱାସ୍ଥ୍ୟସୁବିଧା
୨ 2 ଘରୋଇସ୍ୱାସ୍ଥ୍ୟସୁବିଧା
୭ 3 ଘର
ପ୍ରସବସ୍ୱାଭାବିକଥିଲାକିସିଜରିଆନ୍? 1 ସାଧାରଣ/ସ୍ୱାଭାବିକ 2 ସିଜରିଆନ୍
୨
୮

1 ହଁ
୨ ସମ୍ପ୍ରତିପ୍ରସବସମୟରେକିଛିଜଟିଳତାଥିଲାକି?
୯ 2 ନା

୩ ପ୍ରସବପାଇଁସ୍ୱାସ୍ଥ୍ୟସୁବିଧାପହଞ୍ଚାଇବାପାଇଁତୁ ମଦ୍ୱାରାବ୍ୟବହୃତପ 1 ସରକାରୀଆମ୍ବୁଲାନ୍ସ |

୦ ରିବହନରମୁଖ୍ୟଧାରାକ’ଣଥିଲା? 2 ଅନ୍ୟାନ୍ୟଆମ୍ବୁଲାନ୍ସ
3 ଜିପ୍ / କାର୍ |
 4 ମୋଟରସାଇକେଲ୍ / ସ୍କୁଟର |
5 ବସ୍/ ରେଳଗାଡ଼ି
6 ଟେମ୍ପୋ / ଅଟୋ / ଟ୍ରାକ୍ଟର |
7 ଶଗଡ଼ଗାଡି
8 ପାଦରେ
9 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )

୩ ଆପଣଙ୍କୁପ୍ରସବପାଇଁସ୍ୱାସ୍ଥ୍ୟସୁବିଧାକୁନେବାପାଇଁପରିବହନବ୍ୟବ 1 ଡାକ୍ତର
୧ ସ୍ଥାକିଏକଲା? 2 ସହାୟକନର୍ସଧାତ୍ରୀ
3 ସ୍ୱାସ୍ଥ୍ୟକର୍ମୀ
4 ଆଶା
5 ପଂଚାୟତରାଜସଂସ୍ଥାସଦସ୍ୟ
6 ଅଣସରକାରୀସଂଗଠନ
7 ଗୋଷ୍ଠୀଭିତ୍ତିକସଂଗଠନ
8 ସ୍ୱାମୀ
9 ଶାଶୁ
10 ମାତା
11 ସମ୍ପର୍କୀୟ / ବନ୍ଧୁଗଣ
12 ଆତ୍ମ
13 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )

୩ ଘରୁ ସ୍ୱାସ୍ଥ୍ୟସେବାସୁବିଧାପର୍ଯ୍ୟନ୍ତଦୂରତା (କିମିରେ) __________କି.ମି.

୨ ଯେଉଁଠାରେପ୍ରସବହୋଇଥିଲା?

୩ ପ୍ରସବପରେକେତେଦିନପରେଆପଣଜନନୀସୁରକ୍ଷାଯୋଜନାଅ ଦିନଗୁଡିକ
୩ ଧୀନରେଆର୍ଥିକସହାୟତାପାଇଲେ? ଜାଣନାହିଁ 99998

୩ ଶିଶୁକୁସିଜରିଆନ୍ବିଭାଗଦ୍ୱାରାପ୍ରସବକରାଯାଇଥିଲା, 1 ହଁ
୪ ଅର୍ଥାତ୍ସେମାନେଶିଶୁକୁବାହାରକୁଆଣିବାପାଇଁଆପଣଙ୍କରପେଟ
ଖୋଲିଥିଲେକି? 2 ନା

୩ ଜନନୀଶିଶୁସୁରକ୍ଷାକାର୍ଯ୍ୟକ୍ରମଅଧୀନରେଗର୍ଭବତୀମହିଳାମାନଙ୍କ 1 ମାଗଣାପ୍ରସବ _________

୫ ପାଇଁନିମ୍ନଲିଖିତଅଧିକାରଗୁଡ଼ିକମଧ୍ୟରୁ ,
ଯାହାବିଷୟରେଆପଣଅବଗତଅଛନ୍ତି?
2 ମାଗଣାସିଜରିଆନ୍ବିଭାଗ_________
3 ମାଗଣାଔଷଧଏବଂଉପଯୋଗୀସାମଗ୍ରୀ | _________
4 ମାଗଣାନିଦାନ (ରକ୍ତ, ପରିସ୍ରାପରୀକ୍ଷାଏବଂଅଲଟ୍ରାସୋନୋଗ୍ରାଫି )
________
5 ମାଗଣାସ୍ୱାସ୍ଥ୍ୟପ୍ରତିଷ୍ଠାନରେରହିବାସମୟରେଖାଦ୍ୟ (6
ଟିସାଧାରଣପ୍ରସବପାଇଁ 3 ଦିନଏବଂ C- ବିଭାଗପାଇଁ 7
 ଦିନପର୍ଯ୍ୟନ୍ତ)_________
6 ମାଗଣାରକ୍ତଯୋଗାଣ_________
7 ମାଗଣାଘରୁ ସ୍ୱାସ୍ଥ୍ୟପ୍ରତିଷ୍ଠାନକୁପରିବହନ,
ରେଫରାଲ୍କ୍ଷେତ୍ରରେସ୍ୱାସ୍ଥ୍ୟପ୍ରତିଷ୍ଠାନମଧ୍ୟରେଏବଂଘରକୁଫେରିବା |
_________
8 ସମସ୍ତପ୍ରକାରରଉପଭୋକ୍ତାଦେୟରୁ ମୁକ୍ତି
(ଗର୍ଭାବସ୍ଥାକାଳୀନଏବଂପ୍ରସବକାଳୀନଜଟିଳତାକୁମଧ୍ୟଅନ୍ତର୍ଭୁ କ୍ତକରେ)

୩ ପ୍ରସବପାଇଁସ୍ୱାସ୍ଥ୍ୟସୁବିଧାକୁନଯିବାରକାରଣଗୁଡ଼ିକକ’ଣଥିଲା? 1 ଆବଶ୍ୟକନୁହେଁ |
୬ 2 ବହୁତଦୂର / ପରିବହନନାହିଁ |
3 ପ୍ରଥାନୁହେଁ |
4 ଖରାପଗୁଣବତ୍ତାସେବା |
5 ଅତ୍ୟଧିକମୂଲ୍ୟ
6 ପରିବାରଅନୁମତିଦେଲାନାହିଁ |
7 ଜ୍ଞାନରଅଭାବ |
8 ଯିବାକୁସମୟନାହିଁ |
9 ଅପ୍ରଜୁଯ୍ୟ
10 ଅନ୍ୟାନ୍ୟ

୩ କିଏଆପଣଙ୍କରଶେଷପ୍ରସବକଲା? 1 ଡାକ୍ତର
୭ 2 ସହାୟକନର୍ସଧାତ୍ରୀ/ସେବିକା/ଧାତ୍ରୀ/ମହିଳାସ୍ୱାସ୍ଥ୍ୟପରିଦର୍ଶକ |
3 ଦାଈମା
4 ବନ୍ଧୁଗଣ
5 ଅନ୍ୟାନ୍ୟସ୍ୱାସ୍ଥ୍ୟକର୍ମୀ
6 ଅନ୍ୟ
୩ ପ୍ରସବପରେଆପଣକେତେଦିନହସ୍ପିଟାଲରେରହିଲେ? ___________________________
୮

୩ ନିମ୍ନଲିଖିତରେଦିଆଯାଇଥିବାରାଶିବିଷୟରେଯଦିଆପଣମୋ
୯ ତେସବିଶେଷତଥ୍ୟଦେଇପାରିବେକି?
ସିଧାସଳଖଚିକିତ୍ସାଖର୍ଚ୍ଚ
1 କୋଠରୀଭଡା_________________
2 ପରାମର୍ଶବ୍ୟୟ _____________________
3 ଔଷଧଏବଂଯୋଗାଣ(ସୁବିଧାରୁ ନିର୍ଦ୍ଧେଶିତ)_____________
4 ପରୀକ୍ଷାଗାରଏବଂନିଦାନସେବାଗୁଡିକ_____________
5 ଅସ୍ତ୍ରୋପଚାରଖର୍ଚ୍ଚ ,ଯଦିକୌଣସି_____________
6 ରକ୍ତଦାନ(ରକ୍ତଅନ୍ତରଭରଣପାଇଁଖର୍ଚ୍ଚଅନ୍ତର୍ଭୁ କ୍ତ)_____________
7 ନବଜାତଶିଶୁଯତ୍ନ | ___________________

ସିଧାସଳଖଅଣ-ଚିକିତ୍ସାଖର୍ଚ୍ଚ
1 ପରିବହନସୁବିଧାପାଇଁଯାନବାହାନକୁନିଯୁକ୍ତି______________

୪ ଉପରୋକ୍ତପ୍ରସବକାଳୀନଯତ୍ନହେତୁ ହୋଇଥିବାମୋଟସ୍ୱାସ୍ଥ୍ୟଖର୍ଚ୍ଚ
୦ ମଧ୍ୟରୁ , ଆପଣନିମ୍ନରୁ କୌଣସିପରିଶୋଧପାଇଛନ୍ତିକି?
2 ସୁବିଧାରେରହିବାସମୟରେଖାଦ୍ୟଉପରେଖର୍ଚ୍ଚ ___________
3 ସେବାପାଇବାପାଇଁଟିପ୍ସ____________________
4)ଅନ୍ୟାନ୍ୟ
(ସମସ୍ତଖର୍ଚ୍ଚଅନ୍ତର୍ଭୂ କ୍ତକରିଯାହାମହିଳାମାନେନିର୍ଦ୍ଦିଷ୍ଟବର୍ଗଅଧୀନରେଶ୍ରେଣୀଭୁ
କ୍ତକରିପାରିବେନାହିଁ) ___________
ପରୋକ୍ଷଖର୍ଚ୍ଚ
1 ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀରମଜୁରୀକ୍ଷତି_________
___________
2
ଡାକ୍ତରଖାନାରେରହିବାସମୟରେରୋଗୀସାଙ୍ଗରେଯାଇଥିବାବ୍ୟକ୍ତିଙ୍କରମଜୁ
ରୀକ୍ଷତି_____________________
1 ସରକାରୀଯୋଜନାଗୁଡିକଟଙ୍କା. __________
2 ବ୍ୟକ୍ତିଗତବୀମାଟଙ୍କା __________

ଆପଣସୁମନଅଭିଯୋଗରସମାଧାନଟୋଲ୍ଫ୍ରିନମ୍ବରବିଷୟରେଅ 1 ହଁ
୪ ବଗତକି?
୧
2 ନା

ବିଭାଗ- IV କଷ୍ଟଆର୍ଥିକ

୪୨ ପକେଟରୁ ବାହାରଖର୍ଚ୍ଚକିପରିପୂରଣହେଲା?(ଏକାଧିକଚୟନସମ୍ଭବ) 1 ବ୍ୟାଙ୍କ/ଖାତାସଞ୍ଚୟ

2 ବନ୍ଧୁ / ସମ୍ପର୍କୀୟଙ୍କଠାରୁ ୠଣଉଧାରନେଇଛନ୍ତି
3 ମହାଜନଙ୍କଠାରୁ ୠଣଉଧାରନେଇଛନ୍ତି
4 ସମ୍ପତ୍ତିବିକ୍ରୟ
5 ଅଳଙ୍କାରବିକ୍ରୟ
6 ବୀମା
7 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )

୪୩. ଯଦିବନ୍ଧୁ / ସମ୍ପର୍କୀୟ / ମହାଜନଙ୍କଠାରୁ ଟଙ୍କା /ୠଣଉଧାର ___________________

ନେଇଥିଲେ, ତେବେସୁଧହାରକେତେ?
୪୪. ପ୍ରସବପାଇଁଆପଣକୌଣସିଆର୍ଥିକସହାୟତାପାଇଛନ୍ତିକି? 1 ହଁ 2 ନା

୪୫. ଆପଣନିମ୍ନଲିଖିତଯୋଜନାଗୁଡ଼ିକମଧ୍ୟରୁ ଗର୍ଭାବସ୍ଥାକାଳୀନଯତ୍ନ/ 1 ଜନନୀସୁରକ୍ଷାଯୋଜନା

ପ୍ରସବପାଇଁସହାୟତାପାଇଛନ୍ତିକି? (ଏକାଧିକଚୟନସମ୍ଭବ) 2 ଜନନୀଶିଶୁସୁରକ୍ଷ୍ୟାକାର୍ଯ୍ୟକ୍ରମ
3 ମମତାଯୋଜନା
4 ସମ୍ପୂର୍ଣ (ଶିଶୁଏବଂମାତୃ ମୃତ୍ୟୁହାର
ପୁର୍ଣନିରାକରଣଅଭିଯାନ)
5. ପ୍ରଧାନମନ୍ତ୍ରୀସୁରକ୍ଷିତମାତୃ ତ୍ଵଅଭିଯାନ
 (ପିଏମଏସଏମଏ)
5 ଅନ୍ୟାନ୍ୟସରକାରଯୋଜନାଗୁଡିକ
6 ଅନ୍ୟାନ୍ୟ(ଉଲେଖକରନ୍ତୁ )

ଅଧ୍ୟୟନରେଅଂଶଗ୍ରହଣପାଇଁଧନ୍ୟବାଦ!!!