Health Facility Expansion/Renovation Basic Information: 1. Ministry name: 2. Project Name: 3. Health center/hospital location: □Urban □Rural 4. Please select the Governorate, and write down District, Sub-district and the Village of the project location: Governorate: Sulemani Dohuk Garmian Region □Erbil □ □ □ □Rapareen □ District: Sub-district: Village: Collective Town: 5. GPS Coordinates (if known) Latitude: Longitude: Not Known □ 6. What type of project is this? □Renovation □Expansion 7. What type of health facility is this currently? Branch/Sub-Center Main PHC Family Center □ □ □ Specialized medical center Hospital Other:______________ □ □ □ 8. If you know the type of facility by its letter code, please indicate that here: F A B C D E □ □ □ □ □ □ 9. What will the health facility type be after expansion/renovation (if different): Branch/Sub-Center Main PHC Family Center □ □ □ Specialized medical center Hospital Other:_____________ □ □ □ 10. If you know the type of facility by its letter code after expansion/renovation, please indicate that here (if different): F A B C D E □ □ □ □ □ □ 11. Does this health center/hospital currently provide more than general health service (primary care)? Yes□ No □ 12. Please check all other services that are currently offered at this health center/hospital: Vaccination Injection Oral Rehydration Salts Growth Monitoring □ □ □ □ □Radiology Family Planning Maternity (labor & delivery) Mental Health Management □ □ □ □
Health Facility Expansion/Renovation Basic Information: 1. Ministry name: 2. Project Name: 3. Health center/hospital location: □Urban □Rural 4. Please select the Governorate, and write down District, Sub-district and the Village of the project location: Governorate: □Erbil □ Sulemani □ Dohuk □ Garmian □Rapareen □ Region District: Sub-district: Village: Collective Town: 5. GPS Coordinates (if known) Latitude: Longitude: □ Not Known 6. What type of project is this? □Renovation □Expansion 7. What type of health facility is this currently? □ Branch/Sub-Center □ Main PHC □ Family Center □ Specialized medical center □ Hospital □ Other:______________ 8. If you know the type of facility by its letter code, please indicate that here: □ A □ B □ C □ D □ E □ F 9. What will the health facility type be after expansion/renovation (if different): □ Branch/Sub-Center □ Main PHC □ Family Center □ Specialized medical center □ Hospital □ Other:_____________ 10. If you know the type of facility by its letter code after expansion/renovation, please indicate that here (if different): □ A □ B □ C □ D □ E □ F 11. Does this health center/hospital currently provide more than general health service (primary care)? □ Yes□ No 12. Please check all other services that are currently offered at this health center/hospital: □ Vaccination □ Injection □ Oral Rehydration Salts □ Growth Monitoring □Radiology □ Family Planning □ Maternity (labor & delivery) □ Mental Health Management □