SECTION 6 Health Facility Assessment (fill one per facility visited) *including severe anaemia, hypertension, pre-eclampsia, eclampsia, and diabetes. 6.1 General information 6.1.1 Name of facility 6.1.2 GPS location in decimal digress Contact : 6.1.3 Facility type 6.1.4 Management Hospital Health post Ministry of Health Other (specify) □ □ □ □ Health centre Other NGOs □ □ □ 6.1.5 Is facility temporary or permanent? 6.1.6 Has facility been damaged? Temporary Permanent Yes No □ □ □ □ 6.1.7 Physical access to facility (check 6.1.8 Financial access to facility (check one): one) Easy Free of charge □ □ With obstacles (Explain) Small payment (Explain) □ □ Very difficult (Explain) Large payment (Explain) □ □ Distance in km: …… Number of hours by normal means of transport (specify): Cost per consultation in local currency: …… ….. 6.1.9 Name and type of closest referral facility? 6.1.10 Are vehicles or other means of transport available for referrals? Yes No DNK □ □ □ 6.1.11 Are community-based health services delivered in the catchment area of the health Yes □ □ facility? If yes, who provides & how many? No # _____ village midwives # _____ traditional healer(s) □ □ # _____ community health worker(s) # _____ others (specify) _________ □ □ 6.2 Resources 6.2.1 Who provides health care in this facility? (Check all that apply) # staff # # staff # consultations/day Nurse Midwife □ □ Medical doctor Lab technician □ □ Medical assistant Public health officer □ □ Vaccinator Other ______ □ □ 6.2.2 Essential drugs, vaccines and supplies Available Unavailable Available Unavailable Antibiotics Tetanus toxoid ORS Measles Anti-malarials DPT
*including severe anaemia, hypertension, pre-eclampsia, eclampsia, and diabetes. SECTION 6 Health Facility Assessment (fill one per facility visited) 6.1 General information 6.1.1 Name of facility 6.1.2 GPS location in decimal digress Contact : 6.1.3 Facility type 6.1.4 Management □ Hospital □ Health centre □ Health post □ Other □ Ministry of Health □ NGOs □ Other (specify) 6.1.5 Is facility temporary or permanent? 6.1.6 Has facility been damaged? □ Temporary □ Permanent □ Yes □ No 6.1.7 Physical access to facility (check one): 6.1.8 Financial access to facility (check one) □ Easy □ With obstacles (Explain) □ Very difficult (Explain) Distance in km: …… Number of hours by normal means of transport (specify): ….. □ Free of charge □ Small payment (Explain) □ Large payment (Explain) Cost per consultation in local currency: …… 6.1.9 Name and type of closest referral facility? 6.1.10 Are vehicles or other means of transport available for referrals? □ Yes □ No □ DNK 6.1.11 Are community-based health services delivered in the catchment area of the health facility? If yes, who provides & how many? □ Yes □ No □ # _____ village midwives □ # _____ community health worker(s) □ # _____ traditional healer(s) □ # _____ others (specify) _________ 6.2 Resources 6.2.1 Who provides health care in this facility? (Check all that apply) # staff # consultations/day # staff # □ Nurse □ Midwife □ Medical doctor □ Lab technician □ Medical assistant □ Public health officer □ Vaccinator □ Other ______ 6.2.2 Essential drugs, vaccines and supplies Available Unavailable Available Unavailable Antibiotics Tetanus toxoid ORS Measles Anti-malarials DPT
Final_Emergency-Ass-Guideline_May2014.docx