New Health Facility 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 new 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 health facility will this be? Branch/Sub-Center Main PHC Family Center □ □ □ Consultation Clinic Specialized medical center Hospital Other:____________ □ □ □ □ 7. If you know the type of health facility by its letter code, please indicate that here: F A B C D E □ □ □ □ □ □ 8. Will this health center/hospital provide more than general health service (primary care)? Yes□ No □ 9. Please all other services that will be offered at this health center/hospital: Vaccination Injection Oral Rehydration Salts Growth Monitoring □ □ □ □ □Radiology Family Planning Maternity (labor & delivery) Mental Health Management □ □ □ □ Hypertension Screening Surgery Diabetes Screening TB treatment Dental □ □ □ □ □ Vision Lab services Emergency Services Health Education Pharmacy Other: □ □ □ □ □ 10. Catchment - How many people will this health facility serve? Justification of Need: 11. What is the main reason that this health facility is needed? will accommodate overcrowding at the nearest health facility □Demand: provide additional health services needed □Will provide increased or different hours of operation than the nearest facility □Will Other:___________ □ 12. What is the distance (Km) from the next health center/hospital that offers the same or similar services?
New Health Facility 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 new 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 health facility will this be? □ Branch/Sub-Center □ Main PHC □ Family Center □ Consultation Clinic □ Specialized medical center □ Hospital □ Other:____________ 7. If you know the type of health facility by its letter code, please indicate that here: □ A □ B □ C □ D □ E □ F 8. Will this health center/hospital provide more than general health service (primary care)? □ Yes□ No 9. Please all other services that will be offered at this health center/hospital: □ Vaccination □ Injection □ Oral Rehydration Salts □ Growth Monitoring □Radiology □ Family Planning □ Maternity (labor & delivery) □ Mental Health Management □ Hypertension Screening □ Surgery □ Diabetes Screening □ TB treatment □ Dental □ Vision □ Lab services □ Emergency Services □ Health Education □ Pharmacy □ Other: 10. Catchment - How many people will this health facility serve? Justification of Need: 11. What is the main reason that this health facility is needed? □Demand: will accommodate overcrowding at the nearest health facility □Will provide additional health services needed □Will provide increased or different hours of operation than the nearest facility □ Other:___________ 12. What is the distance (Km) from the next health center/hospital that offers the same or similar services?
Circular%20New%20Health%20Facility%20Project%2018-06-2014.docx