ASHAIncentiveBookletEng PDF

NATIONAL HEALTH MISSION, ASSAM
MESSAGE
Chief Minister
Government of Assam
It gives me immense pleasure to know that National Health Mission,

Assam is bringing out a hand book on various incentives entitled by
ASHAs.
The hard work and eorts put in by the ASHAs and their contribution
towards development in the health sector, especially in the field of
maternal and child health is laudable. I believe that this hand book
would ensure appropriate and timely receipt of incentives by ASHAs
I hope that ASHA incentive manual 2015-16 will be a facilitator for
ASHAs in their field work for be er results.
(Shri Tarun Gogoi)
MESSAGE
Minister of Health & Family
welfare, Govt. of Assam
I am glad to know that National Health Mission, Assam is publishing

a handbook for the benefit of ASHAs working at the grassroot level. The
handbook will help ASHAs as a reference book on various incentives
entitled through dierent schemes and programmes.
The contribution of the ASHAs in the field of health services is
remarkable and laudable. The eorts and incessant hard work put in
by the ASHAs have improved the health parameters of the state by
manifold.
This handbook will be of immense help to the ASHAs in their
performance and delivering financial benefits to them.
(Dr. Nazrul Islam)
ASHA Incen ve Manual - 2015-16
ASHA Incen ve Details

Component
Sl.
No
Amount of
Incen ve
Page Format
Paid to ASHA No Page No
(amount in Rs.)
Name of the ac vi es
1st delivery
1
Maternal
Health
600
nd
2 delivery
600
rd
400
th
200
3 delivery
4 delivery
25
JSY voucher
Discharge slip
26
ANC Card
60
MDR form
(Annexure-VI)
For Ensuring full ANC to pregnant Women
150
Reporting of Maternal Death
200
Providing Home Based New Born Care up

to 42 days a er birth
250
27
HbNC form
Follow up of SNCU graduate ll 1 yr. of age
500
33
HbNC form
Follow up of LBW baby up to 2 yrs. of age
1100
38
HbNC form
Repor ng of under 5 death
50
61-62
CDR forms
Incen ve for IFA Supplementa on against Rs.1 per child

each child
per month
NIPI
compliance
card/Register
Incen ve for SAM child admission &

Follow-up
150
Discharge Card
10
ORS packet distribu on to the family of

under five children in her area.
Rs. 1 (per
packet)
For comple ng growth monitoring of at

11 least 80% of under five children in her
area.
100
For mobilising an ensuring consump on of

Tab. Albendazole by every eligible child
50
Ensuring Full Immuniza on including JE

13 (where applicable) to a child up to 1 yr. of
age
100
14
Ensuring 2nd dose of measles & OPV-DPT

booster
50
15
Mobiliza on of Children under 2 years for

immuniza on (per session)
150
Child Health
12
Rou ne
Immuniza on
Janani Suraksha
Yojana (JSY)
Suppor ng
Documents
[1]
13
ASHA Tally
Sheet
NDD ASHA
Format
51-52 &
54
Immuniza on
form
MCP card
Component
Family
Planning
Rou ne
Ac vi es
NPCB
Sl.
No
Amount of
Incen ve
Page Format
Paid to ASHA No Page No
(amount in Rs.)
Name of the ac vi es
16
Incen ve to ASHA for ensuring limi ng

a er 2 child
1000
17
Ensuring delaying 2 years for first child

birth a er marriage
500
10
18
Ensuring 3 years gap between 1st and 2nd

child birth
500
10
19 Incen ve for mo va ng male Steriliza on
300
11
20
Incen ve for mo va ng Female

Steriliza on
200
11
21
Mo va ng a women for PPS (Female)
300
12
22
Mo va ng a women for PPIUCD inser on
150
Monthly Rou ne ac vi es
1000
1415
for ensuring Treatment of Cataract
250
17
Ensuring successful comple on of first line

(CAT I) TB treatment
1000
23
24
25

(CAT II) TB treatment
Ensuring successful complet ion of
27 intensive phase of mul drug resistant TB
treatment
Ensuring successful comple on of
28 con nua on phase of mul drug resistant
TB treatment
26
RNTCP
NLEP
NVBDCP
NIDDCP
Other
Incen ves
2000
MO I/c
Cer ficate
21-23
57
Format/ASHA
Diary
Discharge
le er from
MO I/c
18
55-56
Nischay card/
ID
58
A endence
that treatment
and diagnosis
slip
63
Claim form
59
Format Diary
Slip
3000
100
250
33 For malaria slide collec on
15
34 For ensuring treatment of posi ve cases
75
[2]
Marriage
cer ficate/MO
cer ficate/
ANM
Cer ficate sign
1500
29 Sensi za on
30 Incen ve for case detec on
for ensuring complete treatment of PB
31
cases
for ensuring complete treatment of MB
32
cases
35 For tes ng 50 salt sample per/month

Menstrual Hygiene, opera on smile,
36 Home Delivery contracep ve
53
Suppor ng
Documents
400
19
600
16
25
19
Details at Page no. 20
TIMELINE OF ASHA PAYMENT

Ac vity
Time Line
Prepara on of Claim forms along with suppor ng documents by ASHA.

1st to 4th day of the following
Approval of claims by MO, ANM, ASHA Supervisor and collect signature in
month.
relevant places.
ASHA Supervisor will assist the ASHA for prepara on and will verify the
documents.
Prepara on of Master Claim form.
Receipt of ASHA claims along with suppor ng documents.
5th to 12th day of the following
Entry of claims in the online ASHA Payment System under Health
month.
Services Monitoring System (www.nrhmassam.info).
Generate receipt of claims.
Verifica on of documents and approval of MO, BPM & BCM (to be
processed in file).
Approval of ac vi es related to NVBDCP, RNTCP, NLEP, NTCP, NPCB, etc (to
be processed in file).
Approval of SDM&HO or i/c BPHC.
Entry of approval in the online ASHA Payment System.
Direct Bank Transfer (DBT) to ASHAs Bank Account using PFMS.
[3]
13th to 22nd day of the

following month.
23rd to 25th day of the month.
Incen ves to ASHA Under JSY

Incen ve to ASHAs under JSY will be as follows
Rs. 600/- per delivery for rural areas: Rs. 300/- for ensuring complete Ante Natal check-up &
Rs. 300/- for facilita ng Ins tu onal delivery.
Rs. 400/- per delivery for urban areas: Rs. 200/- for ensuring complete Ante Natal check-up & Rs. 200/for facilita ng Ins tu onal delivery.
Ante Natal check-up will include the following ac vi es:
Micro Birth Planning:

Early Registra on (1st Check-up) before 12 weeks, *2nd Check-up 16-20 weeks, *3rd check-up 28-32 weeks *
4th Check-up 36 weeks
Promo ng Ins tu onal Delivery: Iden fying the Ins tu on for delivery as per weightage (High risk/
Complica on of pregnancy/Normal).
Break-up of incen ve to ASHA from JSY

Order of delivery
A
A
A
A
A
Ante Natal component
st
er 1 Delivery
er 2nd Delivery
er 3rd Delivery
er 4th Delivery
er 5th Delivery and above
Rs. 300.00
Rs. 300.00
Rs. 200.00
Rs. 100.00
Nil
Facilita ng Ins tu onal delivery

Rs. 300.00
Rs. 300.00
Rs. 200.00
Rs. 100.00
Nil
Total
Rs.600.00
Rs.600.00
Rs. 400.00
Rs. 200.00
Nil
Documents to be submi ed:
Claim Form: JSY Claim Voucher.

Suppor ng document: Discharge Slip.
En tlement:
ASHA Incen ves for JSY are divided into two dis nct set of ac vi es i.e. one on comple on of ANC of pregnant
women and the other on facili ng their ins tu onal delivery. Thus, ASHAs are en tled to Rs. 300/- in rural
areas and Rs. 200/- in urban areas on comple on of antenatal check-ups of pregnant women.
However, the other component of composite ASHA incen ve i.e. incen ve for facilita ng ins tu onal delivery
is payable only when the ASHAs accompany the pregnant women to public health facility for delivery. Thus,
even if the pregnant women deliver at home or in a private hospital, ASHAs are en tled for JSY incen ve for
facilita ng comple on of antenantal check-ups of pregnant women.
ASHAs are not en tled to JSY incen ve for facilita ng ins tu onal delivery i.e. Rs. 300/- in rural areas and Rs.
200/- in urban areas if the pregnant women prefer to deliver in private or accredited private health facility.
In case of pre-term baby, if delivery conducted before due date of 4th ANC, then in that case, ASHA will also
get the Antenatal component of JSY incen ve if other condi ons full filled.
If, ANC registra on could not be done within 1st Trimester but 4 ANCs completed then in that case, ASHA will
also get the Antenatal component of JSY incen ve if other condi ons full filled. However, ASHA will emphasize
for early detec on and registra on of pregnancy within 1st Trimester.
ASHA will also get incen ve if she escort / stay with the pregnant women for delivery in a Government Hospital/ PPP Hospital outside the state. However, proper suppor ng documents like discharge slip to be submi ed
along with claim form.
[4]
Incen ves to ASHA under Maternal Health

On Registra on of PW within 1st TRIMESTER (Rs. 50/-) & FULL ANC (Rs. 100/-)
ASHA /Link workers will play ac ve role for registra on of all Pregnant Women of her village / area at the Sub
centre/ VHND soon a er confirma on of pregnancy within the 1st Trimester.
ASHA / Link worker will be en tled for incen ve against Registra on & Quality ANC in Two Instalments:
a.
Rs 50/- for Registra on within 12 weeks only (1st ANC)
b.
Rs 100/- on full ANC (Total 4 ANCs including Inj. TT2/Booster, consump on of 100/200 IFA Tablets).
One of the ANCs (3rd or 4th ANC) to be done by MO, PHC and be recorded in MCP (Card with Seal &
Signature of MO, PHC.). However, Antenatal check up may also be done by Community Health Ocer
(RHP).
Urine examina on for Albumin / Sugar & also Blood Test for Hb%, Grouping.
ASHA will ensure at least 1 home visit in a week for counselling & support for IFA consump on and
monitoring for any complica on by ques oning on danger sign.
Payment will be made as per verifica on in MCP card and integrated RCH register, a er the comple on
of Full ANC and verified by their respec ve ANM / MOs. (Rs. 50/- on Registra on within 12 weeks and
Rs.100/- for comple on of Full ANC out of which at least one of the ANCs must be done by MO, PHC.)
Claim Form: ANC Claim Coupon.
Suppor ng documents:
MCP Card.
OPD Slip with signature of Medical Ocer/ Community Health Ocer (RHP)
Maternal Death Repor ng (Rs. 200.00)

In case of maternal death repor ng, the incen ve for the primary informer, i.e. ASHA is enhanced to Rs. 200.00
per death reported within 24 hours of occurrence of death by phone. The fund for such incen ve may be u lised
from the FMR Code: A.1.4
Claim Form: Maternal Death Informa on Report (Format for Primary Informer) (Annexure -6).
Suppor ng documents: NIL
[5]
ASHA Incen ves under Child Health

Home Based New Born Care:
A. Follow-up of new-borns up to 42 days: (Rs. 250)

The ASHA is to be paid Rs. 250 for conduc ng a series of home visits for the care of the new-born and postpartum mother. Schedule of visits is as follows:
1.
Six visits in the case of Ins tu onal Delivery (Days 3,7,14,21,28 & 42)
2.
Seven visits in the case of Home Delivery (Days 1,3,7,14,21,28 & 42)
The amount is to be paid based on the completed home visit form as per schedule and first examina on of
the new-born forms validated by supervisors. The payment to the ASHA should be made on me and with
dignity. The payments are made on the 45th day subject to following:
Payment to ASHA:
ASHA will receive Rs. 250 for conduc ng home visits for the care of new-born and post-partum mother
provided she had made all the required 6/7 home visits and the child is alive on 42nd days of birth.
In case delivery outcome is more than one (like twin delivery or triplets) incen ve provided to ASHA will
be 250 total numbers of new-borns. This incen ve will be paid for each alive new-born at the end of
42 days.
In case of Caesarean Sec on delivery or in case of other complica ons like PPH, Placenta reten on, etc.
where the mother has to stay in facility for prolonged dura on; ASHA will be en tled to full incen ve of
Rs. 250 if she completes all the remaining visits.
In case when a new-born is admi ed in SNCU, ASHAs are eligible to full incen ve amount of Rs. 250 for
comple ng the remaining visits.
In case the woman delivers at her maternal house and returns to her husbands house, two ASHAs
undertake the HBNC visits. In such cases each ASHA in such case will get Rs. 125 as an incen ve for
providing HBNC to the new-born.
ASHA will submit the Home Based New-born form signed by ASHA Supervisor and ANM to PHC account
Manager a er taking approval from MO/PHC who will review the implementa on of HBNC during
monthly mee ng of ASHA & ASHA Supervisor.
ANM or ASHA supervisor should cer fy the caesarean sec on delivery or SNCU admission.
Condi onality for making payment to ASHAs:

ASHA will be en tled to receive above men oned incen ve (Rs. 250) only, if she full fills the following
condi onality:
Complete all visit as per guideline.
Recorded weight & temperature in HBNC format properly.
[6]
Enabling that birth weight is recorded in the Maternal and Child Protec on (MCP) Card
Ensuring that the new-born is immunized with: BCG, first doses of OPV and DPT/Pentavalent, and entered
in to the MCP card
Enabling Birth Registra on
Both mother and new-born are safe un l the 42nd day of delivery
Claim Form: HbNC Form (Book)

HbNC Voucher (The districts where it is applicable)
B.
Follow-up of New-borns discharged from SNCU. (Rs. 500)
1.
ASHA will provide follow-up care to each new-born discharged from SNCU through a series of home &
facility visits taken from 3rd month to 12th month (1 visit per month, total 10 visits).
2.
Out of these visits of month 4, 8, 12 has to be completed at the facility level (i.e. at the follow-up OPDs
of nearest SNCU) and remaining visits of month 3,5,6,7,9,10,11 are to be completed at home.
3.
For providing the follow-up care through series of home & facility visits, ASHA will receive an incen ve
of Rs. 50 per visit. Total amount for comple ng the visits per new-born will be Rs. 500 for comple ng 10
visits.
Claim Form: SNCU follow up form (included in the HbNC Book)
C. Follow-up of Low-Birth Weight new-borns. (Rs. 1100)

As per revised HBNC guidelines, ASHA has to provide follow-up care for all LBW (birth weight less than 2500
gms.) new-borns in her area upto the age of 2 years. Under this program ASHA will visit all LBW new-borns in
her area from 3rd month to 24th month of life. (1 visit every month = total 22 visits)
Incen ves Rs. 50 per visit will be paid in two instalments. Rs. 500 will be payable at the end of 1 year, for
comple ng 10 visits from 3rd to 12th month and Rs 600 will be payable at the end of 2 years, for comple ng
12 visits from 13th to 24th month.
Claim Form: LBW follow up form (included in the HbNC Book)
Child Death Repor ng: (Rs. 50)

In case of any child death under the age of 5 years, the ASHA of the concerned village should no fy in the
No fica on Card (Form 1), one copy of the Form 1 to be given to the bereaved family and one copy to the
ANM, ideally within 24 hrs. For every child death repor ng using CDR No fica on Card and a sum of Rs. 50
will be paid to the ASHA. In urban area link worker / Urban ASHA can be engaged as primary informant and
same incen ve can be given to them for no fica on.
[7]
Every month, the child death cases are summed up and are verified by ANM and payment is done to ASHA
every month based on her monthly case repor ng.
Claim Form: CDR no fica on card
Na onal Iron plus Ini a ve:

ASHA will be paid an incen ve of Rs. 1/- per child (6-60 months) for ensuring consump on of at least 8
doses of IFA syrup per month (dose being 1 ml of IFA syrup biweekly). ASHA compliance card is supplied for
maintaining records.
Claim Form: NIPI compliance card
Severe Acute Malnourished (SAM) Children: (Rs. 150)

ASHA will be paid an incen ve of Rs.150/- per child for referral and admission of SAM cases in NRC& ensuring
4 follow-up visits a er discharge from NRC as per specific follow up schedule - 1st week, 2nd week, 2nd
month & 3rd month a er discharge.
Claim Form: follow up cum discharge card.
One me incen ves under Child Health (Applicable only if the ac vity is conducted in state)
IDCF (Intensified Diarrhoea Control Fortnight):

Intensified Diarrhoea Control Fortnight (IDCF) is a set of ac vi es to be implemented in an intensified manner
for control of deaths due to Diarrhoea.,these ac vi es mainly include- intensifica on of advocacy ac vi es,
awareness genera on ac vi es, diarrhoea management service provision, establishing ORS-Zinc corners, ORS
and Zinc distribu on by ASHA, detec on of undernourished children and their treatment, and promo on of
Infant and Young Child Feeding ac vi es.
Goal of IDCF: Improving awareness genera on for use of ORS and zinc in childhood diarrhoea, towards
achieving ul mate goal of zero childhood diarrhoea deaths.
The IDCF is divided into two phases over the two weeks to focus on dedicated thema c areas that aect
diarrhoeal mortality as below:
1.
Week 1: Rs. 1/- per ORS packet distributed to the family of under five children in her area.
2.
Week 2: Rs 100/- per ASHA for comple ng growth monitoring of at least 80% of under five children in
her area,
Claim Form: ASHA tally sheet
[8]
NDD (Na onal Deworming Day):

Rs. 50/- per ASHA for mobilising and ensuring consump on of Tab. Albendazole by every eligible child (1-19
years), out of school and non-enrolled. Incen ve is paid only if ASHA achieves at least 90% coverage in her
area.
Claim Form: ASHA NDD repor ng form
Incen ves to ASHA under family planning

ASHAs are to be u lized for counselling newly married couples to ensure spacing of two years a er marriage
and couples with one child to have spacing for three years a er the birth of first child and counsel Eligible
Couples to adopt permanent limi ng method a er birth of 2nd child.
ASHA would be paid the following incen ves under the scheme:
Rs.500/- to ASHA for ensuring spacing of 2(two) years a er marriage. i.e. delaying first pregnancy for
two years a er marriage.
2. Rs.500/- to ASHA for ensuring gap of 3 years between 1st and 2nd child birth.
3. Rs.1000/- in case of couple who opts for permanent limi ng method a er the birth of the 2nd child.
Note: This scheme would also be applicable for Link workers in the Urban Area.
1.
The scheme is opera onalized from 16th May,2012.
Eligibility under the scheme:

A)
For delaying of first child of a couple up to 2(two) years a er marriage, only those couple would be
considered under the scheme:
Who got married on or a er the no fica on of the scheme by Govt. of India on 16th May, 2012.
Who got married before the no fica on of the scheme but not pregnant with the first child at the
me of no fica on of the scheme by the Govt. of India.
Criteria: To get Rs. 500 by ASHA for delaying first child of a couple up to 2 years, REgistra on of Marriage would
be the criteria to verify the spacing.
Claim Form: Family Planning Claim Form.

Marriage Cer ficate or
Eligible Couple Register (part of RCH Register) with cer ficate of ANM and MO i/c.
[9]
B)
For spacing of three years a er birth of the first child only those couple would be considered
under the scheme:
Who have their first child on or a er the no fica on 16th May, 2012.
Who have their first child before no fica on of the scheme (16th May, 2012) but not pregnant
with the second child at the me of no fica on (16th May, 2012).
Criteria: To get Rs. 500 by ASHA for ensuring spacing of 3 years a er birth of 1st child, Registra on of
the birth of the first child would be the criteria to verify the spacing.
C)
Birth Cer ficate of 1st Child.
For op ng permanent limi ng methods only those couples would be considered under the
scheme:
Who would adopt permanent limi ng methods a er the no fica on (16th May, 2012) of the
scheme a er the birth of the 2nd child.
Criteria: Adop on of permanent limi ng method by a couple a er 2 children, the ASHA in addi on
to already exis ng mo va on money will get Rs. 1000/- for mo va ng couples having only two
children. ASHA will produce cer fica on of having only two children of the couple.
Cer ficate of adop on of Permanent Method (by Mo i/c)/ steriliza on cer ficate.
[ 10 ]
Responsibility of ASHA to get the Incen ves under family planning :

1.
Prepare/ update list of newly married eligible couples, get it cer fied by ANM/ MO. ASHA will
also provide date of marriage in her register and for this, produc on of marriage cer ficate
would be mandatory/ gaon burha cer ficate.
2.
Prepare/ update list of eligible couples with one child or pregnant with first child; get it
cer fied by ANM/ MO. ASHA is to also provide date of birth of the first child in her register
and for this produc on of birth cer ficate would be mandatory.
3.
In addi on ASHA, would also prepare/ update list of eligible couples with 2 children or
pregnant with second child; get it cer fied by ANM/ MO.
4.
Counsel the couple on various benefits of spacing and limi ng.
5.
ASHA to use Nishchay kits (pregnancy tes ng kits) to ascertain pregnancy status of the
women
6.
Submit the informa on to the MO I/C and ANM who in turn would cer fy the spacing in
births and provide incen ve to ASHA.
7.
ASHA would be paid a er she successfully counsels a woman for specified years of spacing
and / or couples op ng for permanent limi ng methods, as per the scheme and cer fied by
ANM/ LHV.
ASHA Incen ve for mo va ng Male Steriliza on (NSV):

ASHA is en tled to get incen ve @Rs. 300/- for mo va ng Male steriliza on (NSV).
Claim Form: payment sheet
Suppor ng documents: cer fica on of opera on.
ASHA Incen ve for mo va ng Female Steriliza on:

ASHA is en tled to get incen ve @Rs. 200/- for mo va ng Female steriliza on.
[ 11 ]
ASHA Incen ve for mo va ng PPS (Female):

ASHA is en tled to get incen ve @Rs. 300/- for mo va ng PPS (Female).
ASHA Incen ve for mo va ng PPUICD:

ASHA is en tled to get incen ve @Rs. 150/- for mo va ng PPIUCD inser on.
[ 12 ]
Incen ve under Immunisa on

Incen ve for Mobiliza on of children to vaccine site: Rs. 150.00
The ASHA will be provided Rs. 150.00 for mobiliza on of all due children up to 16 years and reducing drop
out within 5% per month per session subject to cer fied by the ANM. If the infant is not available at their own
house for the par cular month, the same to be mobilized and vaccinated in the next month and the payment
also cleared in the next month for reducing dropout within 5% for the children 0-16 years.
Claim Form: Immunisaton form
Due beneficiary list
List of due beneficiary for RI
Incen ve for Immuniza on (First Year: Rs. 100.00) and (Second Year: Rs. 50.00)
The ASHA will get an incen ve of Rs. 100.00 per child who is fully immunised (BCG 1 dose, OPV 3 doses,
pentavalent 3 doses, Measles 1 dose ( and JE 1 dose extra where applicable) within one year of age before
the day of 1st birthday of children and another incen ve of Rs. 50.00 per child who is completely immunized
(DPT-1st booster, OPV b, Measles 2nd dose (and JE 2nd dose extra where applicable) up to two years of age of
children.
Documents to be submi ed :
Claim Form: Immunisaton form / Coupon
MCP Card (Immuniza on part)
[ 13 ]
Guideline for payment of incen ves for

monthly rou ne ac vi es of ASHA:
The following incen ves for monthly rou ne ac vi es of ASHAs to be paid w.e.f 1st April, 2015Sl No
Ac vity
Rate of Incen ve
Mobilizing and a ending Village Health and Nutri on Day
Rs. 200/-
Convening and guiding monthly Village Health Sanita on and

Nutri on mee ng
Rs. 150/-
A ending PHC Review Mee ng
Rs. 150/-
a) Line lis ng of household done at beginning of the year and

updated a er every six months
b) Maintaining village health register and suppor ng universal
registra on of births and deaths
c) Prepara on of due list of children to be immunized updated on
monthly basis
d) Prepara on of list of ANC beneficiaries to be updated on monthly
basis
e) Prepara on of list of eligible couples updated on monthly basis
Rs. 500/-
(Rs. 100/-x 5)
For ac vity no 1: The ASHA will organize the VHND on the due date in her area. She will ensure proper
clenliness of the AWC before the scheduled date of the VHND. She will also prepare the due list of beneficiaries
and ensure par cpa on of the same on the day of VHND.
The ASHA Supervisor will ensure the proper arrangement of the VHND by the concerned ASHA and she will
also verify the due list prepared by ASHA in coordina on with the ANM and ensure par cipa on during the
day of VHND. She will cer fy in the prescribed format and forward it to the PHC accountant for payment.
The amount should be transfered to the ASHAs account on the same day.
For ac vity no 2: The ASHA will fix the date of VHSNC mee ng every month in consulta on with the
PRI member. She will prepare the agenda of the mee ng on the basis of the need of the village. She will
ensure the par cipa on of the PRI member along with other members of the commii ee. The minutes and
a endence sheet of the mee ng convened should be maintained by the ASHA. The ASHA Supervisor will
verify the minute and a endence sheet of the mee ng and cer fy in the prescribed format and forward it
to the PHC accountant for payment. The amount should be transfered to the ASHAs account on the same
day.
For ac vity no 3: The ASHA should a end monthly mee ng along with Dairy and HBNC Module. The ASHA
[ 14 ]
Supervisor will maintain the a endance sheet and cer fy in the prescribed format and forward it to the PHC
accountant for payment. The amount should be transfered to the ASHAs account on the same day.
For ac vity no 4:
a)
The ASHA will maintain the linelis ng in the dairy provided to her.The ASHA Supervisor will verify the
line lis ng done by her concerned ASHAs and ensure the same in coordina on with the ANM and PRI
member. A er verifica on she will cer fy the same in the prescribed format and forward it to PHC
accaountant for payment.
b)
The ASHA will maintain the village health register on monthly basis and ensure registarion of each case
of birth and death. The ASHA Supervisor will verify the village health registers of her concerned ASHAs
and ensure the same in coordina on with the ANM and PRI member. She will also ensure the registra on
of birth and death case reported by ASHA. A er verifica on she will cer fy the same in the prescribed
format and forward it to PHC accaountant for payment.
c)
The ASHA will prepare the due list of children up to 16 years of age and record it on monthly basis. The
due list needs to be presented during VHND and ensure the vaccina on as per the due list. The ASHA
Supervisor will verify the due list prepared by her concerned ASHAs in coordina on with the ANM.
A er verifica on she will cer fy the same in the prescribed format and forward it to PHC accountant for
payment.
d)
The ASHA will prepare the list of benefiaries (pregnant women) for the ANC to be provided. During
VHND she will ensure that the due ANCs are provided and will also follow up of the missed ANCs so
that it can be provided at SC. The ASHA Supervisor will verify the list of beneficiaries (pregnant women)
prepared by her concerned ASHAs in coordina on with the ANM. A er verifica on she will cer fy the
same in the prescribed format and forward it to PHC accountant for payment.
e)
The ASHA will prepare the list of eligible couple in her village. It also needs to be ensured that the list
is updated every month. The ASHA Supervisor will verify the list of eligible couple prepared by her
concerned ASHAs in coordina on with the ANM and PRI member. A er verifica on she will cer fy the
same in the prescribed format and forward it to PHC accountant for payment.
Financial:
a)
On receipt of the claims form from ASHA supervisor the PHC account BAM will verify the same and the
payment shall be made by A/C payable cheque or DBT.
b)
Separate register to be maintained for the purpose and all financial guidelines to be follow.
Claim Form: Rou ne ac vi es form (Annexure - II)
ASHA Diary
[ 15 ]
Incen ve under Na onal Vector Borne Disease

control programme
The ASHA will be involved in diagnosis and treatment of malaria cases on a day to day basis. She will screen
fever cases suspected to be suering from malaria, using RDks and blood slides and administer an -malarial
treatment to posi ve cases.
The ASHAs are to be monitored regularly for the blood slides made, RDTs performed and treatment of posi ve
cases detected by RDT/ slide. During the visit the MPW (M)/ MPW (F) will verify the RDTs and blood slides
made between the current and previous visit. This is done by checking the posi ve RDT retained by ASHA
and verifying the slides prepared for fever cases men oned in M Register. She/ he will also verify, by making
household visit, the comple on of radical treatment (including 14 day PQ for Pv cases.) of posi ve cases.
Subsequent to the verifica on she/ he will submit the informa on on RDTs done/slide prepared. and no
of treatment complete case for RDT/ slide posi ve case slides prepared. Put his/ her remarks & signature
in the remarks column of M Register. Beside MTS, MO PHC and other visi ng ocers will also monitor the
performance of ASHA during their visit. All these func onaries will provide suppor ve supervision to ASHA
i.e. training and retraining her on spot to improve her skills for carrying her work in preven on & control of
malaria and other vector borne diseases.
Payment of incen ve to ASHA: the ASHA is to be given incen ve as per following approved rates.
Ac vity
Rate of incen ve
(Rs.)
Source document for

verifica on
Prepara on of blood slide
15/-
M Register of ASHA (Column 1))
Provide complete treatment to RDT
75/-
M Register (Column 19 based on
Posi ve Pf case
posi ve detected in column 8)
Lympha c Filaiasis (For Annual Mass
Rs. 100/- per day for Register
Drug Administra on)
maximum of 3 days
(For Dibrugarh and Sivasagar District
to cover 50 houses or
only)
250 persons
[ 16 ]
The performance incen ve is to be paid at the end of the month during the monthly review mee ng convened
by MO PHC or it should be synchronized with the payment of incen ves under NHM for other ac vi es in
order to avoid visi ng PHC, just for such payments. The payment shall be made on the basis of M Register for
ASHA. At the end of each month, the informa on on slides prepared, treatment completed of RDT posi ve
and slide posi ve cases, will be verified and transmi ed by MPW (M)/ MPW (F) from M register to the PHC
MO. The ASHA will bring the M Register at the monthly mee ng for verifica on of incen ve payment. The
mechanism of payment will be similar to what has been adopted under NHM. The incen ve will be paid
together with other monthly incen ves under NHM. The monthly record of payment is to be maintained in
the Payment Register at the PHC level by the accountant.
The ASHA is to claim the monthly incen ve in the prescribe claim format (Annexure 2) and to be submi ed
in the respec ve PHC.
Claim Form: NVBDCP Form
Incen ve under Na onal Programme for

Control of Blindness (NPCB)
ASHAs would be eligible for Rs. 250/- for suppor ng each operated case (if the pa ent is transported to
the NGO facility for surgery, Rs..250/- shall be paid by NGO out of the Rs.. 1000/- which it receives as
reimbursement for any free cataract surgery performed.)
Claim Form: Format NBCP
[ 17 ]
Incen ve under revised Na onal Tuberculosis

control programme (RNTCP)
A DOTS provider can be anyone from the community (neighbour, teacher etc) including the ASHA. So the
incen ve scheme under DOTS is applicable to all the providers including ASHA.
Under this scheme, if ASHAs are involved as community DOT Provider, they are en tled for the following
incen ve:
Ac vity
Rate of incen ve
Source document for
(Rs.)
verifica on
1000
MO i/c TB Unit compiles the claims and sends

the signed copy to DTO. Unique ID of Nikshay
(CAT I) TB treatment (A er 6-7 month)
and TB no. to be recorded.

(CAT II) TB treatment (A er 8-9 month)
1500

and TB no. to be recorded.
Ensuring
successful
comple on
of
2000
intensive phase of mul drug resistant TB
treatment (a er 6- 9 Months)
and PMDT no. to be recorded.
2nd instalment of incen ve a er successful
3000
comple on of con nuous phase i.e. 18
month from the end of intensive phase
and PMDT no. to be recorded.
Claim Form: RNTCP Format
[ 18 ]
Incen ve under Na onal Leprosy Eradica on

Programme (NLEP)
ASHA are involved in bringing out cases from their villages for diagnosis at PHC or nearest Health ins tu on
and to follow-up the comple on of treatment if a Leprosy case is diagnosed. The incen ve for ASHA under
the programme is:
Ac vity
Sensi za on (A sensi za on mee ng/
workshop is conducted usually for half
day. TA/DA paid to ASHA for a ending
sensi za on mee ng/ workshop)
Incen ve for case detec on
(Payment is made as soon as the diagnosis
is made.
for ensuring complete treatment of PB
cases (6 months)
Rate of incen ve
Source document for
(Rs.)
verifica on
100
250
400
(under supervision of ASHA)

for ensuring complete treatment of MB
cases (1 year) (under supervision of ASHA)
Earlier there was direct cash

payment during the mee ng.
But now direct bank transfer to
ASHAs Account
Claim forms submi ed by ASHA

at BPHC through NMS/NMA. The
compiled form is signed by i/c
BPHC or SDM&HO and sent to
District.
600
Claim Form: Format NLEP
Na onal Iodine Deficiency Disorders Control

Programme (NIDDCP)
ASHA incen ve Rs. 25/- per month for tes ng 50 salt sample per month in endemic districts should be
made available on regular basis to ASHA.
Claim Form: NIDDCP Format
[ 19 ]
ASHA Kiron Scheme

In case of normal or accidental death of a working ASHA, next of kin will be eligible for a compensa on of
Rs. 1,00,000/- (Rupees One lakh)
The payment is made under the following criteria
1. ASHA will nominate any (one or more) members of her family to receive the claim of compensa on of Rs.
1,00,000/- in case of normal or accidental death as per forms provided.
2. In normal and accidental death, the nominated kin of the ASHA will submit claims to the DPM along with
the following documents.
a. Death cer ficate issued by the competent authority
b. Post mortem report where necessary
c. In case more than one person is nominated, individual applica on should be submi ed by all
nominees.
3. A er proper verifica on of the claim, DPM will put up the case to the DC cum Chairman of District Health
Society for approval of payment.
4. The claim of se lement should be se led by the DPMU within 15 days from the approval of Chairman of
District Health Society
5. In case of Suicidal death no claim will be admissible.
In the event of hospitaliza on of the ASHA, the expenditure incurred for treatment of the disease, as given in the
guideline, will be reimbursed by the State Health Society with an upper limit of Rs. 25000.00 per year
(Subject to Govt. of Assam)
Other Incen ves:Sl no
Component
Ac vity
Amount
1.
Menstrua on
Hygiene
By selling a pack of sanitary napkin Free days ASHA get Rs.1 as per
her incen ve.
Rs. 1
Opera on
Smile
Opera on Smile provide Rs. 200 to ASHA worker whenever they

iden fied a new cle pa ents. Their responsibili es of ASHAs are as
follows :
1. Bring the iden fied cle pa ents to Opera on Smile screening camp
generally held at block or district level. Or they may take the pa ents
directly to opera on smile centre, MMCH, Guwaha .
2. They will get incen ves two mes for one pa ents if the pa ents
need two surgery for their cle deformity of cle lip and palate. The gap
between two surgery is six months.
Rs. 200
Mala-N
Rs. 1
EC Pill
Rs. 2
Condom
Rs. 1
2.
3.
Home delivery
contracep ve
[ 20 ]
To
ASHA Incen ve Master Claim Form

SDM&HO or i/c Block PHC
Sub:
Submission of ASHA incen ve claim for the period from .... to ..
Sir/Madam,
With reference to the subject cited above, I have to the honour to submit the ASHA incen ve claims for the
period from ... to .as per statement men oned below.
Sl
No
Ac vity
JSY incen ve for ASHA for 1st Delivery (Rural)

for Antenatal Component.
JSY incen ve for ASHA for 1st Delivery (Rural)
for facilita ng Ins tu onal Delivery.
JSY incen ve for ASHA for 2nd Delivery (Rural)
300.00
JSY incen ve for ASHA for 2nd Delivery (Rural)

JSY incen ve for ASHA for 3rd Delivery (Rural)
JSY incen ve for ASHA for 3rd Delivery (Rural)
JSY incen ve for ASHA for 4th Delivery (Rural)
JSY incen ve for ASHA for 4th Delivery (Rural)
JSY incen ve (Urban) for Antenatal
Component.
JSY incen ve (Urban) for facilita ng
Ins tu onal Delivery.
For ANC registra on within 1st Trimester.
For ensuring full ANC.
For repor ng of Maternal Deaths.
For providing HbNC upto 42 days a er birth.
For follow up of SNCU graduate ll 1 year
of age.
For follow up of LBW baby up to 2 years of
age.
Repor ng of under 5 deaths.
For IFA supplementa on.
For SAM child admission and follow up.
For IDCF - Week 1 (per ORS distribu on)
Week 2 For comple ng growth monitoring
of at least 80% of under 5 children in her
area
300.00
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Rate
(Rs.)
Number
of claims
300.00
300.00
200.00
200.00
100.00
100.00
200.00
200.00
50.00
100.00
200.00
250.00
500.00
1100.00
50.00
1.00
150.00
1.00
100.00
[ 21 ]
Amount
Claimed
(Rs.)
Documents
submi ed
(Yes/No/
Par al)
Amount
Remarks
approved (Rs.) (Approving
(For oce use Authority)
only)
Sl
No
22
23
24
25
26
25
26
27
28
29
30
31
32
33
34
35
Ac vity
Sub Total Page No 1 (sl 1 to 21)

Brought Down (Sub Total from Page no 1 )
For mobilsing and ensuring consump on of
TAB. Albendazole
Ensuring full immuniza on including JE up to
1 year of age.
Ensuring 2nd dose of Measles, OPV, DPT
Booster.
Mobiliza on of Children under 2 years for
Immuniza on per session.
Ensuring limi ng a er 2 child.
Ensuring delaying 2 years for 1st child birth
a er marriage.
Ensuring 3 years gap between 1st and 2nd
child birth.
For mo va ng male steriliza on.
For mo va ng female steriliza on.
For mo va ng a woman for PPS.
For mo va ng a woman for PPIUCD
inser on.
Monthly Rou ne Ac vi es (Rs. 1000/- pm)
a) Mobilizing and a ending Village Health
and Nutri on Day
b) Convening and guiding monthly
Village Health Sanita on and Nutri on
mee ng.
c) A ending PHC Review Mee ng.
d)
I) Line lis ng of household done at
beginning of the year and updated
a er every six months.
II) Maintaining
village
health
register and suppor ng universal
registra on of births and deaths.
III) Prepara on of due list of children
to be immunized updated on
monthly basis.
IV) Prepara on of list of ANC
beneficiaries to be updated on
monthly basis.
V) Prepara on of list of eligible
couples updated on monthly
basis.
NPCB - For ensuring Treatment of Cataract
RNTCP - Ensuring successful comple on of
first line (CAT I) TB treatment
first line (CAT II) TB treatment
intensive phase of mul drug resistant TB
treatment.
Sub Total of Page No 2
Rate
(Rs.)
Number
of claims
50.00
100.00
50.00
150.00
1000.00
500.00
500.00
300.00
200.00
300.00
150.00
200.00
150.00
150.00
500.00
250.00
1000.00
1500.00
2000.00
[ 22 ]
Amount
Claimed
(Rs.)
Documents
submi ed
(Yes/No/
Par al)
Remarks
Amount
only)
Sl
No
Ac vity
Rate
(Rs.)
Brought Down (Sub Total from Page no 2 )

36 RNTCP - Ensuring successful comple on of
con nua on phase of mul drug resistant
TB treatment.
37 NLEP Sensi za on.
38 NLEP - Incen ve for case detec on.
39 NLEP - for ensuring complete treatment of
PB cases.
40 NLEP - for ensuring complete treatment of
MB cases.
41 NVBDCP -For malaria slide collec on.
42 NVBDCP -For ensuring treatment of Malaria
posi ve cases.
43 NIDDCP For tes ng 50 salt samples per
month.
44 Opera on Smile for iden fica on of new
Cle pa ents and bring to screening camp.
Follwing Incen ves received from beneficiary
45 Menstrual Hygiene For selling sanitary
napkin.
46 Home Delivery contracep ve Mala N
47 Home Delivery contracep ve ECP
48 Home Delivery contracep ve Condom
Total
Number
of claims
Amount
Claimed
(Rs.)
Documents
submi ed
(Yes/No/
Par al)
Remarks
Amount
only)
3000.00
100.00
250.00
400.00
600.00
15.00
75.00
25.00
200.00
1.00
1.00
2.00
1.00
Ac vity wise claim forms along with suppor ng documents are also enclosed as per guidelines.
Cer fy that, all claims are genuine and services are rendered by me regarding the ac vi es against which the claim
submi ed. Kindly make the payment.
Yours faithfully,
Name of the ASHA
Account No:
Bank Name & Branch Name:
Contact No:
Village:
SC Name:
Cer fy that the claims men oned above are correct.
Signature of ASHA Supervisor
Signature of ANM
For oce Use Only

An amount of Rs. . (Rupees only) approved for
payment of ASHA incen ve for the period from .. to and the amount is debited to the
account through DBT.
Signature of BAM
Signature of BCM
Signature of BPM
[ 23 ]
Signature of SDM&HO
A ending
SignaASHA monthly
Prepara on of
Total ture of
mee ng in
Mobilizing
list of eligible
Convening and Remark Rupe- ASHA Signature
every month and a ending
of ASHA
couple updaguiding VHSNC (if any)
es
Superat sectoral
VHND
ted (Monthly)
visor
level PHC/
BPHC
Signature of ANM
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Yes /
Remark
Remark
Remark
Remark
Remark
Remark
Remark
Remark
No
No
No
No
No
No
No
No
Maintaining
village health Prepara on
Prepara on
Name Name Line lis ng of register and of due list of of list of ANC
Sl.
households
suppor
ng
children
to
be
of Sub- of the
beneficiries
No.
universal
immunized
center ASHA done (Monto be updated
thly payment) registra on upadatedon
(monthly)
of births and monthly basis
deaths
Incen ve for monthly rou ne ac vi es of ASHAs
Annexure-II
[ 24 ]
Rural
1st delivery
Urban
2nd delivery
3rd delivery
4th delivery
(JSY PAYMENT VOUCHER )
Name of ASHA .............................................................................................................................................................
Village ..................................................................... Sub Centre ................................................................................
JSY Beneficary Name ...................................................................................................................................................
Husband Name ...........................................................................................................................................................
Full address : Vill. ................................................................. P.O ..............................................................................
Thana ................................................................. District ..................................................................
Hospita Registra on No. .............................................................................................................................................
Place of delivery (PHC, CHC etc.) ................................................................................................................................
Children (Boy/Girl), Delivery date & me ...................................................................................................................
MO i/c sign ..................................................................................
Ins tu on Name .........................................................................
Head of the ins tu on ................................................................
Seal & sign ..................................................................................
.....................................................................................................................................................................................
MCTS ID no .......................................................................... LMP date ..............................................................
ANC
1st (within 12 weeks) 2nd (16 to 20 weeks)
3rd (28 to 32 weeks)
4th (36 weeks)
Date
Place of ANC
TT1/TT2/Booster
BP
HB %
Urine
IFA
ANM Sign
ANM Name ..............................................
.....................................................................................................................................................................................
Money receipt
From Block Account Manager ......................................................... Rs. ........................................... I, Shri .................
................................... for ANC Checkup/ensuring ins tu onal delivery under JSY Scheme received.
Name of the sub-centre under ASHA works................................................................................................................
Sign of ASHA
Name of ASHA ..........................................................
Payment approved
ANC Component
Rs.
For Ensuring Ins tu onal Delivery
Rs.
Total
Rs.
Village ............................................................
[ 25 ]
ASHA COPY
ANC STATUS
Serial No.
NAME OF THE DISTRICT

NAME OF THE BLOCK PHC
SUB-CENTRE
NAME OF THE VILLAGE
NAME OF ASHA
NAME OF THE PREGNANT WOMAN
MCTS ID
LMP Date
Details
Date
:
:
:
:
:
:
:
:
ANC STATUS
Period of pregnancy in weeks
TT1/TT2/Booster
BP
HB%
Urine
No of IFA Consumed
Registra on &
1st ANC
2nd ANC
3rd ANC
4th ANC
ANC by MO
Note : Referral if any
Birth Preparedness : Name of the Health Instuon for delivery ....................
Signature of ASHA / Link Worker :

Signature of ANM
ACCOUNTS COPY
ANC STATUS
NAME OF THE DISTRICT
NAME OF THE BLOCK PHC
SUB-CENTRE
NAME OF THE VILLAGE
NAME OF ASHA
NAME OF THE PREGNANT WOMAN
ID NO MCH registra on No.
:
:
:
:
:
:
:
ACCOUNTS COPY
This is cer fied that Mrs. ........................................... integrated RCH registra on No. ...................... ID No...................
registered in first trimester on ......./......./........./
ANC STATUS
Details
Period of preg- TT1/TT2/

Date
nancy in weeks Booster
BP
HB%
No of IFA
Urine
Consumed
Registra on
& 1st ANC
2nd ANC
3rd ANC
4th ANC
ANC by MO
Note : Referral if any
Ms. ................................... ASHA of .............................. village accompanied / mo vated her for early registra on. I
recommend her for payment of Rs. 50 as early registra on
incen ve.
Signature of ANM
Received Rs. 50 as incen ve for early registra on for above
men oned beneficiary.
CERTIFICATE
This is cerfying that the beneficiary whose details are menoned above has completed
full ANC as per ANC schedule. I recommend her for full ANC incenve Rs. 100
Signature of ANM
Verified MCP card & MCH register & found correct Checked & verified by BPM
Signature of MO, I/c
Seal & Sign of ABPM/BAM
Serial No.
Serial No.
Reference of payment
[ 26 ]
Signature of ASHA
Date ....................
Verified MCP card & MCH register & found correct
Checked & verified by BPM
Signature of MO, I/c
Seal & Sign of ABPM/BAM
Reference of payment
[ 28 ]
[ 29 ]
[ 30 ]
[ 31 ]
[ 32 ]
[ 33 ]
[ 34 ]
[ 35 ]
[ 36 ]
[ 37 ]
[ 38 ]
[ 39 ]
[ 40 ]
[ 41 ]
[ 42 ]
[ 43 ]
[ 44 ]
[ 45 ]
[ 46 ]
[ 47 ]
[ 48 ]
[ 49 ]
[ 50 ]
[ 51 ]
within 24 months complete

immuniza on
Assam
Na onal Health Mission
ASHA Coupon
Immuniza on
Na onal Health Mission
ASHA Sign
Date ......................................
BPM Sign
Date ......................................
UIP No. ......................................

Rs. 100 collected
Sign
Date ........................................
MCTS ID ..................................
(Approval of Health ins tu on i/c
Record/verifica on of documents/Mother-child registra on and immuniza on

(Rs. 100)
Received
For Block Account Manager
ANM Sign
ASHA Signature
Date :....................................................
BAM Signature ......................................

Date ......................................................
(UIP no. ..................... Rs. 100 collected)

MCTS ID ...........................................
Signature
Date .............................
Record/documents verified for mother child

health registra on and immuniza on Rs.
100 given.
(Head of the Health ins tu on)
Collec on
Date ..........................
and mother details are there)
ANM .......................................................
Sub centre ...............................................
BPHC .......................................................
(Details of complete immuniza on documents verified, age of child is below 12
months and immuniza on registra on no.
my nearest sub centre UIP, registra on copy
is in file. In registra on copy name of child
Verifica on
ASHA Copy
[ 52 ]
Date/1
Immunization
Place/11
I, Shri .............................................. assure

that child UIP no. ............................ for ......
.................... PHC..................... Sub Centre
.............................. BPHC ...........................
Date ........................ for completa on of
Immuniza on.
DPT 1st booster

OPV - B
Measles 2nd dose
JE 2nd dose (if
applicabele
BCG-1st Dose
OPV 1st
OPV 2nd
OPV 3rd
PV 1st
PV 2nd
PV 3rd
Measles 1st
JE 1st dose (if
appicable)
Immunization/
Child Name ........................................

Mother Name ....................................
Date of Birth (Child) ...........................
(Serial No of MCP Card)
District Name.....................................
BPHC ..................................................
Sub centre .........................................
Village ...............................................
Name of ASHA ...................................
UIP No. ..............................................
MCTS ID .........................................
For ASHA Use
ANM signature
(Details of complete immuniza on

documents verified, age of child
is 24 months and immuniza on
registra on no. my nearest sub
centre UIP, registra on copy is in file.
In registra on copy name of child and
mother details are there) Rs. 50/- is
immuniza on for 2nd year.
BPHC ..............................................................
Sub centre .....................................................
ANM ..............................................................
ASHA Name ..................................................
Mother Name ...............................................
Child Name ...................................................
Village ...........................................................
Sub Centre .....................................................
BPHC ..............................................................
District .........................................................
Sl. no.
For Block Account Manager

Sl. no.
ANM signature
(Above details of child for complete immuniza on verified, age of child is 24

months) Rs. 50/- is immuniza on for 2nd
year.
BPHC ....................................................................
Sub centre ............................................................
ANM .....................................................................
Date of birth (child) ............................................
Mother Name ......................................................
Child Name .........................................................
MCTS ID ...........................................................
UIP No. (MCP card) ...........................................
ASHA Name .........................................................
Village .................................................................
Sub Centre ...........................................................
BPHC ....................................................................
District .................................................................
Oce use
ASHA Incen ves Claim form for Family Planning

1.
FOR DELAYING FIRST CHILD BIRTH TILL 2 (TWO) YEARS AFTER MARRIAGE (Rs. 500)
Sl. No
Name of the lady
Name of family planning

method for delaying pregenancy
First pregenancy (yes/

no)
Age
1
2
3
Who got married on or a er the no fica on of the scheme by Govt. of India on 16th May 2012
Who got married before the no fica on of the scheme but not pregnant with the first child at the me of no ficaon of the scheme by the Govt. of India.
2.
FOR THE DELAYING SECOND CHILD 3 (THREE) YEARS AFTER BIRTH OF THE FIRST CHILD (Rs. 500)
Sl.
No
1
2
3
Name of the lady
Age
Date of birth of
first child
2nd me pregenancy
(yes/no)
Name of the Hospital

where IUCD done
Who got married on or a er the no fica on of the scheme by Govt. of India on 16th May 2012
Who got married before the no fica on of the scheme but not pregnant with the first child at the me of no ficaon of the scheme by the Govt. of India.
3.
ADOPTION OF PERMANENT LIMITING METHOD BY A COUPLE AFTER 2 CHILDREN (Rs. 1000)
Sl.
No
Name of the lady
Age
Date of
birth of
first child
Address
Date of
birth of
2nd child
Date of
Sterilizaon
Name of the hospital & Reg. No.

where Sterilizaon done
1
2
3
For op ng permanent limi ng methods only those couples would be considered under the scheme.
[ 53 ]
MCP CARD
[ 54 ]
Relapse
Failure
Other (Specify)___
New
Transfer in
Treatment after default
Type of patient
[ 55 ]
3 times/week
3 times/week
Date
Lab No.
Smear
Result
Month
/ Year
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Patient
Weight
3 times/week
24
25
26
27
28
29
30
31
(Pulmonary Smear Negative,

not seriously ill : or extra pulmonary,
not seriously ill)
Category III
DMC
Tick ( ) the appropriate date when the drugs have been swallowed under observation; Make a circle ( O ) on the date missed doses
Retreatment,
(relapses, failure, treatment
after default, others)
Category II
End treatment
2 Months CP
End IP/Extended IP
Pretreatment
Month
New case,
(Pulmonary Smear-Positive,
seriously ill Smear Negaive or
seriously ill extra pulmonary)
Category I
Tick ( ) the appropriate Category below
I. INTENSIVE PHASE - Prescribed regimen and dosages :
H/o previous Anti-TB treatment with duration________________________
Disease Classification
Pulmonary
Extra Pulmonary
Site _______________
State_________
City/District with code_______________________
TB Unit with code____________________
Name ___________________________________________________
Patient TB No. / Year ______________________________
Sex
M
F
Age
Occupation ___________
PHI ____________________________________________
Complete Address & Telephone number ________________________
Name and designation of DOT provider & Tel. No.________
________________________________________________________
_______________________________________________
Name and Address of Contact Person & Telephone Number ________
Signature of MO with date __________________________
Initial home visit by ___________________ Date _________________
Treatment Card
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
3 times/week
3 times/week
Category II
Category I
3 times/week
Category III
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
[ 56 ]
Date
By whom
whom
contacted
Reason
Outcome
for missed of retrieval
doses
action
Retrieval Actions for Missed Doses
Details of X ray / EP tests
Date
< 6 yrs.)
By whom
Household contact (Children
Unknown
(1)
Pos
(2)
Neg
(3)
(4)
(5)
(Date) _____________
Initiated on ART :
No
Yes
(Date) ___________________
Pt referred to ART centre (date) : _______________________________
CPT delivered on (date)
HIV status :
Additional Treatments
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Remarks _____________________________________________
Treatment out come with date _________________________________________ Signature of MO with date ______________________________
Month
/ Year
the period during which medicines will be self administrated
Enter X on date when the first dose of drugs has been swallowed under direct observation and draw a horizontal line ( x..................) to indicate
Prescribed regimen
II Continuation Phase
Claim form for ASHA to BPM of DHS, NPCB for Ca arct opera on
(ASHA will get 250 for each eye opera on)
District Name
: ..................................................................................
Name of the operated pa ent: ................................................................................

Address
Details of operated eye
: ................................................................................
Right Eye
Le Eye
Name of Hospital
: ..................................................................................
Mo vator Name
; ..................................................................................
Registra on No. of Hospital : ..................................................................................

OPD Registra on No.
:...................................................................................
Name of the ASHA
: ..................................................................................
Name of village
: ..................................................................................
BPM, NPCB Name
: ..................................................................................
.................................................................................................................... Verified
Seal & Signature
Surgeon Name
Signature of Eye specialist
Signature of Pa et
Amount Collected
Signature of ASHA
BPM Signature
[ 57 ]
Pa ent Card for Monitoring Cases under Supervision of

ASHA under NLEP
Name of Pa ent
Address
Age
Date of Diagnosis
Sex
Date of onset
Type of cases
: MB /PB
Regd. No.
Name of the ASHA
Village
Sub Centre
PHC
:
Ac vity
Date of
Supervised dose
given
Rate of Incen ve
5
10
11
12
Signature of
ANM/MO PHC
Date of RFT
Receipt :
1) Payment of Rs. 250/- received on ____________________________________________________
Signature of MO, PHC
Signature of ASHA
2) Payment of Rs. 400/600 received on _________________________________________________
[ 58 ]
ASHA Format
(Na onal Iodine deficiency disorder control programme)
Claim form of ASHA for Iodine deficiency disorder control programme)
ASHA Village
................................................................................................................
Panchayat Name
................................................................................................................
Sub Centre
................................................................................................................
PHC
................................................................................................................
District Name
................................................................................................................
ASHA Name
................................................................................................................
Age
................................................................................................................
Month
No. of sample salt
0 Iodine sample salt
Not recommended to have salt Recommended to have salt

(<15 ppm)
(>15 ppm)
ANM will collect the ASHA claim form, from sub centre collected form will go to PHC from PHC the verified claim
form will go to district IDD cell.
Date
ASHA Signature
ANM Signature
[ 59 ]
Annexure-6
Maternal Death informa on report

Format for primary informer
(To be compiled for repor ng Maternal Deaths to Civil Surgeon, Deputy Commissioner & the State Director Family
Welfare by the Primary Informer i.e. by Facility Nodal Ocer in case of FBMDR and by SMO Block PHC in case of CBMDR.
Also by ANM to SMO Block PHC in case of CBMDR)
1
2
3
4
5
6
7
8
9
10
Name of district
Nameof Block
Report uder FBMDR or CBMDR
Name, age & address of the deceased woman
Name of husband
Date and me of death
Place of death
Home
Health Facility (Specify name and address of the Facility)
Other (Specity) :
When did death occur
During pregnancy
During delivery
Within 42 days a er delivery
Name of repor ng person & mobile/telephone no.
Time of birth
Signature of repor ng person :

Designa on :
Name of the Su-centre/Facility/Block PHC:
Date & Time :
Payment Voucher for incen ve under NIPI (6-60 month)

For Accounts Use only
Name of ASHA
Name of the Sub Centre
Name of the Block
Name of the district
Week No
No of children given 1st dose
No of children given 2nd dose
Signature of ASHA supervisor

(A er register verifica on)
Week 1
Week 2
Week 3
Week 4
Week 5 (If applicable)
Total
I recommend payment of Rs. ........................./ to ASHA for IFA administra on
Signature
ASHA Supervisor
Signature
Signature and seal
ANM
Block Account Manager
[ 60 ]
Payment Voucher at Nutri on of Rehabilita on Center (NRC)

Name of the child

SAM No.
Name of the mother
Name of the father
Village
SC
Block
Date of admission at NRC
Date of discharge from NRC
Name of the ASHA
Details of following up to the SAM child post discharge
Follow up
Date of follow up
Place of Follow up (NRC /

NCMC)
1st follow up
2nd follow up
3rd follow up
4th follow up
This is to cer fy that the above SAM child was referred to NRC and subsequently was followed up four mes
by ASHA on the dates men oned above.
I recommend to pay Rs. 150/- to ASHA for this
Signature
Die cian/Nutri on Counsellor
Signature
M.O.
Signature and seal

Account Manager
No fica on of CDR Card

Name of the child
: ....................................................................................................................................
Date of Birth
: ....................................................................................................................................
Age
: ....................................................................................................................................
Sex
: ....................................................................................................................................
Father's Name
: ....................................................................................................................................
Address
: ....................................................................................................................................
Phone No.
: ....................................................................................................................................
Date of Death
: ....................................................................................................................................
Place of Death
: ....................................................................................................................................
Name of first informant.......................................................... me .............................................................
Signature
Date of No fica on
[ 61 ]
Payment Voucher at "No fica on of Child Death"

Incen ve by ASHA
Name of the deceased child child :
Mother's Name
Father's Name
Village
BPHC
District
Name of ASHA
Date of Birth
Date of Death
Place of Death
Date of No fica on of death
Home/Transit/Facility
:
This is to cer fy that the death of the deceased child men oned above is no fied by ASHA as per the me
line.
I recommend to pay Rs. 50/- to ASHA for no fica on of death
Signature
ASHA Supervisor
Signature
ANM
[ 62 ]
Signature and seal

Block Account Manager
CLAIM FORM
NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME, ASSAM
(For Malaria work performed by ASHA)
1.
Name of ASHA
2.
Name of Village
3.
Name of Sub-center
4.
Claim Month
Weekly
breakup
Total number
of RDT
performed
Total No of
Posi ve case
detected
No. of Pf
treated
Total
number of
BSC
Total posi ve
detected by
Laboratory
No. of PV
cases given RT
for 14 days.
1st week
2nd week
3rd week
4th week
Month
ending
Claim amount :
......................... No of RDT posi ve treated x Rs. 75.00
Rs. .....................
......................... No of blood Slide collected x Rs. 15.00
Rs. .....................
......................... No of BS +ve treated x Rs. 75.00
Rs. .....................
Total .............................................................................................
Signature of ASHA
Date :
Cer fied that, I have verified the work performed as men oned above from the relevant record/register and
found correct.
Signature of Surveillance Worker/

BHW of the area
Signature of ANM of the S.C/

ASHA Supervisor
[ 63 ]

ASHAIncentiveBookletEng PDF

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NATIONAL HEALTH MISSION, ASSAM

It gives me immense pleasure to know that National Health Mission,

(Shri Tarun Gogoi)

I am glad to know that National Health Mission, Assam is publishing

(Dr. Nazrul Islam)

ASHA Incen ve Manual - 2015-16

ASHA Incen ve Details

For Ensuring full ANC to pregnant Women

Reporting of Maternal Death

Providing Home Based New Born Care up

Follow up of SNCU graduate ll 1 yr. of age

Follow up of LBW baby up to 2 yrs. of age

Repor ng of under 5 death

Incen ve for IFA Supplementa on against Rs.1 per child

Incen ve for SAM child admission &

ORS packet distribu on to the family of

For comple ng growth monitoring of at

For mobilising an ensuring consump on of

Ensuring Full Immuniza on including JE

Ensuring 2nd dose of measles & OPV-DPT

Mobiliza on of Children under 2 years for

ASHA Incen ve Manual - 2015-16

Incen ve to ASHA for ensuring limi ng

Ensuring delaying 2 years for first child

Ensuring 3 years gap between 1st and 2nd

19 Incen ve for mo va ng male Steriliza on

Incen ve for mo va ng Female

Mo va ng a women for PPS (Female)

Mo va ng a women for PPIUCD inser on

for ensuring Treatment of Cataract

Ensuring successful comple on of first line

Ensuring successful comple on of first line

33 For malaria slide collec on

34 For ensuring treatment of posi ve cases

35 For tes ng 50 salt sample per/month

TIMELINE OF ASHA PAYMENT

Prepara on of Claim forms along with suppor ng documents by ASHA.

13th to 22nd day of the

23rd to 25th day of the month.

ASHA Incen ve Manual - 2015-16

Incen ves to ASHA Under JSY

Micro Birth Planning:

Break-up of incen ve to ASHA from JSY

Ante Natal component

Facilita ng Ins tu onal delivery

Documents to be submi ed:

Claim Form: JSY Claim Voucher.

ASHA Incen ve Manual - 2015-16

Incen ves to ASHA under Maternal Health

Rs 50/- for Registra on within 12 weeks only (1st ANC)

Documents to be submi ed:

Claim Form: ANC Claim Coupon.

Maternal Death Repor ng (Rs. 200.00)

Documents to be submi ed:

Suppor ng documents: NIL

ASHA Incen ve Manual - 2015-16

ASHA Incen ves under Child Health

A. Follow-up of new-borns up to 42 days: (Rs. 250)

Condi onality for making payment to ASHAs:

Complete all visit as per guideline.

Recorded weight & temperature in HBNC format properly.

ASHA Incen ve Manual - 2015-16

Enabling Birth Registra on