NRHM/HSC/3/M

Ministry of Health & Family Welfare

(Monitoring & Evaluation Division)
Monthly Format for Sub Center and Equivalent Institutions

Due for Submission on 5th of

State:
following Month

District: Month

Block: Year
City/ Town/
Village:

Facility name

Facility type Public Private

Location Rural Urban

Numbers
reported
during the
month
Part A. REPRODUCTIVE AND CHILD HEALTH

M1 Ante Natal Care Services (ANC)

1 Total number of pregnant women Registered for ANC

1.1 Of which Number registered within first trimester

2 Number of New women registered under Janani Suraksha Yogna

3 Number of pregnant women received 3 ANC check ups

4 Number of pregnant women given

4.1 TT1

4.2 TT2 or Booster

5 Total number of pregnant women given 100 IFA tablets

6 Pregnant women with Hypertension (BP>140/90)

6.1 New cases detected at institution

7 Pregnant women with Anaemia

7.1 Number having Hb level<11 (tested cases)

M2 Deliveries

8 Deliveries conducted at Home

8.1 Number of Home Deliveries attended by

(a) SBA Trained (Doctor/Nurse/ANM)

(b) Non SBA (Trained TBA/Relatives/etc.)

Total {(a) to (b)}

8.2 Number of newborns visited within 24 hours of Home Delivery

8.3 Number of mothers paid Janani Suraksha Yogna incentive for Home deliveries

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 NRHM/HSC/3/M
Numbers
reported
during the
month

9 Deliveries conducted at facility

9.1 Of which Number discharged under 48 hours of delivery

9.2 Number of cases where Janani Suraksha Yogna incentive paid to

(a) Mothers

(b) ASHAs

(c) ANM or AWW (only for HPS States)

M3 Pregnancy outcome & details of new-born

10 Pregnancy Outcome (in numbers)

10.1 Live Birth

(a) Male
(b) Female
Total ({a} + {b})

10.2 Still Birth

10.3 Abortion (spontaneous/induced)

11 Details of Newborn children weighed

11.1 Number of Newborns weighed at birth

11.2 Number of Newborns having weight less than 2.5 kg

12 Number of Newborns breast fed within 1 hour

M4 Post - Natal Care

13 Women receiving post partum check-up within 48 hours after delivery

14 Women getting a post partum check up between 48 hours and 14 days

M5 Family Planning

15 Number of new IUD Insertions

15.1 At facility

16 IUD removals

17 Number of Oral Pills cycles distributed

18 Number of Condom pieces distributed

19 Number of Centchroman (weekly) pills given

20 Number of Emergency Contraceptive Pills distributed

21 Quality in sterilization services

21.1 Number of complications following sterilization
(a) Male
(b) Female
Total {(a) to (b)}

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 NRHM/HSC/3/M
Numbers
reported
during the
month

21.2 Number of failures following sterilization

(a) Male
(b) Female
Total {(a) to (b)}

21.3 Number of deaths following sterilization

(a) Male
(b) Female
Total {(a) to (b)}

M6 CHILD IMMUNISATION

22 Number of Infants 0 to 11 months old who received the following

22.1 BCG
22.2 DPT1
22.3 DPT2
22.4 DPT3
22.5 OPV 0 (Birth Dose)
22.6 OPV1
22.7 OPV2
22.8 OPV3
22.9 Hepatitis-B1
22.10 Hepatitis-B2
22.11 Hepatitis-B3
22.12 Measles
Total number of children aged between 9 and 11 months who have been fully
22.13
immunised (BCG+DPT123+OPV123+Measles) during the month
(a) Male

(b) Female

Total {(a) to (b)}

23 Number of children more than 16 months who received the following

23.1 DPT Booster

23.2 OPV Booster

23.3 Measles, Mumps, Rubella (MMR) Vaccine

24 Immunisation Status

Total number of children aged between 12 and 23 months who have been fully immunised
24.1
(BCG+DPT123+OPV123+Measles) during the month

(a) Male

(b) Female

Total {(a) to (b)}

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 NRHM/HSC/3/M
Numbers
reported
during the
month

24.2 Children more than 5 years given DT5

24.3 Children more than 10 years given TT10

24.4 Children more than 16 years given TT16

24.5 Adverse Event Following Immunisation (AEFI)

(a) Abscess

(b) Death

(c) Others

Total {(a) to (c)}

25 Number of Immunisation sessions during the month

25.1 Sessions planned

25.2 Sessions held

25.3 Number of sessions where ASHAs were present

26 Others {Japanese Encephalitis (JE) etc. Please Specify}

26.1
26.2
26.3
M7 Number of Vitamin A doses
27 Administered between 9 months and 5 years
27.1 Dose-1
27.2 Dose-5
27.3 Dose-9

M8 Number of cases of Childhood Diseases reported during the month (0-5 years)

28 Measles

29 Diarrhoea and dehydration

30 Malaria

Part B. Health Facility Services

M9 Patient Services

Number of Anganwadi centres reported to have conducted

31
VHNDs during the month
32 Outpatient

32.1 OPD attendance (All)

M10 Laboratory Testing Total

33 Lab Tests

33.1 Number of Hb tests conducted

33.2 Of which numbers having Hb < 7 mg

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 NRHM/HSC/3/M
Numbers
reported
during the
month

Part C. Mortality Details

M11 Number of Deaths reported at Sub Centre or at home during the month:

34 Infant deaths within 24 hrs of birth

Up to 1 Between 1 week
35 Infant Deaths up to 4 weeks by cause Weeks of & 4 weeks of Total
Birth birth

35.1 Sepsis

35.2 Asphyxia

35.3 LBW

35.4 Others
Between 1
Between 1 year
36 Infant/Child Deaths up to 5 years by cause month and
& 5 years Total
11 months

36.1 Pneumonia

36.2 Diarrhoea

36.3 Fever related

36.4 Measles

36.5 Others

37 Adolescent/Adult deaths by cause 6-14 yrs 15-55 yrs. Above 55 yrs. Total

37.01 Diarrhoeal diseases

37.02 Tuberculosis

Respiratory diseases including infections

37.03
(other than TB)

37.04 Malaria

37.05 Other Fever Related

37.06 HIV/AIDS

37.07 Heart disease/Hypertension related

37.08 Neurological disease including strokes

37.09 Maternal

(a) Abortion

(b) Obstructed/prolonged labour

(c ) Severe hypertension/fits

(d) Bleeding

(e) High fever

(f) Other Causes (including causes not known)

37.10 Trauma/Accidents/Burn cases

37.11 Suicide

37.12 Animal bites and stings

37.13 Other Diseases

(a) Known Acute Disease

(b) Known Chronic Disease

(c) Causes not known

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 NRHM/HSC/3/M
Numbers
reported
during the
month

Printed as on 10/09/2008 Monthly - H Subcenter

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Ref No.

M1

1.1

1.1.1

1.2

1.3

1.4

1.4.1

1.4.2

1.5

1.6

1.6.1

1.7

1.7.1

M2

2.1

2.1.1

2.1.1(a)

2.1.1(b)

2.1.2

2.1.3

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 NRHM/HSC/3/M

Ref No.

2.2

2.2.1

2.2.2

2.2.2(a)

2.2.2(b)

2.2.2(c)

M4

4.1

4.1.1

4.1.1(a)

4.1.1(b)

4.1.2

4.1.3

4.2

4.2.1

4.2.2

4.3

M6

6.1

6.2

M9

9.05

9.5.1

9.06

9.07

9.08

9.09

9.10

9.11

9.11.1

9.11.1 (a)

9.11.1 (b)

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 NRHM/HSC/3/M

Ref No.

9.11.2

9.11.2(a)

9.11.2(b)

9.11.3

9.11.3 (a)

9.11.3 (b)

M10

10.1

10.1.01

10.1.02

10.1.03

10.1.04

10.1.05

10.1.06

10.1.07

10.1.08

10.1.09

10.1.10

10.1.11

10.1.12

10.1.13

10.1.13 (a)

10.1.13 (b)

10.2

10.2.1

10.2.2

10.2.3

10.3

10.3.1

10.3.1(a)

10.3.1(b)

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 NRHM/HSC/3/M

Ref No.

10.3.2

10.3.3

10.3.4

10.3.5

10.3.5 (a)

10.3.5 (b)

10.3.5 (c)

10.4

10.4.1

10.4.2

10.4.3

10.5

10.5.1

10.5.2

10.5.3

M11

11.1

11.1.1

11.1.2

11.1.3

M12

12.6

12.7

12.8

M14

14.03

14.12

14.12.1

M15

15.1

15.1.1 (a)

15.1.1 (b)

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 NRHM/HSC/3/M

Ref No.

M17

17.1

17.2

17.2.1

17.2.2

17.2.3

17.2.4

17.3

17.3.1

17.3.2

17.3.3

17.3.4

17.3.5

17.4

17.4.01

17.4.02

17.4.03

17.4.04

17.4.05

17.4.06

17.4.07

17.4.08

17.4.09

17.4.09(a)

17.4.09(b)

17.4.09(c )

17.4.09(d )

17.4.09(e )

17.4.09(f )

17.4.10

17.4.11

17.4.12

17.4.13

17.4.13(a)

17.4.13(b)

17.4.13(c )

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 NRHM/HSC/3/M

Ref No.

Printed as on 10/09/2008 Monthly - H Subcenter

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 NRHM/HSC/3/M
LokLF; ,oa ifjokj dY;k.k ea=ky;
fujh{k.k ,oa ewY;kadu foHkkx
ekfld izi=&miLokLF; dsUnz

tek djus dh fnukad gj ekg

jkT; dh 25 rkjh[k

ftyk eghuk
fodkl[k.M o"kZ
'kgj@dLck@xka
o
laLFkk dk uke

laLFkk dk izdkj ljdkjh Hkou fdjk;s dk Hkou

{ks= xzkeh.k 'kgjh

ekg dh
miyC/kh

Hkkx A. iztuu ,oa f'k'kq LokLF;

M1 izloiwoZ lsok;sa (ANC)

1 dqy iathd`r efgykvksa dh la[;k

1.1 izFke frekgh esa iathd`r xHkZorh efgyk,Wa

2 tuuh lqj{kk ;kstuk esa iathd`r efgyk,¡

3 xHkZorh efgyk,Wa ftudh 3 tkapsa gqbZ gSa

4 xHkZorh efgykvksa dh la[;k ftUgsa fuEu lqfo/k nh xbZ

4.1 TT1

4.2 TT2 ;k cwLVj

5 dqy xHkZorh efgyk,wa ftUgsa 100 IFA xksyh nh

6 mPp jDrpki okyh xHkZorh efgyk,W ¼BP>140@90½

6.1 laLFkk esa bl ekg ntZ u, dsl

7 [kwu dh deh okyh xHkZorh efgyk,Wa

7.1 ftudk Hb Lrj 11 ls de gS ¼tkap ds ckn½

M2 izlo

8 ?kj ij gq, izlo

8.1 ?kj ij izlo fdlds }kjk djok, x,

(a) ,l-ch-,- izf'kf{kr O;fDr }kjk

(b) vizf'kf{kr O;fDr }kjk ¼nkbZ] fj'rsnkj vkfn½

dqy {(a) + (b)}

8.2 uotkr f'k'kqvksa dh la[;k ftUgsa 24 ?kaVs ds vUnj x`g HksaV dh xbZ

8.3 izlwrk efgykvksa dh la[;k ftUgsa ?kj ij izlo ds ckn tuuh lqj{kk ;kstuk dh jkf'k nh xbZ

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 NRHM/HSC/3/M

ekg dh
miyC/kh

9 laLFkkxr izlo

9.1 izloksa dh la[;k tks 48 ?kaVs rd laLFkk esa jgs

9.2 tuuh lqj{kk ;kstuk jkf'k dk Hkqxrku fd;k

(a) izlwrk efgyk dks

(b) vk'kk dks

(c) ,-,u-,e@vkaxuokM+h dk;ZdrkZ dks ¼dsoy HPS jkT;ksa esa½

M3 xHkkZoLFkk dk ifj.kke o uotkr f'k'kq tkudkjh

10 xHkkZoLFkk ifj.kke ¼la[;k½

10.1 thfor tUe

(a) ckyd
(b) ckfydk
dqy ({a} + {b})

10.2 e`r tUe

10.3 xHkZikr

11 otu fy, x, uotkr f'k'kq dh tkudkjh

11.1 uotkr f'k'kq dh la[;k ftudk tUe ds le; otu fy;k

11.2 2-5 fdyks ls de otu ds uotkr f'k'kqvksa dh la[;k

12 uotkr f'k'kqvksa dh la[;k ftUgsa 1 ?k.Vs ds vanj Lruiku djk;k x;k

M4 izlo Ik'pkr ns[kHkky ¼PNC½

13 izlwrk efgyk ftUgsa 48 ?k.Vs ds vanj izlo Ik'pkr lqfo/kk feyh

14 izlwrk efgyk ftUgsa 48 ?k.Vs o 14 fnu ds vanj izlo Ik'pkr lqfo/kk feyh

M5 ifjokj fu;kstu

15 ywi fuos'ku dh la[;k

15.1 laLFkk esa

16 fudkys x, ywi dh la[;k

17 forfjr vksjy fiy pØ dh la[;k

18 forfjr fd, x, fujks/k dh la[;k

19 forfjr lkIrkfgd xksyh ¼lsUVØkseku½ dh la[;k

20 forfjr vkikrdkyhu xHkZfujks/kd dh la[;k

21 ulcanh lsokvksa dh xq.koRrk

21.1 ulcanh ds dkj.k mith tfVyrk
(a) iq:"k
(b) efgyk
dqy {(a) to (b)}

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 NRHM/HSC/3/M

ekg dh
miyC/kh

21.2 vlQy ulcUnh

(a) iq:"k
(b) efgyk
dqy {(a) to (b)}

21.3 ulcUnh ds ckn e`R;q

(a) iq:"k
(b) efgyk
dqy {(a) to (b)}

M6 Vhdkdj.k

22 0&12 ekg ds cPps ftUgsa fuEu Vhds fn, x,

22.1 ch-lh-th-
22.2 Mh-ih-Vh- 1
22.3 Mh-ih-Vh- 2
22.4 Mh-ih-Vh- 3
22.5 iksfy;ks 0 ¼tUe ds le;½
22.6 iksfy;ks 1
22.7 iksfy;ks 2
22.8 iksfy;ks 3
22.9 fgi ch 1
22.10 fgi ch 2
22.11 fgi ch 3
22.12 ehtYl
9&12 ekg ds cPpksa dh la[;k ftudk bl ekg esa iw.kZ Vhdkdj.k gqvk ¼chlhth $
22.13
MhihVh 1 2 3 $ iksfy;ks 1 2 3 $ ehtYl½
(a) ckyd

(b) ckfydk

dqy {(a) to (b)}

23 16 ekg ls vf/kd ds cPps ftUgsa fuEu Vhds fn,

23.1 MhihVh cwLVj

23.2 iksfy;ks cwLVj

23.3 ehtYl] eEil] :csyk ¼MMR½

24 Vhdkdj.k Lrj

12&23 ekg ds cPpksa dh la[;k ftudk bl ekg esa iw.kZ Vhdkdj.k gqvk ¼chlhth $ MhihVh 1 2 3 $
24.1
iksfy;ks 1 2 3 $ ehtYl½

(a) ckyd

(b) ckfydk

dqy {(a) to (b)}

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 NRHM/HSC/3/M

ekg dh
miyC/kh

24.2 5 o"kZ ls vf/kd cPps ftUgsa DT5 fn;k

24.3 10 o"kZ ls vf/kd cPps ftUgsa TT10 fn;k

24.4 16 o"kZ ls vf/kd cPps ftUgsa TT16 fn;k

24.5 Vhdkdj.k Ik'pkr~ izfrdwy izHkko

(a) QksM+k

(b) e`R;q

(c) vU;

dqy {(a) to (b)}

25 ekg esa Vhdkdj.k l= dh la[;k

25.1 fu;ksftr l=

25.2 vk;ksftr l=

25.3 l= tgka vk'kk mifLFkr Fkh

26 vU; ¼tsiuhl budsQsykbfVl½

26.1
26.2
26.3
M7 foVkfeu , [kqjkd dh la[;k
27 9 ekg ls 5 o"kZ ds chp nh xbZ [kqjkd
27.1 [kqjkd 1
27.2 [kqjkd 5
27.3 [kqjkd 9

M8 0&5 o"kZ ds cPpksa esa chekjh

28 ehtYl

29 nLr ,oa futZyhdj.k

30 eysfj;k

Hkkx B. LokLF; laLFkk lqfo/kk

M9 ejhtksa dks lqfo/kk

vkaxuokM+h dsUnzksa dh la[;k ftUgksaus bl ekg esa xzke

31
LokLF; ,oa iks"k.k fnol vk;ksftr fd,
32 ckg~; jksxh

32.1 dqy la[;k

M10 iz;ksx'kkyk esa tkap dqy

33 tkapsa

33.1 fd, x, Hb VsLV dh la[;k

33.2 buesa ls 7 gm ls de Hb dh la[;k

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 NRHM/HSC/3/M

ekg dh
miyC/kh

Hkkx C. e`R;q dh foLr`r tkudkjh

M11 ekg esa ?kj ij vFkok miLokLF; dsUnz esa gqbZ e`R;q

34 tUe ds 24 ?kaVs ds vUnj gqbZ uotkr f'k'kq dh e`R;q

4 g¶rs ds vUnj gqbZ uotkr f'k'kq e`R;q tUe ds 1 tUe ds 1&4 g¶rs
35 g¶rs rd rd dqy
ds dkj.k
35.1 laØe.k

35.2 lkal ysus esa rdyhQ

35.3 de out

35.4 vU;

1 ekg ls 11
36 5 lky rd ds cPpksa dh e`R;q ds dkj.k ekg dh mez
1&5 o"kZ dh mez dqy

36.1 fueksfu;k

36.2 nLr

36.3 cq[kkj

36.4 ehtYl

36.5 vU;

37 fd'kksj@o;Ld e`R;q ds dkj.k 6&14 o"kZ 15&55 o"kZ > 55 o"kZ dqy

37.01 nLr

37.02 {k;jksx

37.03 lkal dh chekjh `¼{k;jksx ds vykok½

37.04 eysfj;k

37.05 vU; cq[kkj lacaf/kr

37.06 ,p-vk;-oh@,M~l

37.07 fny@mPp jDrpki dh chekjh

37.08 rkaf=dh@nkSjk

37.09 ekr` e`R;q

(a) xHkZikr

(b) vo:)@foyafcr izlo

(c ) mPp jDrpki@>Vds

(d) jDrL=ko

(e) rst cq[kkj

(f) vU; dkj.k

37.10 pksV@nq?kZVuk@ty tkus ds dkj.k

37.11 vkRegR;k

37.12 Ik'kq@dhM+s ds dkVus ls

37.13 vU; chekjh

(a) xaHkhj chekjh

(b) yach chekjh

(c) dkj.k irk ugha

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jsQjsUl Øekad

M1

1.1

1.1.1

1.2

1.3

1.4

1.4.1

1.4.2

1.5

1.6

1.6.1

1.7

1.7.1

M2

2.1

2.1.1

2.1.1(a)

2.1.1(b)

2.1.2

2.1.3

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jsQjsUl Øekad

2.2

2.2.1

2.2.2

2.2.2(a)

2.2.2(b)

2.2.2(c)

M4

4.1

4.1.1

4.1.1(a)

4.1.1(b)

4.1.2

4.1.3

4.2

4.2.1

4.2.2

4.3

M6

6.1

6.2

M9

9.05

9.5.1

9.06

9.07

9.08

9.09

9.10

9.11

9.11.1

9.11.1 (a)

9.11.1 (b)

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9.11.2

9.11.2(a)

9.11.2(b)

9.11.3

9.11.3 (a)

9.11.3 (b)

M10

10.1

10.1.01

10.1.02

10.1.03

10.1.04

10.1.05

10.1.06

10.1.07

10.1.08

10.1.09

10.1.10

10.1.11

10.1.12

10.1.13

10.1.13 (a)

10.1.13 (b)

10.2

10.2.1

10.2.2

10.2.3

10.3

10.3.1

10.3.1(a)

10.3.1(b)

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10.3.2

10.3.3

10.3.4

10.3.5

10.3.5 (a)

10.3.5 (b)

10.3.5 (c)

10.4

10.4.1

10.4.2

10.4.3

10.5

10.5.1

10.5.2

10.5.3

M11

11.1

11.1.1

11.1.2

11.1.3

M12

12.6

12.7

12.8

M14

14.03

14.12

14.12.1

M15

15.1

15.1.1 (a)

15.1.1 (b)

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M17

17.1

17.2

17.2.1

17.2.2

17.2.3

17.2.4

17.3

17.3.1

17.3.2

17.3.3

17.3.4

17.3.5

17.4

17.4.01

17.4.02

17.4.03

17.4.04

17.4.05

17.4.06

17.4.07

17.4.08

17.4.09

17.4.09(a)

17.4.09(b)

17.4.09(c )

17.4.09(d )

17.4.09(e )

17.4.09(f )

17.4.10

17.4.11

17.4.12

17.4.13

17.4.13(a)

17.4.13(b)

17.4.13(c )

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