{"name": "odk_facilities_checklist", "type": "survey", "title": "SRH Facility Assessment Checklist", "id_string": "srh_facility_assessment", "sms_keyword": "srh_facility_assessment", "default_language": "default", "version": "2024.2", "children": [{"name": "start_time", "label": "Start time", "type": "start"}, {"name": "end_time", "label": "End time", "type": "end"}, {"name": "today_date", "label": "Date", "type": "today"}, {"name": "device_id", "label": "Device ID", "type": "deviceid"}, {"name": "enumerator", "label": "Enumerator", "type": "username"}, {"name": "intro", "label": "Good day. Thank you for agreeing to participate in this brief survey, which will take approximately 90 minutes. Before we begin, I'd like to briefly explain the purpose of this exercise and why we're engaging with you. The SWAP Office, in collaboration with the Federal Ministry of Health (FMoH) and the National Primary Health Care Development Agency (NPHCDA), is implementing targeted interventions across eight priority states, including [insert state], to improve access to family planning and post-abortion care, in response to ongoing RMNCAH challenges. As part of this effort, the facility checklist will assess the availability, accessibility, affordability, and quality of Sexual and Reproductive Health (SRH) services, while capturing data on facility infrastructure, service delivery, costs, supply chain, human resources, and continuity of care. Your perspective will help us identify strengths, gaps, and opportunities for improvement with respect to SRH service delivery. Participation in this survey is voluntary. We will not collect direct personal identifiers such as names or contact details. Your responses will be treated confidentially, reported in aggregate, and you may withdraw at any time without consequence. However, your insights are critical to informing the assessment in [insert state] and influencing future improvements.", "type": "note"}, {"name": "consent", "label": "Do you consent to participating in this?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "location", "label": "Facility Location", "type": "group", "bind": {"relevant": "${consent} = 'yes'"}, "children": [{"name": "state", "label": "State", "type": "select one", "bind": {"required": "yes"}, "children": [{"name": "ondo", "label": "Ondo"}, {"name": "ekiti", "label": "Ekiti"}, {"name": "taraba", "label": "Taraba"}, {"name": "zamfara", "label": "Zamfara"}, {"name": "enugu", "label": "Enugu"}, {"name": "akwa_ibom", "label": "Akwa Ibom"}, {"name": "kebbi", "label": "Kebbi"}, {"name": "benue", "label": "Benue"}]}, {"name": "lga", "label": "LGA (Local Government Area)", "type": "text", "bind": {"required": "yes"}}, {"name": "ward", "label": "Ward", "type": "text", "bind": {"required": "yes"}}, {"name": "facility_name", "label": "Name of Facility", "type": "text", "bind": {"required": "yes"}}, {"name": "facility_type", "label": "Type of Facility", "type": "text", "bind": {"required": "yes"}}]}, {"name": "demographics", "label": "Demographics", "type": "group", "children": [{"name": "gender_of_officer_in_charge", "label": "Gender of the officer in charge", "type": "select one", "bind": {"required": "yes"}, "children": [{"name": "male", "label": "Male"}, {"name": "female", "label": "Female"}]}, {"name": "designation", "label": "Designation of health personnel accompanying the data collector for the facility assessment", "type": "text"}]}, {"name": "services", "label": "Service Availability", "type": "group", "children": [{"name": "maternal_services", "label": "Which maternal health services are offered at this facility? Please select all applicable services", "type": "select all that apply", "children": [{"name": "anc", "label": "Antenatal care Delivery services"}, {"name": "pnc", "label": "Postnatal care"}, {"name": "ref", "label": "Referral services for high-risk pregnancies and complications"}]}, {"name": "family_planning_services", "label": "Which family planning (FP) services are offered at this facility? Please select all app/icab/e services", "type": "select all that apply", "children": [{"name": "couns", "label": "Contraceptive counselling"}, {"name": "sac", "label": "Short-acting contraceptives (condoms, oral contraceptive pills)"}, {"name": "larc", "label": "Long-acting reversible contraceptives (injectables, implants, IUDs)"}, {"name": "pic", "label": "Permanent/irreversible contraceptives (e.g., vasectomy)"}, {"name": "ppfp", "label": "Post-partum family planning"}, {"name": "na", "label": "N/A"}]}, {"name": "cervical_cancer_services", "label": "Which cervical cancer prevention and care services are offered at this facility?", "type": "select all that apply", "children": [{"name": "ccsp", "label": "Cervical cancer screening and prevention"}, {"name": "topc", "label": "Treatment of cervical pre-cancers"}, {"name": "na", "label": "N/A"}]}, {"name": "pac_services", "label": "Which post-abortion care (PAC) services are offered at this facility? Please select all applicable services", "type": "select all that apply", "children": [{"name": "m_management", "label": "Medical management of complications following abortion"}, {"name": "couns_emo_s", "label": "Counselling and emotional support"}, {"name": "fps_p", "label": "Family planning services to prevent unintended pregnancies"}, {"name": "fuc_pm", "label": "Follow-up care for physical and mental health"}, {"name": "sma_mva", "label": "Surgical management of abortion (MVA)"}]}, {"name": "asrh_services", "label": "Which adolescent sexual and reproductive health (ASRH) services are offered at this facility?", "type": "select all that apply", "children": [{"name": "cca", "label": "Contraceptive counselling for adolescents"}, {"name": "pt_hiv", "label": "Pregnancy testing for adolescents STI/HIV screening and treatment"}, {"name": "hpv_p", "label": "HPV prevention and vaccination"}, {"name": "na", "label": "N/A"}]}, {"name": "gbv_services", "label": "Which gender-based violence (GBV) services are offered at this facility?", "type": "select all that apply", "children": [{"name": "screen", "label": "Screening and identification of GBV during health visits"}, {"name": "ecirv", "label": "Emergency care for injuries related to violence"}, {"name": "cpss", "label": "Counselling and psychosocial support for survivors"}, {"name": "referr", "label": "Referral to legal aid and social support services"}, {"name": "hs_screen", "label": "HIV/STI screening"}, {"name": "pep", "label": "Post-Exposure Prophylaxis (PEP)"}, {"name": "na", "label": "N/A"}]}, {"name": "outreach_services", "label": "Which outreach services are offered at this facility? Please select all applicable services", "type": "select all that apply", "children": [{"name": "cmdc", "label": "Community mobilization and demand creation for SRH services, including adolescent and youth-focused outreach"}, {"name": "cbdc", "label": "Community-based distribution of SRH commodities (e.g., condoms, oral contraceptives)"}, {"name": "df_linkage", "label": "Defaulter tracing, follow-up, and linkage of hard-to-reach populations to facility-based SRH services"}, {"name": "clri", "label": "Community-level risk identification and referral, including high-risk pregnancies, STI/HIV risks, and GBV cases"}, {"name": "na", "label": "N/A"}]}]}, {"name": "cost_of_service", "label": "Cost of Service(s)", "type": "group", "children": [{"name": "free_services", "label": "Which of the available services are free? Please select all applicable services", "type": "select all that apply", "children": [{"name": "anc", "label": "Antenatal care Delivery services"}, {"name": "pnc", "label": "Postnatal care"}, {"name": "reff", "label": "Referral services for high-risk pregnancies and complications (including transport)"}, {"name": "sac", "label": "Short-acting contraceptives (condoms, oral contraceptive pills)"}, {"name": "larc", "label": "Long-acting reversible contraceptives (injectables, implants, IUDs)"}, {"name": "perm_c", "label": "Permanent/irreversible contraceptives (e.g., vasectomy)"}, {"name": "ppfp", "label": "Post-partum family planning"}, {"name": "ccsp", "label": "Cervical cancer screening and prevention Treatment of cervical pre-cancers"}, {"name": "sma_mva", "label": "Surgical management of abortion (MVA)"}, {"name": "mmcfa", "label": "Medical management of complications following abortion"}, {"name": "ffsp_pac", "label": "Family planning services provided as part of PAC"}, {"name": "fu_pmh", "label": "Follow-up care for physical and mental health (where clinical visits or medications are involved)"}, {"name": "ptasst", "label": "Pregnancy testing for adolescents STI/HIV screening and treatment"}, {"name": "hpvpv", "label": "HPV prevention and vaccination"}, {"name": "ec_irv", "label": "Emergency care for injuries related to violence (clinical care, drugs, procedures)"}, {"name": "ref_leg", "label": "Referral to legal aid and social support services"}, {"name": "cbd_srh", "label": "Community-based distribution of SRH commodities (e.g., condoms, oral contraceptives), where applicable"}]}, {"name": "anc_cost", "label": "Antenatal care", "type": "integer"}, {"name": "deliv_cost", "label": "Delivery services", "type": "integer"}, {"name": "pnc_cost", "label": "Postnatal care", "type": "integer"}, {"name": "ppfp_cost", "label": "Post-partum family planning", "type": "integer"}, {"name": "ref_hpc_cost", "label": "Referral services for high-risk pregnancies and complications (including transport)", "type": "integer"}, {"name": "sac_cost", "label": "Short-acting contraceptives (condoms, oral contraceptive pills)", "type": "integer"}, {"name": "larc_cost", "label": "Long-acting reversible contraceptives (injectables, implants, IUDs)", "type": "integer"}, {"name": "pic_cost", "label": "Permanent/irreversible contraceptives (vasectomy, hysterectomy)", "type": "integer"}, {"name": "ccsp_cost", "label": "Cervical cancer screening and prevention", "type": "integer"}, {"name": "tcp_cost", "label": "Treatment of cervical pre-cancers", "type": "integer"}, {"name": "sma_cost", "label": "Surgical management of abortion (MVA)", "type": "integer"}, {"name": "mmc_a_cost", "label": "Medical management of complications following abortion", "type": "integer"}, {"name": "fps_pac_cost", "label": "Family planning services provided as part of PAC", "type": "integer"}, {"name": "fcpmh_cost", "label": "Follow-up care for physical and mental health (where clinical visits or medications are involved)", "type": "integer"}, {"name": "pta_cost", "label": "Pregnancy testing for adolescents", "type": "integer"}, {"name": "sti_hiv_cost", "label": "STI/HIV screening and treatment", "type": "integer"}, {"name": "hpv_cost", "label": "HPV prevention and vaccination", "type": "integer"}, {"name": "emc_irv_cost", "label": "Emergency care for injuries related to violence (clinical care, drugs, procedures)", "type": "integer"}, {"name": "ref_leg_cost", "label": "Referral to legal aid and social support services", "type": "integer"}, {"name": "cbd_srh", "label": "Community-based distribution of SRH commodities (e.g., condoms, oral contraceptives), where applicable", "type": "integer"}, {"name": "hi_ss", "label": "Does the facility identify women eligible for existing health insurance or subsidy schemes and support their enrollment or linkage?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "hi_ss_num", "label": "How many women are currently enrolled in an health insurance/subsidy scheme in your facility?", "type": "integer"}]}, {"name": "commodity_availability", "label": "Availability of essential SRH commodities in the facility", "type": "group", "children": [{"name": "maternal_hc", "label": "Which essential maternal health commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option", "type": "select all that apply", "children": [{"name": "ox_i", "label": "Oxytocin injection"}, {"name": "ca_hc", "label": "Carbetocin / Heat-Stable Carbetocin"}, {"name": "m_mt", "label": "Misoprostol & Mifepristone tablet"}, {"name": "ergo", "label": "Ergometrine"}, {"name": "msi", "label": "Magnesium sulfate injection"}, {"name": "tran_acid", "label": "Tranexamic Acid (TXA)"}, {"name": "bp_i", "label": "Benzyl penicillin injection"}, {"name": "genta", "label": "Gentamicin injection"}, {"name": "ceftri", "label": "Ceftriaxone"}, {"name": "amox_tab", "label": "Amoxicillin tablets"}, {"name": "meth", "label": "Methyldopa"}, {"name": "nifed", "label": "Nifedipine"}, {"name": "fes", "label": "Fesolate"}, {"name": "fol_a", "label": "Folic acid"}, {"name": "sulf_pyri", "label": "Sulfadoxine-Pyrimethamine"}, {"name": "tet_tox", "label": "Tetanus toxoid"}, {"name": "uri_dip", "label": "Urinalysis dipsticks"}, {"name": "vit_k", "label": "Vitamin K"}, {"name": "others", "label": "Others"}]}, {"name": "spec_others_mat", "label": "Please specify others", "type": "text"}, {"name": "mat_stockout", "label": "Duration of maternal commodities stockout", "type": "group", "children": [{"name": "oxi_stockout", "label": "Oxytocin injection (Number of Days)", "type": "integer"}, {"name": "carbe_stockout", "label": "Carbetocin / Heat-Stable Carbetocin (Number of Days)", "type": "integer"}, {"name": "misop_stockout", "label": "Misoprostol & Mifepristone tablet (Number of Days)", "type": "integer"}, {"name": "ergo_stockout", "label": "Ergometrine (Number of Days)", "type": "integer"}, {"name": "magn_stockout", "label": "Magnesium sulfate injection (Number of Days)", "type": "integer"}, {"name": "tran_stockout", "label": "Tranexamic Acid (TXA) (Number of Days)", "type": "integer"}, {"name": "benz_stockout", "label": "Benzyl penicillin injection (Number of Days)", "type": "integer"}, {"name": "gent_stockout", "label": "Gentamicin injection (Number of Days)", "type": "integer"}, {"name": "ceft_stockout", "label": "Ceftriaxone (Number of Days)", "type": "integer"}, {"name": "amox_stockout", "label": "Amoxicillin tablets (Number of Days)", "type": "integer"}, {"name": "meth_stockout", "label": "Methyldopa (Number of Days)", "type": "integer"}, {"name": "nife_stockout", "label": "Nifedipine (Number of Days)", "type": "integer"}, {"name": "feso_stockout", "label": "Fesolate (Number of Days)", "type": "integer"}, {"name": "foli_stockout", "label": "Folic acid (Number of Days)", "type": "integer"}, {"name": "sulfa_stockout", "label": "Sulfadoxine-Pyrimethamine (Number of Days)", "type": "integer"}, {"name": "teta_stockout", "label": "Tetanus toxoid (Number of Days)", "type": "integer"}, {"name": "urin_stockout", "label": "Urinalysis dipsticks (Number of Days)", "type": "integer"}, {"name": "vita_stockout", "label": "Vitamin K (Number of Days)", "type": "integer"}]}, {"name": "family_planning_c", "label": "Which essential FP commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option", "type": "select all that apply", "children": [{"name": "male_c", "label": "Male condoms"}, {"name": "female_c", "label": "Female condoms"}, {"name": "oral_c", "label": "Oral contraceptives"}, {"name": "emergency_p", "label": "Emergency contraceptive pills"}, {"name": "injectable_c", "label": "Injectable contraceptives"}, {"name": "implants_I", "label": "Implants"}, {"name": "iucd", "label": "Intra-Uterine Contraceptive Device (IUCD)"}, {"name": "others_O", "label": "Others"}]}, {"name": "spec_others_fp", "label": "Please specify others", "type": "text"}, {"name": "fp_stockout", "label": "Duration of stockout for family planning commodities", "type": "group", "children": [{"name": "mc_stockout", "label": "Male condoms (Number of Days)", "type": "integer"}, {"name": "fc_stockout", "label": "Female condoms (Number of Days)", "type": "integer"}, {"name": "oc_stockout", "label": "Oral contraceptives (Number of Days)", "type": "integer"}, {"name": "pills_stockout", "label": "Emergency contraceptive pills (Number of Days)", "type": "integer"}, {"name": "ic_stockout", "label": "Injectable contraceptives (Number of Days)", "type": "integer"}, {"name": "imp_stockout", "label": "Implants (Number of Days)", "type": "integer"}, {"name": "iucd_stockout", "label": "Intra-Uterine Contraceptive Device (IUCD) (Number of Days)", "type": "integer"}]}, {"name": "pac_c", "label": "Which essential PAC commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option", "type": "select all that apply", "children": [{"name": "miso_mife", "label": "Misoprostol & Mifepristone tablet"}, {"name": "oxy_inj", "label": "Oxytocin injection Tranexamic Acid (TXA)"}, {"name": "genta_inj", "label": "Gentamicin injection"}, {"name": "ceftriax", "label": "Ceftriaxone"}, {"name": "doxycycl", "label": "Doxycycline"}, {"name": "azithrom", "label": "Azithromycin tablets"}, {"name": "metro_tab", "label": "Metronidazole tablets"}, {"name": "ibu_tab", "label": "Ibuprofen tablets"}, {"name": "diaz_tab", "label": "Diazepam tablets"}, {"name": "oth", "label": "Others"}]}, {"name": "spec_others_pac", "label": "Please specify others", "type": "text"}, {"name": "pac_stockout", "label": "Duration of PAC commodities stockout", "type": "group", "children": [{"name": "miso_stockout", "label": "Misoprostol & Mifepristone tablet", "type": "integer"}, {"name": "oxy_stockout", "label": "Oxytocin injection Tranexamic Acid (TXA)", "type": "integer"}, {"name": "gei_stockout", "label": "Gentamicin injection", "type": "integer"}, {"name": "cei_stockout", "label": "Ceftriaxone", "type": "integer"}, {"name": "doi_stockout", "label": "Doxycycline", "type": "integer"}, {"name": "azi_stockout", "label": "Azithromycin tablets", "type": "integer"}, {"name": "mei_stockout", "label": "Metronidazole tablets", "type": "integer"}, {"name": "ibi_stockout", "label": "Ibuprofen tablets", "type": "integer"}, {"name": "dii_stockout", "label": "Diazepam tablets", "type": "integer"}]}, {"name": "gbv_c", "label": "Which essential GBV commodities are available at this facility? Please select all applicable commodities. Verify availability of listed commodities before selecting an option", "type": "select all that apply", "children": [{"name": "hiv_pep", "label": "HIV post-exposure prophylaxis (PEP)"}, {"name": "ecp", "label": "Emergency contraceptive pills"}, {"name": "hiv_tk", "label": "HIV test kits"}, {"name": "vdrl", "label": "VDRL (syphilis test kits)"}, {"name": "az_tab", "label": "Azithromycin tablets"}, {"name": "doxycycl", "label": "Doxycycline"}, {"name": "metronid", "label": "Metronidazole tablets"}, {"name": "clotrima", "label": "Clotrimazole vaginal tablets"}, {"name": "disposab", "label": "Disposable sanitary pads"}, {"name": "oth", "label": "Others"}]}, {"name": "spec_others_gbv", "label": "Please specify others", "type": "text"}, {"name": "gbv_stockout", "label": "Duration of GBV commodities stock-out", "type": "group", "children": [{"name": "hiv_pep_stockout", "label": "HIV post-exposure prophylaxis (PEP) (Number of Days)", "type": "integer"}, {"name": "ecp_stockout", "label": "Emergency contraceptive pills (Number of Days)", "type": "integer"}, {"name": "hiv_tk_stockout", "label": "HIV test kits (Number of Days)", "type": "integer"}, {"name": "vdrl_stockout", "label": "VDRL (syphilis test kits) (Number of Days)", "type": "integer"}, {"name": "azithromycin_stockout", "label": "Azithromycin tablets (Number of Days)", "type": "integer"}, {"name": "doxycycline_tk_stockout", "label": "Doxycycline (Number of Days)", "type": "integer"}, {"name": "metronidazole_stockout", "label": "Metronidazole tablets (Number of Days)", "type": "integer"}, {"name": "clotrimazole_stockout", "label": "Clotrimazole vaginal tablets (Number of Days)", "type": "integer"}, {"name": "disposable_stockout", "label": "Disposable sanitary pads (Number of Days)", "type": "integer"}]}]}, {"name": "commodities_stocking", "label": "Essential commodities stocking", "type": "group", "children": [{"name": "comm_in_stock", "label": "What other essential SRH commodities are in stock?", "type": "text"}, {"name": "comm_out_of_stock", "label": "What other essential SRH commodities are out of stock? What is the stock out duration of each?", "type": "text"}, {"name": "comm_in_excess", "label": "Which SRH commodities are stocked in excess?", "type": "text"}, {"name": "eff_monitor", "label": "Does the facility have effective mechanisms to monitor and respond to stock-outs of SRH commodities, minimizing service disruption?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "priv_consult", "label": "Does the facility have privacy-enhanced consultation spaces for SRH services? Do not rely on staffreports only. Observe the SRH consultation space directly before answering", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "store_criteria", "label": "Are SRH commodities stored in a site that meets the following criteria? Please indicate all that apply. Inspect the SRH commodity storage area and verify that it meets the listed criteria before selecting a response", "type": "select all that apply", "children": [{"name": "clean_pa", "label": "Clean and free from evidence of pests or animals"}, {"name": "wellv_c", "label": "Well-ventilated and cool"}, {"name": "sh_pall", "label": "Stored on shelves, pallets, or cabinets to prevent crushing or placement on the floor"}, {"name": "shild_sun", "label": "Shielded from direct sunlight"}, {"name": "fr_cl", "label": "Free from ceiling leaks"}, {"name": "exp_usa", "label": "Expired products separated from usable products"}, {"name": "sec_sg", "label": "Secure, with lockable storage or a security guard"}]}]}, {"name": "service_delivery", "label": "Service Delivery", "type": "group", "children": [{"name": "maternal_hs", "label": "Are the following services administered during antenatal care in this facility? Tick as appropriate; randomly select five (5) case notes to verify.", "type": "select all that apply", "children": [{"name": "wt_msmnt", "label": "Weight measurement"}, {"name": "bp_chck", "label": "Blood pressure check"}, {"name": "sgns_anae", "label": "Check for signs of anaemia"}, {"name": "hf_exam", "label": "Examination of hands and feet for edema"}, {"name": "fund_ht", "label": "Measurement of fundal height using measuring tape"}, {"name": "fet_heart", "label": "Monitoring fetal heart rate"}, {"name": "pcv_chk", "label": "PCV/Hb Check"}, {"name": "vdrl_screen", "label": "VDRL (Syphilis) screening"}, {"name": "hiv_screen", "label": "HIV screening"}, {"name": "hbsag_screen", "label": "HBsAg screening"}, {"name": "hcv_screen", "label": "HCV screening"}, {"name": "screening_Urinalysis", "label": "Blood sugar level screening Urinalysis"}, {"name": "inj_Administration", "label": "Tetanus Inj. Administration"}, {"name": "anc_drugs", "label": "Routine ANC drugs"}]}, {"name": "labor_record", "label": "Are the following assessed and recorded when admitting women in labour? (Tick as appropriate: randomly select five (5) case notes to verify)", "type": "select all that apply", "children": [{"name": "anc_rec", "label": "ANC records"}, {"name": "preg_hist", "label": "Pregnancy and labour history"}, {"name": "vag_conf", "label": "Vaginal examination and confirmation of labour"}, {"name": "vit_signs", "label": "Vital signs of the woman (Blood Pressure, Pulse Rate, Respiratory Rate, & Temperature)"}, {"name": "fhr", "label": "Fetal heart rate"}, {"name": "flpp", "label": "Foetal Lie, position, and presentation"}, {"name": "urinalysis_labor", "label": "Urinalysis"}, {"name": "hiv_not", "label": "HIV Screening (if not done previously)"}, {"name": "head_moul", "label": "Head positioning and moulding"}, {"name": "cerv_effa", "label": "Cervix dilation and effacement"}, {"name": "cactionff", "label": "Contraction frequency, duration and intensity"}]}]}, {"name": "labor_monitor", "label": "Monitoring of Labor", "type": "group", "children": [{"name": "partograph", "label": "Does the facility consistently use partographs/labour care guides for all women in labor?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "pph_bundles", "label": "Are PPH bundles complete and available at the facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "pph_case", "label": "Are PPH cases correctly identified and managed according to the bundle?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ref_obst_em", "label": "Did referred obstetric emergencies receive appropriate care on arrival?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "comp_pres", "label": "Are women allowed to have their companion of choice during labour and childbirth?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "family_planning_serv", "label": "Family Planning Services", "type": "group", "children": [{"name": "fp_edu", "label": "Is family planning education and/or counseling routinely offered onsite to clients who wish to delay or prevent pregnancy? Confirm from FP register", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "edu_mater", "label": "Are education materials (IEC) about contraception and safe conception on display or available to clients (e.g., pamphlets, posters, brochures) accessing this service ?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "adolescent_srh", "label": "Adolescent SRH services", "type": "group", "children": [{"name": "adol_fr_comm", "label": "How many providers are trained on adolescent-friendly communication and confidentiality principles?", "type": "select one", "children": [{"name": "adol_non", "label": "None"}, {"name": "adol_1", "label": "1"}, {"name": "adol_2plus", "label": "2 and above"}]}, {"name": "ded_ts", "label": "Is there a dedicated time or space for adolescents to receive FP services in this facility? Cite dedicated space/document", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "av_supp", "label": "Is support available to provide adolescent-specific services (e.g., peer leaders, mentor mothers, support groups) Cite supporting document", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "gbv_services_", "label": "Gender-Based Violence Services", "type": "group", "children": [{"name": "pv_svc", "label": "Are post-violence care services accessible and affordable? Tick all that apply", "type": "select all that apply", "children": [{"name": "open_fac", "label": "Post-violence care is offered during all hours a facility is open either by staff who are physically at the facility or on-call to respond"}, {"name": "no_report", "label": "The survivor can receive essential care without reporting the assault to the police (review intake protocol and/or forms to ensure police report is not required to receive services)"}, {"name": "reduced_charges", "label": "Service charge reduced or waived for GBV services"}]}, {"name": "hcw_train", "label": "How many health care workers administering post-violence care services have been trained on these standard procedures (including clinical management specific to children and adolescents? Cite training certificates", "type": "select one", "children": [{"name": "hcw_non", "label": "None"}, {"name": "hcw_one", "label": "1"}, {"name": "hcw_2plus", "label": "2 and above"}]}, {"name": "pvc_doc", "label": "Are referrals for post-violence care documented?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "pac_service_", "type": "group", "children": [{"name": "comp_pac", "label": "Does your facility have equipment to carry out quality comprehensive post abortion care services? Verify the availability and functionality of PAC equipment before selecting a response", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "pac_prep", "label": "Does your facility have PAC preparedness guidelines? Request to see the documented guidelines before selecting a response", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "pac_wast_disp", "label": "Do you have an effective waste disposal system for PAC services? Request to see the disposal system before selecting a response", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "proc_supp", "type": "group", "children": [{"name": "app_supp", "label": "Does the facility have reliable and approved suppliers for SRH commodities to ensure consistent supply?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "func_inv", "label": "Does the facility have a functional inventory management system for SRH commodities?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "inv_mng", "label": "Which of these inventory management system is functional? Please select all applicable", "type": "select all that apply", "children": [{"name": "mng_tool", "label": "The facility uses inventory management tools to keep stock records (e.g. stock cards)"}, {"name": "stk_crds", "label": "Stock cards are updated on a transactional basis (i.e., whenever stock is sent from the storage site to another site within the facility)"}, {"name": "tml_ord", "label": "The facility submits timely orders for the SRH commodities (as defined by the in-country re-supply schedule or during the past 3 months)\""}]}, {"name": "transprt", "label": "What transportation methods are employed for procuring and distributing SRH commodities? Please select all applicable", "type": "select all that apply", "children": [{"name": "ded_vec", "label": "Dedicated facility vehicles"}, {"name": "ccv_rtv", "label": "Cold chain vehicles/Refrigerated trucks or vans)"}, {"name": "tp_cs", "label": "Third-party logistics/courier services"}, {"name": "pub", "label": "Public transport (buses, taxis)"}, {"name": "mb_mc", "label": "Motorbikes/Motorcycles"}, {"name": "ftd", "label": "Foot delivery"}]}, {"name": "transprt_rel", "label": "Are the transportation methods reliable, timely, and appropriate to maintain product quality?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "avail_func", "label": "Please indicate the availability and functionality of the following infrastructure and equipment items critical for SRH service delivery.", "type": "group", "children": [{"name": "rel_pwsup", "label": "Reliable power supply", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "rel_wsup", "label": "Reliable water supply", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "toilet", "label": "Toilet", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "ded_srhw", "label": "Dedicated SRH/Maternity ward", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "op_tht", "label": "Operating theater (CEmONC only)", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "bts", "label": "Blood bank/Transfusion services (CEmONC only)", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "del_bd", "label": "Delivery beds", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "nrk", "label": "Neonatal resuscitation kit", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "ve_f", "label": "Vacuum extractor / forceps", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "sdk", "label": "Sterile delivery kits (clamps, scissors, cord clamps)", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "part_lm", "label": "Partograph/labour care guide for labor monitoring", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "sa_me", "label": "Suction apparatus and Mucus extractor", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "mva_k", "label": "Manual Vacuum Aspiration (MVA) kits", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "iud_inst", "label": "IUD insertion/removal tray with sterile instruments", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "imp_set", "label": "Implant insertion/removal set", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "bpa_stet", "label": "Blood pressure apparatus & stethoscope", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "e_fk", "label": "Examination & forensic kits", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "acv_st", "label": "Autoclave or sterilizer", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}, {"name": "pt_kits", "label": "Pregnancy test kits", "type": "select one", "children": [{"name": "avf", "label": "Available and Functional"}, {"name": "av_nf", "label": "Available but Non-Functional"}, {"name": "nav", "label": "Not Available"}]}]}, {"name": "app_dist", "label": "Are procured SRH commodities received and distributed appropriately at this facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "numfac_srhproc", "label": "How many health facilities procured SRH commodities?", "type": "integer"}, {"name": "numfac_recsrh", "label": "How many health facilities received the procured SRH commodities?", "type": "integer"}]}, {"name": "human_res", "label": "Human Resources for Health (HRH)", "type": "group", "children": [{"name": "curr_engaged", "label": "How many of the following cadres are currently engaged and working at this facility?", "type": "group", "children": [{"name": "obst", "label": "Obstetricians/GynecoIogists", "type": "integer"}, {"name": "med_off", "label": "Medical Officers", "type": "integer"}, {"name": "nurses", "label": "Nurses", "type": "integer"}, {"name": "md_wif", "label": "Midwives", "type": "integer"}, {"name": "comm_ho", "label": "Community Health Officers (CHO)", "type": "integer"}, {"name": "schew", "label": "Senior Community Health Extension Workers (SCHEW)", "type": "integer"}, {"name": "jchew", "label": "Junior Community Health Extension Workers (JCHEW)", "type": "integer"}, {"name": "pharms", "label": "Pharmacists", "type": "integer"}, {"name": "pharm_tech", "label": "Pharmacy Technician / Assistant", "type": "integer"}, {"name": "mls_t", "label": "Medical Laboratory Scientist / Technician", "type": "integer"}, {"name": "med_ro", "label": "Medical Records Officer", "type": "integer"}, {"name": "hlth_ass", "label": "Health Attendants / Assistants", "type": "integer"}]}, {"name": "av_247", "label": "How many health workers are available 24/7?", "type": "group", "children": [{"name": "obst_247", "label": "Obstetricians/GynecoIogists", "type": "integer"}, {"name": "med_off_247", "label": "Medical Officers", "type": "integer"}, {"name": "nurses_247", "label": "Nurses", "type": "integer"}, {"name": "md_wif_247", "label": "Midwives", "type": "integer"}, {"name": "comm_ho_247", "label": "Community Health Officers (CHO)", "type": "integer"}, {"name": "schew_247", "label": "Senior Community Health Extension Workers (SCHEW)", "type": "integer"}, {"name": "jchew_247", "label": "Junior Community Health Extension Workers (JCHEW)", "type": "integer"}, {"name": "pharms_247", "label": "Pharmacists", "type": "integer"}, {"name": "pharm_tech_247", "label": "Pharmacy Technician / Assistant", "type": "integer"}, {"name": "mls_t_247", "label": "Medical Laboratory Scientist / Technician", "type": "integer"}, {"name": "med_ro_247", "label": "Medical Records Officer", "type": "integer"}, {"name": "hlth_ass_247", "label": "Health Attendants / Assistants", "type": "integer"}]}, {"name": "valid_cert", "label": "Are there valid certificates and/or current practicing licenses available for all health workers? Verify certificates and licenses.", "type": "select all that apply", "children": [{"name": "all_hcw", "label": "All HCWs have valid certificates and or current practising licenses"}, {"name": "som_hcw", "label": "Some HCWs have valid certificates and or current practising licenses"}, {"name": "non_hcw", "label": "No HCW had valid certificates and or current practising licenses"}]}, {"name": "mm_in", "label": "How many medical officers have been posted to this facility within the last 12 months?", "type": "integer"}, {"name": "mo_att", "label": "How many medical officers have been posted out of this facility within the last 12 months?", "type": "integer"}, {"name": "nm_in", "label": "How many nurses/midwives have been posted to this facility within the last 12 months?", "type": "integer"}, {"name": "nm_att", "label": "How many nurses/midwives have been posted out of this facility within the last 12 months?", "type": "integer"}, {"name": "chews_in", "label": "How many CHEWS (SCHEWS &JCHEWS) have been posted to this facility within the last 12 months?", "type": "integer"}, {"name": "chews_att", "label": "How many CHEWS (SCHEWS &JCHEWS) have been posted out of this facility within the last 12 months?", "type": "integer"}, {"name": "cho_inn", "label": "How many community health officers (CHO) have been posted to this facility within the last 12 months?", "type": "integer"}, {"name": "cho_att", "label": "How many community health officers (CHO) have been posted out of this facility within the last 12 months?", "type": "integer"}, {"name": "sba_training", "label": "How many SBAs were trained on the following key SRH services in the last 12 months? Input number only", "type": "group", "children": [{"name": "cacs", "label": "Comprehensive abortion care services (includes legal indications for abortion, medical/surgical management of pregnancy termination, and pre/post procedure counseling)", "type": "integer"}, {"name": "pac_iet", "label": "Post abortion care (including emergency treatment for incomplete abortion or complications, empathetic counseling, and immediate provision of voluntary contraceptive methods to prevent repeat unintended pregnancies)", "type": "integer"}, {"name": "tic_icsc", "label": "Trauma-informed care (includes clinical \"stop signals\" for clients, non-judgmenta/ counseling for survivors of violence, and managing secondary traumatic stress for providers)", "type": "integer"}]}]}, {"name": "psc_stigma_red", "label": "PAC stigma-reduction", "type": "group", "children": [{"name": "stg_note", "label": "How many mentorship sessions on the following SRH areas were conducted at the facility in the last 12 months?", "type": "note"}, {"name": "mph_pph", "label": "Management of Postpartum Hemorrhage (PPH)", "type": "integer"}, {"name": "m_encl", "label": "Management of Eclampsia", "type": "integer"}, {"name": "cacs", "label": "Comprehensive abortion care services (includes legal indications for abortion, medical/surgical management ofpregnancy termination, and pre/post procedure counseling)", "type": "integer"}, {"name": "pac_iet", "label": "Post abortion care (including emergency treatment for incomplete abortion or complications, empathetic counseling, and immediate provision of voluntary contraceptive methods to prevent repeat unintended pregnancies)", "type": "integer"}, {"name": "tic_icsc", "label": "Trauma-informed care (includes clinical \"stop signals\" for clients, non-judgmental counseling for survivors of violence, and managing secondary traumatic stress for providers)", "type": "integer"}, {"name": "fp_tycs", "label": "Family planning (includes types of available contraceptive methods, common side effects, etc)", "type": "integer"}]}, {"name": "serv_utiliza", "label": "Service Utilization", "type": "group", "children": [{"name": "service", "label": "Please indicate the number of women who accessed each service at this facility for the first time during the last 30 days", "type": "note"}, {"name": "anc_uti", "label": "Antenatal Care (ANC)", "type": "integer"}, {"name": "del_uti", "label": "Delivery services (including facility-based deliveries)", "type": "integer"}, {"name": "pnc_uti", "label": "Postnatal Care (PNC)", "type": "integer"}, {"name": "fpco_uti", "label": "Family planning- Counseling only", "type": "integer"}, {"name": "sam_uti", "label": "Short-acting methods (condoms, pills, injectables)", "type": "integer"}, {"name": "lam_uti", "label": "Long-acting reversible contraceptives (IUD, implants)", "type": "integer"}, {"name": "pim_uti", "label": "Permanent/irreversible methods (e.g., sterilization, vasectomy)", "type": "integer"}, {"name": "pac_coun_uti", "label": "PAC counseling and medical management", "type": "integer"}, {"name": "pac_com_uti", "label": "PAC complications management", "type": "integer"}, {"name": "chsa_uti", "label": "Counseling, health education, or screening services for adolescents", "type": "integer"}, {"name": "mplss_uti", "label": "Medical, psychosocial, or legal support services", "type": "integer"}, {"name": "stcsti_uti", "label": "Screening, treatment, or counseling for STIs/HlV", "type": "integer"}, {"name": "ccs_uti", "label": "Cervical cancer screening", "type": "integer"}, {"name": "other_uti", "label": "Other reproductive health services (please specify)", "type": "text"}, {"name": "pri_screen", "label": "Are privacy screens or curtains consistently used during patient examinations and procedures to ensure confidentiality?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "most_used", "label": "Which SRH service was the most commonly accessed by new clients in the last 30 days? Please state", "type": "text"}, {"name": "numfrm_reg_note", "label": "Using facility registers, please indicate the total number of the following services provided at this facility during the last 6 months", "type": "note"}, {"name": "anc_num", "label": "Total Antenatal Care (ANC) Visits", "type": "integer"}, {"name": "del_num", "label": "Total Institutional Deliveries", "type": "integer"}, {"name": "cs_num", "label": "Total Cesarean Sections (CEmONC)", "type": "integer"}, {"name": "pac_num", "label": "Post-Abortion Care (PAC) Clients", "type": "integer"}, {"name": "fpna_num", "label": "Family Planning New Acceptors", "type": "integer"}, {"name": "tri_num", "label": "Total Referrals In (Emergency)", "type": "integer"}, {"name": "tro_num", "label": "Total Referrals Out (Emergency)", "type": "integer"}, {"name": "book_num", "label": "Number of bookings (3 years prior)", "type": "integer"}, {"name": "and4_cmplt_num", "label": "Number of pregnant women completing at least 4 ANC visits", "type": "integer"}]}, {"name": "rande_sys", "label": "Referral & Emergency Systems", "type": "group", "children": [{"name": "ref_rmncah", "label": "Does the facility have a functional referral system for RMNCAH/SRH services?", "type": "select one", "children": [{"name": "re_yes", "label": "Yes"}, {"name": "re_pf", "label": "Partially functional"}, {"name": "re_no", "label": "No"}]}, {"name": "ref_com", "label": "Are referral communication mechanisms functional?", "type": "select one", "children": [{"name": "re_yes", "label": "Yes"}, {"name": "re_pf", "label": "Partially functional"}, {"name": "re_no", "label": "No"}]}, {"name": "ref_fdbck", "label": "Are referral feedback mechanisms functional?", "type": "select one", "children": [{"name": "re_yes", "label": "Yes"}, {"name": "re_pf", "label": "Partially functional"}, {"name": "re_no", "label": "No"}]}, {"name": "ref_mech", "label": "What referral mechanisms are used to link clients to higher-level facilities?", "type": "select all that apply", "children": [{"name": "srf_ref", "label": "Standard referral forms"}, {"name": "phon", "label": "Phone calls"}, {"name": "de_ref", "label": "Digital/electronic referrals"}, {"name": "tachwa", "label": "Transport arrangements Community health worker accompaniment"}, {"name": "other_ref", "label": "Other"}]}, {"name": "specify_mech", "label": "Please specify others", "type": "text"}, {"name": "fed_mech", "label": "Are referral feedback mechanisms functional?", "type": "select one", "children": [{"name": "alws", "label": "Always"}, {"name": "smtms", "label": "Sometimes"}, {"name": "rare", "label": "Rarely"}, {"name": "nt_trck", "label": "Not tracked"}]}, {"name": "ref_clinum", "label": "How many referred clients successfully reached higher-level care?", "type": "integer"}, {"name": "helpline", "label": "Is there a functional emergency helpline for RMNCAH/SRH emergencies?", "type": "select one", "children": [{"name": "re_yes", "label": "Yes"}, {"name": "re_pf", "label": "Partially functional"}, {"name": "re_no", "label": "No"}]}, {"name": "em_trsnpt", "label": "What arrangements does this health facility have for patient emergency transport?", "type": "select all that apply", "children": [{"name": "em_none", "label": "None"}, {"name": "em_bike", "label": "Motorcycle or tricycle (keke)"}, {"name": "em_ambu", "label": "Functional ambulance"}, {"name": "em_other", "label": "Other dedicated mechanism for emergency transportation service"}]}, {"name": "other_arrang", "label": "Please state (other) emergency transport system", "type": "text"}, {"name": "ambu_dri", "label": "Is there a dedicated ambulance driver that is available at all times (i.e., 24 hours)?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "ambu_no", "label": "How many ambulances are available for use at this facility?", "type": "integer"}, {"name": "follow_up", "label": "Are follow-up mechanisms in place for clients referred or discharged from the facility?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "foll_type", "label": "What kind of client follow-up does your facility use?", "type": "select all that apply", "children": [{"name": "apptmnt", "label": "Appointment cards or written reminders"}, {"name": "phone_cals", "label": "Phone calls to clients"}, {"name": "sms_text", "label": "SMS/text message reminders"}, {"name": "visit", "label": "Home visits"}, {"name": "chwt", "label": "Community health worker tracking"}, {"name": "sch_apt", "label": "Scheduled clinic appointments"}, {"name": "dig_foll", "label": "Digital follow-up tools like whatsApp or other social media messaging"}, {"name": "fam_outr", "label": "Facility outreach or community follow-up"}, {"name": "cli_in_foll", "label": "Client-initiated follow-up only (no active tracking)"}, {"name": "ref_foll", "label": "Referral follow-up with another facility"}, {"name": "no_form", "label": "No formal follow-up mechanism"}]}, {"name": "foll_rec", "label": "Are records of follow-up and referral outcomes maintained and accessible?", "type": "select one", "children": [{"name": "re_yes", "label": "Yes"}, {"name": "re_pf", "label": "Partially functional"}, {"name": "re_no", "label": "No"}]}, {"name": "women_comm", "label": "Are women enrolled in community-based follow-up systems?", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}]}, {"name": "hmis", "label": "Health Management Information System", "type": "group", "children": [{"name": "sop_doc", "label": "Does the facility have a documented process or set of standard operating procedures to ensure that the data it collects and reports accurately reflect the services provided at the site? Cite SOPs/protocol", "type": "select one", "children": [{"name": "yes", "label": "Yes"}, {"name": "no", "label": "No"}]}, {"name": "serv_revmeeting", "label": "Did the health facility conduct service delivery data review meeting in the last quarter? Cite minutes of the data review meeting.", "type": "select one", "children": [{"name": "not_conduct", "label": "Review meeting not conducted"}, {"name": "no_evide", "label": "Review meeting conducted with no evidence"}, {"name": "evidence", "label": "Review meeting conducted with evidence"}]}, {"name": "mpcdr_meet", "label": "Is there a monthly Maternal and Perinatal Death Surveillance and Response (MPDSR) meeting conducted at the facility?", "type": "select one", "children": [{"name": "not_conduct", "label": "Review meeting not conducted"}, {"name": "no_evide", "label": "Review meeting conducted with no evidence"}, {"name": "evidence", "label": "Review meeting conducted with evidence"}]}, {"name": "mpcdr_impl", "label": "Are maternal and perinatal deaths reviewed and follow-up actions implemented?", "type": "select one", "children": [{"name": "not_conduct", "label": "Review meeting not conducted"}, {"name": "no_evide", "label": "Review meeting conducted with no evidence"}, {"name": "evidence", "label": "Review meeting conducted with evidence"}]}, {"name": "pat_fdbck", "label": "Is there a formal and accessible system in place for collecting patient feedback or complaints regarding SRH services?", "type": "select one", "children": [{"name": "not_conduct", "label": "Review meeting not conducted"}, {"name": "no_evide", "label": "Review meeting conducted with no evidence"}, {"name": "evidence", "label": "Review meeting conducted with evidence"}]}, {"name": "hmis_note", "label": "Using facility registers, please indicate the total number of the following services provided at this facility in the last 2 years", "type": "note"}, {"name": "anc_23", "label": "Total Antenatal Care (ANC) visits in 2023", "type": "integer"}, {"name": "anc_24", "label": "Total Antenatal Care (ANC) visits in 2024", "type": "integer"}, {"name": "anc_25", "label": "Total Antenatal Care (ANC) visits in 2025", "type": "integer"}, {"name": "anc4_", "label": "Percentage (%) of pregnant women completing at least 4 ANC visits (most recent year available)", "type": "integer"}, {"name": "pregbook_23", "label": "Number of pregnancy bookings in 2023", "type": "integer"}, {"name": "pregbook_24", "label": "Number of Pregnancy bookings in 2024", "type": "integer"}, {"name": "pregbook_25", "label": "Number of Pregnancy bookings in 2025", "type": "integer"}, {"name": "vag_birth_23", "label": "Total vaginal deliveries in 2023", "type": "integer"}, {"name": "vag_birth_24", "label": "Total vaginal deliveries in 2024", "type": "integer"}, {"name": "vag_birth_25", "label": "Total vaginal deliveries in 2025", "type": "integer"}, {"name": "csection_23", "label": "Total cesarean deliveries in 2023", "type": "integer"}, {"name": "csection_24", "label": "Total cesarean deliveries in 2024", "type": "integer"}, {"name": "csection_25", "label": "Total cesarean deliveries in 2025", "type": "integer"}, {"name": "fps_23", "label": "Total family planning/contraceptive service visits in 2023", "type": "integer"}, {"name": "fps_24", "label": "Total family planning/contraceptive service visits in 2024", "type": "integer"}, {"name": "fps_25", "label": "Total family planning/contraceptive service visits in 2025", "type": "integer"}, {"name": "hiv_ct_23", "label": "Number of clients counselled and/or tested for STI/HIV in 2023", "type": "integer"}, {"name": "hiv_ct_24", "label": "Number of clients counselled and/or tested for STI/HIV in 2024", "type": "integer"}, {"name": "hiv_ct_25", "label": "Number of clients counselled and/or tested for STI/HIV in 2025", "type": "integer"}, {"name": "hivprev_23", "label": "HIV prevalence among clients in 2023", "type": "integer"}, {"name": "hivprev_24", "label": "HIV prevalence among clients in 2024", "type": "integer"}, {"name": "hivprev_25", "label": "HIV prevalence among clients in 2025", "type": "integer"}, {"name": "mmr_23", "label": "Facility Maternal Mortality Ratio (MMR) in 2023", "type": "integer"}, {"name": "mmr_24", "label": "Facility Maternal Mortality Ratio (MMR) in 2024", "type": "integer"}, {"name": "mmr_25", "label": "Facility Maternal Mortality Ratio (MMR) in 2025", "type": "integer"}, {"name": "nmr_23", "label": "Facility Neonatal Mortality Ratio (MMR) in 2023", "type": "integer"}, {"name": "nmr_24", "label": "Facility Neonatal Mortality Ratio (MMR) in 2024", "type": "integer"}, {"name": "nmr_25", "label": "Facility Neonatal Mortality Ratio (MMR) in 2025", "type": "integer"}, {"name": "oref_23", "label": "Number of outward referrals completed in 2023", "type": "integer"}, {"name": "oref_24", "label": "Number of outward referrals completed in 2024", "type": "integer"}, {"name": "oref_25", "label": "Number of outward referrals completed in 2025", "type": "integer"}, {"name": "recref_23", "label": "Number of referrals received in 2023", "type": "integer"}, {"name": "recref_24", "label": "Number of referrals received in 2024", "type": "integer"}, {"name": "recref_25", "label": "Number of referrals received in 2025", "type": "integer"}]}, {"name": "end_note", "label": "Thank you for your time and and participation. Your responses are very valuable and will immensely help this assessment", "type": "note"}, {"name": "meta", "type": "group", "control": {"bodyless": true}, "children": [{"name": "instanceID", "type": "calculate", "bind": {"readonly": "true()", "calculate": "concat('uuid:', uuid())"}}, {"name": "instanceName", "type": "calculate", "bind": {"calculate": "concat(${state}, ' - ', ${facility_name})"}}]}]}