f a c i l i t y a s s e s s m e n t f o r m- l a b o r a n d d e l i v e r y（我l f c t y s s e s s m e n t f o r m - l b o r n d d e l i v e r y）（8页）.docVIP

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2017-01-23 发布于四川
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f a c i l i t y a s s e s s m e n t f o r m- l a b o r a n d d e l i v e r y（我l f c t y s s e s s m e n t f o r m - l b o r n d d e l i v e r y）（8页）.doc

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f a c i l i t y a s s e s s m e n t f o r m- l a b o r a n d d e l i v e r y（我l f c t y s s e s s m e n t f o r m - l b o r n d d e l i v e r y）（8页）

FACILITY ASSESSMENT FORM: LABOR AND DELIVERY Date(s): _________________ Observer(s) names: __________________ Region: _______________________ Catchment population: __________ District: ________________________ # clients/month: ________ Facility name: ___________________ Type of facility: __________________________________ 1. FACILITY SET-UP YES NO COMMENTS 1.1 Are the following supplies available to implement the program? Prevention of mother-to-child transmission of HIV (PMTCT) guidelines ? Antiretroviral drugs (ARV) guidelines ? Infant feeding guidelines ? Post-exposure prophylaxis (PEP) guidelines ? ? Latest circulars? (PMTCT, ARV, PEP) ? Condoms (female) ? ? Condoms (male) ? ? Videos ? Posters ? 1.2 Is information, graphs on PMTCT displayed? (Could include excerpts of guidelines, program statistics, etc.) ? 1.3 Are information, education, and communication (IEC) materials (e.g., posters, pamphlets) ? ? 1.4 Are the following supplies available to enable practice of universal precautions? ? ? Gloves ? ? Soap ? ? Waste disposal containers ? ? Actions needed/taken, recommendations: 2. STAFFING COMMENTS 2.1 # of staff ? ? 2.2 Adequate staff available to implement program? If “No,” please explain in “comments” section Yes No ? 2.3 Frequency of staff rotation (every # months) ? ? Actions needed/taken, recommendations: 3. COUNSELING # COMMENTS 3.1 Supervision of counselors (# times per month) ? ? 3.2 # of individual pretest counseling sessions (avg. # per month over 3 -month period, = total # pretest counseling sessions in 3 months ÷ 3) ? ? 3.3 # of individual posttest counseling sessions (avg. # per month over 3 -month period, = total # posttest counseling sessions in 3 months ÷ 3) ? ? Actions needed/taken, recommendations: 4. TESTING YES NO COMMENTS 4.1 Is ELISA testing available? ? 4.2 Is rapid testing (RT) available? ? ? # COMMENTS 4.3 # of staff certified in RT ? ?