Health Facility Preparedness Readiness Rapid Assessment Checklist For COVID-19-icddrb-V10

Preparedness & Readiness of Health Facilities for managing COVID-19 in Bangladesh-
Rapid Assessment Checklist
Assessment date: |____ ____|____ ____|____ ____ ____ ____|
Facility Code: |____|____|____|____|
Facility Name: ______________________________________________________________________________________
Facility Status: ☐COVID-Designated☐ COVID-Non-designated
Facility Category:☐ Medical College Hospital☐ District Hospital☐Upazila Health Complex
Division: _____________________________________________
District: _____________________________________
Upazila: _____________________________________
Type of Facility: ☐ Government ☐ Private ☐ NGO ☐ Other (Please specify) ___________________________________
Name of the Assessor: _____________________________________
Assessment Completed: ☐ Yes ☐ No
Have Triage facility: ☐ Yes ☐ No
Have Isolation facility: ☐ Yes ☐ No If yes, number of beds: |___|___|___|
Have ICU facility: ☐ Yes ☐ No If yes, number of beds: |___|___|___|
Emergency mobile number of health facility:|___|___|___|___|___|___|___|___|___|___|___|
Mobile number of Ambulance: |___|___|___|___|___|___|___|___|___|___|___|
1
CONSENT for Health Facility Survey
FIND THE MANAGER, THE PERSON IN-CHARGE OF THE FACILITY, OR THE MOST SENIOR HEALTH WORKER RESPONSIBLE FOR
CLIENT SERVICES WHO IS PRESENT AT THE FACILITY. READ THE FOLLOWING GREETING:
Good day. My name is ________________________. I am here on behalf of the Directorate General of Health
Services (DGHS) and I am from the International Centre for Diarrheal Disease Research Bangladesh (icddr,b).
icddr,b is supporting the government in COVID-19 response by conducting rapid assessment of selected health
facilities.
We have come to your facility as per the list provided by government. We will be asking you questions about
various health services, management issues, committees related to COVID-19 response in this facility. Information
collected about your facility will be used by GoB for planning and improvement of the COVID-19 response.
Neither your name nor the names of any other health workers who participate in this assessment will be included
in the dataset or in any report; however, there is a small chance that any of these respondents may be identified
later. Still, we are asking for your help in order to collect this information.
You may refuse to answer any question or choose to stop the interview at any time. However, we hope you will
answer the questions, which will benefit the government to prepare better for COVID-19 response.
If there are questions for which someone else is the most appropriate person to provide the information, we
would appreciate if you introduce us to that person to help us collect that information.
At this point, do you have any questions about the assessment? Do I have your agreement to proceed?
Date D D M M Y E A R
__________________________ __________________________
INTERVIEWER'S SIGNATURE INTERVIEWEE’S SIGNATURE
May I begin the interview? Yes ……………………….1
No ……………………….2  STOP
INTERVIEW START TIME H H : M M
EXPLAIN TO THE RESPONDENT AT THE START OF THIS INTERVIEW THAT THERE ARE QUESTIONS ON COMMITTEESS, MANAGEMENT MEETINGS AND QUALITY
ASSURANCE ACTIVITIES THAT REQUIRE LOOKING AT RECORDS OF THOSE COMMITTEESS, MEETINGS AND ACTIVITIES. IT WILL THEREFORE BE HELPFUL IF
RECORDS PERTAINING TO MANAGEMENT COMMITTEESS, MEETINGS AND QUALITY ASSURANCE ACTIVITIES ARE GATHERED, IF THEY ARE NOT READILY
AVAILABLE AT THE LOCATION WHERE YOU ARE CONDUCTING THE INTERVIEW.
EXPLAIN ALSO THAT THERE IS A SUBSECTION ON HEALTH CARE STAFF STATISTICS PERTAINING TO COVID-19 RESPONSE . IT WILL BE HELPFUL TO ALSO START
GATHERING SUCH INFORMATION IF INFORMATION IS NOT READILY AVAILABLE WHERE THE INTERVIEW IS BEING CONDUCTED.
THANK THE RESPONDENT AT THE END OF EACH SECTION OR SUBSECTION BEFORE PROCEDING TO
THE NEXT DATA COLLECTION POINT
2
CHAPTER 1: HEALTH WORKFORCE CAPACITY
Find the person most knowledgeable about health workforce capacity in the facility.
Introduce yourself, explain the purpose of the survey and ask the following questions.
a) How many staff in each of the following occupational categories work in this facility?
b) For each occupational category, how many are currently assigned for COVID-19 response?
NO. OCCUPATIONAL CATEGORY A.TOTAL B.TOTAL C.# D.# E.#
NUMBER NUMBER ASSIGNED ASSIGNED ASSIGNED
ASSIGNED IN TRIAGE IN IN ICU
FOR UNIT ISOLATIO
COVID-19 N/
RESPONSE COVID-19
WARD
1.1 Specialist/Consultant Physician
1.1.1 Specialist/Consultant Physician for ICU/

Medicine Indoor
1.2 Medical Officer/Assistant Surgeon/EMO/ IMO/

RMO/Dental Surgeon
1.3 Nurse
1.4 Midwives
1.4.1 Paramedic/SACMO
1.5 Medical technologist (Lab)
1.6 Medical technologist (EPI)
1.7 Ward Boy
1.8 Cleaner
1.9 Ambulance Driver

1.10 Number of Health Care Providers trained on
“Infection Prevention and Control (IPC)”
1.11 Number of support staffs (cleaner/ driver)
trained on “IPC”
1.12 Number of Healthcare Providers trained on
“Clinical management of Corona Virus Disease
2019 (COVID-19)”
1.13 Number of health care providers trained on
“How to run COVID-19 hospitals in
Bangladesh” guideline
1.14 Number of medical technologists trained on
“Sample Collection Storage and
Transportation”
1.15 Number of Statisticians/ Statistical Assistants
oriented on “COVID-19 reporting in DHIS2”
1.16 Number of health workforce trained on
“COVID-19 surveillance”
3
CHAPTER 2: LEADERSHIP / INCIDENCE MANAGEMENT SYSTEM
Objective: Ensuring comprehensive management of the hospital response to the COVID-19 emergency
Find the person most knowledgeable about leadership / incidence management system in the facility.
NO. QUESTIONS AND FILTERS CODING CATAGORIES SKIP
2.1 Have you formed a Core Committee to YES..............................................................................

respond to COVID-19 emergency? NO.............................................................................. 2.3
IN PROGRESS.............................................................. 2.3
2.2 May I see a document that supports OBSERVED..................................................................

formation of the Core Committee? REPORTED, NOT SEEN.................................................
2.3 Have you developed a Term of Reference/Job YES..............................................................................

Responsibility for the core committee? NO.............................................................................. 2.4.1
2.4 May I see a document that described the job OBSERVED..................................................................

responsibilities? REPORTED, NOT SEEN.................................................
[DOCUMENT OF 2.2 AND 2.4 CAN BE THE

SAME DOCUMENT]
2.4.1 Do you have full contact details of the core YES..............................................................................

committee members? NO.............................................................................. 2.5
2.4.2 May I see the contact details? OBSERVED..................................................................

REPORTED, NOT SEEN.................................................
[DOCUMENT OF 2.2, 2.4 and 2.6 CAN BE THE
SAME DOCUMENT]
2.5 Have you a designated room for Core YES..............................................................................

Committee/Hospital Emergency Operation? NO.............................................................................. 2.7
2.6 May I see the room designated for the Core OBSERVED..................................................................
Committee/Hospital Emergency Operation? REPORTED, NOT SEEN.................................................
2.7 Do you have a procedure to keep track YES..............................................................................

and control of documentation (e.g. NO.............................................................................. 2.9
procedures, meeting notes, training
materials, etc.)?
2.8 May I see the last meeting note? OBSERVED..................................................................

2.9 Have you appointed a key communication YES..............................................................................

person for communicating with the NCP, NO.............................................................................. 2.11
patients’ caregivers and media?
4
2.10 Who is the appointed person? Name and RESPONSIBLE PERSON 1
designation.
NAME: __________________________________
[PLEASE BRING INFORMATION OF ALL THE
PERSONS. BRING AT LEAST 3 IF THERE ARE DESIGNATION: ____________________________
MORE THAN 3 PERSONS INVOLVED]
RESPONSIBLE PERSON 2
NAME: __________________________________
DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
2.11 Have you identified a backup member for YES..............................................................................

the assigned communication person? NO.............................................................................. 2.13
2.12 Who is the backup member? Name and RESPONSIBLE PERSON 1

designation.
NAME: __________________________________
NAME: __________________________________
DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
2.13 Have you developed an Emergency YES..............................................................................

Response Plan for your hospital? NO.............................................................................. 2.15
IN PROGRESS.............................................................. 2.15
2.14 May I see the plan? OBSERVED..................................................................

2.15 Do you have a plan to keep track and custody YES..............................................................................

of key supplies (e.g. PPE, ventilators, cleaning NO.............................................................................. 2.17
and disinfection material, alcohol solution, IN PROGRESS.............................................................. 2.17
etc.)

2.17 Do you have a plan for staff absences, in YES..............................................................................

particular due to sick leave or having to care NO.............................................................................. 2.19
for sick people at home? IN PROGRESS.............................................................. 2.19
5
2.21 Do you have a plan to utilize auxiliary forces YES..............................................................................
like 5th year medical students, retired HCW & NO.............................................................................. 2.23
volunteers, if situation get worse? IN PROGRESS.............................................................. 2.23
2.23 Do you have a plan to outsource services if YES..............................................................................
capacities are exceeded? NO.............................................................................. 2.25
IN PROGRESS.............................................................. 2.25
2.25 Does the facility have a functional YES..............................................................................
ambulance? NO.............................................................................. 2.27
2.26 May I see the ambulance? OBSERVED..................................................................
2.27 Does the facility have a dedicated functional YES..............................................................................
ambulance for all suspected/confirmed NO.............................................................................. Next
COVID-19 cases? Chapter
2.28 May I see the ambulance? OBSERVED..................................................................
6
CHAPTER 3: INFECTION PREVENTION AND CONTROL
Objective: Minimizing the risk of transmission of healthcare-associated infection to patients, hospital staff, and visitors
Appropriate practice of IPC is applicable for the whole facility.
If the core committee is formed, find the person assigned for IPC. Otherwise, find the person most knowledgeable about
infection prevention and control in the facility. It could be the facility manager or RMO.
3.1 Do you have an IPC representative in the core YES..............................................................................
committee? NO.............................................................................. 3.3
3.2 Who is the IPC representative?
NAME: __________________________________
DESIGNATION: ____________________________
3.3 Do you have a backup person selected for the YES..............................................................................
IPC representative? NO.............................................................................. 3.5
3.4 Who is the backup person?
NAME: __________________________________
DESIGNATION: ____________________________
3.5 Do you follow the national guideline on IPC in YES..............................................................................
your facility? NO.............................................................................. 3.7
3.6 May I see the national IPC guideline? OBSERVED..................................................................
[SHOW THE TITLE PAGE OF THE GUIDELINE
SAVED IN YOUR PHONE]
3.7 Do you follow the national guideline (SoP) for YES..............................................................................
disinfection and sterilization in your facility? NO.............................................................................. 3.9
[SHOW THE TITLE PAGE OF THE SoP SAVED IN

YOUR PHONE]
3.8 May I see the guideline (SoP) for disinfection OBSERVED..................................................................
and sterilization? REPORTED, NOT SEEN.................................................
3.9 Do you follow the national guideline for YES..............................................................................
rational use of PPE in your facility? NO.............................................................................. 3.11

3.10 May I see the guideline? OBSERVED..................................................................
3.11 Do you follow the national guideline on YES..............................................................................
occupational safety and health? NO.............................................................................. 3.13
3.13 Do you have a stock of PPE? YES..............................................................................
NO.............................................................................. 3.17
3.14 May I see the stock? OBSERVED, YES...........................................................
OBSERVED, NO........................................................... 3.16
3.15 What kind of PPE is available in the stock? OBSERVED, YES OBSERVED, NO
How many? HOW
MANY?
3.15.1 Facemask 1 2
3.15.2 Heavy duty gloves 1 2
3.15.3 Goggles 1 2
7
3.15.4 Face shield 1 2
3.15.5 Hand gloves (general) 1 2
3.15.6 Gown 1 2
3.15.7 Boots or closed work shoes 1 2
3.15.8 FFP2 respirator/ N95/ HEPA (P100) 1 2 3.16
3.15.9 Other masks equivalent to FFP2/N95/HEPA
(P100) Name of the mask: _______________________
3.16 Do you have a monitoring and supervision YES NO
mechanism for the following components of
IPC?
3.16.1 Standard precaution 1 2
3.16.2 Hand hygiene practices 1 2
3.16.3 PPE donning and doffing 1 2
3.17 Do staffs of laboratory, laundry, food services YES..............................................................................
follow IPC guidelines? NO..............................................................................
3.18 Do you disinfect and sterilize the ambulance? YES..............................................................................
NO.............................................................................. 3.22
Ambulance not available ........................................... 3.22
3.19 How often do you it?
…………………. Number of times daily
3.20 Do you have register/log to document the YES..............................................................................
disinfect and sterilize practice of the NO.............................................................................. 3.22
ambulance?
3.21 May I see the register/log? OBSERVED..................................................................
3.22 Do you follow the national waste YES..............................................................................
management guideline in your facility? NO.............................................................................. 3.24
REPORTED, NOT SEEN................................................
3.24 Do you follow the environmental cleaning YES..............................................................................
SoP/protocol in your facility? NO.............................................................................. 3.26
3.25 May I the SoP? OBSERVED..................................................................
[SHOW THE TITLE PAGE OF THE SoP SAVED IN
YOUR PHONE]
3.26 Do you have running water available in your YES..............................................................................
facility? NO.............................................................................. 3.28
3.27 May I see whether running water is available OBSERVED, YES OBSERVED, NO NOT
in the following areas? APPLICABLE
3.27.1 Triage area (outside health facility) 1 2 3
3.27.2 Waiting area 1 2 3
3.27.3 Examination room 1 2 3
3.27.4 Isolation unit 1 2 3
3.27.5 Outdoor (ANC /maternity care) 1 2 3
3.27.6 Outdoor (IMCI/Child care) 1 2 3
3.28 Do you have running water and soap available YES..............................................................................
for hand washing in your facility? NO.............................................................................. 3.30
3.29 May I see whether you have running water OBSERVED, YES OBSERVED, NO NOT
and soap available for hand washing in your APPLICABLE
facility?
8
3.29.5 Outpatient 1 2 3
3.29.6 Inpatient 1 2 3
3.30 Do you have 70% alcohol-based hand YES..............................................................................
sanitiser available for hand washing in your NO.............................................................................. 3.32
facility?
3.31 May I see whether 70% alcohol-based hand OBSERVED, YES OBSERVED, NO NOT
sanitizer is available for hand washing in your APPLICABLE
facility?
3.31.7 Inpatient
3.32 Do you have safe drinking water available in YES..............................................................................
your facility? NO.............................................................................. 3.34
3.33 May I see whether safe drinking water is OBSERVED, YES OBSERVED, NO NOT
available in the following areas? APPLICABLE
3.34 Do you have separate toilets for male and YES..............................................................................
female patients? NO.............................................................................. 3.36
3.35 May I see whether you have separate toilets OBSERVED, YES OBSERVED, NO NOT
for male and female patients in the following APPLICABLE
areas?
3.36 Do you prepare chlorine solution at the YES..............................................................................
central location of the hospital water supply NO..............................................................................
system?
3.37 Is 24-hour cleaning service available in the YES..............................................................................
facility? NO.............................................................................. 3.40
3.38 Do you have a log/register to document the YES..............................................................................
cleaning services? NO.............................................................................. 3.40
3.39 May I see the log/register? OBSERVED..................................................................
3.40 Do you clean the hospital floors with YES..............................................................................
disinfectant? NO.............................................................................. 3.42
3.41 May I see what types of disinfectants you use OBSERVED, YES OBSERVED, NO
for cleaning the hospital floor?
3.41.1 1% Sodium Hypochlorite (chlotech, chlorox) 1 2
3.41.2 Phenol 1 2
3.41.3 Bleaching solution (1 lit. water + two table 1 2
spoon bleaching)
3.42 How often do you clean the hospital floor?
…………………. times daily
9
3.43 Do you maintain a register/log to document YES..............................................................................
the cleaning of hospital floors? NO.............................................................................. 3.45
3.44 May I see the log/register for cleaning of OBSERVED..................................................................
hospital floors? REPORTED, NOT SEEN................................................
3.45 Do you wash the linen with soap water or YES..............................................................................
other appropriate process? NO.............................................................................. 3.49
3.46 May I see what types of materials or process OBSERVED, YES OBSERVED, NO
you use for washing linen?
3.46.1 Soap 1 2
3.46.2 Detergent powder 1 2
3.46.3 Autoclave 1 2
the washing of linen? NO.............................................................................. 3.49
3.48 May I see the log/register for washing of OBSERVED..................................................................
linen? REPORTED, NOT SEEN................................................
3.49 Do you have waste bins available in the YES..............................................................................
outpatient department? NO.............................................................................. 3.51
3.50 May I see which one of the following waste OBSERVED, YES OBSERVED, NO
bins are available in the outpatient
department?
3.50.1 Black 1 2
3.50.2 Yellow 1 2
3.50.3 Red 1 2
3.50.4 Green 1 2
3.50.5 Blue 1 2
inpatient department? NO.............................................................................. 3.53
3.52 May I see which one of the following waste
bins are available in the inpatient OBSERVED, YES OBSERVED, NO
department?
3.52.1 Black 1 2
3.52.2 Yellow 1 2
3.52.3 Red 1 2
3.52.4 Green 1 2
3.52.5 Blue 1 2
emergency department? NO.............................................................................. 3.55
bins are available in the emergency OBSERVED, YES OBSERVED, NO
department?
3.54.1 Black 1 2
3.54.2 Yellow 1 2
3.54.3 Red 1 2
3.54.4 Green 1 2
3.54.5 Blue 1 2
3.55 Do you have a waste disposal system YES..............................................................................
developed as per IPC guideline/protocol? NO.............................................................................. 3.57
OBSERVED, YES OBSERVED, NO
disposal systems are available?
3.56.1 Burn 1 2
3.56.2 Incinerate 1 2
3.56.3 Bury 1 2
3.56.4 Contracting out (check documentation for 1 2
this)
10
3.57 Is hospital wastewater (produced from YES..............................................................................
washbasins, showers, sinks, flushing toilets) NO..............................................................................
removed through city/municipality drainage
system?
3.58 Are hospital wastewaters (produced from YES..............................................................................
washbasins, showers, sinks, flushing toilets) NO..............................................................................
removed through its own on-site disposal
system?
3.58.1 How many beds are available in the impatient
department? …………………. beds
3.58.2 How many toilets are available in the
impatient department? …………………. toilets
3.59 Do you have one (1) toilet for every 6 beds for YES..............................................................................
the inpatient department? NO.............................................................................. Next
Chapter
3.60 May I see whether or not there is one (1) OBSERVED, YES...........................................................
toilet for every 6 beds for the inpatient OBSERVED, NO...........................................................
department?
11
CHAPTER 4: TRIAGE
Objective: Separation of the suspect/confirmed patients from the general people
Ask to be shown the location in the facility where triage is done.
Find the person most knowledgeable about triage in the facility.
4.1 Have you introduced triage for identifying YES..............................................................................

COVID-19 patients in your facility? NO.............................................................................. 4.4
IN PROGRESS.............................................................. 4.4
4.2 Who is responsible for triage today? RESPONSIBLE PERSON 1
[PLEASE BRING INFORMATION OF ALL THE NAME: __________________________________

PERSONS. BRING AT LEAST 3 IF THERE ARE
MORE THAN 3 PERSONS INVOLVED] DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
4.3 May I see the duty roster? OBSERVED..................................................................
4.4 Have you introduced tele-triage system in YES..............................................................................
your facility? NO.............................................................................. 4.7
IN PROGRESS.............................................................. 4.7
4.5 Who is responsible for tele-triage today? RESPONSIBLE PERSON 1
[PLEASE BRING INFORMATION OF ALL THE NAME: __________________________________

MORE THAN 3 PERSONS INVOLVED] DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
12
4.6 May I have the tele-triage number?
NUMBER:
_________________________________
NOT GIVEN.................................................................
4.7 Do you follow Triage Protocol developed by YES..............................................................................
DGHS? (This is described in DGHS’s How to NO.............................................................................. 4.9
Run a COVID Hospital)
4.9 Have you introduced a YES..............................................................................
questionnaire/checklist for triage and NO.............................................................................. 4.12
screening in your facility? IN PROGRESS.............................................................. 4.12
4.10 May I see the questionnaire/checklist? OBSERVED..................................................................
4.11 Does the questionnaire/checklist have OBSERVED, YES...........................................................
standard case definitions of COVID-19 OBSERVED, NO...........................................................
suspected cases based on the national
guideline?
4.12 Do you have any signage and displays YES..............................................................................
showing the patient flow in the outpatient NO.............................................................................. 4.15
department?
4.13 May I see the signage and displays? OBSERVED..................................................................
4.14 Are the signage and displays in Bangla? OBSERVED, YES...........................................................
OBSERVED, NO...........................................................
4.15 Do you have any signage and displays YES..............................................................................
showing the patient flow in the emergency NO.............................................................................. 4.18
department?
4.16 May I see the signage and displays? OBSERVED..................................................................
4.17 Are the signage and displaysin Bangla? OBSERVED, YES...........................................................
OBSERVED, NO...........................................................
4.18 Is there a separate waiting room for YES..............................................................................
suspected COVID-19 cases or patients with flu NO.............................................................................. 4.27
like symptoms?
4.19 May I see the waiting room? OBSERVED..................................................................
4.20 Is there any IPC related information displayed OBSERVED, YES...........................................................
in the waiting room? OBSERVED, NO........................................................... 4.22
4.21 What kind of IPC related information is OBSERVED, YES OBSERVED, NO
displayed in the waiting room?
4.21.1 Poster 1 2
4.21.2 Digital display 1 2
4.21.3 Others (please mention): 1 2
……………………………………
4.22 Are people maintaining physical distancing (1 OBSERVED, YES...........................................................
meter/3 feet) in the waiting room? OBSERVED, NO...........................................................
4.23 Are people maintaining physical distancing (1 OBSERVED, YES...........................................................
meter/3 feet) in the reception area. OBSERVED, NO...........................................................
13
4.24 Is there facilities available for practicing hand OBSERVED, YES...........................................................
hygiene in the waiting room? OBSERVED, NO........................................................... 4.26
4.25 What kind of hand hygiene facilities are OBSERVED, YES OBSERVED, NO
available in the waiting room?
4.25.1 70% alcohol-based hand sanitizers 1 2
4.25.2 Running water 1 2
4.25.3 Soap 1 2
4.25.4 Disposable paper tissues 1 2
4.26 Is there separate toilet facilities in the waiting OBSERVED, YES...........................................................
room? OBSERVED, NO...........................................................
4.27 Have you introduced fever clinic/flu corner in YES..............................................................................
your facility? NO.............................................................................. 4.38
4.28 Who is responsible for fever clinic/flu corner RESPONSIBLE PERSON 1
today?
NAME: __________________________________
NAME: __________________________________
DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
4.29 May I see the duty roster? OBSERVED..................................................................
4.30 May I see the fever clinic/flu corner? OBSERVED..................................................................
4.31 Are the health care providers using PPE in the OBSERVED, YES...........................................................
fever clinic/flu corner? OBSERVED, NO........................................................... 4.33
4.32 What kind of PPE do the health care OBSERVED, YES OBSERVED, NO
providers use in the fever clinic/flu corner
4.32.1 Face mask 1 2
4.32.2 Hand gloves 1 2
4.32.3 Googles 1 2
4.32.5 Gown 1 2
4.32.6 FFP2 respirator/ N95/ HEPA (P100) 1 2
4.32.6.1 Other masks equivalent to FFP2/N95/ HEPA
(P100) Name of the mask: _______________________
4.33 Do the cleaners use PPE? YES.............................................................................. 4.35
NO..............................................................................
4.34 What kind of PPE do the cleaners use in the OBSERVED, YES OBSERVED, NO
fever clinic/flu corner
14
4.34.2 Heavy duty gloves 1 2
4.34.3 Googles 1 2
4.34.5 Gown 1 2
4.34.6 Boots or closed work shoes 1 2
(P100) Name of the mask: _______________________
4.35 Are there facilities available for practicing OBSERVED, YES...........................................................
hand hygienein the fever clinic/flu corner? OBSERVED, NO........................................................... 4.37
4.36 What kind of hand hygiene facilities are OBSERVED, YES OBSERVED, NO
availablein the fever clinic/flu corner.
4.36.3 Soap 1 2
4.37 Are the health care worker and the patient OBSERVED, YES...........................................................
maintaining physical distancing (1 meter/3 OBSERVED, NO...........................................................
feet) in the fever clinic/flue corner?
4.38 Is there a provision of provide face mask to YES..............................................................................
the patients with flu like symptoms? NO..............................................................................
4.39 Do you offer home care for mild and YES..............................................................................
moderate cases? NO.............................................................................. 4.41
4.40 May I see the communication material for OBSERVED..................................................................
this? REPORTED, NOT SEEN.................................................
4.41 Is the triage area cleaned with according to YES..............................................................................
the IPC protocol/guideline? NO.............................................................................. 4.45
4.42 How often is it cleaned?
…………………. Number of times daily
4.43 Do you have a register/service log to YES..............................................................................
document cleaning practice of triage area? NO.............................................................................. 4.45
4.44 May I see the register? OBSERVED..................................................................
4.45 Do you have respiratory hygiene supplies YES..............................................................................
(e.g. mask/ disposable paper tissues) are NO.............................................................................. 5.1
available for staff?
4.46 May I see the respiratory hygiene supplies OBSERVED..................................................................
4.47 Do you have respiratory hygiene supplies YES..............................................................................
(e.g. mask/ disposable paper tissues) are NO.............................................................................. 5.1
available for patients?
4.48 May I see the respiratory hygiene supplies OBSERVED..................................................................
15
CHAPTER 5: CASE MANAGEMENT
Objective: Ensuring adequate treatment of COVID-19 acute respiratory infection
Ask to be shown the location in the facility where COVID-19 case management is done (preferably the isolation unit).
Find the person most knowledgeable about COVID-19 case management in the facility.
5.1 Do you manage COVID-19 patients in this YES..............................................................................
health facility? NO.............................................................................. 5.46
5.2 Do you follow the national COVID-19 case YES..............................................................................
management guideline? NO.............................................................................. 5.4
5.4 Do you follow any specific criteria for YES..............................................................................
admission? NO.............................................................................. 5.7
5.5 What are the admission criteria? Write-down the criteria:
_________________________________________
_
_________________________________________
_
_________________________________________
_ 5.7
NOT MENTIONED.......................................................
5.6 Are the admission criteria consistent with the OBSERVED, YES...........................................................
national guideline? (coded later centrally) OBSERVED, NO...........................................................
referral? NO.............................................................................. 5.10
5.8 What are the referral criteria? Write-down the criteria:
_________________________________________
_
_________________________________________
_
_________________________________________
_ 5.10
NOT MENTIONED.......................................................
5.9 Are the referral criteria consistent with the OBSERVED, YES...........................................................
5.10 Is a referral guideline available? YES..............................................................................
NO.............................................................................. 5.12
discharge? NO.............................................................................. 5.15
16
5.13 What are the discharge criteria? Write-down the criteria:
_________________________________________
_
_________________________________________
_
_________________________________________
_
5.15
NOT MENTIONED.......................................................
5.14 Are the discharge criteria consistent with the OBSERVED, YES...........................................................
5.15 Do you offer mental and psychological YES..............................................................................
support to patients admitted with COVID-19? NO.............................................................................. 5.17
5.16 May I know how?
_________________________________________
_
_________________________________________
_
_________________________________________
_
NOT MENTIONED.......................................................
5.17 Do you have a dedicated isolation unit for YES..............................................................................
clinical management of COVID-19 cases? NO.............................................................................. 5.32
5.18 May I see the isolation unit for clinical OBSERVED..................................................................
management of COVID-19 cases? REPORTED, NOT SEEN................................................. 5.32
5.19 How many beds are there in the isolation …………………. Bed observed
unit?
5.20 Is there at least three feet of distance OBSERVED, YES...........................................................
between the beds in the isolation unit? OBSERVED, NO...........................................................
5.21 Are the health care providers using PPE in OBSERVED, YES...........................................................
the isolation unit? OBSERVED, NO........................................................... 5.23
5.22 What kind of PPE are the health care OBSERVED, OBSERVED, NO
providers using health care providers in the YES
isolation unit.
5.22.3 Googles 1 2
5.22.5 Gown 1 2
(P100) Name of the mask: _______________________
17
5.23 Are the patients wearing PPE in the isolation OBSERVED, YES...........................................................
unit? OBSERVED, NO.........................................................................
5.25
Mention your specific observation:
_____________________________________
_________________________________________
_
_________________________________________
_
5.24 What kind of PPE are the patients using in OBSERVED, OBSERVED, NO
the isolation unit? YES
5.24.1 Facemask 1 2
5.24.3 1 2
Others (Specify):…………………………………
5.25 Is there any facility for practicing hand OBSERVED, YES...........................................................
hygiene in the isolation unit? OBSERVED, NO.........................................................................
5.27
5.26 What kind of facility is available for practicing OBSERVED, OBSERVED, NO
hand hygiene in the isolation unit? YES
5.26.3 Soap 1 2
5.26.4A How many beds are available in the isolation
unit? …………………. beds
5.26.4B How many toilets are available in the
isolation unit? …………………. toilets
5.27 Do the patients have one (1) toilet for every OBSERVED, YES...........................................................
6 beds in the isolation unit? OBSERVED, NO.........................................................................
5.28 Do you disinfect or sterilize the isolation YES..............................................................................
unit? NO.............................................................................. 5.32
5.29 How often do you disinfect or sterilize the
isolation unit? (bring time interval) …………………. times daily
the disinfection or sterilization process? 5.32
NO............................................................................................
REPORTED, NOT SEEN..............................................................
5.32 Do you have a dedicated ICU for clinical YES..............................................................................
management of COVID-19 cases? NO.............................................................................. 5.41
5.33 May I see the dedicated ICU for COVID-19 OBSERVED..................................................................
cases? REPORTED, NOT SEEN.................................................
5.34 How many beds are there in the dedicated
ICU? …………………. beds observed
5.35 Are the beds in the dedicated ICU equipped OBSERVED, YES...........................................................
to monitor vital signs? (bed side monitor) OBSERVED, NO.........................................................................
5.36 Are the health care providers using PPE in OBSERVED, YES...........................................................
the dedicated ICU? OBSERVED, NO........................................................... 5.38
5.37 What kind of PPE are the health care OBSERVED, OBSERVED, NO OBSERVATION
providers using in the dedicated ICU? YES NOT POSSIBLE
5.37.1 Face mask 1 2 3
5.37.2 Hand gloves 1 2 3
5.37.3 Googles 1 2 3
18
5.37.4 Face shield 1 2 3
5.37.5 Gown 1 2 3
5.37.6 FFP2 respirator/ N95/ HEPA (P100) 1 2 3
(P100) Name of the mask: _______________________
5.38 Do you monitor vital signs for all admitted YES..............................................................................
COVID-19 patients? NO............................................................................................
5.41
5.39 May I see the documentation in this regard? OBSERVED..................................................................
5.40 Observe whether the documentation OBSERVED, YES...........................................................
indicate that vital signs were monitored OBSERVED, NO.........................................................................
regularly. Mention your specific observation:
_____________________________________
_________________________________________
_
_________________________________________
_
5.41 Do you provide tele-medicine services to the YES..............................................................................

patients sent to home isolation/quarantine? NO.............................................................................. 5.44
5.42 Do you maintain a register/log for the YES..............................................................................
telemedicine services? NO..............................................................................
5.44 Is Hospital Authority provide nutritious foods YES..............................................................................
for the admitted patients? NO.............................................................................. 5.46
5.45 May I see the documentation in this regard? OBSERVED..................................................................
5.46 Do you have an oxygen plant in this health YES..............................................................................
facility? NO............................................................................................
5.49
5.47 May I see the oxygen plant? OBSERVED..................................................................
REPORTED, NOT SEEN................................................ 5.49
5.48 Is the oxygen plant is functioning? OBSERVED, YES...........................................................
OBSERVED, NO.........................................................................
5.49 Do you have a liquefied oxygen system in this YES..............................................................................
health facility? NO.............................................................................. 5.52
5.50 May I see the liquefied oxygen system? OBSERVED..................................................................
REPORTED, NOT SEEN.............................................................. 5.52
5.51 Is the liquefied oxygen system is functioning? OBSERVED, YES...........................................................
OBSERVED, NO...........................................................
5.52 Do you have an oxygen manifold system in YES..............................................................................
this health facility? NO.............................................................................. 6.1
5.53 May I see the oxygen manifold system? OBSERVED..................................................................
REPORTED, NOT SEEN................................................. 6.1
5.54 Is the oxygen manifold system is functioning? OBSERVED, YES...........................................................
OBSERVED, NO...........................................................
19
CHAPTER 6: MONITORING, SURVEILLANCE & RISK COMMUNICATION
Objective: Ensuring continuous monitoring and surveillance of COVID-19 situation to inform planning and adjustment in
implementation status
Appropriate practice regarding monitoring, surveillance & risk communication is applicable for the whole facility
Find the person most knowledgeable about “MONITORING, SURVEILLANCE & RISK COMMUNICATION” in the facility.
NO QUESTIONS AND FILTERS COADING CATAGORIES SKIP
6.1 Do you upload COVID-19 specific information YES...........................................................................................

in DHIS2 from your facility? NO............................................................................................
6.3
6.2 RESPONSIBLE PERSON 1
NAME: __________________________________
DESIGNATION: ____________________________
Who is responsible for uploading COVID-19
specific information in DHIS2?
NAME: __________________________________
DESIGNATION: ____________________________
NAME: __________________________________
DESIGNATION: ____________________________
6.3 YES...........................................................................................
Did you upload the information for yesterday?
NO............................................................................................
6.5
6.4 OBSERVED................................................................................
Can you show me the report?
6.5 Do you maintain a separate register for YES...........................................................................................

COVID-19 cases in your facility? NO............................................................................................
6.7
6.6 Where do you maintain the separate register REPORTED, NOT

OBSERVED
for COVID-19 cases in your facility? NOT SEEN AVAILABLE
6.6.1 At triage 1 2 3
6.6.2 At isolation unit 1 2 3
6.6.3 ICU 1 2 3
6.6.4 ANC Corner/Maternity Care Room at OPD 1 2 3
6.6.5 IMCI Corner/Child Care Room at OPD 1 2 3
6.7 Do you have COVID-19 related Social and YES...........................................................................................

Behavioral Change Communication (SBCC) NO............................................................................................
6.9
materials in your facility?
20
6.8 What kind of COVID-19 related Social and
REPORTED, NOT
Behavioral Change Communication (SBCC) OBSERVED
NOT SEEN AVAILABLE
materials do you have in your facility?
6.8.1 Poster 1 2 3
6.8.2 Flayer 1 2 3
6.8.3 Job aid 1 2 3
6.8.4 Led message 1 2 3
6.8.5 Others (specify ……………………….) 1 2 3
6.9 Do you have COVID-19 related risk YES...........................................................................................

communication measures in your facility? NO............................................................................................
6.11
6.10 What kind of COVID-19 related risk

REPORTED, NOT
communication measures do you have in your OBSERVED
NOT SEEN AVAILABLE
facility?
6.10.1 Call center 1 2 3
6.10.2 Health education 1 2 3
6.10.3 Miking 1 2 3
6.10.4 Display of message in poster 1 2 3
6.11 Do you have a mechanism to review COVID-19 YES..............................................................................1

situation per day in the facility? NO............................................................................................
Next
Chapter
6.12 May I see the documentation in this regard? OBSERVED..................................................................1

21
CHAPTER 7: ESSENTIAL SUPPORT SERVICE
Objective: Implement financial managerial and administrative support mechanisms needed for the response.
Appropriate practice regarding essential support services is applicable for the whole facility.
Find the person most knowledgeable about essential support service in the facility.
NO QUESTIONS AND FILTERS CODING CATEGORIES SKIP
Does the facility provide accommodations for YES........................................................................1

7.1 health care providers assigned for COVID-19 NO.........................................................................2 7.3
response?
Where is the accommodation facility for INSIDE THE HOSPITAL AREA .................................A
health care workers assigned for COVID-19 OUTSIDE THE HOSPITAL AREA ..............................B
7.2 response?
Please specify: _____________________________
Does the facility supply food for health care YES........................................................................1

7.3
workers assigned for COVID-19 response? NO.........................................................................2 7.7
NAME: __________________________________
DESIGNATION: ____________________________
Who is the responsible person for supplying
food for health care workers assigned for RESPONSIBLE PERSON 2
COVID-19 response?
7.4 NAME: __________________________________
NAME: __________________________________
DESIGNATION: ____________________________
Do you have a log/register to document the YES........................................................................1

7.5
supply of food? NO.........................................................................2 7.7
May I see the log/register? OBSERVED.............................................................1

7.6
REPORTED, NOT SEEN...........................................2
Does the facility have vehicle for YES........................................................................1

7.7 transportation of health care workers NO.........................................................................2 7.11
assigned for COVID-19 response?
May I see the vehicle that is used for OBSERVED.............................................................1

7.8
transportation of health care workers REPORTED, NOT SEEN...........................................2
Do you maintain a log/register to document YES........................................................................1

7.9
the transportation of health care workers NO.........................................................................2 7.11
22
7.10 May I see the log/register? OBSERVED.............................................................1
Does the facility have designated area as a YES........................................................................1

7.11
morgue? NO.........................................................................2 7.13
May I see the designated area for morgue? OBSERVED.............................................................1

7.12
7.13 Are diagnostic procedures free for COVID-19 YES........................................................................1

suspected cases? NO.........................................................................2
7.14 Are treatment costs of COVID-19 infected YES........................................................................1

patients free in the facility? NO.........................................................................2
23
CHAPTER 8: ESSENTIAL HEALTH SERVICES AND PATIENT CARE
Objectives: Ensuring uninterrupted & continuity of essential medical and surgical care (e.g. emergency services, urgent
surgical operations)
Appropriate practice regarding essential health services and patient care for the whole facility
Find the person most knowledgeable about essential health services in the facility
Introduce yourself, explain the purpose of the survey and ask the following questions
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
8.1 Do you have roster duty schedule for health YES........................................................................1
care providers in your facility? NO.........................................................................2 8.3
8.2 May I see the roster duty schedule for health OBSERVED.............................................................1
care providers? REPORTED, NOT SEEN...........................................2
8.3 Does the facility have backup personnel for YES........................................................................1
roster duties? NO.........................................................................2 8.5
8.4 May I see the list of backup personnel for OBSERVED.............................................................1
roster duties? REPORTED, NOT SEEN...........................................2
8.5 Do you provide 24/7 emergency services? YES........................................................................1 8.8
NO.........................................................................2
8.6 Do you have a duty schedule for maintaining YES........................................................................1 8.8
24/7 emergency services? NO.........................................................................2
8.7 May I see the duty schedule for maintaining OBSERVED.............................................................1
24/7 emergency services? REPORTED, NOT SEEN...........................................2
8.8 Do you provide 24/7 inpatient services? YES........................................................................1 8.11

NO.........................................................................2
8.9 Do you have a duty schedule for maintaining YES........................................................................1
24/7 inpatient services? NO.........................................................................2
24/7 inpatient services? REPORTED, NOT SEEN...........................................2
8.11 Do you provide 24/7 emergency OT services? YES........................................................................1 8.14
NO.........................................................................2
8.12 Do you have a duty schedule for maintaining YES........................................................................1

24/7 emergency OT services? NO.........................................................................2
24/7 emergency OT services? REPORTED, NOT SEEN...........................................2
8.14 Do you have an anesthetist/ICU specialist YES........................................................................1 8.17
present at the facility or remain on call for NO.........................................................................2
providing 24/7 ICU services (including
weekends and public holidays)
8.15 Do you have a duty schedule or call list? YES........................................................................1 8.17
NO.........................................................................2
8.16 May I see the duty schedule or call list? OBSERVED.............................................................1
8.17 Do you have adequate human resources YES........................................................................1

available in the facility to ensure the NO.........................................................................2
continuity of the identified essential hospital
services?
8.18 Do you have adequate logistics available in YES........................................................................1
the facility to ensure the continuity of the NO.........................................................................2
identified essential hospital services?
CHAPTER 9: EQUIPMENT
Objectives: To assess the availability and functionality of equipment to manage COVID-19 patients)
24
Find the person most knowledgeable about functional equipment
Do you have the following (A) AVAILABLE (B) FUNCTIONAL & REPAIRABLE
equipment available today
9
in your facility?
Are they functioning?
OBSERVED REPORTED NOT HOW MANY HOW MANY
NOT SEEN AVAILABLE ARE ARE
FUNCTIONAL REPAIRABLE
Oxygen concentrator, 5 1→b 2→b 3→ 9.2
9.1
LPM
Oxygen concentrator, 10 1→b 2→b 3→ 9.3
9.2
LPM
Oxygen cylinder, Size C, 1→b 2→b 3→ 9.4
9.3
170 liters
Oxygen cylinder, Size D, 1→b 2→b 3→ 9.5
9.4
240 liters
Oxygen cylinder, Size E, 1→b 2→b 3→ 9.6
9.5
680 liters
Oxygen cylinder, Size F, 1→b 2→b 3→ 9.7
9.6
1360 liters
Oxygen cylinder, Size G, 1→b 2→b 3→ 9.8
9.7
3400 liters
Oxygen cylinder, Size H, 1→b 2→b 3→ 9.9
9.8
4100 liters
Oxygen cylinder, Size J, 1→b 2→b 3→ 9.10
9.9
6800 liters
Flow-splitter, for oxygen 1→b 2→b 3→ 9.11
9.10
supply
9.11 Flowmeter, Thorpe tube 1→b 2→b 3→ 9.12
9.12 Humidifier, non-heated 1→b 2→b 3→ 9.13
9.13 Humidifier, heated 1→b 2→b 3→ 9.14
Nasal oxygen cannula, with 1→b 2→b 3→ 9.15
9.14
prongs
9.15 Bag Valve mask-adult 1→b 2→b 3→ 9.16
9.16 Bag Valve mask –child 1→b 2→b 3→ 9.17
9.17 Bag Valve mask -infant 1→b 2→b 3→ 9.18
9.18 Pulse Oximeter: Finger top 1→b 2→b 3→ 9.19
9.19 Pulse Oximeter: Handheld 1→b 2→b 3→ 9.20
9.20 Pulse Oximeter: Table top 1→b 2→b 3→ 9.21
9.21 Portable Ultra sonogram 1→b 2→b 3→ 9.22
9.22 Biochemistry analyzer 1→b 2→b 3→ 9.23
9.23 Digital thermometer 1→b 2→b 3→ 9.24
9.24 Non-touch thermometer 1→b 2→b 3→ 9.25
9.25 Cricothyrotomy set 1→b 2→b 3→ 9.26
High Flow Nasal Cannula, 1→b 2→b 3→ 9.27
9.26
with accessories
9.27 Electronic drop counter 1→b 2→b 3→ 9.28
Continuous positive air 1→b 2→b 3→ 9.29
pressure (CPAP), with
9.28 tubing and patient
interfaces for adult and
pediatric
Bilevel positive airway 1→b 2→b 3→ 9.30
9.29
pressure (BIPAP)
25
Ventilator patient, for 1→b 2→b 3→ 9.31
9.30
adult. (Non-invasive)
Ventilator patient, 1→b 2→b 3→ 9.32
9.31
pediatric (Non-invasive)
Patient ventilator, for 1→b 2→b 3→ 9.33
9.32
critical care (invasive)
Colorimetric end tidal CO2 1→b 2→b 3→ 9.34
9.33
detector
Endotracheal tube 1→b 2→b 3→ 9.35
9.34
introducer, Stylet
Endotracheal tube 1→b 2→b 3→ 9.36
9.35
introducer, Bougie
Endotracheal tube, with 1→b 2→b 3→ 9.37
9.36
cuff
Endotracheal tube, 1→b 2→b 3→ 9.38
9.37
without cuff
9.38 First aid box 1→b 2→b 3→ 9.39
9.39 Laryngoscope - adult/child 1→b 2→b 3→ 9.40
9.40 Laryngoscope - neonate 1→b 2→b 3→ 9.41
9.41 Resuscitator, adult 1→b 2→b 3→ 9.42
9.42 Resuscitator, child 1→b 2→b 3→ 9.43
9.43 Suction devices 1→b 2→b 3→ 9.44
Patient monitor, 1→b 2→b 3→ 9.45
9.44 multiparametric with ECG,
with accessories
Patient monitor, 1→b 2→b 3→ 9.46
9.45 multiparametric without
ECG, with accessories
9.46 Infusion pump 1→b 2→b 3→ 9.47
9.47 Blood Gas Analyzer 1→b 2→b 3→ 9.48
Drill, for vascular access, 1→b 2→b 3→ 9.49
9.48 w/accessories, w/transport
bag
Electrocardiograph, 1→b 2→b 3→ 9.50
9.49
portable w/accessories
Tubing, medical gases, int. 1→b 2→b 3→ 9.51
9.50
diam. 5 mm
Filter, heat and moisture 1→b 2→b 3→ 9.52
9.51
exchanger (HMEF)
9.52 Conductive gel, container 1→b 2→b 3→ 9.53
9.53 Nasal Catheter 1→b 2→b 3→ 9.54
9.54 Venturi Mask, 1→b 2→b 3→ 9.55
Airway, nasopharyngeal, 1→b 2→b 3→ 9.56
9.55
sterile
9.56 Airway, oropharyngeal, 1→b 2→b 3→ 9.57
Laryngeal mask airway 1→b 2→b 3→ 9.58
9.57
(LMA)
Lubricating jelly 1→b 2→b 3→ Next
9.58
Chapter
26
CHAPTER 10: MATERNAL, NEWBORN, AND CHILD HEALTH (MNCH)
Objective: Ensuring uninterrupted & continuity of essential maternal and child-care
Ask to be shown the location in the facility where MNCH services are provided.
Find the person most knowledgeable about MNCH services in the facility.
NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP
10.1 Do you provide MNCH and FP service? YES........................................................................1
NO………………………………………………………………………2 Next
Chapter
10.2 Do you have National protocol for MNCH and YES........................................................................1
FP services during COVID-19 available in the NO………………………………………………………………………2 10.4
facility?
10.3 May I see the protocol? OBSERVED.............................................................1
10.4 Have the Health Service Providers received YES........................................................................1
training on providing MNCH and FP service NO………………………………………………………………………2
during Covid19?
10.5 Do you have a log/register that documented YES........................................................................1
the name of health service providers as per NO.........................................................................2 Next
the name of the trainings they received? Chapter
10.6 May I see the log or register? OBSERVED.............................................................1
27
CHAPTER 11: MATERNAL HEALTH SERVICE (ANTENATAL CARE (ANC)
Objective: Provide antenatal care service to pregnant mothers
Ask to be shown the location in the facility where ANC is given.
Find the person most knowledgeable about ANC in the facility.
11.1 Do you provide ANC services in general? YES........................................................................1
NO.........................................................................2 Next
Chapter
11.2 Are you continuing the services in the context YES........................................................................1
of COVID-19 in your facility? NO.........................................................................2 Next
Chapter
11.3 How many face to face ANC visits are you
recommending in the context of COVID-19? ________________ completed numbers
11.4 Do you provide ANC services through tele- YES........................................................................1
medicine in your facility? NO.........................................................................2 11.9
11.5 Do you maintain a separate register for YES........................................................................1
providing ANC service through tele-medicine? NO.........................................................................2 11.7
11.6 May I see the register for documenting the OBSERVED.............................................................1
ANC service through tele-medicine? REPORTED, NOT SEEN...........................................2 11.9
11.7 Do you document ANC services through tele- YES........................................................................1
medicine in the regular ANC register? NO.........................................................................2
(If no separate register is maintained),
11.8 How do you document the tele-medicine ANC

services? (if no in the previous question)
(open ended_)
11.9 Are you facing any challenge in continuing YES........................................................................1

ANC services in the context of COVID-19? NO.........................................................................2 11.11
11.10 What are the challenges that you are facing in
providing ANC services in the context of
COVID-19? [open narrative]
11.11 Do the health care provider and the patient OBSERVED, YES.....................................................1
maintain at least three feet/ one meter to OBSERVED, NO......................................................2
physical distancing in the ANC corner or
room? (observe 1-2 ANC contacts if possible)
11.12 Does the health care provider disinfect the OBSERVED, YES.....................................................1
equipment every time after using? OBSERVED, NO......................................................2
11.13 Does the health care provider use the OBSERVED, YES OBSERVED, NO
following PPE in the ANC service are?
(observe 1-2 ANC contacts if possible)
11.13.1 Face mask 1 2
11.13.3 Googles 1 2
11.13.5 Gown 1 2
11.3.7 Other masks equivalent to FFP2/N95/ HEPA
(P100) Name of the mask: _______________________
11.14 Does the patient use the following PPE in the OBSERVED, YES OBSERVED, NO
ANC service are?
11.14.1 Face mask 1 2
28
CHAPTER 11: MATERNAL HEALTH SERVICE (ANTENATAL CARE (ANC)
Objective: Provide antenatal care service to pregnant mothers
Ask to be shown the location in the facility where ANC is given.
Find the person most knowledgeable about ANC in the facility.
11.14.2 Other (specify, ……………..) 1 2
11.15 Are the following hand hygiene items OBSERVED, YES OBSERVED, NO
available in ANC service area?
11.15.1 70% Alcohol-based hand sanitizers 1 2
11.15.3 Soap 1 2
29
CHAPTER 12: MATERNAL HEALTH SERVICE (LABOUR ROOM)
Objective: Provide delivery care services to the pregnant mother
ASK TO BE SHOWN THE LOCATION IN THE FACILITY WHERE LABOUR ROOM IS LOCATED.
FIND THE PERSON MOST KNOWLEDGEABLE ABOUT LABOUR ROOM IN THE FACILITY.
INTRODUCE YOURSELF, EXPLAIN THE PURPOSE OF THE SURVEY AND ASK THE FOLLOWING QUESTIONS.
12.1 Do you provide labour and delivery services in YES...........................................................................................
your facility in general? NO............................................................................................
Next
Chapter
12.2 Are you continuing the labour and delivery YES...........................................................................................
services in the context of COVID-19 in your NO............................................................................................
Next
facility? Chapter
12.3 Do you provide labour and delivery to suspect YES...........................................................................................
or confirmed COVID-19 women? NO............................................................................................
12.11
12.4 Do you have separate labour room for YES...........................................................................................
suspect or confirmed COVID-19 women? NO............................................................................................
12.5 Do you have separate labour table in the YES...........................................................................................
general labour room for suspect or confirmed NO............................................................................................
COVID-19 women?
12.6 Do you have separate OT for Csection for YES...........................................................................................
12.7 Do you provide mask to the mothers during YES...........................................................................................
delivery? NO............................................................................................
12.8 Do you use separate set of instruments for YES...........................................................................................
individual patients? NO............................................................................................
12.9 Do you disinfect all Instruments after each YES...........................................................................................
delivery? NO............................................................................................
12.10 Do you dispose the miscarried YES...........................................................................................
embryos/fetuses and placenta of COVID-19 NO............................................................................................
infected women in separate biohazard bags?
12.11 Do you wash all surfaces are washed with YES...........................................................................................
1:100 bleach solution (which contains 0.05% NO............................................................................................
chlorine concentration)
12.12 Observe weather the health care providers OBSERVED, YES...........................................................
use PPE in the labour room? OBSERVED, NO......................................................................... 12.14
OBSERVED, NOT POSSIBLE…………………………………..3
12.13 Does the health care provider use the OBSERVED, OBSERVED, NO OBSERVATION
following PPE in the Labour and delivery YES NOT POSSIBLE
area?
(observe 1-2 labour o delivery if possible)
12.13.1 Face mask 1 2 3
12.13.2 Hand gloves 1 2 3
12.13.3 Googles 1 2 3
12.13.4 Face shield 1 2 3
12.13.5 Gown 1 2 3
12.13.6 Shoe cover
12.13.7 FFP2 respirator/ N95/ HEPA (P100) 1 2 3 12.14

12.13.8 Other masks equivalent to FFP2/N95/HEPA
(P100) Name of the mask: _______________________
12.14 Does the patient use the following PPE in the OBSERVED, OBSERVED, NO OBSERVATION
delivery room are? YES NOT POSSIBLE
12.14.1 Face mask 1 2 3
30
12.14.2 Other (specify, ……………..) 1 2 3
12.15 Are the following hand hygiene items OBSERVED, OBSERVED, NO OBSERVATION
available in labour and delivery area? YES NOT POSSIBLE
12.15.1 70% Alcohol-based hand sanitizers 1 2 3
12.15.2 Running water 1 2 3
12.15.3 Soap 1 2 3
12.15.4 Disposable paper tissues 1 2 3
31
CHAPTER 13: FAMILY PLANNING SERVICE
Objective: Provide family planning service
Ask to be shown the location in the facility where family planning service is given.
Find the person most knowledgeable about family planning service in the facility.
Do you provide Family planning services in YES...........................................................................................
13.1 your facility in general? NO............................................................................................
Next
Chapter
Are you continuing the Family planning YES...........................................................................................
13.2 services in the context of COVID-19 in your NO............................................................................................
Next
facility? Chapter
Do you provide Family planning services to YES...........................................................................................
13.3
How many days in a month are family
planning services offered at this facility during
COVID-19 pandemic? …………………. Number of days
13.4
[USE A 4-WEEK MONTH TO CALCULATE # OF
DAYS]
Do you provide family planning services YES..........................................................................................
13.5 through tele-medicine in your facility? NO.............................................................................. 13.11
Do you maintain a separate register for YES...........................................................................................
13.6 providing family planning service through NO.........................................................................2 13.8
tele-medicine?
May I see the register for documenting the OBSERVED.............................................................1
13.7 family planning service through tele- REPORTED, NOT SEEN.................................................
medicine?
Do you document family planning services YES...........................................................................................
through tele-medicine in the regular family NO..............................................................................
13.8
planning register?
(If no separate register is maintained),
How do you document the tele-medicine
family planning services? (if no in the previous
13.9
question)
(open ended)
What type of method do you suggest over
13.10 phone that is available without prescription? ……………………………………………………..
(OPEN ENDED)
Do you give more amount of short acting YES...........................................................................................
13.11
contraceptives than usual to the clients? NO.........................................................................2 13.13
Which contraceptive method do you use most
commonly to ensure immediate post-partum
13.12
contraceptive services during COVID-19? ……………………………………………………..
(OPEN ENDED)
Are you facing any challenge in continuing YES........................................................................1
13.13 family planning servicesin the context of NO.........................................................................2 13.15
COVID-19?
What are the challenges that you are facing in
13.14 providingfamily planning servicesin the
context of COVID-19? [open narrative]
Do the health care provider and the patient OBSERVED, YES.....................................................1
maintain at least three feet/ one meter to OBSERVED, NO.........................................................................
13.15 physical distancing in the family planning
service room? (observe 1-2 FP contacts if
possible)
32
Does the health care provider use the OBSERVED, YES OBSERVED, NO
following PPE in the during proving family
13.16
planning services(observe 1-2 FP contacts if
possible)
13.16.1 Face mask 1 2
13.16.3 Googles 1 2
13.16.5 Gown 1 2
(P100) Name of the mask: _______________________
Does the patient use the following PPE in the OBSERVED, YES OBSERVED, NO
13.17
family planning services area?
13.17.1 Face mask 1 2
13.17.2 Other (specify, ……………..)
Are the following hand hygiene items OBSERVED, YES OBSERVED, NO
13.18
available in family planning services area?
13.18.3 Soap 1 2
Does this facility provide (i.e., stock the
PROVIDE PRESCRIBE/
commodity) or prescribe, counsel or refer NOT
13.19 (STOCK THE COUNSEL OR
clients for any of the following modern AVAILABLE
COMMODITY) REFER
methods of family planning?
13.19 Oral pills 1 2 3
13.19.1 Condoms 1 2 3
13.19.2 IUD 1 2 3
13.19.3 Implant 1 2 3
13.19.4 Emergency contraceptive pills 1 2 3
13.19.5 Vasectomy 1 2 3
13.19.6 Ligation 1 2 3
13.19.7 Counsel clients on lactation amenorrhea 1 2 3
(LAM)
33
CHAPTER 14: CHILD HEALTH SERVICE
Objective: Provide health care service to the children
Ask to be shown the location in the facility where child health service delivery point located.
Find the person most knowledgeable about child health service in the facility.
14.1 Do you provide child health service in YES...........................................................................................
general? NO............................................................................................
Next
Chapter
14.2 Are you continuing the services in the context YES...........................................................................................
of COVID-19 in your facility? NO............................................................................................
Next
Chapter
14.3 Do you provide child health service to the YES...........................................................................................
suspected or confirmed COVID children? NO............................................................................................
14.3.1 How many days in a month are child health
service offered at this facility during COVID-19
pandemic? …………………. Number of days
[USE A 4-WEEK MONTH TO CALCULATE # OF

DAYS]
14.3.2 Do you provide child health service through YES..........................................................................................
tele-medicine in your facility? NO............................................................................................
14.4
14.3.3 Do you maintain a separate register for YES...........................................................................................
providing child health service through tele- NO............................................................................................
14.4
medicine?
14.3.4 May I see the register for documenting the OBSERVED.............................................................1
child health service through tele-medicine? REPORTED, NOT SEEN..............................................................
14.4 Do you sanitize all equipment (thermometer, YES...........................................................................................
ARI timer, MUAC tape) properly with 70% NO.........................................................................2
alcohol-based hand sanitizer after each use?
14.5 Do you wash all surfaces with 1:100 bleach YES...........................................................................................
solution (which contains 0.05% chlorine NO.........................................................................2
concentration)
14.6 Do the health care provider and the patient OBSERVED, YES.....................................................1
maintain at least three feet/ one meter to OBSERVED, NO.........................................................................
physical distancing in the child health care
corner or room? (observe 1-2 contacts if
possible)
14.7 Does the health care provider use the OBSERVED, YES OBSERVED, NO
following PPE in the child health servicearea?
14.7.3 Googles 1 2
14.7.5 Gown 1 2
14.7.6 FFP2 respirator/ N95/ HEPA/(P100) 1 2 14.8
(P100) Name of the mask: _______________________
14.8 Does the patient use the following PPE in the OBSERVED, YES OBSERVED, NO
child health service area?
14.8.2 Other (specify, ……………..) 1 2
14.9 Are the following hand hygiene items OBSERVED, YES OBSERVED, NO
available in the child health service area?
34
14.9.3 Soap 1 2
35
CHAPTER 15: IMMUNIZATION AND NUTRITION SERVICES
Objective: To ensure uninterrupted & continuity of immunization and nutrition services
Ask to be shown the location in the facility where immunization and nutrition services are provided.
Find the person most knowledgeable about immunization and nutrition services in the facility.
NO. QUESTIONS AND FILTERS CODING CATEGORIES
15.1 Do you provide immunization service in YES........................................................................1
general? NO.........................................................................2 Next
Chapter
of COVID-19 in your facility? NO.........................................................................2 Next
Chapter
15.3 May I see the immunization register? OBSERVED.............................................................1
15.4 How many days in a month immunization
services offered in this facility during COVID-
19 pandemic? …………………. Number of days
USE A 4 WEEK MONTH TO CALCULATE # OF
DAYS
15.5 Do you provide essential nutrition service in YES........................................................................1
general? NO..............................................................................
of COVID-19 in your facility? NO..............................................................................
15.7 Do you provide nutrition service to the YES........................................................................1
suspected or confirmed COVID children? NO..............................................................................
15.8 How many days in a month Nutrition services
offered in this facility during COVID-19
pandemic? …………………. Number of days
USE A 4 WEEK MONTH TO CALCULATE # OF
DAYS
36
CHAPTER 16: DRUGS
Objectives: To estimate availability of drugs for COVID-19 patients
Ask to be shown the main location in the facility where medicines and other supplies are stored.
Find the person most knowledgeable about storage and management of medicines and supplies in the facility.
I would like to know if the following medicines are available today in this facility. If any of the medicines I mention is
stored in another location in the facility, please tell me where in the facility it is stored so I can go there to verify.
Are any of the following drugsavailable (A) OBSERVED AVAILABLE (B) NOT OBSERVED
in this facility/location today? AT LEAST AVAILABLE REPORTED NOT NEVER
16
CHECK TO SEE IF AT LEAST ONE IS VALID ONE VALID NONE VALID AVAILABLE AVAILABLE AVAILABLE
(NOT EXPIRED) NOT SEEN TODAY/DK
16.1 Paracetamol/ acetaminophen 1 2 3 4 5
16.2 Antihistamine 1 2 3 4 5
16.3 Intravenous fluid 1 2 3 4 5
16.4 Crystalloid and colloid fluid 1 2 3 4 5
16.5 Norepinephrine 1 2 3 4 5
16.6 Vasopressor 1 2 3 4 5
16.7 Epinephrine 1 2 3 4 5
16.8 Dopamine 1 2 3 4 5
16.9 Dobutamine 1 2 3 4 5
16.10 Intravenous hydrocortisone (IV) 1 2 3 4 5
16.11 Systemic corticosteroid (Prednisolone) 1 2 3 4 5
16.12 Zinc 1 2 3 4 5
16.13 Vitamin C 1 2 3 4 5
16.14 Oseltamivir 1 2 3 4 5
16.15 Lopinavir 1 2 3 4 5
16.16 Ritonavir 1 2 3 4 5
16.17 Penicillin 1 2 3 4 5
16.18 Cephalosporins 1 2 3 4 5
16.19 Linezolid 1 2 3 4 5
16.20 Ceftriaxone 1 2 3 4 5
16.21 Moxifloxacin 1 2 3 4 5
16.22 Vancomycin 1 2 3 4 5
16.23 Imipenem 1 2 3 4 5
37
Additional information:
Signature: Signature:
Data collector’s name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name of health manager: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Designation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Designation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Contact number: Contact number:
Name of agency: Name of health facility:
List of responders with name designation and contact number:
N.B please send scan copy to hss@mis.dghs.gov.bd; arif24ju@gmail.com; directorhospital@ld.dghs.gov.bd
38

Health Facility Preparedness Readiness Rapid Assessment Checklist For COVID-19-icddrb-V10

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Health Facility Preparedness Readiness Rapid Assessment Checklist For COVID-19-icddrb-V10

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Preparedness & Readiness of Health Facilities for managing COVID-19 in Bangladesh-

Rapid Assessment Checklist

Assessment date: |____ ____|____ ____|____ ____ ____ ____|

Facility Code: |____|____|____|____|

Facility Name: ______________________________________________________________________________________

Facility Status: ☐COVID-Designated☐ COVID-Non-designated

Facility Category:☐ Medical College Hospital☐ District Hospital☐Upazila Health Complex

Type of Facility: ☐ Government ☐ Private ☐ NGO ☐ Other (Please specify) ___________________________________

Name of the Assessor: _____________________________________

Assessment Completed: ☐ Yes ☐ No

Have Triage facility: ☐ Yes ☐ No

Have Isolation facility: ☐ Yes ☐ No If yes, number of beds: |___|___|___|

Have ICU facility: ☐ Yes ☐ No If yes, number of beds: |___|___|___|

Emergency mobile number of health facility:|___|___|___|___|___|___|___|___|___|___|___|

Mobile number of Ambulance: |___|___|___|___|___|___|___|___|___|___|___|

INTERVIEWER'S SIGNATURE INTERVIEWEE’S SIGNATURE

May I begin the interview? Yes ……………………….1

INTERVIEW START TIME H H : M M

1.1 Specialist/Consultant Physician

1.1.1 Specialist/Consultant Physician for ICU/

1.2 Medical Officer/Assistant Surgeon/EMO/ IMO/

1.5 Medical technologist (Lab)

1.6 Medical technologist (EPI)

1.7 Ward Boy

1.9 Ambulance Driver

2.1 Have you formed a Core Committee to YES..............................................................................

2.2 May I see a document that supports OBSERVED..................................................................

2.3 Have you developed a Term of Reference/Job YES..............................................................................

2.4 May I see a document that described the job OBSERVED..................................................................

[DOCUMENT OF 2.2 AND 2.4 CAN BE THE

2.4.1 Do you have full contact details of the core YES..............................................................................

2.4.2 May I see the contact details? OBSERVED..................................................................

2.5 Have you a designated room for Core YES..............................................................................

2.7 Do you have a procedure to keep track YES..............................................................................

2.8 May I see the last meeting note? OBSERVED..................................................................

2.9 Have you appointed a key communication YES..............................................................................

2.11 Have you identified a backup member for YES..............................................................................

2.12 Who is the backup member? Name and RESPONSIBLE PERSON 1

2.13 Have you developed an Emergency YES..............................................................................

2.14 May I see the plan? OBSERVED..................................................................

2.15 Do you have a plan to keep track and custody YES..............................................................................

2.16 May I see the plan? OBSERVED..................................................................

2.17 Do you have a plan for staff absences, in YES..............................................................................

[SHOW THE TITLE PAGE OF THE SoP SAVED IN

[SHOW THE TITLE PAGE OF THE GUIDELINE

4.1 Have you introduced triage for identifying YES..............................................................................

[PLEASE BRING INFORMATION OF ALL THE NAME: __________________________________

[PLEASE BRING INFORMATION OF ALL THE NAME: __________________________________

5.41 Do you provide tele-medicine services to the YES..............................................................................

6.1 Do you upload COVID-19 specific information YES...........................................................................................

6.2 RESPONSIBLE PERSON 1

6.5 Do you maintain a separate register for YES...........................................................................................

6.6 Where do you maintain the separate register REPORTED, NOT

6.6.2 At isolation unit 1 2 3

6.6.4 ANC Corner/Maternity Care Room at OPD 1 2 3

6.6.5 IMCI Corner/Child Care Room at OPD 1 2 3

6.7 Do you have COVID-19 related Social and YES...........................................................................................

6.8.3 Job aid 1 2 3

6.8.4 Led message 1 2 3

6.8.5 Others (specify ……………………….) 1 2 3

6.9 Do you have COVID-19 related risk YES...........................................................................................

6.10 What kind of COVID-19 related risk

Assessment date: | | | |

Facility Code: |||||

Have Isolation facility: ☐ Yes ☐ No If yes, number of beds: |_|_|___|

Have ICU facility: ☐ Yes ☐ No If yes, number of beds: |_|_|___|

Emergency mobile number of health facility:|_|_|_|_|_|_|_|_|_|_|___|

Mobile number of Ambulance: |_|_|_|_|_|_|_|_|_|_|___|