Functionality of ASHA's (ASHA facilitators Format)

Name of PHC: DUSI Mandal: AMADALAVALASA District: SRIKAKULAM Month & Year : APRIL 2022

1 2 3 4 5 6 7 8 9 10
Total No. of
S.N Set of home visits for new born care as Successful referral of IUD, female Total no. of tasks on which ASHAs who are
Newborn visits on first Attending Supporting institutional Management of childhood Fever cases seen/malaria Holding or attending ASHA reported being Remarks
o specified in the HBNC guidelines (six Household visits with ASHAs acting as sterilization or male sterilization functional on at
Name of ASHA day of birth in case of VHNDs/Promoting delivery - Making Birth illness – especially diarrhea slides made in malaria village/VHSNC functional
visits in case of Institutional delivery nutrition counseling DOTS provider cases and/or providing least 6/10 tasks
home deliveries immunization Plans and pneumonia endemic area meeting
and seven in case of a home delivery) OCPs/Condoms

1 Smt B.Vasantha 0 0 1 1 0 220 yes yes yes yes 7

2 Smt V.Kumari 0 1 1 1 0 251 yes yes yes yes 8

3 Smt T.Meenakshi 0 1 1 1 0 238 yes yes yes yes 8

4 Smt M.Damayanthi 0 1 1 1 0 120 yes yes yes yes 8

5 Smt Y.Narayanamma 0 0 1 1 0 270 yes yes yes yes 7

6 Smt G.Adilakshmi 0 1 1 1 0 197 yes yes yes yes 8

7 Smt M.Ramalakshmi 0 1 1 1 0 198 yes yes yes yes 8

8 Smt Y.Bharathi 0 1 1 1 0 219 yes yes yes yes 8

9 Smt P.Satyavathi 0 1 1 1 0 238 yes yes yes yes 8

10 Smt P.Lakshmi 0 1 1 1 0 290 yes yes yes yes 8

11 Smt P.Punyavathi 0 1 1 1 0 151 yes yes yes yes 8

12 Smt B.Govindamma 0 1 1 1 0 210 yes yes yes yes 8

13 Smt M.Devi 0 1 1 1 0 200 yes yes yes yes 7

14 Smt M.Santhamma 0 0 1 1 0 378 yes yes yes yes 8

Total 0 11 14 14 0 3180 yes yes yes yes 109

Signature of the ASHA Facilitator

Date:
 ASHA’s Functionality - PHC Reporting Format
Format-2 (A)

Name of the PHC : Dusi Name of the District: Srikakulam

Total No. of ASHA's in the PHC Month of Reporting: APRIL 2022

No. of ASHA's Under ASHA No. of ASHA's functional on No. of ASHA's functional on at least No. of ASHA's functional on less than
S.No Name of the ASHA Facilitator
Facilitator each of the 10 Tasks 6/10 Tasks or On 60% Tasks 6 Tasks

1 S.V.RAMANA MPHS(F) 14 14 0

MEDICAL OFFICER, PHC DUSI

 ASHA’s Functionality - PHC Reporting Format
Format-2(B)
Name of the PHC: Dusi Name of the District: Srikakulam

Total No. of ASHA's in the PHC: 14 Month of Reporting: APRIL 2022

Total No. of ASHA Functional on

S.No Task / Indicator
each of task / Indicator

1 Newborn visits on first day of birth in case of home deliveries 0

Set of home visits for new born care as specified in the HBNC guidelines (six visits in case of Institutional delivery 11
2 and seven in case of a home delivery)
3 Attending VHNDs/Promoting immunization 14
4 Supporting institutional delivery - Making Birth Plans 14
5 Management of childhood illness – especially diarrhea and pneumonia 0
6 Household visits with nutrition counseling 3180
7 Fever cases seen/malaria slides made in malaria endemic area yes
8 ASHAs acting as DOTS provider yes
yes
9 Holding or attending village/VHSNC meeting
yes
10 Successful referral of IUD, female sterilization or male sterilization cases and/ or providing OCPs/Condoms
11 Total Number of Tasks on Which ASHA reported being functional 109
12 Total Number of ASHA's who are functional on at least 6/10 tasks or on 60 % tasks.

MEDICAL OFFICER, PHC DUSI