CSSM MONTHLY REPORTING FORM

Sachivalyam Name:: Name of ANM: Month:            Year:2021 

During the Month

Sl. By ANM at
No.
Indicators At Other Govt. At Private
Home/ Total
Facilities Facilities
Subcentre

1 2 3 4 5 6
1 Maternal Health
a).Total No. of ANCs Registered:
b).No. of ANC's with 1st Pregnancy:
c).No. of ANC's with 2nd & above Pregnancy:
d).No. of ANCs registered within 1st Trimister:
e).No. of ANCs with Age below 19yrs (Teenage Pregnancies):
f).No. of High Risk ANCs(Identified):
g).No. of ANCs received 4 check-ups:
h).No. of PW given 180 IFA Tablets
i).No. of PW given 360 Calcium Tablets:
j).No. of PW Identified with Anemia <11 grms:
k).No. of PW Identified with Severe Anemia <7 grms:

l).No.of Pregnant Women with Hiper tension(BP>140/90) detected

m).Pregnant Women tested Postive for Gestational Diabetes

Mellitus(GDM)

n).No.of Pregnant Women tested for HIV(First Time):

o).No.of Pregnant Women tested HIV Positive(First Time):

p).No.of Pregnant Women tested for Syphilis(First Time):

q).No.of Pregnant Women tested Positive for Syphilis(First Time):

r) No. of Pregnant Women tested for HBsAg (First Time):

s) No. of Pregnant Women tested Positive for HBsAg (First Time):

t) Out of positive PW for HBsAg, number reffered for Institutional

Delivery
2 Deliveries
a).Total Deliveries:
b).C-Section Deliveries:
c).Home Deliveries by Trained SBA(Doctor/Nurse/ANM):
d).Home Deliveries by Un-Trained SBA(trained birth
attendant/relatives/etc.):
3 Births
a).No.of  Live Births:
b).Male:
c).Female:
d).No.of Still Births:
4 Home Based New Born Care
a).No.of Newborns received 6 HBNC visits after institutional Delivery:

b).No.of Newborns received 7 HBNC visits in case of home delivery:

5 Newborn Low Birth Weight

No.of Newborn Low Birth Weight <2.5 Kgs:
a).No.of LBW children refered by ASHAto NRC:
b).No.of sick Children refered by ASHA to SNCU:

c). NO. of SNCU discharged babies provided Followup visit of by

ASHA(below 1year):

6 Breast Feeding

Breast Feeding with in 1 hour after delivery:

 During the Month
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No. Indicators At Other Govt. At Private
Home/ Total
Facilities Facilities
Subcentre

7 Postnatal checkups

a).Mothers recieved 1st Postnatal Checkups by ANM with in 48 hours

after delivery:

b).Mothers received 1st Postnatal Checkup by ANM between 48 hours to

14 days after delivery:

c) No. of Lactating Mothers tested for Anemia

d) Out of above tested Lactating Mothers, number identified with
Anemia <11 Grms.
e) Number of Anemic Lactating mothers provided IFA tablets.
Anemia in "Women in Reproductive Age Group" (WRA) (Women
8
excluding Pregnant Women & Lactating Mothers)
a) No. of Women in Reproductive Age Group (WRA) tested for
Anemia
b) Out of above tested Women in Reproductive Age Group (WRA),
number identified with Anemia (<11 Grms)

c)Number of Anemic women in WRA age group provided IFA tablets.

9 Immunization

A Pregnant Women: 

a).TT(2nd dose + Booster):

B Infants 

a).Vitamin K1(Birth Dose):

b).BCG:

c).OPV Birth dose (0 dose):

d).Hep-B Birth dose (0 dose):

e).Polio (1st dose):

f).Polio (2nd dose):

g).Polio (3rd dose):

h).Pentavalent (1st dose):

i).Pentavalent (2nd dose):

j).Pentavalent (3rd dose):

k).Rota Virus Vaccine (1st Dose):

l).Rota Virus Vaccine (2nd Dose):

m).Rota Virus Vaccine (3rd Dose):
n).Inactivated Polio Vaccine (1st Dose):
o).Inactivated Polio Vaccine (2nd Dose):
p).Measles & Rubella 1st:
q).Full Immunisation (Infants):
r).JE (1st dose):

s).Measles & Rubella 2nd:

t).OPV Booster:
u).DPT Booster:

v).JE (2nd Dose):

w).Vitamin-A (1st dose):

x).Vitamin-A (5th dose):

y).Vitamin-A (9th dose):

z).Child Immunization-Typhoid:

aa).DPT(5 years):

ab).TT(10 Years) :

ac).TT(16 Years):
 During the Month
Sl. By ANM at
No. Indicators At Other Govt. At Private
Home/ Total
Facilities Facilities
Subcentre

10 Family Planning Beneficiaries

A Vasectomy
a).Conventional :
b).NSV:
B Tubectomy
a).Traditional:
b).D.P.L:
Total: (Vas+Tub)
C IUCD (CUT) Insertions:

a).Number of Interval IUCD Insertions (excluding PPIUCD and PAIUCD):

b).Number of Postpartum (within 48 hours of delivery) IUCD insertions
(PPIUCD):
c).Number of Post Abortion (within 12 days of spontaneous or surgical
abortion) IUCD insertions (PAIUCD):
Total IUCD (Interval IUCD+PP IUCD+PA IUCD)
D Nirodh Pieces
a).Total Nirodh Pieces distributed:
b).Nirodh Pieces Distributed to Vasectomised Persons:
c).Regular Nirodh Users:
E Oral Pills Cycles
a).Oral Pills Cycles distributed:
b).Oral Pills Users:
11 No. of MTP/Abortions Cases done:
12 Vital Events
A Total No. of Infant Deaths:
B Infant Deaths Age Wise:
a). 0-1 Day:
b). 1-7 Days:
c). 7 days to 4 weeks:
d). 4 weeks to 12 Months:
C Infant Deaths Cause Wise:
a).Sepsis:
b).Asphyxia:
c).Pneumonia:
d).Diarrhoea:
e).Fever Related:
f).Measles:
g).Other causes:
D Total No. of child deaths(1-5years):
E Child Deaths Cause Wise
a).Pneumonia:
b).Diarrhoea:
c).Fever Related:
d).Measles:
e).Other causes:
F Total No of Maternal Deaths:
G Maternal Deaths Cause Wise
a).Bleeding:
b).High Fever:
c).Abortion:
d).Obstructed / Prolonged labour:
e).Severe Hypertension / Fits:
f).Other caused (including causes notknown):
Other Adult Deaths (except Infant deaths, child deaths & Maternal
H
Deaths):