`OFFICE OF THE DISTRICT MEDICAL & HEALTH OFFICER:

SIDDIPET DISTRICT.
CRITERIA AND GUIDELINES FOR NOMINATIONS

FOR DISTRICT LEVEL AWARDS

PROFORMA

NOMINATIONS FOR SELECTION OF BEST STAFF NURSE

Sl. Name of the PHC Name of the No. of Copper –T No. ANTARA Inj. REMARK
No. staff nurse Insertions at PHC At PHC
A B C D E F
1
2
3
4

PROFORMA
NOMINATIONS FOR SELECTION OF BEST MPHAs (F)
Name of the Name of the Population Sterilization ANTARA IUD Achie
PHC MPHA (F) cases Achievem vement
promoted ent
2021-2022
A B C D E F

PROFORMA
NOMINATIONS FOR SELECTION OF BEST ASHA
Sl. No Name of the PHC Name of the ASHA Population FP Cases Promoted
A B C D E
1
2

4
 PROFORMA
LIST OF COUPLES UNDER DIFFERENT CATEGORIES FOR AWARDS DURING 2021-2022
Category-I( Contraceptive Injectable(ANTARA) Injection since one year
Sl.No. E.C. No. Name of Name of the Antara Injection 1st 2nd 3rd 4th
the phc Beneficiary spouse full address Injection Injectio Injection Injectio
& Age Date n Date Date n Date
1

Category-II (Acceptors of Sterilization with 1 child) names should be

sent
Sl.N Name of the E.C. Name of the Acceptor & Spouse Age Method Date and Place of
o. PHC No. with Address (Minimum 10 names) Operation

Category-III (Acceptors of PPIUCD / IUCD for more than 05 years

Sl.N E.C. Name of the Name of the PPIUCD / IUCD No.of Children Age of Interval IUCD
o. No. phc Full Address last Child /PPIUCD and
Total Female Date, Place