Name of Facility:

Type of Facility:
Regional:
District:
Date of Inspection (eg. 29-Apr-2018)
CHPS

SECTION A

(GOVERNANCE, INFRASTRUCTURE AND SAFETY)

SECTION B
(CLINICAL/PUBLIC HEALTH SERVICES)
OVERALL SCORING
 SECTIONS

Organisational Management

Staffing Requirement

TOTAL
Human Resource Management
Equipment Maintenance
Management Information Systems
Safety and Security

TOTAL
Water, Sanitation and Infection Prev./Control

TOTAL
Client Washroom
TOTAL
Staff Washroom
TOTAL
Clinical Services
Reception / Registration / General Waiting Area (optional)
Triage/Nurses Bay
Resuscitation Area
TOTAL
General Changing Rooms (optional)
Treatment and Procedure Room
TOTAL
Laboratory Services
Decontamination & Sterilization Area
Maternity Care

TOTAL
Public Health Service
TOTAL
SCORE
0
 OVERALL TOTAL
SECTIONS SCORE
ATTAINABLE SCORE

I. Registered General Nurse with 3years or more Post-

qualification Experience)
II. Additional Staff
TOTAL 0 0

I. Structural
II. Signage
TOTAL 0 0
I. Water
II. Waste Management
TOTAL 0 0
I. Toilet Facilities
TOTAL 0 0
I. Toilet Facilities
TOTAL 0 0

Area (optional)

TOTAL 0 0

I. Treatment Set
TOTAL 0 0

I. Equipment and Medication

II. Maternity Unit & Add. Maternity Equip. & Protocol
TOTAL 0 0

TOTAL 0 0
OVERALL TOTAL ATTAINABLE SCORE SCORE (%)
0 #NAME?
SCORE (%)
RE (%)
AME?
 Name of Facility: 0
Type of Facility: 0
Regional: 0
District: 0
Date of Inspection: 30-Dec-1899
SECTION Percentage Scores
Organisational Management
INFRASTRUCTURE AND SAFETY)

Staffing Requirement
Human Resource Management
(GOVERNANCE,
SECTION A

Equipment Maintenance
Management Information Systems
Safety and Security
Water, Sanitation and Infection Prev./Control
Staff Washroom
Clinical Services
Reception/ General Waiting Area
(CLINICAL/PUBLIC HEALTH SERVICES)

Triage/Nurses Bay
Resuscitation Area
Consulting Rooms
SECTION B

General Changing Rooms

Treatment and Procedure Room
Laboratory Services
Decontamination & Sterilization Area
Maternity Care
Public Health Service

Overall Percentage Score/Grade #DIV/0!

 0
0
0
0
30-Dec-1899
Grading
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Not Applicable

#DIV/0!