INSPECTION REPORT OF ESIS HOSPITAL ……………………… DATED……

S.No. Actions Factual position in general

1. General Cleanliness & upkeep of the
Hospitals
2. Manpower Availability Staff Sanctioned In-position
(Medical + Para Medical) Doctors

Staff Nurse

Pharmacist

3. Linen- VIBGYOR colour code of bed Yes/No

sheet being followed
4. Pathological facilities including ECG Yes/No
5. X-ray facility available or not Yes/No
6. Separate OPD for senior citizens and Yes/No
physical challenged persons
7. Help Desk facility available Yes/No
8. Signage/Display Boards Yes/No
9. Arrangement of Kitchen services Yes/No
10. Ayurveda, Yoga, Homeopathy Yes/No
arrangement available
11. Availability and Distribution of Drugs Yes/No
and Dressings

Signature of SMC/SSMC
INSPECTION REPORT OF ESIC DISPENSARY………………… DATED……

S.No. Actions Factual position in general

1. General Cleanliness & upkeep of the
Dispensary
2. Manpower Availability Staff Sanctioned In-position
(Medical + Para Medical) Doctors

Pharmacist

3. Pathological facilities including ECG Yes/No

4. X-ray facility available or not Yes/No
5. Separate OPD for senior citizens and Yes/No
physical challenged persons
6. Help Desk facility available Yes/No
7. Signage/Display Boards Yes/No
8. Ayurveda, Yoga, Homeopathy Yes/No
arrangement available
9. Availability and Distribution of Drugs Yes/No
and Dressings

Signature of SMC/SSMC