Cheklist 5

THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,

GENDER, ELDERLY AND CHILDREN
TECHNICIAN CERTIFICATE (NTA LEVEL 5) IN

NURSING AND MIDWIFERY PROGRAMME
ORAL AND PRACTICAL ASSESSMENT CHECKLIST
Ministry of Health, Community Development, Gender, Elderly and Children

Government city, Mtumba -Dodoma
P.O. Box 743,
Dodoma.
JUNE, 2021
Table of Contents
Table of Contents ............................................................................................................. i
Acknowledgement ............................................................................................................ii
Acronyms ........................................................................................................................ iii
INTRODUCTION ............................................................................................................. 1
Background ..................................................................................................................... 1
SECTION I: ROLES AND RESPONSIBILITIES OF THE HEALTH TRAINING
INSTITUTIONS ............................................................................................................... 3
SECTION II: CHECKLISTS FOR ASSESSING LEARNER’s COMPETENCES DURING
SEMESTER TWO EXAMINATIONS ............................................................................... 1
Checklist 1.1 Management of a woman in second stage of labour ................................. 1
Checklist 2.1 Manual removal of the placenta ................................................................. 4
Checklist 3.1 Resuscitation of a New born ...................................................................... 7
Checklist 4.1 Management of a patient with Sexual Transmitted Infections (STIs) ....... 10
Checklist 5.1 Scoring guide for community project report ............................................. 13
Oral and Practical Assessment Checklist for Technician Certificate (NTA Level 5) Page i
ACKNOWLEDGEMENT
The Development of this Clinical/Practical assessment checklist has been made
possible through combined efforts of MoHCDGEC- Human Resources Development
Department and other stakeholders. The MoHCDGEC expresses its gratitude to Dr.
Loishook Saitore Laizer Director of Human Resource, Dr Fadhili Musa Lyimo, the
assistant Director of Human resources and Dr. Vumilia B. Mmari (PhD), the Coordinator
for Nursing and Midwifery Training for their commitment and guidance to the
development of the Clinical/Practical assessment checklist.
Moreover, MoHCDGEC appreciate professional technical expertise from Ms. Naomi P.

Chamhene (MSc PN), Ms. Anna S. Mangula (MSc MH), Ms. Upendo G. Chamlomo
(MSc PN), Ms. Saliath A. Ntamubano (MSc NE), Mr. Ernest S. Singoye (MSc NE), Ms.
Saphina M. Mvungi (BSc N), Mr. Gerald N. Mgaya (Diploma in Nursing), Mr. Andrew A.
Gerald (Diploma in IT with Education) for their commitment and expertise in preparing the
first draft of Clinical/Practical Assessment Checklists for NMT Level 4, 5 and 6
Finally, MoHCDGEC thanks all participants from various Health Training Institutions
(HTI) for their commitment and expertise in developing the Clinical/Practical
assessment checklist as per appendix ii.
Dr. Loishook Saitore Laizer

Director of Human Resource Development
Oral and Practical Assessment Checklist for Technician Certificate (NTA Level 5) Page ii
ACRONYMMS
AP Assessment Plan
BP Blood Pressure
BSc N Bachelor of Science in Nursing
CBET Competence based Education and Training
COHAS Collage of Health and Allied Science
CPR Cardio Pulmonary Resuscitation
DECOHAS Decca Collage of Health and Allied Sciences
DIHAS Dodoma Institute of Health and Allied
FG Facilitator Guide
GBV Gender Based Violence
HTI Health Training Institution
ICU Intensive Care Unit
IHAS Institute of Health and Allied Science
IM Intramuscular
IPD In Patient Department
IT Information Technology
IV Intravenous
KICHAS - Kilimanjaro Institute of Health and Allied Sciences
Mo HCDGEC Ministry of Health, Community Development, Gender, Elderly and
Children
MSc MH Masters of Science in Mental Health
MSc NE Masters of Science in Nursing Education
MSc PN Masters of Science in Paediatric Nursing
MUHAS Muhimbili University of Health and Allied Health Sciences
MWACHAS Mwanza College of Health and Allied Sciences
NACTE National Council for Technical Education
NMT Nursing and Midwifery Training
NTA National Technical Award
OPD Outpatient Department
OPD Out Patient Department
PEP Post Exposure Prophylaxis
PhD Doctor of Philosophy
RCH Reproductive and Child Health
RN Registered Nurse
SM Semester Examination
SON School of Nursing
STIs Sexual Transmitted Infections
TPR Temperature Pulse Respiration
VAC Violence Against Children
Oral and Practical Assessment Checklist for Technician Certificate (NTA Level 5) Page iii
INTRODUCTION
Background
The Ministry of Health, Community Development, Gender, Elderly and Children
(MoHCDGEC) in collaboration with NACTE developed a Curriculum for Ordinary
Diploma (NTA Level 6) in Nursing and Midwifery. To ensure commitment in curriculum
implementation, the MoHCDGEC prepared standardized training materials to support
tutors and ensure that leaners gain the required competencies. These training materials
are the Facilitators Guide (FG), Student Manual (SM), Assessment Plan (AP), Delivery
register book and practical procedure book.
The MoHCDGEC has also harmonized the assessment of learners learning outcomes
by developing standardized Clinical/Practical assessment checklists for each module
that will be used by the tutors when teaching and assessing learner’s performance.
It is the expectation of the MoHCDGEC that all Health Training Institutions implementing
Nursing and Midwifery Programme shall use these standardized Clinical/Practical
assessment checklists to assess learners learning outcomes for End of Semester II
Examination effectively.
This Clinical/Practical assessment checklist was prepared by the MoHCDGEC to

ensure that there is harmonization on assessment of practical learning outcomes to
learners among health training institutions. This tool is among the document required
during the implementation of the Competence Based Education and Training (CBET)
curricula. The tool has taken into account clinical/practical competences to be assessed
during End of Semester II Examinations as stipulated in the curriculum and assessment
plan.
Aim of the Clinical/Practical Assessment Checklist

The aim of this checklist is to assist tutors to assess learner’s acquisition of
competences in a more systematic manner both in health training institutions and health
care facilities. It promotes standardization of assessment among learners to ensure that
all of them have acquired the same competencies upon completion of the programme.
Organization of the Clinical/Practical Assessment Checklist

The tool is organized into two major sections as follows:
Section I: Roles and Responsibilities of Health Training Institutions and Assessors
Section II: Checklists for assessing learners Competences during End of Semester II
How to Use the Checklist

This tool is intended to be used by Tutors and Assessors in a Health Training
Institutions for assessing learners during end of semester examinations. Tutors and
Oral and Practical Assessment Checklist for Technician Certificate (NTA Level 5) Page 1
Assessors are expected to read the instructions and the competences in the checklist
including the grading of the checklist and discuss with the Principal of the Institution for
clarifications of issues. The assessment tools include the essential competences to be
achieved by learners therefore, it is important to make sure that learners are exposed to
the competences before assessment.
SECTION I: ROLES AND RESPONSIBILITIES OF THE HEALTH TRAINING
INSTITUTIONS AND ASSESSORS
Responsibilities of the Head of Health Training Institutions

 The Heads of health training institutions are required to ensure that:
 Settings for practical assessment are prepared as indicated on nursing and
midwifery curriculum
 Tutors are familiar with the assessment tools
 Tutors orient learners on the assessment tools
 Academic team/officer compute/translate the score obtained into appropriate
weights per module as indicated in the curriculum
 Assessors are familiar with the assessment tools before using
Responsibilities of Tutors
 Tutors are required to:
 Assess learners using the assessment checklists during end of semester II

examinations
 Compute total score obtained by the learners from the checklist
 Write general examination report as per given guidelines
Responsibilities of Assessors
 Assessors are required to:
 Observe the learners while performing the skills for practical performance and
assign score accordingly
 Read the checklist carefully to identify competences and grade according to criteria
on the checklist
 Compute total score obtained by the learners from the checklist
 Write general examination report as per given guidelines
CONDITATE NO: ……………………………… REGISTRATION NO: ……………………………….
SECTION II: CHECKLISTS FOR ASSESSING LEARNER’s COMPETENCES DURING

SEMESTER TWO EXAMINATIONS
Oral and Practical Assessment checklist for Caring of a Woman in Normal Labour and
Puerperium
Instructions
 This checklist is used to assess learners’ competences on a Module Name: Care of a
Woman in Normal Labour and Puerperium during end of semester II practical
examination
 The setting of practical examination is in health care facility (RCH, Antenatal ward, and
labour ward)
 This examination may be conducted in skills laboratory if there is no patient/client in health
care facility
 Time allocated is 1 hour (45 minutes for procedure and 15 minutes for evaluation)
 The assessor is required to assign one (1) mark when criterion and all sub-criteria are
done/observed, if not done assign zero (0) and provide a comment in the comments ‘column
 Write the total score at the end of assessment
 Write the final score at the top right corner after getting the average score from internal and
external examiner
 Write general comments below the checklist, if any, after the examination
 Learners should provide ward/unit information based on the following:
i. Number of staff and name of in- charge
ii. Total number of patients present
iii. Number of serious patient
iv. Top ten condition of the ward/ unit
Checklist 1.1 Management of a woman in second stage of labour

Name of the Institution/Centre: Name of the Unit/Ward:
Module Code: NMT 05208 Academic Year:
Module Name: Care of a Woman in Normal Labor and Puerperium Semester II Exam
NTA Level: 5
Date: Time: 45 Minutes
S/N Description of Criteria Scores Comments
competence
1.0 Preparing 1.1 Establishes good nurse- client
environment for relationship
conducting the 1.1.1.Greets the mother
second stage of 1.1.2. Introduces her/himself to the
labour mother
1.2 Informs the mother about the
(Total score 4) procedure
1.3 Screens the client
1.4 Washes hands before and after the
procedure.
2.0 Preparing equipment 2.1 Prepares three sterile surgical gloves
and supplies for 2.2 Prepares clean gloves
conducting second
2.3 Prepares two kidney dishes
stage of labour 2.4 Prepares pair of scissors/ surgical

blades
(Total score 13) 2.5 Prepares cord clamps
2.6 Prepares five - drapes
2.7 Prepares forceps
2.8 Prepares gauze
2.9 Prepares swabs
2.10 Prepares syringe (2.5 cc/5cc)
2.11 Prepares oxytocin 10 IU
2.12 Prepares antiseptic solution
2.13 Prepares receiver for used materials
3.0 Cleaning the woman’s 3.1 Assists the woman to lie in dorsal
perineum with position
antiseptic solution 3.2 Wears apron
3.3 Wears three sterile gloves.
(Total score 6) 3.4 Drapes the mother by using sterile
drapers
3.5 Takes five swabs using dominant hand
then drops one after another to a non-
dominant hand.
3.6 Cleans perineum on one side using
one stroke technique as follows
3.6.1.Cleans far labia majora
3.6.2.Cleans near labia majora
3.6.3.Cleans far labia minora
3.6.4.Cleans near labia minora
3.6.5. Finishes by cleaning the center
of vagina by separating labia majora.
4.0 Delivering the head 4.1 Confirms full dilatation of the cervix
4.2 Encourages the mother to push and /or
(Total score 10) breathe so that the head will be slow
and controlled
4.3 Encourages the mother
spontaneously bearing down until
crown of the head
4.4 Places clean pad under the mothers
perineum to absorb any fluids/ faces
4.5 Delivers the head spontaneously when
crowning occur
4.6 Controls the birth of the head with
finger of one hand applying a firm
gentle downward
4.7 Allows the natural stretching of
perineal tissue and prevent tears
4.8 Uses the other hand to support the

perineum using a compressor or cloth
and allow the head to crown slowly
and be born spontaneously
4.9 Wipes the mucus from the baby’s
mouth and nose with clean swab
4.10 Feels around the baby’s neck to
ensure that the umbilical cord is not
around it.
5.0 Delivering the 5.1. Allows the baby’s head to restitute
shoulders 5.2. Places a hand on each side of the
baby’s head over the ears, avoiding
(Total score 13) pressure around the neck
5.3. Advices the woman to push gently with
the next contraction
5.4. Applies slow gentle pressure
downward and outwards until the
anterior shoulder slips under the pubic
bone
5.5. Guides the head upwards towards the
woman’s abdomen as the posterior
shoulder is born over the perineum
when the axilla is seen
5.6. Supports the baby’s head with one
hand and the rest of the baby’s body
with the other hand as it is slides out
5.7. Places the baby on the woman’s
abdomen
5.8. Confirms undiagnosed twins
5.9. Asks assistant to administers oxytocin
10 I.U intramuscular
5.10. Wipes and cover the baby with clean
clothes
5.11. Clamps and cut the umbilical cord
5.12. Shows the mother her baby and
identify the sex
5.13. Handles management of third stage
of labour to an assistant
Total Score 46
General comments
………………………………………………………….…………………………………………...………
……………………………………………………………………………………………………………….
…………………………………………………………………………………………………..…………...
Name of the Internal Examiner: …………………… ……. Signature……………….…………………
Name of the External Examiner: …………………………..Signature…………………………………
Oral and Practical Assessment Checklist for Pre-Referral Management of a Woman with
Abnormal Pregnancy, Labour and Puerperium
Instructions
 This checklist is used to assess learners’ competences on a Module Name: Pre-Referral
Management of a Woman with Abnormal Pregnancy, Labour and Puerperium during
end of semester II practical examination
 The setting of practical examination is in health care facility (Labour ward)
care facility
done/observed, if not done assign zero (0) and provide a comment in the comments ‘column
external examiner
Checklist 2.1 Manual removal of the placenta

Name of the Institution/Centre: Name of the
Unit/Ward:
Module Name: Pre-Referral Management of a Woman with Abnormal Semester II Exam
Pregnancy, Labour and Puerperium.
NTA Level: 5
Competences
1 Preparing environment for 1.1 Establishes good nurse – patient
performing the procedure relationship
1.1.1 Greets patient
(Total score 4) 1.1.2 Introduces herself/himself to
patient
1.2 Informs the patient about the
procedure.
1.3 Washes hands before and after
the procedure.
1.4 Screens the patient
2 Preparing equipment and 2.1 Prepares long sterile surgical
supplies for manual gloves
removal of placenta 2.2 Prepares oxytocin
2.3 Prepares IV fluid ringers lactate
(Total score 14) 2.4 Prepares giving set
2.5 Prepares receiver
2.6 Prepares sterile gloves
2.7 Prepares catheter

2.8 Prepares urinal bag
2.9 Prepares swab
2.10 Prepares gauze
2.11 Prepares syringe with needle
2.12 Prepares ampicillin injection
2.13 Prepares IV metronidazole
2.14 Prepares sterile drapers
3. Performing procedure for 3.1 Puts on long sterile surgical
Manual removal of placenta gloves on both hands
3.2 Cleans vulva and perineal area.
(Total score 26) 3.2.1 Uses a right hand to pick the
moistened swab and dropping it on
the left hand side
3.2.2 Swabs the farthest labia majora
starting from the up downwards
stroke and discard the swabs
3.2.3 Repeats the same to the
nearest labia majora, then farthest
labia minora, ending with nearest
labia minora
3.2.4 Applies one stroke swab at the
center
3.3 Places sterile drape beneath the
woman’s buttocks
3.4 Introduces urethral catheter to
drain urine
3.5 Holds the umbilical cord with a
clamped forceps
3.6 Pulls the cord gently until it is
parallel to the floor
3.7 Places the fingers of one hand
into the vagina and the uterine cavity,
following the direction of the cord
until the placenta is located
3.8 Places hand onto the abdomen to
support the fundus abdominally to
prevent uterine inversion
3.9 Moves the fingers of the hand in
the uterus laterally until the edge of
the placenta is located
3.10 Keeps the fingers tightly
together, ease the edge of the hand
gently between the placenta and the
uterine wall, with the palm facing the
placenta
3.11 Moves the hand back and forth

in a smooth lateral motion until the
whole placenta is separated from the
uterine wall
3.12 Withdraws slowly the hand from
the uterus bringing the placenta with
it
3.13 Picks sterile gauze and
evacuate inside of the uterine cavity
to ensure that all placental tissue has
been removed
3.14 Continues to provide counter-
traction to the fundus by pushing it in
the opposite direction of the hand
that is being withdrawn
3.15 Gives oxytocin 10 IU IM
3.16 Assists to massage the fundus
to encourage uterine contraction
3.17 Gives a single dose of
prophylactic antibiotics: Ampicillin 2 g
IV /IM and, Metronidazole 500 mg IV
8 hourly for 48 hours
3.18 Gives IV fluids ringers lactate
slowly for at least 1 hour after
removal of placenta when bleeding
stop
3.19 Does quick assessment of the
placenta to ensure that it is complete
3.20 Examines the woman’s
perineum carefully
3.21 Cleans the perineum
3.22 Applies perineal pad
3.23 Removes gloves and place
them in a leak proof container or
plastic bag
3.24 Monitors vaginal bleeding
3.25 Takes the woman’s vital signs
3.26 Records findings of the
procedure and drugs given
Total Score 44
General comments
………………………………………………………….………............................………………………
…………........................................................................................................................................
………….......................................................................................................................................
Name of the Internal Examiner: ………......................Signature………………….........................
Name of the External Examiner: ……........................Signature…………….....................……….
Oral and Practical Assessment checklist for Caring of a Normal Newborn
Instructions
 This checklist is used to assess learners’ competences on a Module Name: Care of a
Normal Newborn during end of Semester II Practical Examination
 The setting of practical examination is in health facilities (Labour ward)
care facility
done/observed, if not done assign zero (0) and provide a comment in the respective column
external examiner
iv. Top ten condition of the ward/unit
v. Top ten medicine of the ward/unit
Checklist 3.1 Resuscitation of a new born

Unit/Ward:
Module Name: Care of a Normal Newborn Semester II Exam
NTA Level: 5
Competences
1.0 Preparing environment 1.1 Tells the woman (and her support
person) what is going to be done
(Total score 3) 1.2 Provides continual emotional support
and reassurance
1.3 Washes hands before and after
procedure
2.0 Preparing equipment 2.1 Prepares Ambubag
and supplies for 2.2 Prepares Suction catheter or bulb
newborn resuscitation syringe
2.3 Prepares 2 cloths already laid out,
(Total score 5) folded towel or cloth to put under
newborn’s shoulders in place
2.4 Prepares gauze to wipe newborn’s
face
2.5 Prepares gloves
Resuscitating using 3.1 Puts on gloves
3.0 bag and mask 3.2 Places the newborn on its back on a
clean, warm surface on top of 2 towels
(Total score 22) or cloths already laid out
3.3 Dries newborn quickly and firmly with a
towel or cloth, from head to toe
3.4 Takes away wet towel
3.5 Wraps newborn, except for the head,
face and upper chest
3.6 Positions the head in a slightly
extended position
3.7 Clears the airway by sucking the
mouth first and then the nose:
3.7.1. Introduces catheter no more
than 5 cm into the newborn’s
mouth and suction while
withdrawing catheter
3.7.2. Introduces catheter no more
than 3 cm into each nostril and
suction while withdrawing
catheter
3.8 Stimulates the newborn by rubbing a
hand up and down the newborn’s
spine
3.9 Rechecks quickly the position of the
newborn’s head if the newborn is still
not breathing
3.10 Places the mask on the newborn’s
face so that it covers the chin, mouth
and nose
3.11 Forms a seal between the mask and
the newborn’s face
3.12 Squeezes the bag with two fingers
only or with the whole hand, depending
on the size of the bag
3.13 Ventilates two times to observe if the
chest rises
3.14 Ventilates at a rate of 40
breaths/minute
3.15 Observes the chest for an easy rise
and fall
3.16 Stops ventilating to evaluate if the
newborn is breathing spontaneously
3.17 Counts breathing rate
3.18 Observes for chest in drawing and
grunting
3.19 Puts in skin-to-skin contact with
mother
3.20 Observes breathing at frequent

intervals
3.21 Measures the newborn’s axillary
temperature and rewarm if
temperature is less than 36° C
3.22 Encourages mother to begin
breastfeeding
4.0 Caring of equipment 4.1 Disinfects catheter & mucus
extractors in 0.5% chlorine solution
(Total score 8) for 10 minutes for decontamination
4.2 Washes in water and detergent
4.3 Uses a syringe to flush
catheters/tubing
4.4 Places catheter in an appropriate
chemical solution (0.1 chlorine/cidex)
4.5 Takes the valve and mask apart and
inspect for cracks and tears
4.6 Washes the valve and mask with
water and detergent and rinse
4.7 Washes hands thoroughly with soap
and water and dry with a clean, dry
cloth or air dry
4.8 Reassembles the bag
5.1. Records condition of the newborn at
5.0 Documenting the birth
findings 5.2. Records procedures performed
(Total score 6) 5.3. Notes time from birth to initiation of
spontaneous breathing
5.4. Records clinical observations during
and after resuscitation measures
5.5. Records outcome of resuscitation
measure
5.6. Records names of providers involved
Total Score 44
General comments
………………………………………………………….……………………………………………………
……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
Name of the Internal Examiner: ……………………………Signature……….....……………………..
Name of the External Examiner: ……………………………Signature……………..…………………
Oral and Practical Assessment checklist for Management of Communicable Diseases
Instructions
 This checklist is used to assess learners’ competences on a Module Name: Management of

Communicable Diseases during end of Semester II Practical Examination
 The setting of practical examination is in health facilities (OPD, Medical Ward, RCH clinic,
Gynecological ward )
care facility
done/observed, if not done assign zero (0) and provide a comment in the comments
‘column
external examiner
v. Top ten medicines of the ward/unit
Checklist 4.1 Management of a patient with Sexual Transmitted Infections (STIs)

Unit/Ward:
Module Name: Management of Communicable Diseases Semester II Exam
NTA Level: 5
S/N Description of Competences Criteria Scores Comments
1.0 Preparing environment for 1.1 Establishes good nurse – patient
performing the procedure relationship
(Total score 4) 1.1.1 Welcomes the patient and show

him/her where to sit
1.1.2. Greets the patient and
introduce yourself
1.2 Informs the patient about the
procedure and assure
confidentiality
1.3 Screens the patient
1.4 Washes hands/ Applies hand rub
before and after procedure
2.1 Asks Demographic information

of the patient
2.0
Taking history from the patient. 2.1.1 Name
2.1.2 Age
(Total score 6). 2.1.3 Sex
2.1.4 Place
2.1.5 Tribe
2.1.6 Occupation
2.2 Asks on chief complains
2.3 Obtains history of present
illness.
2.3.1 Onsets of condition /disease
2.3.2 Durations how long had this
condition.
2.3.3 Asks for any treatment taken
self-prescribed
2.4 Takes past medical
2.4.1 Asks if had STIs
2.4.2 Asks history of any chronic
illness
2.5 Asks if had any surgery;
Obstetric, gynecologic including
circumcision
2.6 Asks about sexual history
2.6.1 Asks Types sexual behavior
activity (anal sex ,oral sex,)
2.6.2 Frequency of sexual activity
2.6.3.Number of sexual
contacts/partners
2.6.4.Asks for preventive practices
including use of barrier
contraceptives
Preparing supplies for physical 3.1 Prepares Sterile gloves
3.0
examination 3.2 Prepares Patients file
3.3 Prepares Pen
(Total score 3)
4.0 Performing physical 4.1 Obtains verbal consent from
examination the patient
4.2 Puts on sterile gloves
(Total score 7) 4.3 Inspects oropharyngeal
4.4 Positions the patient (for
female lithotomy position)
4.5 Inspects the genitalia and
anorectal for:-
4.5.1.Discharges
4.5.2.Gapping
4.5.3.Bruises
4.6 Removes gloves

4.7 Records findings on the
patient’s file
5.0 Preparing equipment’s and 5.1 Prepares patient medicines
supplies for administration of 5.2 Prepares drinking cup
medicine 5.3 Prepares safe drinking water
5.4 Prepares treatment charts
(Total score 7) 5.5 Prepares spoon
5.6 Prepares medicine cup
5.7 Prepares medicine
prescription
6.0 Administering prescribed 6.1 Gives proper medicines to
medicine according to patient as per syndromic case
syndromic case management management regime.
6.2 Records medicines given on
(Total score 2) patient’s file
7.0 Counselling to patient with 7.1 Instructs client on adherence of
STIs prescribed medicines
7.2 Advices on use of preventive
(Total score 6) barriers
7.3 Advices on regular body
hygiene
7.4 Advices on having only one
sexual partner
7.5 Tells on contacting her/his
sexual partner for examination
and treatment
7.6 Thanks the patient
Total Score 35
General comments
………………………………………………………….……………………………………………………
……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
Name of Internal Examiner …………………………………Signature……….....…………..…………

Name of External Examiner: ……………………..…………Signature……………..…….……………
Assessment Checklist for Community for Community Health Nursing

Instructions
 This checklist is to be used to assess learners’ competences on Module Name: Community
Health Nursing in field work experience during end of semester II examination
 The checklist will be used to score both group and individual community field project report
 The assessor is required to assign one (1) mark when criterion is done or observed, if not
done assign zero ‘0’ and provide a comment in the comment’s column.
 Write general comments bellow the checklist if any, after assessment
Checklist 5.1 Scoring guide for community project report

Name of the Institution/Centre: Academic Year:
Module Code: NMT 05212
Module Name: Community Health Nursing Semester II Exam
Date: NTA Level: 5
Competences
1.0 Description of 1.1 Report tittle stated
Preliminary 1.2 Summary of the report written
information of report
shown
(Total scores 2)
2.0 Narrating 2.1 Background information
Introduction of the explained
community field 2.2 Objectives of the community field
work report work stated
(Total scores 2)
3.0 Conducting 3.1 Historical background of the
community health village in respective community
needs assessment stated
3.2 Location of the village shown
(Total scores 35)
3.3 Boundaries located
3.4 Water sources indicated
3.5 Water safety explained
3.6 Water accessibility explained
3.7 Number of toilets stated
3.8 Quality of toilet described
3.9 Utilization of toilets stated
3.10 Waste disposal practice
explained
3.11 Housing types explained
3.12 Ventilation and adequacy of the
house explained
3.13 GBV and VAC Records
described
3.14 Prevention of GBV and VAC in
the Community explained
3.15 Management of GBV and VAC
survivors described
3.16 Unlawful events explained
3.17 Soil conservation stated
3.18 Climatic conditions explained
3.19 Total population indicated
3.20 Age distribution indicated
3.21 Gender distribution explained
3.22 Population growth explained
3.23 Mortality rates indicated
3.24 Morbidity rates indicated
3.25 Organization structure shown
3.26 Committees explained
3.27 Political parties explained
3.28 Immunization coverage indicated
3.29 Family planning coverage
indicated
3.30 Common health problem stated
3.31 Dietary practices for different
groups in the society explained
3.32 Main sources of income stated
3.33 Communication system
explained
3.34 Transportation system observed
3.35 Cultural practices that
hinder/promote health explained
4.0 Assessing School 4.1 School history stated
health 4.2 Number of pupils/students
recorded
(Total scores 17)
4.3 Age distribution of
pupils/students recorded
4.4 Gender distribution of
pupils/students recorded
4.5 School human resource
explained
4.6 Number of classrooms indicated
4.7 School dropout and reasons
explained
4.8 Number of toilets and bathrooms
indicated
4.9 Sources of water stated
4.10 Hand washing facilities stated
4.11 School food programme
existence explained
4.12 School first aid existence
explained
4.13 School playing grounds
existence explained
4.14 Health education programme
existence explained
4.15 Self – reliance activities

explained
4.16 Academic performance recorded
4.17 Common health problems stated
5.0 Assessing Health 5.1 History of health facility indicated
Facility 5.2 Number of health facility
buildings stated
(Total scores 16)
5.3 Sharps products handling
explained
5.4 Infectious waste products
handling explained
5.5 Adequacy of medicine and
medical supplies explained
5.6 Disinfections process explained
5.7 Health services provided
indicated
5.8 Number of deliveries at the
health facility and TBAs per year
indicated
5.9 Number of people served per
year indicated
5.10 Top ten conditions/diseases to
children and adults stated
5.11 Universal infection prevention
precautions and PEP services
explained
5.12 Referral and communication
system stated
5.13 Distance to health facility
indicated
5.14 Affordability of health services
stated
5.15 Acceptability of health services
stated
5.16 Main health problems identified
stated
6.0 Assessing Family 6.1 Family name and composition
Care needs stated
6.2 Family genogram (3 generations)
(Total scores 15 )
stated
6.3 Type of house explained
6.4 House ventilation and adequacy
explained
6.5 Use of toilet explained
6.6 Waste disposal practice
explained
6.7 Water sources and accessibility
explained
6.8 Water safety explained
6.9 Type of food for different age
group explained
6.10 Quantity and quality of food
explained
6.11 Source of income of family
explained
6.12 Sources of information explained
6.13 Family health care seeking
behaviors explained
6.14 Family health related practices
explained
6.15 Taboos and beliefs
promoting/hindering health
explained
7.0 Description of 7.1 Community strength and
Community weaknesses stated
diagnosis 7.2 Actual and potential diagnosis
clearly stated
(Total scores3 )
7.3 Priority clearly set
8.0 Community 8.1 Explained how community was
involvement in involved in planning intervention
Planning the 8.2 Priority setting on problems
interventions identified observed
(Total scores 2)
9.0 Description of the 9.1 Interventions clearly stated
Implemented 9.2 Counseling sessions explained
intervention 9.3 Collaboration of mult-sector
explained
(Total scores 4)
9.4 Health education provided
explained
10.0 Evaluation the 10.1 Appropriate method of evaluation
implemented explained
intervention 10.2 List of unsolved problems and
reasons stated
(Total scores 2)
11.0 Description of the 11.1 Recommendations relevant to
Recommendations the field work findings clearly
and Conclusion explained
11.2 Conclusion based to field work
(Total scores 2)
findings stated
Total Scores 100
General comments
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Name of Supervisor …………………….…………….…………..Signature…………………………..
Name of External Examiner …….………….…………………….Signature…………………………..
Appendix i: List of Checklist Developers
SN Names of Participants Title Institution
1. Dr. Vumilia B.E Mmari Training Coordinator MoHCDGEC

(RNM-PhD)
2. Naomi P. Chamhene Nurse Tutor Dodoma Institute of Health and
Allied Sciences (DIHAS)
3. Anna .S. Mangula Nurse Tutor DECCA College of Health and
Allied Sciences (DECOHAS)
4. Upendo .G. Chamlomo Nurse Tutor Dodoma Institute of Health and
5. Saliath .A. Ntamubano Nurse Tutor Dodoma Institute of Health and
6. Ernest .S. Singoye Nurse Tutor Dodoma Institute of Health and
7. Saphina .M. Mvungi Nurse Tutor Dodoma Institute of Health and
8. Gerald .N. Mgaya Nurse Tutor DECCA College of Health and
Allied Sciences (DECOHAS)
Appendix ii: List of Reviewers
SN Name of Participants Title Institution
1. Alfreda Hyasint Ndunguru Nurse Tutor Kibondo SON

2. Anande A. Mungure Nurse Tutor Mbulu NTC
3. Dorice T. Ntahindwa Nurse Tutor Kabanga COHAS
4. Elizabeth John Bigilwa Nurse Tutor MOHCDGEC
5. Esther Zephania Nurse Tutor MWACHAS
6. Esther Msechu Nurse Tutor MOH - Dodoma
7. Felicia Myinga Nurse Tutor PHCI - Iringa
8. Florian Mbungu Nurse Tutor Mtwara COHAS
9. Godfrey S. Nduwile Nurse Tutor Mbeya COHAS
10. Happiness Mbise Nurse Tutor Korogwe NTC
11. Kelvin Moshi ITO Mbalizi H T I
12. Lazaro Amon Haule Ass. Lecturer MUHAS
13. Loyce Manyandi Nurse Tutor Morogoro COHAS
14. Lyidia Chuwa Nurse Tutor Bukumbi SON
15. Philipina Burchard Kilaya Nurse Tutor MUCOHAS
16. Reuben William Nurse Tutor Sumve SON
17. Salome Osward Mlabwa Nurse Tutor Muhimbili COHAS
18. Sarah John Mallya Nurse Tutor KICHAS KCMC
19. Shukran S.Ndumula Nurse Tutor Mbalizi H T I
20. Somoe Tulinje Nurse Tutor Newala SON
21. Stanley Mahundo Nurse Tutor RRH-Dodoma
22. Stephen A. Madembwe Nurse Tutor Kibaha COHAS
23. Suzana S. Matiku Nurse Tutor Njombe IHAS
24. Tatu Japhet Nurse Tutor Tarime NTC
25. Vicent P. Ombay Nurse Tutor Kondoa SON
26. Yuster Chanafi Makule Nurse Tutor Kiomboi SON

Cheklist 5

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Cheklist 5

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THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,

TECHNICIAN CERTIFICATE (NTA LEVEL 5) IN

ORAL AND PRACTICAL ASSESSMENT CHECKLIST

Ministry of Health, Community Development, Gender, Elderly and Children

Moreover, MoHCDGEC appreciate professional technical expertise from Ms. Naomi P.

Dr. Loishook Saitore Laizer

This Clinical/Practical assessment checklist was prepared by the MoHCDGEC to

Aim of the Clinical/Practical Assessment Checklist

Organization of the Clinical/Practical Assessment Checklist

How to Use the Checklist

Responsibilities of the Head of Health Training Institutions

 Assess learners using the assessment checklists during end of semester II

SECTION II: CHECKLISTS FOR ASSESSING LEARNER’s COMPETENCES DURING

Checklist 1.1 Management of a woman in second stage of labour

stage of labour 2.4 Prepares pair of scissors/ surgical

4.8 Uses the other hand to support the

Name of the Internal Examiner: …………………… ……. Signature……………….…………………

Name of the External Examiner: …………………………..Signature…………………………………

Checklist 2.1 Manual removal of the placenta

2.7 Prepares catheter

3.11 Moves the hand back and forth

Name of the Internal Examiner: ………......................Signature………………….........................

Name of the External Examiner: ……........................Signature…………….....................……….

Oral and Practical Assessment checklist for Caring of a Normal Newborn

Checklist 3.1 Resuscitation of a new born

3.20 Observes breathing at frequent

Name of the Internal Examiner: ……………………………Signature……….....……………………..

Name of the External Examiner: ……………………………Signature……………..…………………

Oral and Practical Assessment checklist for Management of Communicable Diseases

 This checklist is used to assess learners’ competences on a Module Name: Management of

Checklist 4.1 Management of a patient with Sexual Transmitted Infections (STIs)

(Total score 4) 1.1.1 Welcomes the patient and show

2.1 Asks Demographic information

4.6 Removes gloves

Name of Internal Examiner …………………………………Signature……….....…………..…………

Assessment Checklist for Community for Community Health Nursing

Checklist 5.1 Scoring guide for community project report

4.15 Self – reliance activities

Name of External Examiner …….………….…………………….Signature…………………………..

SN Names of Participants Title Institution

1. Dr. Vumilia B.E Mmari Training Coordinator MoHCDGEC

SN Name of Participants Title Institution

1. Alfreda Hyasint Ndunguru Nurse Tutor Kibondo SON

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