MIZORAM HEALTH SYSTEMS STENGTHENING PROJECT

CHECKLIST AND REPORT FOR COACHING VISIT TO IPA UNIT

Name of the District :

Name of IPA UNIT : Date of Visit:
Address of IPA UNIT :
Type of UNIT :  PHC/UPHC  CHC  SDH  DHT  SHT  MSHCS (please tick whichever is applicable)

Basic Information IPA Unit:

IPA assessment baseline IPA Quarter wise score
Date:
IPA assessment baseline IPA budget allocated
Score:
Last Date of NQAS IPA budget received
Assessment: during the quarter
NQAS Score: IPA budget cumulative
received / Expenditure

Name of the Visiting Officer/s and Staff Designation

Staff met during visit

Follow-upon previous visit (For action points, refer to previous visit reports)
Date of last visit: Name of the officer visited last time:
Action points of last visit Action taken (Status)

Support extended by the visiting officer

(Briefly list the support extended to the IPA Unit during the visit, based on gaps identified by Assessment team and any other areas of Quality
Improvement, following are few suggestive areas)
Support for Quality Improvement:
 MIZORAM HEALTH SYSTEMS STENGTHENING PROJECT
CHECKLIST AND REPORT FOR COACHING VISIT TO IPA UNIT

Support in Action Plan preparation/revision:

Support on Financial Management of IPA:

Any other:

Observations/Suggestions: (For facility if any):

Sl. Responsible
Observation Suggestion/action to be taken Timeline
No. person

(Attach additional sheet as required)

_______________________________ __________________________________
Name & Signature of visiting officer Name & Signature of the IPA Unit in-charge