1.

3 Daily RMNCH Form

<strong>Section
I:Identification</stro
ng>

1 Facility ID 3 Signature of Facility

In-charge
2 Facility Name 4 Designation

1.3 Daily RMNCH Form

<strong>Section II:
Maternal and
Newborn Health
(From Maternal
Health &amp;
Obstetric
Registers)</strong>

1 1supst/sup 14 Number of
Antenatal Care Premature Births
visits (ANC-I) (&lt;37 weeks /
&lt;2.5 Kg ))
2 ANC-1 women with 15 Stillbirths in the
Hb. &lt;10 g/dl facility
3 2supnd/sup 16 Maternal death
Antenatal Care
visits (ANC-II)
4 3suprd/supAntenat 17 Intra Uterine death
al Care visits (ANC- (IUD)
III)
5 4supth/sup &amp; 18 Total No of
Above Antenatal Neonatal Deaths
Care visits (ANC- within 28 days (
IV&amp; Above) &lt;28 Days ONLY)
6 1supst/sup
Postnatal Care
visit(PNC-1) in the
facility
7 Postnatal Care strongNeonatal
Revisit deaths in the
facility
(Complications)
/strong
(strongwithin 28
days, /strong)
strongDeliveries in 19 Birth Trauma
the facility/strong
8 Normal vaginal 20 Birth Asphyxia
deliveries
9 Vacuum / Forceps 21 Bacterial sepsis
deliveries
10 Cesarean Sections 22 Congenital
Abnormalities
11 Total No. of 23 Prematurity
Abortions
 1.3 Daily RMNCH Form

<strong>
Section
III:
Family
Planning
Services/
Commod
ities
(From FP
Register)
</strong
>

1 Total FP Total Below 2 New 3 No. of 4 Clients

Visits 25 Years Visits Counsell Referre
ing - d by
<strong LHW
>New</
strong>
5 Total Total Below 6 Total Total Below
PPFP 25 Years PAFP 25 Years
strongN
umber
of
Clients/s
trong
1 POP 5 IUCD
Clients
2 COC 6 Implants
Clients
3 DMPA 7 Tubal
InjClient Litigatio
s n
4 Condom 8 Vasecto
Clients my

1.3 Daily RMNCH Form

<strong>
Section
IV:
Immuniz
ation (
From EPI
Register
)</stron
g>

strongA strongD strongA strongD

ntigen/s ose/stro ntigen/s ose/stro
trong ng trong ng
1 BCG 7 Rota
2 Hepatiti 8 Measles
s B Birth /
Dose Rubella
3 OPV 9 Typhoid
Conjuga
te
Vaccine
4 Pentaval 10 DTP
ent
5 Pneumo 11 TT/Td
coccal
6 IPV
 1.3 Daily RMNCH Form

<strong>Section V:
Community
Meetings</strong>

strongNo of strongSr No/strong strongIndicator/str strongMale/strong strongFemale/stron strongTotal/strong

community health ong g
sessions/strong

1.3 Daily RMNCH Form

<strong>Sectio
n V: Nutritional
Screening</str
ong>

strongSr strongCategor strongChildre strongWomen

No/strong y/strong n/strong /strong
1 Screening
2 SAM
3 MAM

1.3 Daily RMNCH Form

<strong>Sect
ion VII:
Newborn
Indicators
(Form KMC
Register)
</strong>(No
te: This
Section is
Only for
DHQ&rsquo;s
where KMC
Project is
Implemented
)

strongSr strongBabie strongTotal/ strongSr strongInfor strongTotal/ strongSr strongInfor strongTotal/

No/strong s Initiated strong No/strong mation on strong No/strong mation on strong
with KMC KMC KMC Follow-
Services/stro Outcome/str up/strong
ng ong
1 No. of 1 No. of 1 No. of
Babies Babies Babies
initiated received received 1st
with KMC KMC &amp; follow-up
Services discharge as
per protocol
2 No. of 2 No. of 2 No. of
Babies born Babies Babies
in Facility received received 2nd
initiated KMC &amp; follow-up
KMC discharge on
Services request
 1.3 Daily RMNCH Form

3 No. of 3 No. of 3 No. of

Babies born Babies Babies
outside the initiated received 3rd
Facility KMC&amp; follow-up
received referred /
KMC discontinued
Services due to
complication
4 No. of 4 No. of
Babies die Babies
during KMC received 4th
follow-up

Generated: 2023-10-02