A. GENERAL INFORMATION: 1. Name of Organization Date 2. District 3. Block 4. Village/Ward 5. Name of Respondent 6. Designation of respondent 7. MMU Vehicle Number 8. Details of the MMU visited Vehicle no. Odometer Reading(Km) Year of Manufacturing Year of Commissioning B. INFRASTRUCTURE (ROAD WORTHINESS of MMU VEHICLE) 1. Is service manual available in the vehicle? (1=Yes; 2=No) 1.1 If yes, is service done as per service manual? (1=Yes; 2=No) 1.2. If yes, date of last service?. 2. Whether PUC (Pollution under Control) certification done? (1=Yes; 2=No) 2.1 If yes, date of last PUC. 3. Is there any standard operating procedure for MVI inspection? (1=Yes; 2=No) 3.1 If yes, date of last MVI inspection. 1
4. Examine the following aspects of the vehicle and mark your observation in the status column: Sl Description Status 1= Satisfactory; 2=Needs Repair; 3=Needs Replacement; 4= Not Available 1 Condition of tires 2 Condition of AC 3 Mirrors & Indirect Vision Devices 4 Lights 5 Glass & View of the Road 6 Windscreen wipers 7 Speedometer 8 Horn 9 Hand Lever Operating Mechanical Brakes 10 Interior of Body, Passenger Entrance, Exit Steps & Platforms 11 Siren 12 Door 5. INFRASTRUCTURE (EQUIPMENT FUNCTIONING) Sl Description 1 Folding chairs 2 Examination Table 3 Blood donation cot 4 Screen 5 Biological Research Microscope 6 Stretcher 7 Waste Basket with foot cover 8 Cold storage (vaccine carrier) 9 IUD Insertion Kit 10 Sterilization Drum 11 Linen 12 Mattress 13 Mackintosh (rubber) sheets 14 Weighing Machine (Adults) 15 Weighing Machine (Infants) 16 Autoscope 17 Stethoscope 18 Blood pressure monitor 19 Hemoglobinometer 1=Available and working 2=Needs Repair; 3=Needs Replacement; 4= Not Available 2
20 Emergency drugs kit 21 First Aid Kit 22 Autoclave W&H Lisa 300 23 Portable X-Ray Unit 24 HIV Kits 25 Suction tube Portable Electrocardio Graph 3 channel (ECG) 26 Machine 27 Auto Analyzer 28 Genset 29 Telemedicine facility 30 Suture instruments 31 Drinking Water Storage Device 32 Torch 33 Thermometer 34 Oxygen cylinder 35 ENT and Eye examination kit 36 Needle cutter 37 Display board on services offered by MMU 38 Spare wheel C. CONSUMABLES: Sl Description Status 1=Stock Adequate; 2=Stock Inadequate; 3=Not in stock; 1 Malaria test kit 2 Blood test reagents 3 X-ray Films 4 Tetanus Toxoid Injection 5 IUD 6 HIV-Kit 7 Pregnancy Test kit 8 First aid kit 9 Oral Contraceptives 10 Syringes and Needles 11 Suture material 12 Glass slides 13 Stationery 14 Patient cards with NRHM logo 15 Analgesics 16 Anesthetic 17 Antiallergic 18 Anti-infective 19 Sterile gloves/sterile dressings 20 Anti snake venom 3
21 Condoms 22 Antipyretics 23 Anti-inflammatory 24 Chlorine tablets 25 Povidone Iodine Solution 5%, 10% 26 Hydrogen Peroxide Solution 6% 27 Oral Rehydration Salts 28 Activated charcoal powder 29 Iron and Folic Acid Tablets D. HUMAN RESOURCE AVAILABILITY: Sl Description Whether Qualification Nature of Training Received available at the (1=Non- employment related to MMU MMU site (1=Yes; 2=No) matriculate; 2=Matriculate; (1=contractual part time; operation (1=Orientation; 3=Intermediate; 2=contractual 2=Refresher; 4=Diploma; full time; 3=No training) 5=Graduate; 3=permanent) 6=MBBS; 7=MBBS-MD 1 Driver 2 Medical Officer (Doctor) 3 Lady Medical Officer (Doctor) 4 ANM or Staff Nurse 5 X-Ray Technician 6 Lab Technician 6 Helper 7 Pharmacist E. PROCESS FOR MMU MAINTENANCE AND REPORTING: 1. Any Standard Operating Procedure (SOP) for recording driver's vehicle defect report? (1=Yes; 2=No) 2. If yes, when was the last vehicle defect report. 3. Is there any maintenance plan available for the vehicle? (1=Yes; 2=No) 4. Is there any maintenance plan for the equipment? (1=Yes; 2=No) 5. Whether daily format filled and duly signed by PRI member? (1=Yes; 2=No) 5.1 if yes write the name of the PRI member and last signed date 5.2 If no, what are the reasons? (i).. 4
(ii).. 6. Whether monthly report filled and duly sent to government as per schedule? (1=Yes; 2=No) 6.1 if yes write that date when was the last monthly report sent to the government 6.2 If No, what are the reasons? (i) (ii) F. Information to be captured from NGO Office/MMU Coordinator 1. When was the last invoice submitted?... 2. How long did it take for the last invoice to get approved? (Enter days) 3. How long did it take for the amount as per last invoice to be credited to your account? (Enter days) 4. Do you have separate account for each MMU? (1=Yes; 2=No) 5. Is there any SOP for internal monthly review? (1=Yes; 2=No) 5.1 If yes, when was the last review held?.. 5.2 If yes, are the review proceedings documented? (1=Yes; 2=No) 5.3 If yes, are the review proceedings shared with govt.? (1=Yes; 2=No) 6. Is there any SOP for review with government? (1=Yes; 2=No) 6.1 If yes, when was the last review held at the district level?. 6.2 If yes, when was the last review held at the state level? 7. Is there any SOP to determine what medicines are to be procured? (1=Yes; 2=No) 7.1 If yes, how was it determined? (i) (ii) 7.2 If No, how do you determine what medicines are to be procured? 5
(i).. (ii). 7.3 If yes, whether it is revised over a period of time. 8. Is there any SOP for disposing expired drugs? (1=Yes; 2=No) 8.1 If no, how are expired drugs disposed (i) (ii) 9. Is there separate account to manage finance for each MMU? (1=Yes; 2=No) G. CHALLENGES FACED BY FIELD TEAM IN OPERATING MMU: 1 2... 3... H. SUGGESTIONS FROM FIELD TEAM FOR IMPROVING MMU SERVICE: 1. 2. 3... Signature of the Respondent Date: Signature of the Surveyor Date: 6