RBSK New Format

Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (Delivery Point) - FORM No - I
Name of State: Bihar Name of District: Name of Block:

Name of Delivery Facility Code as
Point Type of facility - per MCTS
(DH/SDH/FRU/CHC/PHC/SC) (if available)
Contact No.
Reporting Month Reporting Year 2018 (if available)
Birth-6
Delivery points
Male
Number of deliveries in the facility in the reporting month (Delivery outcome)
Number of live birth in the facility in the reporting month
Number of children screened for Defects at Birth at the delivery point in the reporting
month
Cumulative number of Children born in the facility in the year ________
From ________ To (reporting month)_____________
Cumulative number of newborn screened in the year ________
Total Number of new born children identified through screening
Sl No Defect at Birth: 0
1 Neural tube defect
2 Down’s Syndrome
3 Cleft Lip & Palate
4 Club foot
5 Developmental dysplasia of the hip
6 Congenital cataract
7 Congenital deafness
8 Congenital heart diseases
9 Retinopathy of Prematurity
Primary care Secondary Care

Total Children Refered (PHC/CHC) (DH/SDH/SNCU)
Male
Neural tube defect
Female
Male
Down’s Syndrome
Female
Male
Cleft Lip & Palate
Female
Male
Club foot
Female
Developmental dysplasia Male
of the hip Female
Male
Congenital cataract
Female
Male
Congenital deafness
Female
Male
Congenital heart diseases
Female
Male
Retinopathy of Prematurity
Female
Report prepared by Report ve
Name & Signature
Designation
Date
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
FORMAT (Delivery Point) - FORM No - I
Birth-6 weeks
Female Total
0
0
0 0
Tertiary Care Total =

(DEIC)/MC 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Report verified by
Government of India
MONTHLY REPORTING FORMAT (ASHA,HBNC) - FORM No - II
Name of State: Bihar Name of District

Name of ASHA ASHA ID (if available)
2018
Reporting Month Reporting Year
Birth-6 we
ASHA, HBNC
Male
Total number of deliveries reported in catchment area of ASHA in the
reporting month
Total number of New borns to be visited in the month (Planned)
Number of newborn visited by the ASHA in HBNC visit in the month
Cumulative Number of deliveries in the year ________
Cumulative Number of Children screened for defects at birth during HBNC

visits in the year ________
Number of newborn screened by the ASHA in HBNC visit for Defects at

Birth in the reporting month
Sl No Defects at Birth: 0
1 Neural tube defect
2 Down’s Syndrome
3 Cleft Lip & Palate
4 Club foot
5 Developmental dysplasia of the hip
Secondary Care
Total Children Refered Primary care (PHC/CHC)
(DH/SDH/SNCU)
Male
Neural tube defect
Female
Male
Down’s Syndrome
Female
Male
Cleft Lip & Palate
Female
Male
Club foot
Female
Male
Developmental
dysplasia
of the hip Female
Report prepared by Asha Report verified by ANM Report verified by AS
Name
Signature
Date
Government of India
triya Bal Swasthya Karyakram (RBSK)
PORTING FORMAT (ASHA,HBNC) - FORM No - II
Name of Block
Name of ASHA Supervisor
Contact Detail of ASHA
(if available)
Birth-6 weeks
Female Total
0
0
0 0
Tertiary Care (DEIC) Total =

/MC 0
0
0
Report verified by ASHA supervisor

Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
State: Bihar District 0 Name of Block
6 weeks to 3 years (MHT)

Target : Total No. of children No. of children Percentage of total Found positive for Referred for this Target :
children to be screened in screened children screened selected health current month/year Total children to be
screened in current month cumulative till till this month conditions in current screened in complete
complete year by /Yearby M.H.T. current month (Cumulative) month/year year by M.H.T.
M.H.T.
Male 0%
Female 0%
Total 0 0 0 0% 0 0 0
Screening details at AWCs/Schools (Planning)

Annual plan : Total AWC/School Total AWC/School Cumulative gap
visit planned in this visit conducted this including carry
Total visit to month by Mobile month by Mobile forward from previous
be planned in this Health Teams Health Teams month of the current Total Number of
year year MHT Details
MHT
Visit 1 Approved
AWCs
Visit 2 In-place
Govt and Govt aided schools Trained
Functional
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
6 weeks to 3 years 3 years to 6 years
Number of Children screened in Screened Children with Health Condition Screened Children with Health Condition
……………………………….
Male Female Total Male Female Total
(Reporting Month)
0 0 0 0 0 0
Defects at Birth: Total 0 0 0 0 0 0
Neural tube defect 0 0

Down’s Syndrome 0 0
Cleft Lip & Palate 0 0

Club foot 0 0
Developmental dysplasia of the hip 0 0
Congenital cataract 0 0
Congenital deafness 0 0
Congenital heart diseases 0 0
Retinopathy of Prematurity 0 0
Deficiencies:Total 0 0 0 0 0 0
Severe Anaemia 0 0
Vitamin A deficiency (Bitot spot) 0 0
Vitamin D Deficiency, (Rickets) 0 0

Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
A) SAM 0 0
B) Severe Thinning 0 0
C) Obesity 0 0
Goitre 0 0
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Childhood Diseases:Total 0 0 0 0 0 0
Skin conditions 0 0
Otitis Media 0 0
Rheumatic heart disease 0 0
Reactive airway disease 0 0

Dental Conditions 0 0
Convulsive disorders 0 0
Developmental Delays
0 0 0 0 0 0
including Disabilities:Total
Vision impairment 0 0
Hearing Impairment 0 0
Neuro motor impairment 0 0
Motor delay 0 0
Cognitive delay 0 0
Language delay 0 0
Behaviour disorder (Autism) 0 0
Learning disorder 0 0
Attention deficit hyperactivity disorder 0 0

Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Others 0 0
Adolescent Health:Total 0 0 0 0 0 0
Growing up concerns 0
Substance abuse 0
Feel depressed 0
Delay in menstruation cycles 0
Irregular periods 0
Pain or burning sensation while urinating 0
Discharge/ foul smelling discharge from the

0
genitor-urinary area
Pain during menstruation 0
6 weeks to 3 years 3 years to 6 years
Total Children Refered with Heatlth Conditions Secondary Care Secondary Care
Primary care Tertiary Care Primary care Tertiary Care
(DH/SDH/ (DH/SDH/
(PHC/CHC) (DEIC)/MC (PHC/CHC) (DEIC)/MC
SNCU) SNCU)
Male
Neural tube defect
Female
Male
Down’s Syndrome
Female
Male
Cleft Lip & Palate
Female
Male
Club foot
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Club foot
Female
Developmental dysplasia Male
of the hip Female
Male
Congenital cataract
Female
Male
Congenital deafness
Female
Male
Female
Male
Retinopathy of Prematurity
Female
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Male
Severe Anaemia
Female
Vitamin A deficiency Male
(Bitot spot) Female
Vitamin D Deficiency, Male
(Rickets) Female
Male
A)SAM Female
Male
B)Severe Thinning Female
Male
C)Obesity Female
Male
Goitre Female
Male
Skin conditions Female
Male
Ottis Media Female
Male
Rheumatic Heart Disease Female
Male
Reactive Airway Disease Female
Male
Dental Conditions Female
Male
Convulsive Disorders Female
Male
Vision impairment Female
Male
Hearing Impairment Female
Male
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Neuro motor impairment Female
Male
Motor delay Female
Male
Cognitive delay Female
Male
Language delay Female
Male
Behaviour disorder
(Autism) Female
Learning disorder Male
Female
Attention deficit hyperactivity Male
disorder
Female
Others Male
Female
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Growing up concerns Male
Female
Substance abuse Male
Female
Feel depressed Male
Female
Delay in menstruation cycles Male
Female
Irregular periods Male
Female
Pain or burning sensation while Male
urinating
Female
Discharge/ foul smelling discharge Male
from the
Female
Male
Pain during menstruation
Female
Male 0 0 0 0 0 0
Defects at Birth
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Deficiencies
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Childhood Diseases
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Male 0 0 0 0 0 0
Adolescent Health
Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Adolescent Health
Female 0 0 0 0 0 0
Grand Total Male 0 0 0 0 0 0

Female 0 0 0 0 0 0
Report prepared by
Name of the Nodal Person

Signature
Designation
Date
overnment of India
TING FORMAT (MHT) - FORM No - III
MHT Team Code Reporting Month Reporting Year 2018
3-6 years (MHT) 6-18 years enrolled in Govt and Govt aided schools (MH
No. of children No. of children Percentage of total Found positive for Referred for this Target : No. of children No. of children Percentage of total
screened in screened cumulative till children screened selected health current Total screened in screened children screened
current current month till this month conditions in current month/year children to be current cumulative till till this month
month/year by (Cumulative) month screened in month/year by current month (Cumulative)
M.H.T. complete year by M.H.T.
M.H.T.
0% 0%
0% 0%
0 0 0% 0 0 0 0 0 0%
Composition of Mobile Health Team

Doctors Pharmacist ANM/ Staff nurse Total
Male Female Male Female Male Female Doctors Pharmacist ANM/SN
0 0 0
0 0 0
0 0 0
0 0 0
overnment of India
6 years to 18 years Total Number of Children Screened
Screened Children with Health Condition Screened Children with Health Condition
Remarks by MHT Team
Male Female Total Male Female Total
0 0 0 0 0 0
0 0 0 0 0 0 Defect at Birth
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0 0 Deficiencies
0 0 0 0
0 0 0 0
0 0 0 0
overnment of India
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
overnment of India
0 0 0 0 0 0 Childhood Diseases
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0 0 0 Developmental Delays including Disabi
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
overnment of India
0 0 0 0
0 0 0 0 0 0 Adolescent Health
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0
0
0 0 0 0
6 years to 18 years Total Number of Children Refered at
Secondary Care
Secondary Refer Children for Health Conditions at f
Primary care Tertiary Care Primary care Care Tertiary Care
(DH/SDH/
(PHC/CHC) (DEIC)/MC (PHC/CHC) (DH/SDH/ (DEIC)/MC
SNCU)
SNCU)
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
overnment of India
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
overnment of India
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
overnment of India
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
overnment of India
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
overnment of India
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
Report verified by Block/ District / State Nodal person
2018
d schools (MHT)
Found positive Referred for
for selected this current
health conditions month/year
in current month
0 0
T Team
th
s
ases
ding Disabilities
alth
nditions at facility
al person
Minist
Rashtriya
MONTHLY REPORTING
Name of State/UT: Bihar No of Reported Districts: 0
6 weeks to 3 years (MHT) 3-6 years years enrolled in Govt and
Target : No. of No. of children Percentage of total Found positive for Referred for this Target : No. of children No. of children
children screened children screened till selected health current month/year Total screened in screened
Total children to be screened in cumulative till this month conditions in children to be current cumulative till
screened in current current month (Cumulative) current month/year screened in month/year by current month
complete year by month complete year by M.H.T.
M.H.T. /Yearby M.H.T.
M.H.T.
Male 0 0 0 0% 0 0 0 0 0
Female 0 0 0 0% 0 0 0 0 0
Total
0 0 0 0% 0 0 0 0 0
Annual plan Total AWC/School Total AWC/School Cumulative gap
: visit planned in visit conducted including carry
this month by this month by forward from
Total visit Mobile Health Mobile Health previous month of
to be Teams Teams the current year Number of Total HR in
planned in DEIC Manager
DEIC DEIC
this year
Number Number Number Number Approved
Visit 1 0 0 0 0 In-place
AWC
Pages 39 of 119
Minist
Rashtriya
MONTHLY REPORTING
AWC
Visit 2 0 0 0 0 Trained
Govt and Govt aided schools 0 0 0 0 Operational
Birth-6 weeks 6 weeks to 3 years
Number of Children screened in the
Delivery points ASHA, HBNC Screened Children with Health C
year : Current Reporting Month (From)
__________ (To) End of Rerpoting
Month _____________ Male Female Total Male Female Total Male Female
0 0 0 0 0 0 0 0
Defects at Birth: Total 0 0 0 0 0 0 0 0

Neural tube defect 0 0 0 0 0 0 0 0
Down’s Syndrome 0 0 0 0 0 0 0 0
Cleft Lip & Palate 0 0 0 0 0 0 0 0
Club foot 0 0 0 0 0 0 0 0
Developmental dysplasia of the hip 0 0 0 0 0 0 0 0
Congenital cataract 0 0 0 0 0 0
Congenital deafness 0 0 0 0 0 0
Congenital heart diseases 0 0 0 0 0 0
Retinopathy of Prematurity 0 0 0 0 0 0
Deficiencies:Total 0 0 0 0 0 0 0 0
Severe Anaemia 0 0 0 0
Vitamin A deficiency (Bitot spot) 0 0 0 0
Vitamin D Deficiency, (Rickets) 0 0 0 0
A) SAM 0 0 0 0
C) Obesity 0 0 0 0
Goitre 0 0 0 0
Pages 40 of 119
Minist
Rashtriya
MONTHLY REPORTING
Childhood Diseases:Total 0 0 0 0 0 0 0 0
Skin conditions 0 0 0 0
Otitis Media 0 0 0 0
Reactive airway disease 0 0 0 0
Dental Conditions 0 0 0 0
Convulsive disorders 0 0 0 0
Pages 41 of 119
Minist
Rashtriya
MONTHLY REPORTING
Developmental Delays including

Disabilities:Total 0 0 0 0 0 0 0 0
Vision impairment 0 0 0 0
Hearing Impairment 0 0 0 0
Neuro motor impairment 0 0 0 0
Motor delay 0 0
Cognitive delay 0 0
Language delay 0 0
Learning disorder
Attention deficit hyperactivity disorder
Others
Adolescent Health:Total 0 0 0 0 0 0 0 0
Growing up concerns 0 0
Substance abuse 0 0
Feel depressed 0 0
Delay in menstruation cycles 0 0
Irregular periods 0 0
Pain or burning sensation while urinating 0 0

0 0
Pain during menstruation 0 0
Pages 42 of 119
Minist
Rashtriya
MONTHLY REPORTING
Birth-6 weeks 6 weeks to 3 years
Delivery points ASHA, HBNC Refered Children with Health C

Total Children Refered
Secondary
Primary Secondary Care
Tertiary Care Primary care Secondary Care Tertiary Care Primary care Care
care (DH/SDH/
(DEIC)/MC (PHC/CHC) (DH/SDH/MC) (DEIC) (PHC/CHC) (DH/SDH/
(PHC/CHC) SNCU)
SNCU)
Neural tube defect
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Down’s Syndrome
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Cleft Lip & Palate
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Club foot
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Developmental dysplasia
of the hip Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Congenital cataract
Male 0 0 0 0 0
Female 0 0 0 0 0
Pages 43 of 119
Minist
Rashtriya
MONTHLY REPORTING
Congenital deafness
Male 0 0 0 0 0
Female 0 0 0 0 0

Male 0 0 0 0 0
Female 0 0 0 0 0
Retinopathy of
Prematurity Male 0 0 0 0 0
Female 0 0 0 0 0
Pages 44 of 119
Minist
Rashtriya
MONTHLY REPORTING
Severe Anaemia
0 0
Male
0 0
Female
Vitamin A deficiency
(Bitot spot) 0 0
Male
0 0
Female
Vitamin D Deficiency,
(Rickets) 0 0
Male
0 0
Female
A)SAM
0 0
Male
0 0
Female
B)Severe Thinning
Male
Female
C)Obesity
0 0
Male
0 0
Female
Goitre
0 0
Male
0 0
Female
Skin conditions
0 0
Male
Pages 45 of 119
Minist
Rashtriya
MONTHLY REPORTING
Skin conditions
0 0
Female
Ottis Media
0 0
Male
0 0
Female
Rheumatic Heart Disease
Male
Female
Reactive Airway Disease
0 0
Male
0 0
Female
Dental Conditions
0 0
Male
0 0
Female
Convulsive Disorders
0 0
Male
0 0
Female
Pages 46 of 119
Minist
Rashtriya
MONTHLY REPORTING
Vision impairment
0 0
Male
0 0
Female
Hearing Impairment
0 0
Male
0 0
Female
Neuro motor impairment
0 0
Male
0 0
Female
Motor delay
0 0
Male
0 0
Female
Cognitive delay
0 0
Male
0 0
Female
Language delay
0 0
Male
0 0
Female
Behaviour disorder
(Autism) 0 0
Male
0 0
Female
Learning disorder
Male
Pages 47 of 119
Minist
Rashtriya
MONTHLY REPORTING
Learning disorder
Female
Attention deficit
hyperactivity disorder
Male
Female
Others
Male
Female
Pages 48 of 119
Minist
Rashtriya
MONTHLY REPORTING
Growing up concerns
Male
Female
Substance abuse
Male
Female
Feel depressed
Male
Female
Delay in menstruation
cycles
Male
Female
Irregular periods
Male
Female
Pain or burning sensation
while urinating
Male
Female
Discharge/ foul smelling
discharge from the
genitor-urinary area Male
Female
Pages 49 of 119
Minist
Rashtriya
MONTHLY REPORTING
Male
Female
Male 0 0 0 0 0 0 0 0
Defects at Birth
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Deficiencies
Female 0 0 0 0 0 0 0 0
Childhood Male 0 0 0 0 0 0 0 0
Diseases
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Grand Total
Female 0 0 0 0 0 0 0 0
Report prepared by Report verified
Name
Signature
Designation
Date
Pages 50 of 119
Ministry of Health & Family Welfare Minis
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK) Rashtriy
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-IV MONTHLY REPORTING
Name of State/UT: 0 No of Blocks : Reporting Month
3-6 years years enrolled in Govt and Govt aided schools
6 weeks
(MHT)
to 3 years (MHT) 6-18 years enrolled in Govt and Govt aided schools (MHT)
Target : Percentage of Found Referred for this Target : No. of No. of children Percentage of total Found positive for
total children positive for current Total children children screened cumulative children screened selected health
Total children to be screened till this selected month/year to be screened in screened in till current month till this month conditions in current
screened in month health complete year by current (Cumulative) month
complete year by (Cumulative) conditions in M.H.T. month/year by
M.H.T. current M.H.T.
month
Male 0 0% 0 0 0 0 0 0% 0
Female 0 0% 0 0 0 0 0 0% 0
Total
0 0% 0 0 0 0 0 0% 0
DEIC and MHT Information
Doctors Pharmacist ANM/ Staff nurse
Total MHT
Male Female Male Female Male Female Doctors
0 0 0 0 0 0 0 0
Visit 1 0 0 0 0 0 0 0 0
AWC
Pages 51 of 119
Government of India
AWC
Visit 2 0 0 0 0 0 0 0 0
Govt and Govt aided schools 0 0 0 0 0 0 0 0
6 weeks to 3 years 3 years to 6 years 6 years to 18 years To
Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition Screened Child
Month _____________ Total Male Female Total Male Female Total Male
0 0 0 0 0 0 0 0
Defects at Birth: Total 0 0 0 0 0 0 0 0
Neural tube defect 0 0 0 0 0 0 0 0
Down’s Syndrome 0 0 0 0 0 0 0 0
Cleft Lip & Palate 0 0 0 0 0 0 0 0
Club foot 0 0 0 0 0 0 0 0
Developmental dysplasia of the hip 0 0 0 0 0 0 0 0
Congenital cataract 0 0 0 0 0 0 0 0
Congenital deafness 0 0 0 0 0 0 0 0
Congenital heart diseases 0 0 0 0 0 0 0 0
Retinopathy of Prematurity 0 0 0 0 0 0 0 0
Deficiencies:Total 0 0 0 0 0 0 0 0
Severe Anaemia 0 0 0 0 0 0 0 0
Vitamin A deficiency (Bitot spot) 0 0 0 0 0 0 0 0
Vitamin D Deficiency, (Rickets) 0 0 0 0 0 0 0 0
A) SAM 0 0 0 0 0 0
B) Severe Thinning 0 0 0 0 0 0
C) Obesity 0 0 0 0 0 0 0 0
Goitre 0 0 0 0 0 0 0 0
Pages 52 of 119
Government of India
Childhood Diseases:Total 0 0 0 0 0 0 0 0
Skin conditions 0 0 0 0 0 0 0 0
Otitis Media 0 0 0 0 0 0 0 0
Rheumatic heart disease 0 0 0 0 0 0
Reactive airway disease 0 0 0 0 0 0 0 0
Dental Conditions 0 0 0 0 0 0 0 0
Convulsive disorders 0 0 0 0 0 0 0 0
Pages 53 of 119
Government of India

Disabilities:Total 0 0 0 0 0 0 0 0
Vision impairment 0 0 0 0 0 0 0 0
Hearing Impairment 0 0 0 0 0 0 0 0
Neuro motor impairment 0 0 0 0 0 0 0 0
Motor delay 0 0 0 0 0 0 0 0
Cognitive delay 0 0 0 0 0 0 0 0
Language delay 0 0 0 0 0 0 0 0
Behaviour disorder (Autism) 0 0 0 0 0 0 0 0
Learning disorder 0 0 0 0 0 0
Attention deficit hyperactivity disorder 0 0 0 0 0 0
Others 0 0 0 0 0 0 0
Adolescent Health:Total 0 0 0 0 0 0 0 0
Growing up concerns 0 0 0 0 0 0
Substance abuse 0 0 0 0 0 0
Feel depressed 0 0 0 0 0 0
Delay in menstruation cycles 0 0 0 0 0 0
Irregular periods 0 0 0 0 0 0
Pain or burning sensation while urinating 0 0 0 0 0 0
0 0 0 0 0 0
Pain during menstruation 0 0 0 0 0 0
Pages 54 of 119
Government of India
6 weeks to 3 years 3 years to 6 years 6 years to 18 years To
Refered Children with Health Condition Refered Children with Health Condition Refered Children with Health Condition Refered Childre
Total Children Refered
Secondary
Primary Primary Secondary Care
Tertiary Care Care Tertiary Care Tertiary Care Primary care
care care (DH/SDH/
(DEIC)/MC (DH/SDH/ (DEIC)/MC (DEIC)/MC (PHC/CHC)
(PHC/CHC) (PHC/CHC) SNCU)
SNCU)
Neural tube defect
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Down’s Syndrome
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Cleft Lip & Palate
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Club foot
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
of the hip Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Congenital cataract
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Pages 55 of 119
Government of India
Congenital deafness
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Retinopathy of
Prematurity Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Pages 56 of 119
Government of India
Severe Anaemia
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
(Bitot spot)
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
(Rickets)
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
A)SAM
Male
0 0 0 0 0
Female
0 0 0 0 0
B)Severe Thinning
Male
0 0 0 0
Female
0 0 0 0
C)Obesity
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Goitre
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Skin conditions
Male
0 0 0 0 0 0 0 0
Pages 57 of 119
Government of India
Skin conditions
Female
0 0 0 0 0 0 0 0
Ottis Media
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Male
0 0 0 0
Female
0 0 0 0
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Dental Conditions
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Pages 58 of 119
Government of India
Vision impairment
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Hearing Impairment
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Motor delay
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Cognitive delay
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Language delay
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Behaviour disorder
(Autism)
Male
0 0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0 0
Learning disorder
Male
0 0 0 0 0 0 0
Pages 59 of 119
Government of India
Learning disorder
Female
0 0 0 0 0 0 0
Attention deficit
Male
0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0
Others
Male
0 0 0 0 0 0 0
Female
0 0 0 0 0 0 0
Pages 60 of 119
Government of India
Growing up concerns
Male
0 0 0 0
Female
0 0 0 0
Substance abuse
Male
0 0 0 0
Female
0 0 0 0
Feel depressed
Male
0 0 0 0
Female
0 0 0 0
cycles
Male
0 0 0 0
Female
0 0 0 0
Irregular periods
Male
0 0 0 0
Female
0 0 0 0
while urinating 0 0 0 0
Male
Female
0 0 0 0
discharge from the
Male
0 0 0 0
Female
0 0 0 0
Pages 61 of 119
Government of India
Male
0 0 0 0
Female
0 0 0 0
Male 0 0 0 0 0 0 0 0
Defects at Birth
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Deficiencies
Female 0 0 0 0 0 0 0 0
Childhood Male 0 0 0 0 0 0 0 0
Diseases
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Female 0 0 0 0 0 0 0 0
Male 0 0 0 0 0 0 0 0
Grand Total
Female 0 0 0 0 0 0 0 0
Name
Signature
Designation
Date
Pages 62 of 119
) - FORM-IV MONTHLY R
Name of State/UT: Reporting Year 2018
6-18 years enrolled in Govt and Govt aided schools (MHT) 6 weeks to 3 years (MHT) Birth to 6 weeks
Target : Referred for this current Delivery points (DP) ASHA, HBNC
month/year
Total children to be Total number of Number of ASHA
notified delivery in the block
screened in
points in the
complete year by block
M.H.T.
Number of DP Number of ASHA
reported reported
No. of children Found positive No. of children Found positive for

screened at the for Defects at screened by Defects at Birth
delivery points birth ASHAs
Male 0 0 0 0 0 0
Female 0 0 0 0 0 0
Total
0 0 0 0 0 0
mation Screening details at AWCs/Schools (Planning)
Total
Remarks by State RBSK Team

Pharmacist ANM/SN
0 0
Visit 1 0 0
AWC
Pages 63 of 119
AWC
Visit 2 0 0
Govt and Govt aided schools 0 0
Total children
Screened Children with Health Condition
Screening Children
Month _____________ Female Total
0 0
Defects at Birth: Total 0 0 Defect at Birth
Neural tube defect 0 0
Down’s Syndrome 0 0
Cleft Lip & Palate 0 0
Club foot 0 0
Developmental dysplasia of the hip 0 0
Congenital cataract 0 0
Congenital deafness 0 0
Congenital heart diseases 0 0
Retinopathy of Prematurity 0 0
Deficiencies:Total 0 0 Deficiencies
Severe Anaemia 0 0
Vitamin A deficiency (Bitot spot) 0 0
Vitamin D Deficiency, (Rickets) 0 0
A) SAM 0 0
C) Obesity 0 0
Goitre 0 0
Pages 64 of 119
Childhood Diseases:Total 0 0 Childhood Diseases

Skin conditions 0 0
Otitis Media 0 0
Reactive airway disease 0 0
Dental Conditions 0 0
Convulsive disorders 0 0
Pages 65 of 119
Developmental Delays including Developmental Delays including

0 0
Disabilities:Total Disabilities
Vision impairment 0 0
Hearing Impairment 0 0
Neuro motor impairment 0 0
Motor delay 0 0
Cognitive delay 0 0
Language delay 0 0
Learning disorder 0 0
Attention deficit hyperactivity disorder 0 0
Others 0 0
Adolescent Health:Total 0 0 Adolescent Health
Growing up concerns 0 0
Substance abuse 0 0
Feel depressed 0 0
Delay in menstruation cycles 0 0
Irregular periods 0 0
Pain or burning sensation while urinating 0 0
genitor-urinary area 0 0
Pain during menstruation 0 0
Pages 66 of 119
Total children
Refered Children with Health Condition at

Total Children Refered Refer Children for Health Conditions
Secondary Care
Tertiary Care
(DH/SDH/
(DEIC)/MC
SNCU)
Neural tube defect

Male 0 0
Female 0 0
Down’s Syndrome
Male 0 0
Female 0 0
Cleft Lip & Palate
Male 0 0
Female 0 0
Club foot
Male 0 0
Female 0 0
of the hip Male 0 0
Female 0 0
Congenital cataract
Male 0 0
Female 0 0
Pages 67 of 119
Congenital deafness
Male 0 0
Female 0 0
Male 0 0
Female 0 0
Retinopathy of
Prematurity Male 0 0
Female 0 0
Pages 68 of 119
Severe Anaemia
Male
0 0
Female
0 0
(Bitot spot)
Male
0 0
Female
0 0
(Rickets)
Male
0 0
Female
0 0
A)SAM
Male
0 0
Female
0 0
B)Severe Thinning
Male
0 0
Female
0 0
C)Obesity
Male
0 0
Female
0 0
Goitre
Male
0 0
Female
0 0
Skin conditions
Male
0 0
Pages 69 of 119
Skin conditions
Female
0 0
Ottis Media
Male
0 0
Female
0 0
Male
0 0
Female
0 0
Male
0 0
Female
0 0
Dental Conditions
Male
0 0
Female
0 0
Male
0 0
Female
0 0
Pages 70 of 119
Vision impairment
Male
0 0
Female
0 0
Hearing Impairment
Male
0 0
Female
0 0
Male
0 0
Female
0 0
Motor delay
Male
0 0
Female
0 0
Cognitive delay
Male
0 0
Female
0 0
Language delay
Male
0 0
Female
0 0
Behaviour disorder
(Autism)
Male
0 0
Female
0 0
Learning disorder
Male
0 0
Pages 71 of 119
Learning disorder
Female
0 0
Attention deficit
Male
0 0
Female
0 0
Others
Male
0 0
Female
0 0
Pages 72 of 119
Growing up concerns
Male
0 0
Female
0 0
Substance abuse
Male
0 0
Female
0 0
Feel depressed
Male
0 0
Female
0 0
cycles
Male
0 0
Female
0 0
Irregular periods
Male
0 0
Female
0 0
while urinating 0 0
Male
Female
0 0
discharge from the
Male
0 0
Female
0 0
Pages 73 of 119
Male
0 0
Female
0 0
Male 0 0
Defects at Birth
Female 0 0
Male 0 0
Deficiencies
Female 0 0
Childhood Male 0 0
Diseases
Female 0 0
Male 0 0
Female 0 0
Male 0 0
Grand Total
Female 0 0
Block/ District / State Nodal person
Name
Signature
Designation
Date
Pages 74 of 119
Ministry of Heal
Governm
Rashtriya Bal Swast
MONTHLY REPORTING FORMAT
Name of State/UT: Bihar No of Reported Districts:
Referal
Identified through screening Secondary Care
S.No Health Condition Details Primary care (PHC/CHC) Tertiary Care (DEIC)
(DH/Medical)
Male Female Male Female Male Female Male
Birth-6 weeks
Delivery Point 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
1
Neural tube
Defect 6 Weeks- 3 Yrs 0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
Down
2
Syndrome 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
3
Cleft Lip
& Palate
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
Cleft Lip
3
& Palate
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
4 Club foot 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
5
of the hip
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
S.No Developmental dysplasia
Health Condition Details Primary care (PHC/CHC) Tertiary Care (DEIC)
5
(DH/Medical)
of the hip
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
6 Congenital cataract 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
7 Congenital Deafness 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
8 Congenital Heart Diseases 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
9 Retinopathy of Prematurity 6 Weeks- 3 Yrs

0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 Yrs
0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
10 Severe Anaemia 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
11 Vitamin A deficiency (Bitot spot) 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
12 Vitamin D Deficiency, (Rickets) 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
13 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
A) SAM 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
B) Severe
Thinning 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
C) Obesity 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
14 Goitre 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
15 Skin conditions
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
16 Otitis Media
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
6 Weeks- 3 Years
0 0 0 0 0 0 0
17 Rheumatic heart disease
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
18 Reactive airway disease
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
19
Dental
6 Weeks- 3 Years
0 0 0 0 0 0 0
Conditions
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
6 Weeks- 3 Years
0 0 0 0 0 0 0
20 Convulsive disorders
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
21
Vision
6 Weeks- 3 Years
0 0 0 0 0 0 0
impairment
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
Birth-6 weeks
0 0 0 0 0 0 0
22
Hearing
6 Weeks- 3 Years
0 0 0 0 0 0 0
Impairment
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
Birth-6 weeks
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
23 Neuro motor impairment
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
24 Motor delay 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
25 Cognitive delay
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
25 Cognitive delay 3- 6 Yrs

0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
26 Language delay 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
27 Behaviour disorder (Autism) 3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
28 Learning disorder
6-18 yrs
0 0 0 0 0 0 0
29
Attention deficit hyperactivity
3- 6 Yrs
0 0 0 0 0 0 0
disorder
6-18 yrs
0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
3- 6 Yrs
0 0 0 0 0 0 0
30 Others
6-18 yrs
0 0 0 0 0 0 0
31 Growing up concerns 6-18 yrs
0 0 0 0 0 0 0
32 Substance abuse 6-18 yrs
0 0 0 0 0 0 0
33 Feel depressed 6-18 yrs
0 0 0 0 0 0 0
34 Delay in menstruation cycles 6-18 yrs
0 0 0 0 0 0 0
35 Irregular periods 6-18 yrs 0 0 0 0 0 0 0
Pain or burning sensation while 6-18 yrs
0 0 0 0 0 0 0
36
urinating

37 discharge from the 6-18 yrs
0 0 0 0 0 0 0
38 Pain during menstruation 6-18 yrs

0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
Defect at Birth 6 Weeks- 3 Yrs 0 0 0 0 0 0 0
3- 6 Yrs 0 0 0 0 0 0 0
6-18 Yrs 0 0 0 0 0 0 0
6 Weeks- 3 Years 0 0 0 0 0 0 0
Deficiency 3- 6 Yrs 0 0 0 0 0 0 0
6-18 yrs 0 0 0 0 0 0 0
Birth-6 weeks 0 0 0 0 0 0 0
6 Weeks- 3 Years 0 0 0 0 0 0 0
Childhood Diseases
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs 0 0 0 0 0 0 0
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
Birth-6 weeks
0 0 0 0 0 0 0

6 Weeks- 3 Years 0 0 0 0 0 0 0
Disabilities
3- 6 Yrs 0 0 0 0 0 0 0
6-18 yrs 0 0 0 0 0 0 0
Adolescent Health 6-18 yrs 0 0 0 0 0 0 0
Birth-6 weeks
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
Birth- 6 Weeks
Total Children
0 0 0 0 0 0 0
6 Weeks- 3 Years
0 0 0 0 0 0 0
3- 6 Yrs
0 0 0 0 0 0 0
6-18 yrs 0 0 0 0 0 0 0
Report prepared by
Ministry of Heal
Governm
Rashtriya Bal Swast
Referal
(DH/Medical)
Name
Signature
Designation
Date
Government of India
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: 0 No of Blocks : Reporting Month 0 Reporting Yea
Number of children with selected health conditions
Referal Managed
Confirmed
S.No Tertiary Care (DEIC)
Health Condition Medical Surgery Early Intervention AFHC counse
Female Male Female Male Female Male Female Male Female Male
0
0
1
Neural tube
Defect 0
0
0
0
0
Down
2
Syndrome 0
0
0
0
0
3
Cleft Lip
& Palate
Government of India
Referal Managed
Confirmed
Cleft Lip
3
& Palate 0
0
0
0
0
4 Club foot
0
0
0
0
0
5
of the hip 0
0
Government of India
Referal Managed
Confirmed
S.No Developmental Tertiary Care (DEIC)
dysplasia
5
of the hip
0
0
0
6 Congenital cataract
0
0
0
Government of India
Referal Managed
Confirmed
0
0
7 Congenital Deafness
0
0
0
0
0
8 Congenital Heart Diseases
0
0
0
0
0
Government of India
Referal Managed
Confirmed
0
0
0
0
10 Severe Anaemia
0
0
0
11 Vitamin A deficiency (Bitot spot)
0
0
0
12 Vitamin D Deficiency, (Rickets)
0
0
Government of India
Referal Managed
Confirmed
13
0
A) SAM
0
0
0
B) Severe
Thinning 0
0
0
C) Obesity
0
0
Government of India
Referal Managed
Confirmed
0
14 Goitre
0
0
0
0
15 Skin conditions
0
0
0
0
16 Otitis Media
0
0
0
Government of India
Referal Managed
Confirmed
0
0
0
0
0
0
0
0
19
Dental 0
Conditions
0
0
0
Government of India
Referal Managed
Confirmed
0
0
0
0
21
Vision 0
impairment
0
0
Government of India
Referal Managed
Confirmed
22
Hearing 0
Impairment
0
0
0
0
0
0
0
24 Motor delay
0
0
0
25 Cognitive delay
Government of India
Referal Managed
Confirmed
25 Cognitive delay
0
0
0
26 Language delay
0
0
0
27 Behaviour disorder (Autism)
0
0
0
29
Attention deficit hyperactivity 0
disorder
0
Government of India
Referal Managed
Confirmed
0
30 Others
0
31 Growing up concerns
0
32 Substance abuse
0
33 Feel depressed
0
34 Delay in menstruation cycles
0
35 Irregular periods 0
Pain or burning sensation while
0
36
urinating

37 discharge from the
0
38 Pain during menstruation

0
Government of India
Referal Managed
Confirmed
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Defect at Birth
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Deficiency
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Childhood Diseases
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Government of India
Referal Managed
Confirmed
0 0 0 0 0 0 0 0 0 0
Developmental Delays including 0 0 0 0 0 0 0 0 0 0
Disabilities
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Adolescent Health 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Total Children
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Government of India
Referal Managed
Confirmed
Name
Signature
Designation
Date
ORM-V
d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling
Female Male Female
0 0
0 0
0 0
1
Neural tube
Defect
0 0
0 0
0 0
0 0
0 0
2
Down
Syndrome
0 0
0 0
0 0
0 0
3
Cleft Lip
& Palate
ORM-V
d health conditions
Managed
Female Male Female
0 0
3
Cleft Lip
& Palate
0 0
0 0
0 0
0 0
4 Club foot 0 0
0 0
0 0
0 0
0 0
0 0
5
of the hip
0 0
ORM-V
d health conditions
Managed
S.No Developmental AFHC counselling
dysplasia
Health Condition
5
of the hip
Female Male Female
0 0
0 0
0 0
6 Congenital cataract 0 0
0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0
0 0
7 Congenital Deafness 0 0
0 0
0 0
0 0
0 0
8 Congenital Heart Diseases 0 0
0 0
0 0
0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
9 Retinopathy of Prematurity 0 0
0 0
0 0
0 0
10 Severe Anaemia 0 0
0 0
0 0
11 Vitamin A deficiency (Bitot spot) 0 0
0 0
0 0
12 Vitamin D Deficiency, (Rickets) 0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
13
0 0
A) SAM 0 0
0 0
0 0
0 0
B) Severe
Thinning
0 0
0 0
C) Obesity 0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0
14 Goitre 0 0
0 0
0 0
0 0
15 Skin conditions
0 0
0 0
0 0
0 0
16 Otitis Media
0 0
0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Dental
0 0
19
Conditions
0 0
0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0
0 0
0 0
0 0
Vision
0 0
21
impairment
0 0
0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0
Hearing
0 0
22
Impairment
0 0
0 0
0 0
0 0
0 0
0 0
0 0
24 Motor delay 0 0
0 0
0 0
25 Cognitive delay
ORM-V
d health conditions
Managed
Female Male Female
25 Cognitive delay 0 0
0 0
0 0
26 Language delay 0 0
0 0
0 0
27 Behaviour disorder (Autism) 0 0
0 0
0 0
0 0
Attention deficit hyperactivity
0 0
29
disorder
0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0
30 Others
0 0
31 Growing up concerns 0 0
32 Substance abuse 0 0
33 Feel depressed 0 0
34 Delay in menstruation cycles 0 0
35 Irregular periods 0 0
0 0
36
Pain or burning sensation while
urinating

37 discharge from the
0 0
38 Pain during menstruation 0 0

ORM-V
d health conditions
Managed
Female Male Female
0 0 0
0 0 0
Defect at Birth
0 0 0
0 0 0
0 0 0
0 0 0
Deficiency
0 0 0
0 0 0
0 0 0
0 0 0
Childhood Diseases
0 0 0
0 0 0
ORM-V
d health conditions
Managed
Female Male Female
0 0 0
Developmental Delays including 0 0 0

Disabilities
0 0 0
0 0 0
Adolescent Health 0 0 0
0 0 0
0 0 0
Total Children
0 0 0
0 0 0
0 0 0
0 0 0
Block/ District / State Nodal person
ORM-V
d health conditions
Managed
Female Male Female
Name
Signature
Designation
Date

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Ministry of Health & Family Welfare

Name of State: Bihar Name of District: Name of Block:

1 Neural tube defect

3 Cleft Lip & Palate

5 Developmental dysplasia of the hip

8 Congenital heart diseases

Primary care Secondary Care

Tertiary Care Total =

Name of State: Bihar Name of District

Cumulative Number of Children screened for defects at birth during HBNC

Number of newborn screened by the ASHA in HBNC visit for Defects at

1 Neural tube defect

3 Cleft Lip & Palate

5 Developmental dysplasia of the hip

Report prepared by Asha Report verified by ANM Report verified by AS

Tertiary Care (DEIC) Total =

Report verified by ASHA supervisor

State: Bihar District 0 Name of Block

6 weeks to 3 years (MHT)

Screening details at AWCs/Schools (Planning)

Neural tube defect 0 0

Cleft Lip & Palate 0 0

Vitamin A deficiency (Bitot spot) 0 0

Vitamin D Deficiency, (Rickets) 0 0

Reactive airway disease 0 0

Attention deficit hyperactivity disorder 0 0

Delay in menstruation cycles 0

Pain or burning sensation while urinating 0

Discharge/ foul smelling discharge from the

Pain during menstruation 0

6 weeks to 3 years 3 years to 6 years

Grand Total Male 0 0 0 0 0 0

Name of the Nodal Person

MHT Team Code Reporting Month Reporting Year 2018

Composition of Mobile Health Team

Male Female Male Female Male Female Doctors Pharmacist ANM/SN

0 0 0 0 0 0 Developmental Delays including Disabi

6 years to 18 years Total Number of Children Refered at

Number Number Number Number Approved

Defects at Birth: Total 0 0 0 0 0 0 0 0

Developmental Delays including

Pain or burning sensation while urinating 0 0

Discharge/ foul smelling discharge from the

Birth-6 weeks 6 weeks to 3 years

Delivery points ASHA, HBNC Refered Children with Health C

Congenital heart diseases

Developmental Delays including

6 weeks to 3 years 3 years to 6 years 6 years to 18 years To

No. of children Found positive No. of children Found positive for

Remarks by State RBSK Team

Childhood Diseases:Total 0 0 Childhood Diseases

Developmental Delays including Developmental Delays including

Refered Children with Health Condition at

Neural tube defect

Male Female Male Female Male Female Male

Male Female Male Female Male Female Male

Male Female Male Female Male Female Male

Male Female Male Female Male Female Male

Male Female Male Female Male Female Male

9 Retinopathy of Prematurity 6 Weeks- 3 Yrs

Male Female Male Female Male Female Male

Male Female Male Female Male Female Male

Male Female Male Female Male Female Male