Council (e.g. TC, MC, DC or CC): Village or Mtaa Vitongoji. Registration ID: CTC ID: MSD ID: MTUHA Code:
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1 The United Republic of Tanzania Ministry of Health, Community Development, Gender, Elderly and Children Health Facility Registry Data Collection Form 1. Administrative Divisions Zone: District: Ward: For District Council with Township Only: Region: Council (e.g. TC, MC, DC or CC): Village or Mtaa Vitongoji Township Authority Mtaa 2. Identification Registered/Official Facility Name: Common Facility Name: Registration ID: CTC ID: MSD ID: MTUHA Code: 3. Contact Information Postal Address: Postal Code: Official Phone number: Official Fax number: Official Address Website: Facility In-Charge Name: Cadre: Mobile Phone number: NID #: Registration/License #: 4. Physical Location Location Description (e.g. Landmarks): Geographic Coordinates WaypointNumber/Facility Name: Latitude (S):. Service and Catchment Area Altitude (Elev): Longitude (E):. Service Area (Mention): Service Population: Catchment Area (Mention): Catchment Population: Date Inaugurated/Opened/Upgraded (dd/mm/yyyy): / / (If Day/Month unknown, leave blank) 5. Classification Type of Health Facility Dispensary Health Center Clinic Eye Clinic Dental Clinic Others, Specify: Nursing Home Maternity Home Health Labs Diagnostic centre Hospital National Hospital Zonal Super Specialist Hospital Zonal Referral Hospital Super Specialist Hospital Regional Referral Hospital Designated District Hospital District Hospital Other Hospital Page 1 of 5
2 Ownership Public MoHSW LGA Other MDAs Military Prisons Regional Secretary Police Parastatal Private For profit Faith based Organization (FBO) NGOs Owner Detail / Name: Operating Status Operating Under Construction Pending Operation - Construction Complete Closed (Temporary) Permanent Closed Regulatory Status Registered Registration Pending Certification Registration Suspended Registration Cancelled Not Registered 6. Infrastructure/Facilities Number of Rooms Reception: Consultation: Dressing: Injection: Ward: Observation: Clinical Laboratory: Laboratory for specific services: Physiotherapy: Operating Theatre; Radiology: Pharmacy: Dispensing: Store: Maintenance & Repair Workshop: Remarks: Number of Vehicles # of ambulance # of cars # of motorcycles Specify, Other: # of Other: Number of Beds HF Bed capacity Available in Patient Beds: Delivery Beds: Examination Bed: Baby Cots: Equipment, Infection prevention and Control Autoclave Sterilizer Pressure Pot Boiling Pot Safety Box None Means of Transport to Referral Point: Distance to referral point Challenges/Remarks to reach at referral point: Source of Energy National Grid Generator Solar Panels Communication Network TTCL Airtel Vodacom Source of Water Piped water into Health Facility Piped water to yard/plot Public tap or standpipe Page 2 of 5
3 No Electricity Other, Specify: Tigo Zantel Other, Specify: Toilet Facility Flush toilet piped into sewer system Flush toilet piped into septic tank Flush/pour flush to pit latrine Ventilated improved pit latrine (VIP) Improved traditional Pit latrine with washable slab Tradition Pit latrine Composting toilet No toilet Remarks: Tube well or borehole Protected dug well Protected spring Rainwater Harvesting Others, Specify: Waste Management Incinerator, Functional? Yes No Burning Chamber Burning Pit Placenta Pit, With lid? Yes No Garbage storage Others, Specify: None Page 3 of 5
4 7. Services Offered 7.1) Clinical Services 7.1) Clinical Services Cont. OPD - Outpatient Services IPD - Inpatient Services IMCI - Integrated Management of Childhood Illness Non-Communicable Disease Care and Treatment Diabetes Care and Treatment NCD - Other Non-Communicable Disease Care and Treatment (e.g. Asthma, Hypertensive & Rheumatism) Ophthalmology Mental Health Services Physiotherapy Major Surgical Interventions Malaria Diagnosis and Treatment Slide Microscopy mrdt - Rapid Diagnostic Test First Line Treatment Treatment of Complicated Malaria TB Diagnosis, Care & Treatment Smear Microscopy Tuberculosis Culture X-Ray First Line Treatment MDRTB Treatment Cardiovascular Care and Treatment ECG ECHO Oxygen Concentrator Cardiac Bed HIV/AIDS Prevention Services STI - Management of other Sexually Transmitted Illness VCT -Voluntary Counselling and Testing PITC - Provider Initiated Counselling and Testing DCT - Diagnostic Counselling and Testing EID - Early Infant Diagnosis PMTCT- ANC (ANC PMTCT) PMTCT MATERNITY (MAT PMTCT) VMMC - Voluntary Medical Male Circumcision Services PEP - Post Exposure Prophylaxis HIV/AIDS Care and Treatment Paed ART - Pediatric ART Only Adult ART - Adult ART Only Both Adult and Pediatric HBC - Home and Community Based Care 7.2) Therapeutics Pharmacy Dispensing Room 7.3) Prosthetics and Medical Devices Prosthetics (e.g., Miguu / Mikono Bandia) Other Medical Devices (e.g., Neck collar) 7.4) Health Promotion and Disease Prevention Disease Surveillance and Response Health education School Health Intervention Psychosocial support Enforcement of public health laws and regulations 7.5) Diagnostic Services Laboratory Parasitology Microbiology Clinical Chemistry Immunology and Serology Hematology Blood Transfusion Pathology Histopathology (Tissue Diagnosis) Cytology Mortuary Services Radiology and imaging Services X-Ray Ultrasound CT-Scan MRI Page 4 of 5
5 7.6) Reproductive and Child Health Care Service 7.7) Growth Monitoring/Nutrition Surveillance Family Planning FP-NONINV - Noninvasive Method FP-INV Invasive Method Emergency Contraception Antenatal Care Postnatal Care Adolescent Reproductive Health Services BEmOC - Basic Emergency Obstetric Care CEmOC - Comprehensive Emergency Obstetric Care Vaccination IMM-Basic - Basic Immunization IMM-ADD - With Additional Vaccine PORT - Port Immunization Services Nutrition Rehabilitation Nutrition Counseling 7.8) Oral Health Service (Dental Service) Dental Laboratory Services (Prosthesis) Emergency Dental Services Post-Abortion Care Restoration Scaling Newborn Care Surgical Intervention Dental Chair Management of Hypertensive Pregnancies Pre-eclampsia 7.9) ENT Services, (Check box if service available) Reproductive Cancer Screening and Management Cervical Cancer Breast Cancer GBV Trauma counseling VAC Trauma counseling GBV PEP VAC PEP 7.10) Other Support Services Kitchen Services Laundry Services Security Services 7.11) Emergency Preparedness and response Basic Emergency Preparedness Comprehensive Emergency Preparedness 7.12) Telemedicine (Check box if service available) Emergency Medicine Health Care Technical services (Check box if service available) 7.14) Please Specify Any Other Services: For Official Use Only Filled by: / / Name of Officer Signature Date Mobile Number Title Checked by: / / Name of Facility In-charge Signature Date Approved by: / / Name of District Medical Officer Signature Date Page 5 of 5
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