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: ARWAL 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 January Reporting Year 2019 (if available)

Birth-6
Delivery points
Male
Number of deliveries in the facility in the reporting month (Delivery outcome) 482
Number of live birth in the facility in the reporting month 480
Number of children screened for Defects at Birth at the delivery point in the reporting
0
month
Cumulative number of Children born in the facility in the year ________
0
From ________ To (reporting month)_____________
Cumulative number of newborn screened in the year ________
0
From ________ To (reporting month)_____________
Total Number of new born children identified through screening 0

Sl No Defect at Birth: 0

1 Neural tube defect 0

2 Down’s Syndrome 0

3 Cleft Lip & Palate 0

4 Club foot 0

5 Developmental dysplasia of the hip 0

6 Congenital cataract 0

7 Congenital deafness 0

8 Congenital heart diseases 0

9 Retinopathy of Prematurity 0

Primary care Secondary Care

Total Children Refered (PHC/CHC) (DH/SDH/SNCU)

Male 0 0
Neural tube defect
Female 0 0
Male 0 0
Down’s Syndrome
Female 0 0
Male 0 0
Cleft Lip & Palate
Female 0 0
Male 0 0
Club foot
Female 0 0
Developmental dysplasia Male 0 0
of the hip Female 0 0
Male 0 0
Congenital cataract
Female 0 0
Male 0 0
Congenital deafness
Female 0 0
Male 0 0
Congenital heart diseases
Female 0 0
Male 0 0
Retinopathy of Prematurity
Female 0 0
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
418 900
417 897

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

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
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Report verified by
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (ASHA,HBNC) - FORM No - II

Name of State: Bihar Name of District ARWAL

Name of ASHA ASHA ID (if available)

January 2019
Reporting Month Reporting Year
Birth-6 we
ASHA, HBNC
Male
Total number of deliveries reported in catchment area of ASHA in the
532
reporting month
Total number of New borns to be visited in the month (Planned) 532

Number of newborn visited by the ASHA in HBNC visit in the month 516

Cumulative Number of deliveries in the year ________

0
From ________ To (reporting month)_____________

Cumulative Number of Children screened for defects at birth during HBNC

visits in the year ________ 0
From ________ To (reporting month)_____________

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

0
Birth in the reporting month

Sl No Defects at Birth: 0

1 Neural tube defect 0

2 Down’s Syndrome 0

3 Cleft Lip & Palate 0

4 Club foot 0

5 Developmental dysplasia of the hip 0

Secondary Care
Total Children Refered Primary care (PHC/CHC)
(DH/SDH/SNCU)

Male 0 0
Neural tube defect
Female 0 0

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

Male 0 0
Club foot
Female 0 0

Male 0 0
Developmental
dysplasia
of the hip Female 0 0

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

Name

Signature

Date
Ministry of Health & Family Welfare
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

492 1024

492 1024
481 997

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

Tertiary Care (DEIC) Total =

/MC 0

0 0

0 0

0 0

0 0
 0 0

0 0

0 0

0 0

0 0

0 0

Report verified by ASHA supervisor

 Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING

State: Bihar District ARWAL 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% 38182
Female 0% 38744
Total 0 0 0 0% 0 0 76926

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 9
AWCs
Visit 2 749 70 55 15 In-place 9
Govt and Govt aided schools 635 73 74 Trained 9
Functional 9
 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 2419 2349 4768
Defects at Birth: Total 0 0 0 6 1 7

Neural tube defect 0 0

Down’s Syndrome 0 0

Cleft Lip & Palate 0 3 0 3

Club foot 0 2 1 3
Developmental dysplasia of the hip 0 0
Congenital cataract 0 0
Congenital deafness 0 1 0 1
Congenital heart diseases 0 0
Retinopathy of Prematurity 0 0
Deficiencies:Total 0 0 0 1 2 3

Severe Anaemia 0 0

Vitamin A deficiency (Bitot spot) 0 1 2 3

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 79 68 147
Skin conditions 0 28 26 54
Otitis Media 0 36 15 51
Rheumatic heart disease 0 0

Reactive airway disease 0 3 12 15

Dental Conditions 0 10 14 24
Convulsive disorders 0 2 1 3

Developmental Delays
0 0 0 7 2 9
including Disabilities:Total

Vision impairment 0 0
Hearing Impairment 0 0
Neuro motor impairment 0 4 1 5
Motor delay 0 0
Cognitive delay 0 1 0 1
Language delay 0 2 1 3
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 3
Cleft Lip & Palate
Female 0
Male 2
Club foot
 Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Club foot
Female 1
Developmental dysplasia Male
of the hip Female
Male
Congenital cataract
Female
Male 1
Congenital deafness
Female
Male
Congenital heart diseases
Female
Male
Retinopathy of Prematurity
Female
 Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Male
Severe Anaemia
Female
Vitamin A deficiency Male 2
(Bitot spot) Female 1
Vitamin D Deficiency, Male
(Rickets) Female
Male
A)SAM Female
Male
B)Severe Thinning Female
Male
C)Obesity Female
Male
Goitre Female
Male 28
Skin conditions Female 26
Male 36
Ottis Media Female 15
Male
Rheumatic Heart Disease Female
Male 3
Reactive Airway Disease Female 12
Male 10
Dental Conditions Female 14
Male 2
Convulsive Disorders Female 1
Male
Vision impairment Female
Male 3
Hearing Impairment Female 2
Male 4
 Ministry of He
Govern
Rashtriya Bal Swa
MONTHLY REPORTING
Neuro motor impairment Female 1
Male
Motor delay Female
Male 1
Cognitive delay Female 0
Male 2
Language delay Female 1
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
genitor-urinary area
Female

Male
Pain during menstruation
Female
Male 0 0 0 0 0 6
Defects at Birth
Female 0 0 0 0 0 1
Male 0 0 0 0 2 0
Deficiencies
Female 0 0 0 0 1 0
Male 0 0 0 0 79 0
Childhood Diseases
Female 0 0 0 0 68 0

Male 0 0 0 0 0 10
Developmental Delays

Female 0 0 0 0 0 4

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 81 16

Female 0 0 0 0 69 5
Report prepared by

Name of the Nodal Person

Signature
Designation
Date
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III

MHT Team Code Reporting Month January Reporting Year 2019

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.

2419 2419 6% 107 109 61538 4696 4696 8%

2349 2349 6% 95 95 65775 5276 5276 8%

4768 4768 6% 202 204 127313 9972 9972 8%

Composition of Mobile Health Team

Doctors Pharmacist ANM/ Staff nurse Total

Male Female Male Female Male Female Doctors Pharmacist ANM/SN

18 0 9 0 9 18 9 9
16 0 6 0 7 16 6 7
18 0 9 0 9 18 9 9
16 0 6 0 7 16 6 7
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
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

4696 5276 9972 7115 7625 14740

3 3 6 9 4 13 Defect at Birth

0 0 0 0

0 0 0 0

0 3 0 3

1 2 3 3 3 6

0 0 0 0

0 0 0 0

1 0 1 2 0 2

0 0 0 0

1 1 2 1 1 2

22 20 42 23 22 45 Deficiencies

0 1 1 0 1 1

1 2 3 2 4 6

0 0 0 0
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
0 0 0 0

0 0 0 0

21 17 38 21 17 38

0 0 0 0
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
139 133 272 218 201 419 Childhood Diseases

44 35 79 72 61 133

26 26 52 62 41 103

0 0 0 0

1 29 30 4 41 45

67 41 108 77 55 132

1 2 3 3 3 6

30 45 75 37 47 84 Developmental Delays including Disabi

2 2 4 2 2 4

3 2 5 3 2 5

0 4 1 5

0 0 0 0

4 8 12 5 8 13

0 2 1 3

0 0 0 0

0 2 2 0 2 2

1 1 2 1 1 2
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
20 30 50 20 30 50
0 2 2 0 2 2 Adolescent Health

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0

0 2 2 0 2 2

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 3
0 0 0
1 0 0 3
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
2 0 0 3
0 0 0
0 0 0
0 0 0
0 0 0
1 0 0 2
0 0 0
0 0 0
0 0 0
1 0 0 1
1 0 0 1
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
0 0 0
0 0 0
1 0 3 0
2 0 3 0
0 0 0
0 0 0
0 0 0
0 0 0
21 0 21 0
17 0 17 0
0 0 0
0 0 0
0 0 0
0 0 0
44 0 72 0
35 0 61 0
26 0 62 0
26 0 41 0
0 0 0
0 0 0
1 0 4 0
29 0 41 0
67 0 77 0
41 0 55 0
1 0 3 0
2 0 3 0
2 0 2 0
2 0 2 0
0 0 3
0 0 2
0 0 4
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
0 0 1
0 0 0
0 0 0
4 0 0 5
8 0 0 8
0 0 2
0 0 1
0 0 0
0 0 0
0 0 0
0 0 0
1 0 0 1
1 0 0 1
20 0 20 0
30 0 30 0
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0
2 2 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0
0 0 3 0 0 9
0 0 3 0 0 4
0 22 0 0 24 0
0 19 0 0 20 0
0 139 0 0 218 0
0 133 0 0 201 0

0 22 5 0 22 15

0 32 9 0 32 13

0 0 0 0 0 0
of Health & Family Welfare
overnment of India
l Swasthya Karyakram (RBSK)
TING FORMAT (MHT) - FORM No - III

2 0 0 2 0 0

0 183 8 0 264 24
2 184 12 2 253 17
Report verified by Block/ District / State Nodal person
 2019

d schools (MHT)
Found positive Referred for
for selected this current
health conditions month/year
in current month

210 217
236 233

450 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: ARWAL
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 38182 2419 2419

Female 0 0 0 0% 0 0 38744 2349 2349

Total
0 0 0 0% 0 0 76926 4768 4768
Screening details at AWCs/Schools (Planning)
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
Name of State/UT: Bihar No of Reported Districts: ARWAL
AWC
Visit 2 749 70 55 15 Trained
Govt and Govt aided schools 635 73 74 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
B) Severe Thinning 0 0
C) Obesity 0 0 0 0
Goitre 0 0 0 0
Pages 40 of 119
 Minist

Rashtriya
MONTHLY REPORTING
Name of State/UT: Bihar No of Reported Districts: ARWAL

Childhood Diseases:Total 0 0 0 0 0 0 0 0
Skin conditions 0 0 0 0
Otitis Media 0 0 0 0
Rheumatic heart disease 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
Name of State/UT: Bihar No of Reported Districts: ARWAL

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
Behaviour disorder (Autism) 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

Discharge/ foul smelling discharge from the

0 0
genitor-urinary area
Pain during menstruation 0 0

Pages 42 of 119
 Minist

Rashtriya
MONTHLY REPORTING
Name of State/UT: Bihar No of Reported Districts: ARWAL

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
Name of State/UT: Bihar No of Reported Districts: ARWAL
Congenital deafness
Male 0 0 0 0 0

Female 0 0 0 0 0

Congenital heart diseases

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
Name of State/UT: Bihar No of Reported Districts: ARWAL
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
Name of State/UT: Bihar No of Reported Districts: ARWAL

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
Name of State/UT: Bihar No of Reported Districts: ARWAL
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
Name of State/UT: Bihar No of Reported Districts: ARWAL

Female
Attention deficit
hyperactivity disorder
Male

Female
Others
Male

Female

Pages 48 of 119
 Minist

Rashtriya
MONTHLY REPORTING
Name of State/UT: Bihar No of Reported Districts: ARWAL
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
Name of State/UT: Bihar No of Reported Districts: ARWAL
Pain during menstruation
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
Developmental Delays

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: ARWAL No of Blocks : Reporting Month January
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 6% 93 16 61538 4696 4696 8% 194

Female 0 6% 73 5 65775 5276 5276 8% 203

Total
0 6% 166 21 127313 9972 9972 8% 397
Screening details at AWCs/Schools (Planning)
DEIC and MHT Information
Doctors Pharmacist ANM/ Staff nurse

Total MHT
Male Female Male Female Male Female Doctors

9 18 0 9 0 0 9 18
Visit 1 9 16 0 6 0 0 7 16
AWC
Pages 51 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: ARWAL No of Blocks : Reporting Month January
AWC
Visit 2 9 18 0 9 0 0 9 18
Govt and Govt aided schools 9 16 0 6 0 0 7 16
6 weeks to 3 years 3 years to 6 years 6 years to 18 years To
Number of Children screened in the
Screened Children with Health Condition Screened Children with Health Condition Screened Children with Health Condition Screened Child
year : Current Reporting Month (From)
__________ (To) End of Rerpoting
Month _____________ Total Male Female Total Male Female Total Male
0 2419 2349 4768 4696 5276 9972 7115
Defects at Birth: Total 0 6 1 7 3 3 6 9
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 3 0 3 0 0 0 3
Club foot 0 2 1 3 1 2 3 3
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 1 0 1 1 0 1 2
Congenital heart diseases 0 0 0 0 0 0 0 0
Retinopathy of Prematurity 0 0 0 0 1 1 2 1
Deficiencies:Total 0 1 2 3 22 20 42 23
Severe Anaemia 0 0 0 0 0 1 1 0
Vitamin A deficiency (Bitot spot) 0 1 2 3 1 2 3 2
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 21 17 38 21
Goitre 0 0 0 0 0 0 0 0
Pages 52 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: ARWAL No of Blocks : Reporting Month January

Childhood Diseases:Total 0 79 68 147 139 133 272 218

Skin conditions 0 28 26 54 44 35 79 72
Otitis Media 0 36 15 51 26 26 52 62
Rheumatic heart disease 0 0 0 0 0 0
Reactive airway disease 0 3 12 15 1 29 30 4
Dental Conditions 0 10 14 24 67 41 108 77
Convulsive disorders 0 2 1 3 1 2 3 3

Pages 53 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: ARWAL No of Blocks : Reporting Month January

Developmental Delays including

Disabilities:Total 0 7 2 9 30 45 75 37

Vision impairment 0 0 0 0 2 2 4 2
Hearing Impairment 0 0 0 0 3 2 5 3
Neuro motor impairment 0 4 1 5 0 0 0 4
Motor delay 0 0 0 0 0 0 0 0
Cognitive delay 0 1 0 1 4 8 12 5
Language delay 0 2 1 3 0 0 0 2
Behaviour disorder (Autism) 0 0 0 0 0 0 0 0
Learning disorder 0 0 0 2 2 0
Attention deficit hyperactivity disorder 0 0 1 1 2 1
Others 0 0 0 20 30 50 20
Adolescent Health:Total 0 0 0 0 0 2 2 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 2 2 0
Pain or burning sensation while urinating 0 0 0 0 0 0
Discharge/ foul smelling discharge from the
genitor-urinary area
0 0 0 0 0 0
Pain during menstruation 0 0 0 0 0 0

Pages 54 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: ARWAL No of Blocks : Reporting Month January

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 3 0 0 0 0

Female 0 0 0 0 0 0 0 0
Club foot
Male 0 0 0 2 0 0 1 0

Female 0 0 0 1 0 0 2 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 0 0 0

Female 0 0 0 0 0 0 0 0

Pages 55 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: ARWAL No of Blocks : Reporting Month January
Congenital deafness
Male 0 0 0 1 0 0 1 0

Female 0 0 0 0 0 0 0 0
Congenital heart diseases
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 1 0

Female 0 0 0 0 0 0 1 0

Pages 56 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: ARWAL No of Blocks : Reporting Month January
Severe Anaemia
Male
0 0 0 0 0 0 0 0

Female
0 0 0 0 0 0 0 0
Vitamin A deficiency
(Bitot spot)
Male
0 0 2 0 0 1 0 0

Female
0 0 1 0 0 2 0 0
Vitamin D Deficiency,
(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 21 0 0

Female
0 17 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 28 0 0 44 0 0
Pages 57 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
Skin conditions
Name of State/UT: ARWAL No of Blocks : Reporting Month January

Female
0 0 26 0 0 35 0 0
Ottis Media
Male
0 0 36 0 0 26 0 0

Female
0 0 15 0 0 26 0 0
Rheumatic Heart Disease
Male
0 0 0 0

Female
0 0 0 0
Reactive Airway Disease
Male
0 0 3 0 0 1 0 0

Female
0 0 12 0 0 29 0 0
Dental Conditions
Male
0 0 10 0 0 67 0 0

Female
0 0 14 0 0 41 0 0
Convulsive Disorders
Male
0 0 2 0 0 1 0 0

Female
0 0 1 0 0 2 0 0

Pages 58 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: ARWAL No of Blocks : Reporting Month January
Vision impairment
Male
0 0 0 0 0 2 0 0

Female
0 0 0 0 0 2 0 0
Hearing Impairment
Male
0 0 0 3 0 0 0 0

Female
0 0 0 2 0 0 0 0
Neuro motor impairment
Male
0 0 0 4 0 0 0 0

Female
0 0 0 1 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 1 0 0 4 0

Female
0 0 0 0 0 0 8 0
Language delay
Male
0 0 0 2 0 0 0 0

Female
0 0 0 1 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
 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
Learning disorder
Name of State/UT: ARWAL No of Blocks : Reporting Month January

Female
0 0 0 0 0 0 0
Attention deficit
hyperactivity disorder
Male
0 0 0 0 0 1 0

Female
0 0 0 0 0 1 0
Others
Male
0 0 0 0 20 0 0

Female
0 0 0 0 30 0 0

Pages 60 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: ARWAL No of Blocks : Reporting Month January
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
Delay in menstruation
cycles
Male
0 0 0 0

Female
2 0 0 2
Irregular periods
Male
0 0 0 0

Female
0 0 0 0
Pain or burning sensation
while urinating 0 0 0 0
Male

Female
0 0 0 0
Discharge/ foul smelling
discharge from the
Male
0 0 0 0
genitor-urinary area

Female
0 0 0 0

Pages 61 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: ARWAL No of Blocks : Reporting Month January
Pain during menstruation
Male
0 0 0 0

Female
0 0 0 0

Male 0 0 0 6 0 0 3 0
Defects at Birth

Female 0 0 0 1 0 0 3 0

Male 0 0 2 0 0 22 0 0
Deficiencies

Female 0 0 1 0 0 19 0 0

Childhood Male 0 0 79 0 0 139 0 0

Diseases
Female 0 0 68 0 0 133 0 0

Male 0 0 0 10 0 22 5 0
Developmental Delays

Female 0 0 0 4 0 32 9 0

Male 0 0 81 16 0 183 8 0
Grand Total

Female 0 0 69 5 0 184 12 0
Report verified by Block/ District / State Nodal person
Name
Signature
Designation
Date

Pages 62 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
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 8 0 0 0 0
Female 0 12 0 0 0 0

Total
0 20 0 0 0 0
mation Screening details at AWCs/Schools (Planning)
Total

Remarks by State RBSK Team

Pharmacist ANM/SN

9 9
Visit 1 6 7
AWC
Pages 63 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
AWC
Visit 2 9 9
Govt and Govt aided schools 6 7
Total children
Number of Children screened in the
Screened Children with Health Condition
year : Current Reporting Month (From)
Screening Children
__________ (To) End of Rerpoting
Month _____________ Female Total
7625 14740
Defects at Birth: Total 4 13 Defect at Birth
Neural tube defect 0 0
Down’s Syndrome 0 0
Cleft Lip & Palate 0 3
Club foot 3 6
Developmental dysplasia of the hip 0 0
Congenital cataract 0 0
Congenital deafness 0 2
Congenital heart diseases 0 0
Retinopathy of Prematurity 1 2
Deficiencies:Total 22 45 Deficiencies
Severe Anaemia 1 1
Vitamin A deficiency (Bitot spot) 4 6
Vitamin D Deficiency, (Rickets) 0 0
A) SAM 0 0
B) Severe Thinning 0 0
C) Obesity 17 38
Goitre 0 0
Pages 64 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019

Childhood Diseases:Total 201 419 Childhood Diseases

Skin conditions 61 133
Otitis Media 41 103
Rheumatic heart disease 0 0
Reactive airway disease 41 45
Dental Conditions 55 132
Convulsive disorders 3 6

Pages 65 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019

Developmental Delays including Developmental Delays including

47 84
Disabilities:Total Disabilities

Vision impairment 2 4
Hearing Impairment 2 5
Neuro motor impairment 1 5
Motor delay 0 0
Cognitive delay 8 13
Language delay 1 3
Behaviour disorder (Autism) 0 0
Learning disorder 2 2
Attention deficit hyperactivity disorder 1 2
Others 30 50
Adolescent Health:Total 2 2 Adolescent Health
Growing up concerns 0 0
Substance abuse 0 0
Feel depressed 0 0
Delay in menstruation cycles 0 0
Irregular periods 2 2
Pain or burning sensation while urinating 0 0
Discharge/ foul smelling discharge from the
genitor-urinary area 0 0
Pain during menstruation 0 0

Pages 66 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019

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 3

Female 0 0
Club foot
Male 0 3

Female 0 3
Developmental dysplasia
of the hip Male 0 0
Female 0 0
Congenital cataract
Male 0 0

Female 0 0

Pages 67 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
Congenital deafness
Male 0 2

Female 0 0
Congenital heart diseases
Male 0 0

Female 0 0
Retinopathy of
Prematurity Male 0 1

Female 0 1

Pages 68 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
Severe Anaemia
Male
0 0

Female
0 0
Vitamin A deficiency
(Bitot spot)
Male
3 0

Female
3 0
Vitamin D Deficiency,
(Rickets)
Male
0 0

Female
0 0
A)SAM
Male
0 0

Female
0 0
B)Severe Thinning
Male
21 0

Female
17 0
C)Obesity
Male
0 0

Female
0 0
Goitre
Male
0 0

Female
0 0
Skin conditions
Male
72 0
Pages 69 of 119
) - FORM-IV MONTHLY R
Skin conditions
Name of State/UT: January Reporting Year 2019

Female
61 0
Ottis Media
Male
62 0

Female
41 0
Rheumatic Heart Disease
Male
0 0

Female
0 0
Reactive Airway Disease
Male
4 0

Female
41 0
Dental Conditions
Male
77 0

Female
55 0
Convulsive Disorders
Male
3 0

Female
3 0

Pages 70 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
Vision impairment
Male
2 0

Female
2 0
Hearing Impairment
Male
0 3

Female
0 2
Neuro motor impairment
Male
0 4

Female
0 1
Motor delay
Male
0 0

Female
0 0
Cognitive delay
Male
0 5

Female
0 8
Language delay
Male
0 2

Female
0 1
Behaviour disorder
(Autism)
Male
0 0

Female
0 0
Learning disorder
Male
0 0
Pages 71 of 119
) - FORM-IV MONTHLY R
Learning disorder
Name of State/UT: January Reporting Year 2019

Female
0 0
Attention deficit
hyperactivity disorder
Male
0 1

Female
0 1
Others
Male
20 0

Female
30 0

Pages 72 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
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
Delay in menstruation
cycles
Male
0 0

Female
0 0
Irregular periods
Male
0 0

Female
0 0
Pain or burning sensation
while urinating 0 0
Male

Female
0 0
Discharge/ foul smelling
discharge from the
Male
0 0
genitor-urinary area

Female
0 0

Pages 73 of 119
) - FORM-IV MONTHLY R
Name of State/UT: January Reporting Year 2019
Pain during menstruation
Male
0 0

Female
0 0

Male 0 9
Defects at Birth

Female 0 4

Male 24 0
Deficiencies

Female 20 0

Childhood Male 218 0

Diseases
Female 201 0

Male 22 15
Developmental Delays

Female 32 13

Male 264 24
Grand Total

Female 253 17
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
Delivery Point 0 0 0 0 0 0 0
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
Delivery Point 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
3
Cleft Lip
& Palate
 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

Cleft Lip
3
& Palate
6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
3 0 0 0 0 0 3
6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Delivery Point 0 0 0 0 0 0 0
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
2 1 0 0 0 0 2
6-18 Yrs
1 2 0 0 0 0 1
Birth-6 weeks
Delivery Point 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
Developmental dysplasia
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
MONTHLY REPORTING FORMAT
Name of State/UT: Bihar No of Reported Districts:

Referal
Identified through screening Secondary Care
S.No Developmental dysplasia
Health Condition Details Primary care (PHC/CHC) Tertiary Care (DEIC)
5
(DH/Medical)
of the hip

Male Female Male Female Male Female Male

6-18 Yrs
0 0 0 0 0 0 0
Birth-6 weeks
Delivery Point 0 0 0 0 0 0 0
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
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
7 Congenital Deafness 6 Weeks- 3 Yrs
0 0 0 0 0 0 0
3- 6 Yrs
1 0 0 0 0 0 1
6-18 Yrs
1 0 0 0 0 0 1
Birth-6 weeks
Delivery Point 0 0 0 0 0 0 0
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
Delivery Point 0 0 0 0 0 0 0
Birth-6 weeks
ASHA,HBNC 0 0 0 0 0 0 0
9 Retinopathy of Prematurity
 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

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
1 1 0 0 0 0 1
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 1 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
1 2 0 0 2 1 0
6-18 yrs
1 2 0 0 1 2 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
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

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 21 17 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
21 17 0 0 0 0 0
 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

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
28 26 0 0 28 26 0
6-18 yrs
44 35 0 0 44 35 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
36 15 0 0 36 15 0
6-18 yrs
26 26 0 0 26 26 0
Birth-6 weeks
0 0 0 0 0 0 0
 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

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
3 12 0 0 3 12 0
6-18 yrs
1 29 0 0 1 29 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
10 14 0 0 10 14 0
6-18 yrs
67 41 0 0 67 41 0
Birth-6 weeks
0 0 0 0 0 0 0
 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

6 Weeks- 3 Years
0 0 0 0 0 0 0
20 Convulsive disorders
3- 6 Yrs
2 1 0 0 2 1 0
6-18 yrs
1 2 0 0 1 2 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
2 2 0 0 2 2 0
 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
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 3
6-18 yrs
3 2 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
4 1 0 0 0 0 4
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
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

25 Cognitive delay 3- 6 Yrs

1 0 0 0 0 0 1
6-18 yrs
4 8 0 0 0 0 4
6 Weeks- 3 Years
0 0 0 0 0 0 0
26 Language delay 3- 6 Yrs
2 1 0 0 0 0 2
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 2 0 0 0 0 0

29
Attention deficit hyperactivity
3- 6 Yrs
0 0 0 0 0 0 0
disorder
6-18 yrs
1 1 0 0 0 0 1
 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

3- 6 Yrs
0 0 0 0 0 0 0
30 Others
6-18 yrs
20 30 0 0 20 30 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 2 0 0 0
35 Irregular periods 6-18 yrs 0 2 0 0 0 0 0
Pain or burning sensation while 6-18 yrs
0 0 0 0 0 0 0
36
urinating

Discharge/ foul smelling

37 discharge from the 6-18 yrs
0 0 0 0 0 0 0
genitor-urinary area

38 Pain during menstruation 6-18 yrs

0 0 0 0 0 0 0
 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
Defect at Birth 6 Weeks- 3 Yrs 0 0 0 0 0 0 0
3- 6 Yrs 6 1 0 0 0 0 6
6-18 Yrs 3 3 0 0 0 0 3
6 Weeks- 3 Years 0 0 0 0 0 0 0
Deficiency 3- 6 Yrs 1 2 0 0 2 1 0
6-18 yrs 22 20 0 0 22 19 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
79 68 0 0 79 68 0
6-18 yrs 139 133 0 0 139 133 0
 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
0 0 0 0 0 0 0

Developmental Delays including

6 Weeks- 3 Years 0 0 0 0 0 0 0
Disabilities
3- 6 Yrs 7 2 0 0 0 0 10
6-18 yrs 30 45 0 0 22 32 5
Adolescent Health 6-18 yrs 0 2 0 2 0 0 0
Birth-6 weeks
Delivery Point 0 0 0 0 0 0 0
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
93 73 0 0 81 69 16
6-18 yrs 194 203 0 2 183 184 8
Report prepared by
 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

Name
Signature
Designation
Date
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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

Cleft Lip
3
& Palate 0
0 3 0 0 0
0
0
0
4 Club foot
0
1 2 1 0 0

2 1 2 0 0

0
0
Developmental dysplasia
5
of the hip 0
0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January Reporting Yea
Number of children with selected health conditions
Referal Managed
Confirmed
S.No Developmental Tertiary Care (DEIC)
dysplasia
Health Condition Medical Surgery Early Intervention AFHC counse
5
of the hip

Female Male Female Male Female Male Female Male Female Male

0
0
0
6 Congenital cataract
0
0
0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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
7 Congenital Deafness
0
0 1 0 0 0

0 1 0 0 0

0
0
8 Congenital Heart Diseases
0
0
0
0
0
9 Retinopathy of Prematurity
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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

9 Retinopathy of Prematurity
0
0
1 1 1 0 0

0
10 Severe Anaemia
0
0 1 0 0 0

0
11 Vitamin A deficiency (Bitot spot)
0 2 1 0 0

0 1 2 0 0

0
12 Vitamin D Deficiency, (Rickets)
0
0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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

13
0
A) SAM
0
0
0
B) Severe
Thinning 0
0 21 17 14 11

0
C) Obesity
0
0 21 17 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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
14 Goitre
0
0
0
0
15 Skin conditions

0 28 26 23 11

0 44 35 32 40

0
0
16 Otitis Media

0 36 15 24 12

0 26 26 19 20

0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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
17 Rheumatic heart disease

0
0
0
0
18 Reactive airway disease

0 3 12 1 6

0 1 29 1 13

19
Dental 0
Conditions
0 10 14 7 9

0 67 41 27 10

0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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
20 Convulsive disorders

0 2 1 0 0

0 1 2 0 0

21
Vision 0
impairment
0
0 2 0 2 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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

22
Hearing 0
Impairment
2 3 2 0 0

0
0
0
23 Neuro motor impairment

1 4 1 0 0

0
0
24 Motor delay
0
0
0
25 Cognitive delay
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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

25 Cognitive delay
0 1 0 0 0

8 4 8 0 0

0
26 Language delay
1 2 1 0 0

0 2 1 0 0

0
27 Behaviour disorder (Autism)
0
0
0
28 Learning disorder

0 2 0 0 0

29
Attention deficit hyperactivity 0
disorder
1 1 1 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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
30 Others

0 20 30 18 16

31 Growing up concerns
0
32 Substance abuse
0
33 Feel depressed
0
34 Delay in menstruation cycles
0 2 0 0

35 Irregular periods 0 0 2 0 0

Pain or burning sensation while

0
36
urinating

Discharge/ foul smelling

37 discharge from the
0
genitor-urinary area

38 Pain during menstruation

0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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 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
1 6 1 0 0 0 0 0 0 0
3 3 3 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Deficiency
0 2 1 0 0 0 0 0 0 0
0 44 36 14 11 0 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 79 68 55 38 0 0 0 0 0
0 139 133 79 83 0 0 0 0 0
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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 0 0 0 0 0 0 0 0
Developmental Delays including 0 0 0 0 0 0 0 0 0 0
Disabilities
4 10 4 0 0 0 0 0 0 0
9 31 40 20 16 0 0 0 0 0
Adolescent Health 0 2 2 0 0 0 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

5 97 74 55 38 0 0 0 0 0
12 219 214 113 110 0 0 0 0 0
Report verified by Block/ District / State Nodal person
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
MONTHLY REPORTING FORMAT (BLOCK/ DISTRICT/ STATE) - FORM-V
Name of State/UT: ARWAL No of Blocks : Reporting Month January 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

Name
Signature
Designation
Date
ORM-V
Name of State/UT: Reporting Year 2019

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
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
3
Cleft Lip
& Palate

3 0
0 0
0 0
0 0
4 Club foot 0 0
2 1
1 2
0 0
0 0
0 0
5
Developmental dysplasia
of the hip

0 0
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
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
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
0 0
7 Congenital Deafness 0 0
1 0
1 0
0 0
0 0
8 Congenital Heart Diseases 0 0
0 0
0 0
0 0
0 0
9 Retinopathy of Prematurity
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

9 Retinopathy of Prematurity 0 0
0 0
1 1
0 0
10 Severe Anaemia 0 0
1 0
0 0
11 Vitamin A deficiency (Bitot spot) 2 1
1 2
0 0
12 Vitamin D Deficiency, (Rickets) 0 0
0 0
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

13
0 0
A) SAM 0 0
0 0
0 0
0 0
B) Severe
Thinning

7 6
0 0
C) Obesity 0 0
21 17
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
14 Goitre 0 0
0 0
0 0
0 0
15 Skin conditions
5 15
12 -5
0 0
0 0
16 Otitis Media
12 3
7 6
0 0
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
17 Rheumatic heart disease
0 0
0 0
0 0
0 0
18 Reactive airway disease
2 6
0 16
0 0
Dental
0 0
19
Conditions
3 5
40 31
0 0
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
20 Convulsive disorders
2 1
1 2
0 0
Vision
0 0
21
impairment
0 0
0 0
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
Hearing
0 0
22
Impairment
3 2
0 0
0 0
0 0
23 Neuro motor impairment
4 1
0 0
0 0
24 Motor delay 0 0
0 0
0 0
25 Cognitive delay
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

25 Cognitive delay 1 0
4 8
0 0
26 Language delay 2 1
2 1
0 0
27 Behaviour disorder (Autism) 0 0
0 0
0 0
28 Learning disorder
2 0
Attention deficit hyperactivity
0 0
29
disorder
1 1
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0
30 Others
2 14
31 Growing up concerns 0 0
32 Substance abuse 0 0
33 Feel depressed 0 0
34 Delay in menstruation cycles 2 0
35 Irregular periods 0 2
0 0
36
Pain or burning sensation while
urinating

Discharge/ foul smelling

37 discharge from the
genitor-urinary area
0 0

38 Pain during menstruation 0 0

ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0 0
0 0 0
Defect at Birth
0 0 0
0 6 1
0 3 3
0 0 0
Deficiency
0 2 1
0 30 25
0 0 0
0 0 0
Childhood Diseases

0 24 30
0 60 50
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

0 0 0

Developmental Delays including 0 0 0

Disabilities
0 10 4
0 11 24
Adolescent Health 0 2 2

0 0 0

0 0 0

Total Children
0 0 0

0 0 0

0 42 36
0 106 104
Block/ District / State Nodal person
ORM-V
Name of State/UT: Reporting Year 2019

d health conditions
Managed
Waiting for service access
S.No Health Condition AFHC counselling

Female Male Female

Name
Signature
Designation
Date