MIDEGA PRIMARY HOSPITAL
HMIS Office Checklist
Interview the facility manager or person in charge of the RHIS at the district office or the health facility
EQUIPMENT INVENTORY AND CONDITION
Please verify if the following equipment or type of service is available in the A. Total quantity B. Total quantity that are
facility or office. in working condition
(If none, enter 0) (If none, enter 0)
FOC_011 Laptop computer
FOC_012 Desktop computer
FOC_013 Printers
FOC_014 Modems
FOC_015 Uninterruptible power supply (UPS)
FOC_016 Circuit breaker
FOC_017 Generators
FOC_018 Calculator
EQUIPMENT AND SERVICES INVENTORY
Please use the following checklist to assess whether or not the facility/office has the following inventory:
FOC_019 Data back-up unit 1. Server 1. Yes 2. No
2. USB key 1. Yes 2. No
→ If all answers are no, go to
FOC_021
3. CD (compact disc) 1. Yes 2. No
4. External hard drive 1. Yes 2. No
5. Zip drive 1. Yes 2. No
FOC_020 Back-up unit(s) is/are kept on site 1. Yes 2. No
FOC_021 Telephone (regular or radio) 1. Yes 2. No
FOC_022 Facility/office official mobile phone with access to telephone 1. Yes 2. No
network
FOC_023 Personal mobile phone with access to telephone network 1. Yes 2. No
FOC_024 Fax 1. Yes 2. No
FOC_025 Is there access to an Internet network? 1. Yes 2. No → Go to FOC_028
FOC_026 If yes, on average, how many days in a month do you have 1. 20 days or more
Internet access?
2. 10-19 days
3. Less than 10 days
FOC_027 Wi-Fi (Wireless Fidelity) 1. Yes 2. No
UTILITIE
S
FOC_028 Is there a continuous electricity supply? 1. Yes → Go to FOC_030
2. No
FOC_029 If no, on average, how many days in a month is the electricity 1. 20 days or more
supply interrupted? 2. 10-19 days
3. Less than 10 days
FOC_030 Does the room where the computer hardware is kept have air- 1. Yes 2. No
conditioning?
AVAILABILITY OF REGISTERS/FORMS
FOC_031 FOC_032 FOC_033 FOC_034 FOC_035
Type of records, tally sheets, or reports Is the tool Is the tool a Have you run out If yes, for
available? standard of this form in the how long
Please enter the name of the records, tally sheets, or reporting RHIS tool? past six months? were you
forms that are used at the facility/office level in this column out of stock?
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
1. Yes 1. Yes 1. Yes
2. No 2. No 2. No
For the next sections:
➔ Go to FOC_036 if the assessment is being conducted at a health facility
➔ Go to FOC_040 if the assessment is being conducted at a district office
ORGANIZATION OF THE HEALTH FACILITY [SKIP THIS SECTION AT THE DISTRICT LEVEL]
FOC_036 Please describe the total number of people under each category below.
(Adapt according to the country context)
Title/ post Number by sex Title/ post Number by sex
(If none, enter 0; if (If none, enter 0; if
post not applicable, post not applicable,
leave blank) leave blank)
M F M F
1. Medical officer 10. Health educator
2. Comprehensive nurse registered 11. Health inspector
12. Laboratory technician
3. Comprehensive nurse enrolled
4. Nursing assistant 13. Public health dental assistant
5. Clinical officer 14. Anesthetic officer
6. Laboratory assistant 15. Midwife
7. Health assistant 16. Support staff
8. Dispenser 96. Other (specify)
9. Health information assistant
_________________________
FOC_037 Who is responsible for filling out the registers at the facility?
(ANSWER USING THE NUMBER CODES FROM FOC_036)
FOC_038 Who is responsible for preparing/completing the monthly HMIS reports?
(ANSWER USING THE NUMBER CODES FROM FOC_036)
FOC_039 List the staff members who received any training in the following skills during the past three years, the number of trainings
received, and the year of the latest training.
1. Title/post 2. Number of training 3. Year of last 4. Topic(s) of last training
courses/sessions training
(Use the number received by this Use the following codes and list all that apply:
codes from question person in the past (Within the
FOC_036) three years past three 1. Data collection
years) 2. Data analysis
3. Data display
4. Data reporting
5. Using data for decision making
