Observation Checklist Template
ADVERTISEMENT
1
2Observation Checklist Template
Observation Checklist Template
Name of Health Facility/ Community
Name of supporting NGO
Facility Type:
Names of supervision team
County/District
Date
Name of supervisor completing the checklist
GPS Coordinates
MAINTENANCE
Y
N
1. Example - Facility is clean (no litter, no medical waste, no cobwebs, floor is swept)
2.
3.
4.
5.
6.
EQUIPMENT
7. Health facility has basic equipment that works:
8.
Example - Child/infant scale
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
MANAGEMENT
24. Example - The opening/closing times are clearly visible
25.
26.
27.
28.
29.
30.
31.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life