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DEPARTMENT OF COMMUNITY MEDICINE
VMCH&RI
II M.B.B.S., VILLAGE HEALTH SURVEY
Guidelines for Filling up the Proforma
Interview as far as possible the head of the family or wife of the head of
the family. If this is not possible interview a responsible adult member of the family
who will be able to furnish the details of the household members.
House No : Denotes building Number
Household No : Family/ies residing in the building
Name of the informant : Information provider ( to be an adult of the family)
Name : To start with the name of the head of the household
Head of the family : Eldest male earning member of the family. If not
Possible take the opinion of the family.
Age : Record in completed years. Check the age with the.
important events in their life.
Relationship to Head : Enter as head / son / daughter / father / mother /
Sister / etc…
Marital Status : Follow the code
Literacy status : Record only for those who have attended formal
Schooling.
Education : Follow the code
Income : Monthly income.Record for all the members. For
those who are not Working enter as student /
housewife / dependent
Occupation : Record for all the members. If not working
Follow the code given below
If the occupation is agriculture use the following abbreviation:
L- Land Owner * A person who owns land, employ others to
cultivate his land and he himself does not
work in the field (or) A person who owns land
and leases to a tenant to cultivate it.
CO – Cultivator Owner * A person who owns land and cultivates it
himself; may also in addition hire other
people to work in his land.
CT – Cultivator Tenant * He gets the land on lease basis from some
one else and he cultivated it. He may also
hire other people to work.
LAL – Landless Agricultural
Labourer * A person who works for wages
(in cash or kind)
In case, a person can be classified in more than one classification, select the
highest.
For other than agriculture record the name of the occupation, Occupation is to
be filled for all persons. If not employed use abbreviation given below.
HW* - Housewife
RT - Retired
D - Disabled
O - Old age (aged 60 and above)
S - Student
UN - Unemployed
PS - Children under 5 years
HHW* - Housewife needs to be distinguished from an unmarried girl who
does domestic work.
Type of house:
Hut : Thatched roof, mud / thatched wall and mud flooring.
Semi pucca : Thatched roof, cemented wall and cemented flooring.
Pucca : Tiled / concrete roof, cemented wall and cemented
flooring.
Distance of source
of drinking water : Enter in feet
Overcrowding : Convert the family members into consumption units.
Adult : 1 unit
Children
(1-10 years) : Half unit
Infants : Not to be considered
Occupation:
Skilled : Specialised training, knowledge, ability and experience to
acquire a high degree of proficiency. Ex: Teacher
Unskilled : Requires very little training, knowledge. Ex: manual
Labourers
Skilled : Intermediate between skilled and unskilled. It requires
moderate training, knowledge and ability. Ex: Drivers
Past History
Eligible Couple : Currently married couple wherein the female component is
in the age group of 15 –49.
Whether to collect data on this page (i.e. Past history) can
be checked with the first page.
If an EC gave birth to more than one child enter the data in
all the columns for all the children one by one.
Registration : Registration means whether they have attended any
health facility during pregnancy. Ex : PHC /Private/
RMMC&H /G.H.
For each pregnancy it has to be entered as Yes OR No
TT : Immunisation to mother Two doses
If pregnant with in five years of last immunization one dose
Present History
Trimester : Enter 1st
,2nd
or 3rd
trimester OR months of pregnancy
IFA Recd : Whether received Iron and Folic Acid tablets. It has to be
indicated as Yes or No
Prelacteal Feeding : What is given to the newborn before breastmilk. Ex: Sugar
water
Time of initiation of
Breastfeeding : When the child was breastfed. EX: Immediately / After One
hour / Second day
How long
Exclusively given : How many months the child is given only breast milk.
When stopped
Completely : Complete stoppage of breast milk
Weaning : Gradual introduction of semisolid foods along with breast
milk. It is not complete stoppage of breast milk.
Weaning Time
Initiation : At what month started
Food started : Eg. Biscuit / Smashed vegetables
Immunisation :
Collected details for children who have completed one year but below 2
years.
Child Care:
Weight : Monthly / bimonthly / once in 3 months
Where ? : Balwadi / Sub Centre / Private Hospital / G.H.
Child Care:
Weight : Monthly / bimonthly / once in 3 months
Where ? : Balwadi / Sub Centre / Private Hospital / G.H.

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Guidelines for filling Village Health Survey proforma

  • 1. DEPARTMENT OF COMMUNITY MEDICINE VMCH&RI II M.B.B.S., VILLAGE HEALTH SURVEY Guidelines for Filling up the Proforma Interview as far as possible the head of the family or wife of the head of the family. If this is not possible interview a responsible adult member of the family who will be able to furnish the details of the household members. House No : Denotes building Number Household No : Family/ies residing in the building Name of the informant : Information provider ( to be an adult of the family) Name : To start with the name of the head of the household Head of the family : Eldest male earning member of the family. If not Possible take the opinion of the family. Age : Record in completed years. Check the age with the. important events in their life. Relationship to Head : Enter as head / son / daughter / father / mother / Sister / etc… Marital Status : Follow the code Literacy status : Record only for those who have attended formal Schooling. Education : Follow the code Income : Monthly income.Record for all the members. For those who are not Working enter as student / housewife / dependent
  • 2. Occupation : Record for all the members. If not working Follow the code given below If the occupation is agriculture use the following abbreviation: L- Land Owner * A person who owns land, employ others to cultivate his land and he himself does not work in the field (or) A person who owns land and leases to a tenant to cultivate it. CO – Cultivator Owner * A person who owns land and cultivates it himself; may also in addition hire other people to work in his land. CT – Cultivator Tenant * He gets the land on lease basis from some one else and he cultivated it. He may also hire other people to work. LAL – Landless Agricultural Labourer * A person who works for wages (in cash or kind) In case, a person can be classified in more than one classification, select the highest. For other than agriculture record the name of the occupation, Occupation is to be filled for all persons. If not employed use abbreviation given below. HW* - Housewife RT - Retired D - Disabled O - Old age (aged 60 and above) S - Student UN - Unemployed PS - Children under 5 years HHW* - Housewife needs to be distinguished from an unmarried girl who does domestic work.
  • 3. Type of house: Hut : Thatched roof, mud / thatched wall and mud flooring. Semi pucca : Thatched roof, cemented wall and cemented flooring. Pucca : Tiled / concrete roof, cemented wall and cemented flooring. Distance of source of drinking water : Enter in feet Overcrowding : Convert the family members into consumption units. Adult : 1 unit Children (1-10 years) : Half unit Infants : Not to be considered Occupation: Skilled : Specialised training, knowledge, ability and experience to acquire a high degree of proficiency. Ex: Teacher Unskilled : Requires very little training, knowledge. Ex: manual Labourers Skilled : Intermediate between skilled and unskilled. It requires moderate training, knowledge and ability. Ex: Drivers Past History Eligible Couple : Currently married couple wherein the female component is in the age group of 15 –49. Whether to collect data on this page (i.e. Past history) can be checked with the first page. If an EC gave birth to more than one child enter the data in all the columns for all the children one by one. Registration : Registration means whether they have attended any health facility during pregnancy. Ex : PHC /Private/
  • 4. RMMC&H /G.H. For each pregnancy it has to be entered as Yes OR No TT : Immunisation to mother Two doses If pregnant with in five years of last immunization one dose Present History Trimester : Enter 1st ,2nd or 3rd trimester OR months of pregnancy IFA Recd : Whether received Iron and Folic Acid tablets. It has to be indicated as Yes or No Prelacteal Feeding : What is given to the newborn before breastmilk. Ex: Sugar water Time of initiation of Breastfeeding : When the child was breastfed. EX: Immediately / After One hour / Second day How long Exclusively given : How many months the child is given only breast milk. When stopped Completely : Complete stoppage of breast milk Weaning : Gradual introduction of semisolid foods along with breast milk. It is not complete stoppage of breast milk. Weaning Time Initiation : At what month started Food started : Eg. Biscuit / Smashed vegetables Immunisation : Collected details for children who have completed one year but below 2 years.
  • 5. Child Care: Weight : Monthly / bimonthly / once in 3 months Where ? : Balwadi / Sub Centre / Private Hospital / G.H.
  • 6. Child Care: Weight : Monthly / bimonthly / once in 3 months Where ? : Balwadi / Sub Centre / Private Hospital / G.H.