Facility questionnaire nigeria

Questionnaire identification number: <<<<FFFF____________________________________>>>>
SERVICE AVAILABILITY MAPPING (SAM)
FACILITY QUESTIONNAIRE
1
FOR USE IN HEALTH CARE FACILITIES. ONE QUESTIONNAIRE
SHOULD BE USED PER FACILITY.
Please fill the information below before beginning.
Please write clearly, in ink:
001. Date (dd/mm/yyyy):
/ /
002. LGA name: __________(Drop down)
003. Ward name: __________(Drop down)
004. Facility name: _______________________
005. Facility location (urban/rural)
Definitions:
Urban: more than XX people
Rural: les than XX people
_______________________
(check list: urban or rural)
Ownership: Please check one box below:
Government (public) facility
Private, non profit facility. These
include mission and faith based
facilities, NGOs
006.
Private, for profit facility.
Facility type: Please check one box below.007.
Tertiary/third level hospital, e.g.
a. Teaching hospital
b. Federal medical centre
a.
b.

2
c. Specialist hospital.
d. Other tertiary
c.
d.
Second level referral hospital.
e. General hospital
f. Cottage hospital.
g. Other secondary
e.
f.
g.
Primary health care level
h. Comprehensive health centre
i. Primary health center.
j. Health post/clinic/dispensary
k. Other primary
h.
i.
j.
k.
008. Interviewer name (last, first): _______________________
009. Respondent name (last, first): _______________________
010. Respondent job title: _______________________
Telephone:_______________011. Facility telephone and fax
numbers (including local
telephone codes): Fax:____________________
Latitude: N_______________012. Facility geographic co-ordinates:
Longitude: E______________

3
Questionnaire overview:
Section 1: General characteristics
Section 2: General purpose equipment
Section 3: Injection and sterilization equipment
Section 4: Human resources
Section 5: Trained staff
Section 6: Drugs and commodities
Section 7: Lab tests
Section 8: Information on interventions available in the facility

4
Section 1. General characteristics.This section of the questionnaire
focuses on basic characteristics of the facility including the number of
outpatients, inpatient and maternity beds available. It also asks about
the availability of specific resources such as electricity, water,
telephones and radios.
Note to interviewers: Please indicate respondent's answers in the grey,
rightmost column. By previous month we mean the last completed
calendar month.
No. Question Answer
We are interested in knowing how many patients and beds are available in
this facility. We would also like to ask about the types of beds available.
101 How many out-patients were seen in this
facility during the previous month?
102 Total number of functional and non-functional
beds
ENTER THE NUMBER
OF BEDS:
Yes……………………1
ENTER THE NUMBER
OF BEDS:
103 Does this facility have functional in-patient
beds (excluding delivery baby cots*)?
By in-patient beds we mean functional beds
with mattresses in good condition (i.e., no
springs breaking through).
* These are cots for newborn babies awaiting
discharge. No………………………2
104 Of the functional beds how many are maternity
beds ?
ENTER THE NUMBER
OF delivery couches:
Enter "0" if none
105 How many functional delivery couches are
there in the facility?
ENTER THE NUMBER
OF maternity BEDS:
Enter "0" if none
106 How many in-patients were admitted in this
facility during the previous month?
Enter "0" if none

5
The following questions ask about general resources available in the facility.
107 What is the main source of water in this
facility?
Piped water............1
Water from
open well………….2
Water from covered
well or
borehole…………..3
Surface water…….4
Rain water
harvesting………...5
Tanker truck……...6
108 What is the most common way that solid
waste is disposed of in this facility?
Incinerated……….1
Buried…………….2
Open dumping….3
Burned (not
incinerated)………4
Other………………5
109 What is/are this facility's main sources of
electricity?
Note: More than one answer is possible.
National power
grid…………………1
Back up
generators………..2
Lanterns…………..3
Other………………4

6
Yes…………..........1110 Does the facility have a functioning land line
telephone?
No……………........2
Yes…………..........1111 Does the facility have functioning cellular
telephones (either private or supported by the
facility)? No…………............2
Yes…………..........1112 Does the facility have a functioning short-wave
radio for radio calls?
No……………........2
Yes………........…..1113 Does the facility have a functioning computer
for staff use?
No…………........…2
SKIP TO 115
Yes……….......…..1114 Does this facility have functioning internet
services for staff use?
No………….......…2

7
We would now like to ask you about guidelines available in this facility. Are
guidelines for the following available here:
Yes………….........1115 Management of malaria
No…….......………2
Yes…….......……..1116 Integrated Management of Childhood Illness
(IMCI)
No………...........…2
Yes…………...........1117 Treatment and care of people living with
HIV/AIDS
No………….........…2
Yes…………...........1118 HIV antibody testing and counselling
No………….........…2
Yes…………...........1119 Prevention of Mother to Child Transmission
(PMTCT) of HIV No………….........…2
Yes…………...........1120 Management of TB/HIV co-infection
No………….........…2
Yes…………...........1121 Integrated management of adult illness (IMAI)
No………….........…2
Yes…………...........1122 STI diagnosis and treatment
No………….......…..2
Yes…………...........1123 Family Planning
No………….......…..2
Yes………….........1124 DOTS implementation
No………….......…2
Yes………….........1125 Life saving skills (LSS)
No………….......…2

8
Section 2. General purpose equipment. This section of the
questionnaire explores the availability of specific health-related
resources.
Note to interviewers: This section is divided into two sections. The first
section should be applied in secondary and tertiary health care
facilities (i.e., hospitals) only. The second section should be applied in
primary health care facilities. Please indicate respondent's answers in
the grey, rightmost column.
FOR HOSPITALS (tertiary and secondary health care facilities) ONLY:
No.
Question Answer
We are interested in knowing if the following health-specific resources are
available in this hospital. These are all yes/no questions.
Please indicate whether or not the following are available and functional in
this facility:
Yes…………..1201
X-ray machine
No……………2
Yes…………..1202 Oxygen system/cylinders
No……………2
a.
Yes…………..1
No……………2
b.
Yes………….1
No……………2
203 Sterilization (ask about each a, b, AND c):
a. Autoclave
b. Boiling
c. Chemical sterilization
c.
Yes…………1
No……………2
Yes…………..1204 Infusion kits for intravenous solution
No……………2
Yes…………..1205 Operating theatre
No……………2
Yes…………..1206 Anaesthetic machine
No……………2
Yes…………..1207 Hemocytometer (for total lymphocyte and full
blood counts) No……………2

9
Yes…………..1208 Cytoflowmeter (for CD4 counts)
No……………2
Yes…………..1209 Microscope
No……………2
Yes…………..1210 Refrigerator
No……………2
Yes…………..1210 Slides
No……………2
Yes…………..1211 Sutures and needles
No……………2
Yes…………..1212 Ambulance or other emergency transport vehicle
No……………2

10
For all primary health care facilities:
No.
Question Answer
We are interested in knowing if the following health-specific resources are
available in this facility. These are all yes/no questions.
Please indicate whether or not the following are available and functional in
this facility:
Yes…………..1201 Blood pressure machine
No……………2
Yes…………..1202 Stethoscope(s)
No……………2
Yes…………..1203 Microscope
No……………2
Yes…………..1204 Slides
No……………2
Yes…………..1205 Weighing scale for adults
No……………2
Yes…………..1206 Weighing equipment (i.e. Salter scale or similar
hanging scale) for under-five-year-olds No……………2
Yes…………..1207 Clinical thermometer
No……………2
Yes…………..1208 Latex gloves in stock
No……………2
Yes…………..1209 Refrigerator
No……………2
Yes…………..1210 Immediate access to emergency transport
vehicles or the Medical Response Emergency
Service
No……………2

11
Section 3. Injection and sterilization equipment. This section of the
questionnaire asks about the main types of injection equipment used
in this facility.
rightmost column.
No. Question Answer
We are interested in knowing what type of injection and sterilization
equipment is available in this facility. You will be asked to choose the most
common type of needles and syringes used for general health services
(apart from immunization activities). We would also like to ask the most
common type of sterilization equipment used. Finally, we will ask whether
or not disinfectants are available in this facility.
Disposable………1
Re-usable…………2
301 Please indicate which of the following is
the most commonly used type of needles
and syringes for general health services
(apart from immunization activities) in this
facility:
Auto-destruct……3
Autoclave…………1
Sterilizers…………2
Pressure pots…….3
Boiling pot………..4
Other ………………5
(please specify):
_________________
_________________
302 Please indicate which of the following is
the most commonly used method of
sterilisation for general health services:
None……………….6
Yes………………...1303 Is environmental disinfectant (i.e., bleach,
Dettol, Izal, Hibitane, etc.) available in this
facility ?
No…………………..2

12
Section 4. Human resources. This section of the questionnaire asks
about the human resources available in this facility.
rightmost column. Questions ask about whether a human resource is
available, and the number present on the day of the interview.
No. Question Answer
In this section we would like to know how many of the following health
personnel are available. We would also like to ask about the number for
each resource that is present here today. If a human resource is not
applicable, please indicate this to the interviewer.
Medical doctors:
(a) How many medical doctors work full time at
this facility?
(b) How many medical doctors work part time at
this facility?
401
(c) How many medical doctors are present at
this facility today?
Certified/registered midwives:
(a) How many certified/registered midwives
work at this facility?
402
(b) How many certified/registered midwives are
present at this facility today?
Certified/registered nurses:
(a) How many certified/registered nurses work
at this facility?
403
(b) How many certified/registered nurses are

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Certified/registered nurse midwives
(a) How many certified/registered nurse
midwives work at this facility?
404
(b) How many certified/registered nurse
midwives are present at this facility today?
Auxiliary nurses/Nurse assistants/Nurse aides
(a) How many auxiliary nurses/nurse
assistants/nurse aides work at this facility?
405
(b) How many auxiliary nurses/nurse
assistants/nurse aides are present at this
facility today?
Medical laboratory scientists/technologists
(a) How many medical laboratory
scientists/technologists work at this facility?
406
(b) How many medical laboratory
scientists/technologists are present at this
facility today?
Medical laboratory technicians
(a) How many medical laboratory technicians
407
(b) How many medical laboratory technicians
are present at this facility today?
Medical laboratory assistants
(a) How many medical laboratory assistants
408
(b) How many medical laboratory assistants are
Pharmacists
(a) How many pharmacists work at this facility?
409
(b) How many pharmacists are present at this
facility today?

14
Pharmacy technicians
(a) How many pharmacy technicians work at
this facility?
410
(b) How many pharmacy technicians are present
at this facility today?
Pharmacy assistants
(a) How many pharmacy assistants work at this
facility?
411
(b) How many pharmacy assistants are present
HMIS/M&E officers/records officers
(a) How many HMIS/M&E officers/records
officers work at this facility?
412
(b) How many HMIS/M&E officers/records
officers are present at this facility today?
Records assistants in all facilities
(a) How many records assistants work at this
facility?
413
(b) How many records assistants are present at
Full time or dedicated health service managers responsible for
overall management of this facility?
(a) How many health service managers work at
this facility?
414
(b) How many health service managers are
Community health officers (CHO), Community Health Extension
Workers (CHEW), etc.
(a) How many community health officers work at
this facility?
415
(b) How many community health officers are

15
Health educators
(a) How many health educators work at this
facility?
416
(b) How many health educators are present at
Environmental health officers
(a) How many environmental health officers
417
(b) How many environmental health officers are
What other cadres work at this facility?
(a) Circle all that apply:
Radiotherapists
Radiologists
Medical Physicists
Physiotherapists
Dietetics
Librarians
Security personnel
418
(b) How many of these other cadres are present

16
Section 5. Trained staff. This section of the questionnaire asks about
the number of staff in this facility that have received training in a
number of specific interventions.
rightmost column.
No. Question Answer
In this section we would like to know how many of your staff have
received training on the delivery of specific health interventions. For each
intervention, please indicate the number of staff that have received pre-
or in-service training during the last two (2) years.
501 Integrated management of childhood illness
(IMCI)
ENTER "00" if
none.
ENTER "98" if
don't know.
502 Maternal and child health
ENTER "00" if
none.
ENTER "98" if
don't know.
503 Life-saving skills
ENTER "00" if
none.
ENTER "98" if
don't know.
504 Adolescent sexual and reproductive health
(ASRH)
ENTER "00" if
none.
ENTER "98" if
don't know.
505 HIV/AIDS opportunistic infection treatment and
care
ENTER "00" if
none.
ENTER "98" if
don't know.

17
506 Counselling for HIV/AIDS
ENTER "00" if
none.
ENTER "98" if
don't know.
507 Prevention of mother to child transmission
(PMTCT) of HIV
ENTER "00" if
none.
ENTER "98" if
don't know.
508 ART patient treatment and monitoring
ENTER "00" if
none.
ENTER "98" if
don't know.
509 Family planning
ENTER "00" if
none.
ENTER "98" if
don't know.
510 STI diagnosis and treatment
ENTER "00" if
none.
ENTER "98" if
don't know.
511 Infection control/ universal precautions for
handling blood and other bodily fluids
ENTER "00" if
none.
ENTER "98" if
don't know.

18
512 Diagnosis and treatment of malaria
ENTER "00" if
none.
ENTER "98" if
don't know.
513 Drug management
ENTER "00" if
none.
ENTER "98" if
don't know.
514 HMIS training
ENTER "00" if
none.
ENTER "98" if
don't know.
515 Health services management
ENTER "00" if
none.
ENTER "98" if
don't know.
516 DOTS implementation
ENTER "00" if
none.
ENTER "98" if
don't know.

19
Section 6. Drugs and commodities. This section of the questionnaire
asks about the availability of specific drugs and commodities in the
facility. These are all yes/no questions.
rightmost column.
No. Question Answer
In this section we would like to know if the following drugs or
commodities are available today in this facility. These are all yes/no
questions.
Yes……….1601 Injectable antibiotics
No…………..2
Yes……….1602 Oral antibiotics
No…………..2
Yes………...1603 Oral contraceptive pills
No…………..2
Yes………...1604 Intra uterine contraceptive device (IUCD)
No…………..2
Yes…………1605 Injectable contraceptives
No…………..2
Yes…………1606 Condoms
No…………..2
Yes…………1607 Iron (e.g. ferrous sulphate)
No…………..2
Yes…………1608 Vitamin A capsules
No…………..2
Yes…………1609 Measles vaccine
No…………..2
Yes…………1610 First-line anti-malarial drugs
(ACT)
No…………..2
Yes…...…….1611 Second-line anti-malarial drugs
(Fansidar, Metakelfin)
No…………..2
Yes...……….1612 Antihypertensive drugs
No…………..2

20
Yes……..….1613 Magnesium Sulphate for eclampsia treatment
No…………..2
Yes……..….1614 Ergometrine for post-partum hemorrhage
No…………..2
Yes……..….1615 Oral rehydration salts (ORS)
No…………..2
Yes……..….1616 Antiretroviral drugs for treatment of HIV
No…………..2
Yes……….1617 Brochures, posters, or other materials on safer
sex practices*
* We are interested in knowing that these are present and
appropriate. By appropriate we mean that the brochures,
posters and materials are accessible to people with
limited literacy, they have pictures and use words that are
widely understood.
No…………..2

21
Section 7. Laboratory tests. This section of the questionnaire asks
about the availability of specific laboratory tests in the facility. We are
interested in knowing what normal procedure is for laboratory tests.
rightmost column.
No. Question Respondent answer
In this section of the questionnaire, we would like to ask if the following
laboratory tests can be carried out in this facility. For each test, please
indicate whether or not this test can be done and results received on-site
today, if the test can be done off site and results can be received within
two days (that is, a sample is sent to a lab for analysis and results are
returned to the facility), or if the service is not available (that is, you cannot
take a sample, nor refer the patient to another facility).
The test can be done on-
site today……….……..1
The test can be done off
site and results can be
received within two days
time………………………2
701 HIV antibody test
Service is not available
……………….…………3
site today……….………..1
time………………………2
702 Haemoglobin
……………………………3

22
time………………………2
703 Blood count
……………………………3
time………………………2
704 Blood glucose level
……………………………3
site today……….……..1
received within a few
hours……………………2
705 Giemsa stain for malaria
……………………………3
time………………………2
706 RPR or VDRL for syphilis
……………………………3

23
time………………………2
707 Urinalysis
……………………………3
Yes……………………….1708 In this facility, are the resources and
capacity present to grow cultures and
carry out sensitivity tests? No…………………………2

24
Section 8. Information on interventions available in the facility. This is
the final section of the questionnaire. It asks for information about some of
the health interventions that may be offered in this facility.
rightmost column.
No. Question Answer
We are interested in knowing more information about health interventions that
may be offered in this facility. By previous month we mean the last completed
calendar month.
The facility provides
HIV antibody testing
and
counselling…………….
1
counselling
only……….2
testing only 3
801 Is HIV antibody testing and counselling
available in this facility?
The facility does not
provide counselling or
testing…………4
SKIP TO 804
802 How many HIV antibody testing
and counselling clients did the facility see
in the previous month?
803 How many HIV antibody testing and
counselling clients returned for their
results in the previous month?
Yes……………………..1804 Are antenatal services provided in this
facility?
No………………………2
SKIP TO 810

25
805 How many antenatal clients were seen in the
previous month?
ENTER "0" if none.
Yes……………………..1806 Is HIV counselling provided to pregnant
women?
No………………………2
Yes……………………..1807 Is HIV testing provided to pregnant
women?
No………………………2
Yes……………………..1808 Is nevirapine or AZT provided to prevent
mother to child transmission of HIV?
No………………………2
SKIP TO 810
809 How many patients received nevirapine or
AZT in the previous month?
Yes……………………..1810 Is ARV therapy offered at this facility?
No………………………2
SKIP TO 814
811 How many patients are currently enrolled in
the ARV program?
812a. Of the total number of patients
provided in question 810, how many of
them are children under 15 years of age?
812b. Of the total number of patients
them are women over 15 years of age?
812c. Of the total number of patients
them are men over 15 years of age?
CHECK: 812a through 812c should add to the total
number indicated in 811.

26
813 How many patients picked up their ARV
drugs in the previous month?
Yes……………………..1814 Does this facility provide STI diagnosis and
treatment?
No………………………2
SKIP TO 816
815 How many patients were seen for STI
diagnosis and treatment in the previous
month? ENTER "0" if none.
Yes……………………..1816 Is a register of suspected TB cases kept at
this facility?
No………………………2
Yes……………………..1817 Is smear microscopy available in this
facility for TB diagnosis?
No………………………2
Yes……………………..1818 Is TB treatment available in this facility?
No………………………2
Yes……………………..1
No………………………2
819 Is direct observation of short course
chemotherapy for TB provided in this
facility or in the surrounding community?
No………………………2
HIV antibody testing
for all TB
patients…………….1
The facility provides a
referral to HIV testing
services
……………….2
820 Is HIV antibody testing available in this
facility for all TB patients (suspected or
confirmed)?
The facility does not
test TB
patients…………….3
Yes…………..1
821 Does this facility offer child immunization
services?
No……………2
SKIP TO 823

27
822 How many children were immunized* in the
previous month?
* All vaccinations combined
ENTER "0" if none.
Yes……………………..1823 Does your facility conduct any prevention
outreach in the community?
No………………………2
Yes, provision of
contraceptives
including
condoms…….………1
Yes, STI
management...............2
Yes, HIV counselling
and
testing…………….…..3
824 Are there any sexual and reproductive
health services provided in this facility
tailored* specifically to adolescents and
young people?
*Note: By “tailored” we mean a service provided by
a health provider specifically trained to work with
adolescent clients; and/or an area designated
specifically to receive adolescent clients; and/or a
specific time during the day/week designated to
receive adolescent clients
No………………………4
This is the end of the questionnaire. We thank
you very much for the time you have taken to
answer these questions.

Facility questionnaire nigeria

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