College of Nursing, Dhamtari Baseline Survey Form of Community Assessment

COLLEGE OF NURSING, DHAMTARI
BASELINE SURVEY FORM OF COMMUNITY ASSESSMENT
1.Name of the area rural/urban – Urban Area

2.Name of the Health Centre - Primary Health Center Bhatgaon
3. Name of the Head of the family – Tula Ram Dewangan
Address – Village – Bhatgaon , Post – Bhatgaon , Dist – Dhamtari (C.G.)
4. Type of family .1 Single (√) .2 Joint

: …………………………………..……..…
5. Religion :1 Hindu …(√)……….. (Specially the sub cast) :…Kosta……
2 Muslim: ……………………………………………..
3 Christian: ………………………...…………………
4 Any other:…………………………………………...
6.Housing Condition :
6.1 Type of house :
1) Pucca 2) Semi Pucca (√) 3) Kutcha
6.2 Rooms :
1) Number -3
2) Adequate / Inadequate(√)
6.3 Occupancy
1) Tenant 2) Owner (√) 3) Monthly Rent
6.4 Ventilation:
1) Adequate 2) Inadequate (√) 3) No ventilation
6.5 Lighting
1) Electricity(√) 2) Gas lamp 3) Oil Lamp
6.6 Source of water supply (Drinking/Washing purpose) :
1) Tap/hand pump (√) 2) Well (√) 3) Open tank
6.7 Kitchen
1) Separate 2) Corner of the room(√) 3) Veranda
6.8 Cooking Fuel :1) Chulha (√) 2) Cooking gas 3) Sigri
6.9 Breeding area of Insects &Rodents: 1) Present 2) Absent (√)
6.10 Are the cattle and poultry housed hygienically?
1) Separate 2) Within house
6.11 System of waste disposal:
1) Composing(√) 2) Burning (√) 3) Burying
6.12 Disposal of sewage water:
1. Drainage (Open/Closed system)(√) 2) Soak pit 3) Kitchen garden
6.13 Lavatory:
1) Own latrine 2) Public latrine 3) Open air defecation (√)
7.Family Composition :
RELATIO
-TIONOCCUPA
EDUCA-
INCOM
S.NO NAME AGE SEX NSHIP
OF THE
E
HEAD
1. Mr. TulaRam 38yr M Self 7th 6000
Dewangan. class Driver
2. Mrs.Nitu 35yr F Wife 4th 5500

Dewangan class Bidhi
Maker
3. Kirti 9yr F Daughter 4th Student
class -
4. Jitendra 5yr M Son 1st Student -

class
5. Umesh 3yr M Son - -
7. A Total Income of family 7.B EDUCATION STATUS NUMBER

a)Below 1000 a) Not literate -
b) 1001-5000 b)Primary education - 1
c) 5001-10000 (√) c)Middle school -
d) 10001 and above d)High school -
8. Transport and communication media
8.1 Transport 8.2 Communications

a) Transport ………… a) Mobile …(√)……………
b) Owns Tempo/Tractor ………… b) Television …(√)……………
c) Uses B T S / KSRTC ………… c) Radio ………………
d) Use Private buses ……(√)…… d) Newspaper/magazine …………
e) Train ………… e) Post and above …(√)……………
8.3 Languages : 8.4 Language Known :

a) Mother Tongue ………… a) Chhattisgarhi read/write/speak(√)
b) Chhattisgarhi …(√)……… b) English read/write/speak
c) Hindi ………… c) Hindi read(√)/write(√)/speak
d) Specify others ………… d) Specify others ………. Read/write
9.Dietary pattern :
Food Available Food Used Traditional Ideal Unhygienic
Rice √ √
Ragi √
Jawar
Wheat
Vegetables √ √
Fish √ √
Meat √ √ √
Egg √ √ √
Milk and
Milk Products
Pulse √ √
Tubers
10.Statement of expenditure of the family :
S.No. Item Amount Spent (Approx). % of total expenditure

1. Food 1200 10.47
2. Clothing 1400 12.17
3. Housing (Rent)
4. Medicine 300 2.60
5. Children Education 200 1.73
6 Recreation (Movies
etc)
7 Smoking and /
Liquor
8 Debt
9 Savings 6400 55.65
10 Other (Specify) 2000 17.39
11.It there any case of fever (If yes, write name, age, treatment with remarks) :
a) With rigors ?
b) With cough ?
c) With rash
S.No. Name Age Disease Treatment Remarks
11.1
11.2
11.3
12. Does any one have any skin Disease (e.g. itching, patch, rash)
S.No. Name Age Disease Treatment Remark

13. Does any one have cough for more than 2 weeks .

1
2
3
14.Does any one have any other illness ?

1
2
3
15.Is any woman pregnant, if yes, writes the following remarks .

a) Specify gravid
b) Has she been registered
c) Is she getting iron and folic acid
d) Has she had tetanus toxoid
S.No. Name 15.1 15.2 15.3 15.4
16.Have there been any (within year) _ Vital statistics.

16.1 Birth ?
S.No. Date of Birth Sex Parents Name Remarks
16.2 Death ?
S.No. Date of Death Sex Parents Name Remarks

1
2
3
16.3 Marriages ?
S.No. Date of Marriage Sex Parents Name Remarks

Bride
Bridegroom
17.Are the any children below five years who have not received immunization(Specify name,
age and reason for not being immunized in remarks)
1.1 BCG vaccination

1.2 DPT vaccination
1.3 Poliomyelitis vaccination
1.4 Measles vaccination
1.5 Vitamin A Solution
S.No. Name Age Sex 17.1 17.2 17.3 17.4 17.5

1 2 3
1
2
3
4
Remarks ………………………………
18. Is there any eligible couple :(If so list them on priority)

S.No Name Age Sex I (Priority) II (Priority) PS SS EM
.
1. Mr.TulaRam/ Mrs 38yr M Permanent
Nitu 35yr F family
planning
(TT Done)
2.
3.
PS : Primary sterility SS:Secondary sterility
EM : Early menopause
18.1 Using contraceptive method ? If yes, (√) specify. (TT Done)
18.2 Intendings to undergo 18.2.1 Vasectomy

18.2.1 Tubal ligation
18.3Not interested to adopt FP Method (state the reason)
19. Is there any child 0-5 years in family who shows signs of Malnutrition ?
19.1Kwashiorkor
19.2Marasmus
19.3Vitamin A deficiency
19.4Anemia
19.5Rickets
S.No. Name Age Sex 19.1 19.2 19.3 19.4 19.5

1
2
3
4
5
Remarks : …………………………………
20.Is The Sullage Water Being Disposed Of Hygienically?
20.1 Drain (√) 20.2 Soakpit 20.3 Kitchen Garde

If no state
reasons…………………………………………………………………………………………………
………………..
21.IS THE RUBBISH BEING DISPOSED HYGIENICALLY? If yes,tick any one/all.
21.1 Composing (√) 21.2 Burning (√) 21.3Burying
If no state reasons……………………………………………………………………………………
22.IF THE EXCRETA BEING DISPOSED OFF HYGIENICALLY? Yes(√)/No
If no state reasons…………………………………………………………………………………….
23.ARE THE CATTLE AND POULTRY HOUSED HYGIENICALLY?Yes /No
23.1 Separate 23.2 Within house
State
reasons………………………………………………………………………………………………
24.IS THERE A WELL OR HANDPUMP?
24.1 Is it maintain in good order. Yes /No (√) if no state reasons.- No any information
24.2 When was the well chlorinated? (Date)- State reasons for not chlorinating-No Govt. supply.
25. WHETHER HOUSE IS KEPT CLEAN? Yes(√)/No.if no state reasons
26. WHEN WAS THE HOUSE LAST SPRAYED? (Date)- if no state reasons.-no.any
information
27. IS THERE ANY BREEDING PLACE OF INSECTS AND RODENTS? Yes(√)/No.
28. ARE THERE ANY STRAY DOGS IN THE VICINITY. Yes/No(√).if yes write approximate
no. of dogs.
29. Are official health agencies services adequate ? Yes(√)/No

If no state reason ………………………………………
Note : In addition to the above, students are expected to obtain following information
by observation and other methods.
1. Description of the community location, topography, climate, history etc. Type of

Government, no. of schools, no. of health care agencies, Balwadi or ICDS centers, places of
worship (e.g. Temple) and any other relevant information related to health.
2. List of target couple with details on priority basis.
3. Maintain record of Road to Health Card “for knowing the degree of malnutrition for under –
5s where or necessary and use-Nutritional Assessment Form promptly.
4. Use problem solving approach / construct good nursing care plan by using “PRONE” format
taught to you in recent community Nursing Process Lectures.
5. Remarks can be written in separate sheets quoting code no.
6. (eg. 12.2 no sensation found on the patches needs referral and follow us services)
Date of Survey : 11/01/19 Name of Signature of student

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COLLEGE OF NURSING, DHAMTARI

BASELINE SURVEY FORM OF COMMUNITY ASSESSMENT

1.Name of the area rural/urban – Urban Area

4. Type of family .1 Single (√) .2 Joint

2. Mrs.Nitu 35yr F Wife 4th 5500

4. Jitendra 5yr M Son 1st Student -

5. Umesh 3yr M Son - -

7. A Total Income of family 7.B EDUCATION STATUS NUMBER

8. Transport and communication media

8.1 Transport 8.2 Communications

8.3 Languages : 8.4 Language Known :

10.Statement of expenditure of the family :

S.No. Item Amount Spent (Approx). % of total expenditure

S.No. Name Age Disease Treatment Remark

S.No. Name Age Disease Treatment Remarks

S.No. Name Age Disease Treatment Remarks

15.Is any woman pregnant, if yes, writes the following remarks .

16.Have there been any (within year) _ Vital statistics.

S.No. Date of Birth Sex Parents Name Remarks

S.No. Date of Death Sex Parents Name Remarks

S.No. Date of Marriage Sex Parents Name Remarks

1.1 BCG vaccination

S.No. Name Age Sex 17.1 17.2 17.3 17.4 17.5

18. Is there any eligible couple :(If so list them on priority)

18.2 Intendings to undergo 18.2.1 Vasectomy

S.No. Name Age Sex 19.1 19.2 19.3 19.4 19.5

20.Is The Sullage Water Being Disposed Of Hygienically?

20.1 Drain (√) 20.2 Soakpit 20.3 Kitchen Garde

21.1 Composing (√) 21.2 Burning (√) 21.3Burying

22.IF THE EXCRETA BEING DISPOSED OFF HYGIENICALLY? Yes(√)/No

23.ARE THE CATTLE AND POULTRY HOUSED HYGIENICALLY?Yes /No

23.1 Separate 23.2 Within house

24.IS THERE A WELL OR HANDPUMP?

25. WHETHER HOUSE IS KEPT CLEAN? Yes(√)/No.if no state reasons

27. IS THERE ANY BREEDING PLACE OF INSECTS AND RODENTS? Yes(√)/No.

29. Are official health agencies services adequate ? Yes(√)/No

1. Description of the community location, topography, climate, history etc. Type of

Date of Survey : 11/01/19 Name of Signature of student

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