Obstetric Care Facility Assessment Form
Please complete the following assessment to evaluate the key aspects of this obstetric care facility. Your feedback will help identify strengths and areas for improvement.
Overall cleanliness of the facility
*
1
2
3
4
5
Availability of essential obstetric equipment
*
Not available
1
2
3
4
Fully available
5
1 is Not available, 5 is Fully available
Staff qualification and training
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Patient privacy and confidentiality
*
Not ensured
1
2
3
4
Always ensured
5
1 is Not ensured, 5 is Always ensured
Emergency preparedness and response
*
Not prepared
1
2
3
4
Fully prepared
5
1 is Not prepared, 5 is Fully prepared
Please rate the following aspects of the facility
*
Rows
Poor
Fair
Good
Excellent
Cleanliness of delivery rooms
1
2
3
4
Availability of medications
5
6
7
8
Timeliness of care
9
10
11
12
Respectful treatment of patients
13
14
15
16
Is there a dedicated area for neonatal care?
*
Yes
No
Does the facility have 24/7 on-call obstetric staff?
*
Yes
No
Are infection prevention protocols visibly practiced?
*
Yes
No
Additional comments or observations
Submit Assessment
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