Ministry of Health & Family Welfare

Government of India
Rashtriya Bal Swasthya Karyakram (RBSK
DEIC Monthly Reporting Checklist

Name of the State

Name of the District

Name of facility where DEIC located

Total deliveries as per HMIS in current reporting month

in DH where the DEIC is located ( Reproted Delivery only
in DH (HMIS) )

No of SNCUs in the District

As per SNCU online in

current reporting month
Total New borns Admission Total Discharge

SNCU 1 Name
43 28
SNCU 2 Name

SNCU 3 Name

Total

Q1 Is DEIC functionally and structurally integrated with SNCU and MCH wing/ward ? Y/N
Data Items
Number of children referred to the DEIC from Mobile
1.1 Health Teams
(a) less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of children referred to the DEIC from other
1.2 public facilities
(a) less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of children referred to the DEIC from other
1.3 private facilities
(a) less than 1 year
(b) 1-3 years
 (c) 4-6 years
(d) 6-18 years
Number of children walked into the DEIC on their
1.4 own
(a) less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
1.5 Number of children referred by ASHAs in the DEIC
a.1 For Birth Defect
a.1.1 less than 1 year
a.1.2 1-3 years
a.1.3 4-6 years
a.1.4 6-18 years
a.2 For Developmental delays from revised MCP card
a.2.1 less than 1 year
a.2.2 1-3 years
a.2.3 4-6 years
Number of repeat visit children in the DEIC
1.6
(a) less than 1 year

(b) 1-3 years

(c) 4-6 years

(d) 6-18 years
2 Number of Children managed in DEIC
(a) less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of Children referred to secondary and
3 tertiary facilities

(a) less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
A Medical Equipments ( A1- A8)
A1 Stethoscope (Paediatric)
A2 Sphygmomanometer with Paediatric cuff with 3 different
sizes (Infant, Child and Adult) Reusable
A3 Infantometer with integrated head piece and sliding leg
positioner 10-99cm
A4 Electronic Baby Weighing Scale
A5 Electronic Adult Weighing Scale (Platform Type)
A6 Height Measuring scale -Stadiometer
A7 MUAC tape
 A8 Head circumference tape-Non stretchable TEFLON
synthetic material

Dedicated space available for medical check up for the

patient, (Y/N)

if available, write Length X Breadth (in ft.) of the space.

Designation Name of Staff

Paedatirician
MBBS (MO)

B ECG Equipments
B1 ECG machine with pediatric Chest leads:
B2 Ultrasound cum ECHO Machine for Pediatric and ne
Q4 If ECG digital machine and ECHO machines are
available, please respond to followings
1 Number of Children managed with CHD/RHD
(a) Less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of Children referred to secondary and
2 tertiary facilities

(a) Less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years

C Hearing Equipments
C1 Screener pediatric audiometer
C2 PURE TONE AUDIOMETER WITH BONE CONDUCTOR:
C3 Paediatric Video Auroscope (Otoscope)
C4 Portable handheld Tympanometer/Impedance Audio
C5 Oto-acoustic emission(OAE) instrument
C6 Automatic ABR screener without disposable electrod
C7 Brainstem Evoked Response Audiometer with insert
C8 Tuning Fork 1 set-4 tuning fork of 4 different freq
C9 Speech and Voice software
C10 OPD material.
C11 LED Head light
C12 Thudicum’s speculum set
C13 Killian’ speculum set
C14 Laryngeal mirrors set
C15 Posterior rhinoscopic mirrors
C16 Aural Speculum all sizes black finish
 C17 Nasal Packing Forceps
C18 Aural Suction Tips (Micro suction adapter)
C19 Nasal Suction Tips
C20 Tuning Forceps 512
C21 Hartman’s Forceps
C22 Eustachian tube catheter
C23 Punch biopsy forceps
C24 Laryngeal biopsy forceps
C25 BP Handles of various sizes
C26 Tongue depressor
Q3 is theAudiometry room sound proofed Y/N
Designation Name of staff

Audiologist

What are the number of new born screened for

auditory impairment

1 Number of newborn found with auditory

impairment
(a) New borns
(b) SNCU discharged
2 Number of newborn found with auditory
impairment managed
(a) New borns
(b) SNCU discharged
Number of Children with auditory impairment
3 managed
(a) less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of Children referred to secondary and
4 tertiary facilities

(a) less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
D Vision Equipments :
D1 Ophthalmic Refraction Chair Unit
D2 Infant and toddler VEP or Visual Evoked Potential T
D3 Pencil torch with yellow light
D4 Lea Grating Paddles
D5 Lea Near vision single symbol Playing cards
D6 Lea Near vision cards with symbols with Cord
D7 Lea Symbol 13-Line Translucent Distance Chart (10
 D8 LEA Symbols Low Contrast 10M Flip chart
D9 Lea 3-D Puzzle
D10 Hiding Heidi Low Contrast Face Test, serial no. : 25
D11 Heidi Expressions Test Game serial no. 254505
D12 Hiding Heidi Low Contrast Face Test, serial no. : 25
D13 Heidi Expressions Test Game serial no. 254505
D14 Spectacle Occluder Item # 52327
D15 Occluder Glasses Item # 52851
D16 AAPOS Vision Screening Kit item no. # 120
D17 LEA SYMBOLS® Chart for Vision Rehabilitation item
D18 Leo Learns by doing- DVD for interaction with a visi
D19 COVD Pediatric Kit –400444 SKU number
D20 Lea Fixation stick
D21 Mini Spinning Fixation Globes
D22 Canon Power shot TX1 digital camera
D23 Log Mar Charts
D24 Snellen’s Chart
D25 Direct Ophthalmoscope
D26 Streak Retinoscope
D27 Hand held slit lamp
D28 Pediatric Trail Lens Set
D29 Children’s Trial frame
D30 Vision testing drum
D31 Illuminated Near Vision Test Drum
D32 Random Dot Butterfly stereopsis test with intermedi
E R.O.P Equipments
E1 Binocular Indirect Opthalmoscope with a 20, 28 or 3
E2 Eye speculum (Alfonso infant wire speculum)
E3 Scleral depressor (wire vectis)
E4 ROP speculum
E5 Laser console plus laser indirect opthalmoscope with
E6 Retinal/Fundas camera
Q2 Are New Born and SNCU discharges being
screened for visual impairment ? Y/N
If Yes, What are the number of new born screened

1 Number of Children found with Visual impairment

(a) New borns

(b) SNCU discharged
2 Number of newborn found with Visual
impairment managed
(a) New borns
(b) SNCU discharged
3 Number of new born found suffering from RoP
 (a) New borns
(b) SNCU discharged
4 Number of new born with RoP managed
(a) New borns
(b) SNCU discharged
5 Number of Children referred to secondary and
tertiary facilities
(a) New borns
(b) SNCU discharged
Designation Name of staff

Optometrist

Number of Children with Visual impairment

1 managed

(a) Less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of Children referred to secondary and
2 tertiary facilities

(a) Less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years

F Equipments for Psychological Tests

F1 Receptive-Expressive Emergent LanguageTest—

ThirdLinguistic
F2 LPT: Edition (REEL-3)
profile test
F3 Developmental assessment for Indian Infants
(DASSI) Social Maturity Scale
F4 Vineland
F5 Vineland Adaptive Behaviour Scales
F6 Developmental Screening Test (DST) by Bharat Raj

F7 Denver Developmental Screening Test II (DDST-II)

F8 Stanford Binet (Indian adaptation-Kulshreshta)

F9 Bayley-III Screening Test Complete Kit Includes;

Manual, Stim Book, Picture Book, Record Forms 25
Packs.
 F10 Piagets Sensori-motor Intelligence Scale 0-2 years
• Piagetian Cognitive Tasks

F11 Dyslexia Early Screening Test 4-6 years (DEST)

F12 Dyslexia Screening Test Junior (6-11 years)

F13 NIMHANS battery
F14 Childhood Behavioral Checklist CBCL
F15 Cerebral Palsy and Neuro-motor impairment:
INCLEN (INDT -NMI)
F16 INCLEN Diagnostic Tool for Epilepsy (INDT -EPI)
F17 INCLEN-ASD or Indian Scale for Assessment of
Autism (ISAA)
F18 ADHDT2
F19 SANGUIN FORM BOARD
Designation Name of staff

Psychologist

Number of Children managed

1
(a) Less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of Children referred to secondary and
2 tertiary facilities

(a) Less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years

G Lab Equipments
G1 Automated Blood cell Counter (3 part)
G2 Microscope
G3 Semi-automated analyzer
G4 Digital Hemoglobinometer(with cuvic and lancet)
G5 Isoelectric focusing (IEF)
G6 Hemoglobin HPLC system
G7 ELISA Reader and Washer

H Dentist Equipments
H1 Pediatric Dental Chair
H2 Wall mounted dental x ray along with consumable
(Dental IOPA xray film)
 H3 RVG (Radiovisiography)
H4 Intra Oral Camera
H5 Table top Front Loading Autoclave (electrical)
H6 LED Curing Light source (composite)
H7 Specific dental equipments :
H7.1 Forceps set for extraction: 2 Set (1 Adult +1 Paediatr
H7.2 Restorative Filling and Carving Instruments
Set : 1 set along with consumable :
a. GIC filling (15gm powder/8g liquid)
b. Zinc oxide powder (110 g)
c. Zinc phosphate cement

H7.3 Elevators set of 10 (ten): 1 Set

H7.4 Airotor: 1 along with consumable:
Diamond
H7.5 Contra burs-Air
angle rotar handpiece-assorted
handpiece
Burs assorted for contrangle handpiece(round,
taper fissure, in-verted cone)

H7.6 Dental ultrasonic scaler( complete set): 1 along

with consumable:
(Polishing brush and cup)
H7.7 Composite Filling Instruments: 1 kit along with
consumable:
a. Composite kit with etchant and bonding agent
b. Composite syringes individual
c. Composite finishing and polishing kit

H8 Dental Electric Brushless Micromotor

H9 Automatic Water Distiller: 1
H10 Mouth Mirrors:40
H11 Probes-Straight: 40
H12 Explorers: 40
H13 Tweezers: 40
H14 Cheatle forceps: 1
H15 Kidney trays 10
H16 Plastic Cheek Retractors 2 each
H17 Mouth Props (Adult + Pedo) 1 each
H18 Cement Spatula (Plastic and Metal) 1 each
H19 Matrix Band and retainer(both no1 & 8) 1 set
along with consumable: (Matrix band no1 & 8)

H20 Dental Impression Trays (upper and lower) 1 set

each along with consumable:
a. Impression material alginate dust free(450 g)
b. Plaster of paris

H21 Rubber Bowls 2

H22 Plaster Spatula- straight and curved 1 each
H23 Suction tips (Metal) 2
H24 Mallet - Dental 1
 H25 Scissors 1
H26 Needle Holder- 1
H27 Bone Chisel- 1
H28 Glass slab
H29 Scalpel handle : 1
H30 Plastic patient drape 2
H31 Hand scaler(complete set) 1
H32 Portable dental darkroom along with consumable:
a.Developer
b. Fixer

H33 Mortar And pestel : 1

H34 Lead Apron: 1
H35 G.P point15-80 assorted set
H36 K file set assorted 15-40,45-80 (21 mm and 25 mm)
H37 Pit and fissure sealant
H38 Topical fluoride varnish
H39 Local Anesthesia (topical and injectable)(2%
lidocaine with epinephrine & without epinephrine)
Designation Name of staff

MO, Dental
Dental technician

Number of Children managed

1
(a) 1-3 years
(b) 4-6 years
(c) 6-18 years
Number of Children referred to secondary and
2 tertiary facilities

(a) 1-3 years

(b) 4-6 years
(c) 6-18 years

I Physiotherapy Equipments
I1 Therapy ball:
I1.1 65 cm
I1.2 45 cm and a pump for inflation
I3 Therapy mats- 6ft x3ft ( Length 6 ft and breadth 3ft, thickness 4 cm
I4 Bolster:
I4.1 2ft long, diameter- 8 inch
I4.2 2ft long, diameter- 10 inch
I5 Small roll-13 inch long, diameter -3 inch
 I6 Prone wedges
Foam filled wedges covered with Nylon, fitted with
Rexene straps to position the child

I6.1 Big-
Height-14 inch;
Length- 31 inch,
breadth 17 inches
I6.2 Small-
Height-10 inch;
Length- 26 inch,
breadth 17 inches

I7 Balance Board
Rexene covered cushioned platform, size 45
cmX60 cmX15cm high

I8 Kaye-Walker
(height-48-64 cm distance between hand grips 34
cm, frame width 58-60cm, frame length 69-83 cm,
user height 107-137 cm, maximum user weight 39
kg., frame weight 3.85 kg)

I9 Trampoline
I10 Bolster Swing
With nylon rope or straps with hooks to fit in the
swing frame. Size 25 cm diameter X 90 cm long

I11 Wooden Benches with cushion and Rexene cover

I11.1 a) Small (3ft long, height 8 inches,breath 6 inches)
I11.2 b) Big (3ft long, height 12 inches, breath 8 inches)
I12 Splints (Ankle Foot Orthosis)
I13 Special chair
with cut-out tray (Tailor made according to need of
the child)

I14 Cut-out floor table (2ft×2ft)

I15 Floor seat (Pelvic strap):

I16 looking mirrors
I17 Toys (for play and stimulation)
I17.1 Small rattles:
I17.2 Squeaky toys :
I17.3 Puja bell (clapper bell) :
I17.4 Soft toy :
I17.5 Brush for tactile stimulation :
I17.6 Theraputty: Gluten free, non-toxic, red, yellow and
blue colors :
 I17.7 Peg board : laminated square board having 10
holes to hold smoothly finished solid plastic pegs
in five different bright colours :

I17.8 Ball Pool : The dense foam padded mini Ball Pool is
Soft, safe and perfect for small children. It provides
an excellent sensory stimulating activity. The
round pool is 120cm in diameter x 50cm high, &
has 10cm thick padded sides. The pool contains
500 multi color balls of 7cm or 8cm diameter. Pool
side and bottom is covered with durable Rexene
that easily wipes clean. : 1

I17.9 Balls of different size :

I18 Gaiters :
Aluminium/bamboo stick of 8”,10”, 12”,14” long
inserted in the pockets of thick canvas, 3 velcro
straps to be wound around Total 8 nos (1 pair of
each size mentioned)

I19 Thick handle spoon Stainless steel spoon, padded

I20 handle 3
Thick handle bent spoon Stainless steel bent
spoon, spoon
I21 Plastic paddedwith
handle
long3handle (for babies) ,
Long handle bright color spoon
I22 Plastic glass with rim cut on one side : Plastic glass
with one side of the rim is cut to accommodate
nose

I23 Stainless steel plates with high rim : High rim to

prevent spilling
I24 Spouted cups : over of food

Designation Name of staff

Physiotherapist

Number of Children managed

1
(a) Less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
2 Number of Children referred to secondary and
tertiary
(a) Less thanfacilities
1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
J Sensory Integration Equipments
J1 Pinspot and Mirror Ball
J2 Mirror Ball Motor
J3 LED Mirror Ball
J4 Fire ball -mounted on the roof
J5 Sound Activated Light
J6 LED Bubble Tube
J7 OPTIC fibers
J8 Blue LED Lights
J9 150 bulb blue LED light chain
J10 Bubble Tube
J11 Rotating Drum
J12 Chime Frame and Beater
J13 Mirror Chime bout
J14 Swings:
J14.1 Bolster swing
J14.2 Platform swing
J14.3 Tyre tube swing
J14.4 Rope ladder swing
J15 Rhythmic Rocker
J16 Balance boards
J17 Ball Pool
J18 Tunnel
J19 Bean bags including white one
J20 Real size animal toys
J21 Soft play walls
J22 Soft mattresses for floor
J23 Auditory addition to the Multi-Sensory Room.
J24 Nursery set : Boat shaped
J25 Nursery set : Platform slide
J26 Soft-play Mirror Corner set
J27 White room
J28 Soft play kerbs
J29 Interactive Ballpool
J30 The Standard Bubble Tube
J31 Multi-Sensory Den
J32 Fibre Optic shower frame
J33 Bamboo fibre optic slide glow :
J34 UV Jumbo Fibre Optic Side glow
J35 Sensory deluxe room Mini sensory room

Designation Name of staff

Early interventionist cum

special educator

1 Number of Children managed

 (a) Less than 1 year
(b) 1-3 years
(c) 4-6 years
(d) 6-18 years
Number of Children referred to secondary and
2 tertiary facilities

(a) Less than 1 year

(b) 1-3 years
(c) 4-6 years
(d) 6-18 years

K IT Equipments
K2 Computers with LAN
L Plaster area with bath tub
M Gender Specific and User-friendly toilets

N Reception area and waiting room

O Special education room
P Social worker room
Q DEIC Manager and data entry
R Additional OPD space
S Play area
T Sensory integration garden
U Other Human Resource Details

Designation Name of staff

SN
Social worker
Lab technician
DEIC manager
 Ministry of Health & Family Welfare
Government of India
Rashtriya Bal Swasthya Karyakram (RBSK)
DEIC Monthly Reporting Checklist

Bihar Month of Reporting March

Year
Gaya 2022
Prabhawati Hospital HMIS/MCTS Facility code of DH (As
Gaya aviliable)

Total live birth as per HMIS in current reporting month in DH where

the DEIC is located

Weight of newborn on Admission

Write Number

1500-2499 gm 1000-1499 gm <1000gm

42 1 0

ated with SNCU and MCH wing/ward ? Y/N "--Select-"

Previous Month April "Financial Year"- till date
33

3
9
18
3
14

5
1
3
5
4

2
1
 1
0
10

3
2
3
2

3
2
33
4
10
12
7
21

7
1
9
4
Essential / Optional number for each DEIC Available ? Y/N
E 4
E 2

E 2

E 2
E 2
E 2
E 5
E 5

Date of Joining Trained in Basic DEIC 15 days training at If Trained date of training at Nodal
Nodal Centre, Y/N centre

Essential / Optional number for each DEIC Available ? Y/N

Optional ONE
Optional ONE
Previous Month April "Financial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N

E 1
E 1
E 2
E 1
E 1

E 1
E 1
E 1

E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E Decible in Audiometry room
Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre

Previous Month April "Financial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N

E 1 (2 in Model DEIC)
OPT 1
E 2
E 2
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1 (2 in Model DEIC)
E 1
E 1
E 1
Essential / Optional number for each DEIC Available ? Y/N
E 1
E 1
E 1
E 1
OPT
OPT

Previous Month April "Financial Year"- till date

Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre

Previous Month April "Financial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N

E 1
E 1
E 1
E 1
E 1
E 1

E 1

E 1

E 1
E 1

E 1

E 1
E 1
E 1
E 1

E 1
E 1

opt 1
1
Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre

Previous Month April "Financial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N

E one
E one
OPT one
OPT one
OPT
OPT
OPT

Essential / Optional number for each DEIC Available ? Y/N

E ONE
E ONE
E ONE
E

E 1
E 1

E 1
E 1
E 1

E 1

E 1

E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1

E 1

E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1

E 1
E 1
E 1
E 1
E 1
E 1
E 1

Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre

Previous Month April "Fimnancial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N

E 1
E 1
6

E 3
E 1 EACH
E 1
E 1

E 1

E 1

E 1

E 1
E 1

E 1
E 1
E 1 PAIR
E 1

E 1

E 1
E

E 10
E 3
E 2
E 10
E 2
E 3 containers
E 2

E 1

E 5
E Total 8 no.
(1 pair of each size mentioned)

E 3
E 3
E 3

E 3

E 3
E 3

Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre

Previous Month April "Financial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1

E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
E 1
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT
OPT

Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre

Previous Month April "Financial Year"- till date

Essential / Optional number for each DEIC Available ? Y/N
E 6+1
E 1+1
E 1+1

E 1+3
E 1
E 1
E 1
E 2
E 2

Date of Joining Trained in Basic DEIC 15 days training If Trained date of training at Nodal
at Nodal Centre, Y/N centre
 March
2022

Pre term

"--Select-"
 s

Functional Y/N
ned date of training at Nodal
centre

Functional Y/N

Functional Y/N
ned date of training at Nodal
centre

Functional Y/N
Functional Y/N
ned date of training at Nodal
centre

Functional Y/N
ned date of training at Nodal
centre

Functional Y/N

Functional Y/N
ned date of training at Nodal
centre

Functional Y/N
ned date of training at Nodal
centre
 Functional Y/N

ned date of training at Nodal

centre
 Functional Y/N

If yes write area -

Length X Breadth
in Ft.

ned date of training at Nodal

centre