Medical Facility Baseline Survey
Thank you for taking time to complete this survey. This survey is for assessment purposes only.
Any information collected will be treated with strict confidentiality.
(Version: March 2015)
Clinic/Hospital Details
Name of Clinic/Hospital
Address
Country
Phone and Email
Are you a
 Referral Hospital
 District Hospital
 Health Clinic
Director or Administrator of Clinic/Hospital
Director Name and Title
Email
Mobile phone / Cell number
Clinic/Hospital Information
Patient Numbers
Catchment Area Population Served?
Average Outpatients per Month?
Number of Hospital Beds?
Average Inpatients per Month?
Indicative Hospital Staffing Numbers
Surgeons
Obstetric Gynaecologists (Ob Gyns)
Paediatricians
Physicians
Other Doctors
Nurses
Midwives
Do you have a permanent Biomedical Technician?
Yes / No
Clinic/Hospital Services and Departments
Maternal & Child
Do you have an ante natal service?
Yes / No
Do you have a special care unit for newborns?
Yes / No
Deliveries in last 12 months
Estimated Caesarian Sections in last 12 months
Do you provide any Family Planning services?
Yes / No
Surgical
How many Operating Theatres do you have?
 One
How many working Anaesthetic Machines do you have?
How many working Patient Monitors do you have?
Infectious Diseases
HIV Treatment
Yes / No
Number on ARV treatment?
TB Treatment
Yes / No
Number on treatment?
Do you treat Malaria?
Yes / No
Do you treat STDs (Sexually Transmitted Diseases)?
Yes / No
Pathology
 More than one
 Other
Do you have in-house pathology?
Yes / No
If yes, please indicate what testing is done on-site?
If no, please indicate quality of the service you currently
outsource:
 Good service
 Reasonable service
 Poor service
Utilities
Power
Do you have reliable mains power?
Yes / No
Do you have a back-up generator?
Yes / No
What percentage of time is there without mains power?
________ %
Do you have any solar power generation?
Yes / No
Do you have any voltage stabilizers (or automatic voltage regulators)?
Yes / No
If no, do you have or use surge protectors for your medical equipment?
Yes / No
What is the voltage?
What is the main socket type?
Please indicate by writing a letter from diagram below e.g. A, B, C
 110
 220
Oxygen
What is your primary source of oxygen?
 Generation Plant
 Bottled Oxygen (Cylinder)
 Oxygen Concentrators
Insufficient oxygen for patient treatment?
 Often
 Sometimes
 Never
Water
Do you have permanent access to clean water?
Yes / No
If no, do you rely on:
 Rain tanks
 Water pump
Equipment
Equipment Status
Type
Current total
WORKING units
in your facility
How many more
units needed
Name of Department in
which need is greatest
Can your clinic/hospital
make some contribution
to the cost?
Ultrasounds
Oxygen Concentrators
Patient Monitors
Pulse Oximeters
ECGs
Suction Machines
X-Rays (reference only)
n/a
n/a
n/a
Autoclaves (reference only)
n/a
n/a
n/a
Please note:
* Demand for equipment is much greater than the capacity to supply.
* Please do not over-estimate the units needed.
Maintenance
Is the current maintenance of your equipment adequate?
Yes / No
Do you have staff training programs on the use and maintenance of
equipment?
Yes / No
Name of the person who knows most about the state of your
equipment and carries out the minor repairs or maintenance:
Source of current equipment
How did your clinic/hospital source your current equipment?
________ % DONATED
________ % PURCHASED
________ % GOVERNMENT
Patients
Patient Charges
Do you charge patients for basic services?
Yes / No
Is the charge:
 Subsidized
 Discounted
 Normal
Data Collection
Are individual patient records kept?
Yes / No
If yes, are they retained at the clinic / hospital?
Yes / No
How are records kept
 Paper
 Electronic
 Both
Comments
Please add any comments you think are relevant:
Thank you for taking time to complete this survey. This survey is for information collection only.
Signature:
___________________________________________________________________
Name and Title:
___________________________________________________________________
Date:
____________________________
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