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Please tick mark the appropriate option for the elements below:

YesNoNeeds repair/ replacementRemarks
Prominent Display board in local language for (pictorial/ local language):

Facility Branding

Name of facility prominently displayed in front of building

Citizen Charter in local language

OPD timings (if any)

Display of services available at facility

Information about Teleconsultation services / Roster displayed

All functional areas identified by their respective signage

Entitlements under different schemes

Biomedical waste management protocols

Hand Hygiene/ Infection control protocols

Adequate seating / waiting space for patients

Power Supply

Power back up

Internet Access IT / IOT devices functionality Facility Application version upgrade

Handwashing Basin

Toilet with running water