Please tick mark the appropriate option for the elements below:
| Yes | No | Needs repair/ replacement | Remarks | |
| 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 | ||||