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I 1 Date 2000
  Name of Respondent
  Name of Facility
II 1

What is the level of your facility?

II 2 Decipline of medicine followed
III 1 Type of management
III 2 What is the surrounding environment like?
III 3 What is the area / population served by the facility?
III 4 a. What is the area? (in m2) plot built up
  b. How many sides have open spaces?
  c. What is the condition of the structure?
  d. Type of tenure
III 5 a. What is the width of the main access road?
  b. Is it motorable?
  c. What is the road surface?
  d. How is the accessibility to your facility?
III 6 a. Do you have ambulance/s?
  b. Do you have adequate parking spaces for staff? two wheeler four wheeler
  c. Do you have adequate parking spaces for visitors? two wheeler four wheeler
IV 1 List the major epidemics you have faced over the last year
IV 2 How many inpatients does the facility have? male female paediatric
  What are the visiting hours?
IV 3 How many outpatients does the facility have during peak season off-peak season
IV 4 How many beds does the facility have? medical surgical maternity ic paediatric isolation other
IV 5 a. How many doctors does the facility have? resident non resident
  c. How many nurses does the facility have? resident non resident
  e. How many other staff does the facility have? resident non resident
IV 6 a. How much electricity does the facility use? HT LT
  b. How much water does the facility use? municipal line well bore well
  c. How does the facility dispose rainwater?
  d. How does the facility dispose sewage?
  e. How does the facility dispose medical waste?
V 1 a. What is the annual income of the facility?
  b. What is the annual expenditure of the facility?
V 2 Does the facility have any growth or expansion plans for the near future?
VI 1 How would patients rate your facility in terms of  
  Service (docs/ nurses/ staff/ etc.)

  Infrastructure (facility/ diagnostics/ etc.)

  Materials (consumables/ drugs/ food/ etc.)

  Hygiene (cleanliness/ sterility/ etc.)

  Concern for patient (privacy/ etc.)

  Concern for relatives (sensitivity/ etc.)

  Overall Rating

Below 25% 25-50% 50-75% Above 75%

VII 1 In your opinion, how good is health awareness in Goa state?
VII 2 In your opinion, how good is medical education in Goa state?
VII 3 Are you aware of any religio-cultural reservations to medicine within Goa?
VII 4 Any other comments about the health system in Goa
Thank You!

List of abbreviations used:
CHC    Community Health Centre
SHC    Subsidiary Health Centre
HIV     Human Imuno Virus
TGM   Tar Bound Macadam
WBM  Water Bound Macadam
HT   High Tension
AIIMS  All India Institute of Medical Sciences
PHC Primary Health Centre
RMD Rural Medical Dispensary
AIDS Acquired Imuno Deficiency Syndrome
CC   Cement Concrete
m    meters
LT       Low Tension

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Quais Fatehi, Architect Quais Fatehi, 2001