NATIONAL URBAN HEALTH MISSION, UP

(PERSONAL DATA)
Designation :
Date of Joining : Date of Birth :
Place of Joining : Year of Posting :
Present Posting :
Type of Posting :
Salary Per Month @:
Name (in English) :
(fgUnh esa):
Father’s Name :
Mother’s Name :
Marital Status (if Yes, Name Plz.) :
Qualification :
Address - 1 (Permanent) :

Address - 2 (Correspondence) :

Contact Number : 1. 2.
PAN Number :
AADHAR card Number :
Bank Details : Bank /Branch
Complete Account No.
Verification :

Affix Recent Signature

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Signature
 National Urban Health Mission, UP
Performance Appraisal Form
MEDICAL OFFICER
Part-I
(Common for All Categories)
Review Period :
Name :
Date of Joining :
Location :
Date of Complication of Contract :
Part – II
1- Major responsibilities assigned during the review period (as per assigned duties)
i.
ii.
iii.
iv.
v.
2- Performance & Achievements (Please comment on the major achievements during the
reporting period.

A. QUANTITATIVE ASSESMENT :

Sl. Activities Achievement

1 No of OPD Cases Attended
2 No of ANC Cases Handled at the Facility
3 High Risk Pregnancy detected & listed
4 No of Emergency Cases Attended Against the Total No of
Cases
5 No of Labour Cases Handled at the Facility
6 No of PNC Cases Handled at the Facility
7 No of Infant/Neonatal Cases Attended
8 No of Family Planning Cases Attended for Family Planning
Method
9 No of Cases of IUCD Insertions
10 No of communicable & Non communicable disease cases seen
11 No of Children referred to RBSK Unit
12 Physical/Financial Review

Details Regarding the Field Visits:

Sl. Activities Achievement
1 No of Outreach Camps Supervised
2 No of Meeting/Staff Meeting at U-PHC Level
3 No of UHND Session Supervised
B. QUALITATIVE ASSESSMENT:

 Interpersonal Relationship (Attitude Towards and Degree of Co-ordination with Colleagues,

Superiors and Other Departments) Plz. Tick the Column.

Outstanding Very Good Good Average Poor

 Behaviour with Patients

Outstanding Very Good Good Average Poor

 Flexibility and Adoptability

Outstanding Very Good Good Average Poor

 Punctuality

Always Sometimes Never

 Dependable for Tasks Assigned

Always Sometimes Never

C. Any Extraordinary Achievements Made or Reasons for Shortfall, If any During the
Reporting Period (Please comment) :

D. Remarks of the Assessing Authority

Overall Assessment of the Appraisal:

: Recommendation :
Contract Renewed Contract Terminated

Nodal Officer, NUHM CMO

Reviewing Officer Accepting Officer
 National Urban Health Mission, UP
Performance Appraisal Form
STAFF NURSE
Part-I
(Common for All Categories)
Review Period :
Name :
Date of Joining :
Location :
Date of Complication of Contract :
Part – II
1- Major responsibilities assigned during the review period (as per assigned duties)
i.
ii.
iii.
iv.
v.

2- Performance & Achievements (Please comment on the major achievements during the
reporting period.

A. QUANTITATIVE ASSESMENT :

Sl. Activities Achievement

1 No of OPD Cases Attended
2 No of ANC Registered
3 No of Pregnant Women Immunized with 2 TT inj. & Ensured
with Complete ANC checkup
4 High Risk Pregnancy detected & listed
5 No of Deliveries Conducted
6 No of PNC check up
6 Family Planning Services (Details)
 No of Beneficiaries Counseled
 No of IUCD inserted
 No of Sterilization Referred
7 Immunization by Staff Nurse at UPHC (Antigen wise)
Record Keeping :
Sl. Activities Achievement
1 ANC Register
2 Register (Delivery/JSY/Referral)
3 Family Planning Register
B. QUALITATIVE ASSESSMENT :

 Interpersonal Relationship (Attitude Towards and Degree of Co-ordination with Colleagues,

Superiors and Other Departments) Plz. Tick the Column.

Outstanding Very Good Good Average Poor

 Behaviour with Patients

Outstanding Very Good Good Average Poor

 Flexibility and Adoptability

Outstanding Very Good Good Average Poor

 Punctuality

Always Sometimes Never

 Dependable for Tasks Assigned

Always Sometimes Never

C. Any Extraordinary Achievements Made or Reasons for Shortfall, If any During the
Reporting Period (Please comment) :

D. Remarks of the Assessing Authority

Overall Assessment of the Appraise :

: Recommendation :
Contract Renewed Contract Terminated

Nodal Officer, NUHM CMO

Reviewing Officer Accepting Officer
 National Urban Health Mission, UP
Performance Appraisal Form
PHARMACIST
Part-I
(Common for All Categories)
Review Period :
Name :
Date of Joining :
Location :
Date of Complication of Contract :
Part – II
1- Major responsibilities assigned during the review period (as per assigned duties)
i.
ii.
iii.
iv.
v.
2- Performance & Achievements (Please comment on the major achievements during the
reporting period.

A. QUANTITATIVE ASSESMENT :

Sl. Activities Achievement

1
2
3
4
5
6
7

Record Keeping :
Sl. Activities Achievement
1 Stock Register
2 Expiry Register
3 Consumable Register
4 Proper leveling on rack & daily distribution site
B. QUALITATIVE ASSESSMENT :

 Interpersonal Relationship (Attitude Towards and Degree of Co-ordination with Colleagues,

Superiors and Other Departments) Plz. Tick the Column.

Outstanding Very Good Good Average Poor

 Behaviour with Patients

Outstanding Very Good Good Average Poor

 Flexibility and Adoptability

Outstanding Very Good Good Average Poor

 Punctuality

Always Sometimes Never

 Dependable for Tasks Assigned

Always Sometimes Never

C. Any Extraordinary Achievements Made or Reasons for Shortfall, If any During the
Reporting Period (Please comment) :

D. Remarks of the Assessing Authority

Overall Assessment of the Appraise :

: Recommendation :
Contract Renewed Contract Terminated

Nodal Officer, NUHM CMO

Reviewing Officer Accepting Officer
 National Urban Health Mission, UP
Performance Appraisal Form
LAB-TECHNICIAN
Part-I
(Common for All Categories)
Review Period :
Name :
Date of Joining :
Location :
Date of Complication of Contract :
Part – II
1- Major responsibilities assigned during the review period (as per assigned duties)
i.
ii.
iii.
iv.
v.
2- Performance & Achievements (Please comment on the major achievements during the
reporting period.

A. QUANTITATIVE ASSESMENT :

Sl. Activities Achievement

1 No of Routine Blood Test (TLC/DLC/HB/ESR)
2 Stool and Urine Tests
3 Bleeding Time/Clotting Time
4 Diagnosis of RTI/STD with Wet Mounting, Gram Strain etc.
5 Sputum Testing for Tuberculosis (if Designated as a
microscopy center under RNTCP)
6 Blood Smears Examination for Malaria Parasite
7 Rapid Tests for Pregnancy
8 Rapid Tests for Malaria
9 Rapid Tests for HIV/AIDs

Record Keeping :
Sl. Activities Achievement
1 Stock Register
2 Expiry Register
3 OPD
4 Lab testing Register
B. QUALITATIVE ASSESSMENT :

 Interpersonal Relationship (Attitude Towards and Degree of Co-ordination with Colleagues,

Superiors and Other Departments) Plz. Tick the Column.

Outstanding Very Good Good Average Poor

 Behaviour with Patients

Outstanding Very Good Good Average Poor

 Flexibility and Adoptability

Outstanding Very Good Good Average Poor

 Punctuality

Always Sometimes Never

 Dependable for Tasks Assigned

Always Sometimes Never

C. Any Extraordinary Achievements Made or Reasons for Shortfall, If any During the
Reporting Period (Please comment) :

D. Remarks of the Assessing Authority

Overall Assessment of the Appraise :

: Recommendation :
Contract Renewed Contract Terminated

Nodal Officer, NUHM CMO

Reviewing Officer Accepting Officer
 National Urban Health Mission, UP
Performance Appraisal Form
ANM
Part-I
(Common for All Categories)
Review Period :
Name :
Date of Joining :
Location :
Date of Complication of Contract :
Part – II
1- Major responsibilities assigned during the review period (as per assigned duties)
i.
ii.
iii.
2- Performance & Achievements (Please comment on the major achievements during the
reporting period.

A. QUANTITATIVE ASSESMENT :

Sl. Activities Achievement

1 No of Pregnant Women Registered
2 No of Pregnant Women Immunized with 2 TT inj. & Ensured
with Complete ANC Checkup and 2 Postnatal Visits
3 No of Fully Immunized Children in her Area
4 No of cases of Malnutrition among Infants & Young Children
(upto 5 yrs) Identified and Necessary advice & treatment given
or Referred serious cases to higher unit (NRC, etc.)
Details Regarding Field Visit :
Sl. Activities Achievement
1 No of UHND/RI Session Planned/Held
2 No of ANC Registered/Immunized
3 No of Children Immunization (Antigen wise)
4 No of Malnourished Children Identified & Referred
5 No of Cases Counseled for Family Planning Services
6 No of UHND Session done
7 No of High Risk Pregnancy (HRP) Cases Registered on MCTS Portal
8 No of IUCD inserted
9 No of IUCD Cases referred
10 No of Sterilization referred
11 No of monthly meeting of Mahila Arogya Samiti done with Urban ASHA
12 No of Monthly Meeting done with Incharge of Unit at U-PHC
B. QUALITATIVE ASSESSMENT :

 Interpersonal Relationship (Attitude Towards and Degree of Co-ordination with Colleagues,

Superiors and Other Departments) Plz. Tick the Column.

Outstanding Very Good Good Average Poor

 Behaviour with Patients

Outstanding Very Good Good Average Poor

 Flexibility and Adoptability

Outstanding Very Good Good Average Poor

 Punctuality

Always Sometimes Never

 Dependable for Tasks Assigned

Always Sometimes Never

C. Any Extraordinary Achievements Made or Reasons for Shortfall, If any During the
Reporting Period (Please comment) :

D. Remarks of the Assessing Authority

Overall Assessment of the Appraise :

: Recommendation :
Contract Renewed Contract Terminated

Nodal Officer, NUHM CMO

Reviewing Officer Accepting Officer