CANDIDATE’S NUMBER …………………………………. SIGN.

OF CAND …………………
CENTRE……………………………………………………………….. DATE …………………….
TASK: REGISTRATION OF A BABY AT CHILD WELFARE CLINIC
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.

COMPONENT TASK RATING

1. Welcomes mother/caretaker and offers a seat 0 1 2 3 4
2. Introduces self and examiner 0 1 2 3 4
3. Enquires about the health of the child and the family 0 1 2 3 4
4. Collects the child’s card if old client and if new client, issues a new card 0 1 2 3 4
5. Takes child’s history and fills the card 0 1 2 3 4
6. Register the child in the registration book if new and give registration and
serial numbers 0 1 2 3 4
7. If old client, checks her name, registration and serial number in the
registration book 0 1 2 3 4
8. Enters the needed information in the registration book 0 1 2 3 4
9. Determines whether the child is due for immunization 0 1 2 3 4
10. Thanks mother/care taker for her cooperations 0 1 2 3 4
11. Refers client to the next stage 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER…………………………………………..… SIGNATURE………………………….
RANK OF EXAMINER ………………………………………….… DATE…………………………………
CANDIDATE’S NUMBER ………………………………………. SIGN. OF CAND ……………………
CENTRE…………………………………………………………… DATE ………………………………
TASK: PHYSICAL EXAMINATION OF BABY AT A CHILD WELFARE CLINIC
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Explains procedure to mother and applies alcohol rub to the hands 0 1 2 3 4
2. Asks mother to place baby on her lap for physical examination 0 1 2 3 4
3. Observes the size and shape of the head 0 1 2 3 4
4. Feels the skull for anterior and posterior fontanelles, and observes for any
abnormalities 0 1 2 3 4
5. Opens baby’s eyes gently with the thumb and index finger and examines
the eyes 0 1 2 3 4
6. Examinees the nose, mouth and the ears 0 1 2 3 4
7. Examines the neck for enlarged lymph nodes 0 1 2 3 4
8. Examines the armpit, upper limbs and nails 0 1 2 3 4
9. Test for reflexes ( at least one) 0 1 2 3 4
10. Examines the skin for any rashes and muscle tone 0 1 2 3 4
11. Examines the trunk and abdomen 0 1 2 3 4
12. Observes umbilicus for any rashes and muscle tone
13. Examines the groins for swelling, vulva for discharges, scrotum for
cleanliness and undescended testes 0 1 2 3 4
14. Examines the lower limbs and nails 0 1 2 3 4
15. Turns child and examines the back, buttocks and anal area for any
abnormalities 0 1 2 3 4
16. Asks mother to dress up baby, discusses findings with mother and refers
if necessary 0 1 2 3 4
17. Applies alcohol rub to hands, records and report findings to examiner 0 1 2 3 4
SCORE OBTAINED ……………………………………………………………………………………………
NAME OF EXAMINER…………………………………………..… SIGNATURE………………………….
RANK OF EXAMINER ………………………………………….… DATE…………………………………
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: COUNSELLING OF A MOTHER AT CHILD WELFARE CLINIC
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.

COMPONENT TASK RATING

1. Ensure privacy and confidentiality 0 1 2 3 4

2. Finds out about the health of the family 0 1 2 3 4
3. Re-inspects the child’s health record book for entries made 0 1 2 3 4
Interviews and counsels mother on:
4. The child’s growth pattern using the child’s health record book 0 1 2 3 4
5. Diet 0 1 2 3 4
6. Immunization 0 1 2 3 4
7. Personal hygiene and general care 0 1 2 3 4
8. Family Planning 0 1 2 3 4
9. Importance of child health record book and CWC 0 1 2 3 4
10. Any other problems 0 1 2 3 4
11. Compliments mother and informs her of the next child welfare clinic day 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………….
RANK OF EXAMINER ………………………………………… DATE………………………………….
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: GIVING ORAL POLIO VACCINE (OPV) / ROTARIX
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.

COMPONENT TASK RATING

1. Explains procedure to mother 0 1 2 3 4

2. Finds out from mother the type of immunization the child has had
previously 0 1 2 3 4
3. Checks the child’s health record book and find out which vaccine to give 0 1 2 3 4
4. Explains the procedure to the mother and asks for feedback 0 1 2 3 4
5. Shows mother how to hold the child and applies alcohol rub to hands 0 1 2 3 4
6. Picks vaccine with right hand, check vaccine vial monitor (VVM) expiry
date and opens it 0 1 2 3 4
7. Uses left hand to open the mouth by pressing the lower jaw gently 0 1 2 3 4
8. Squeezes 2 to 3 drops of vaccine at the back of the tongue of child 0 1 2 3 4
9. Compliments the mother for bringing her child for immunization and
reminds her of the next visit 0 1 2 3 4
10. Washes, dries hands and records procedure 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE……………………………………….
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: GIVING DPT / HIP / HEB (QUINVAXEM) / MEASLES / YELLOW
FEVER / PNEUMOCOCCAL IMMUNIZATION
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Finds out from the mother the type of immunization the child has had. 0 1 2 3 4
2. Looks at the child’s health record book and checks on which vaccine to give. 0 1 2 3 4
3. Explains the procedure to the mother 0 1 2 3 4
4. Explains any side effects to the mother and discusses with her what she can
do about them 0 1 2 3 4
5. Asks mother for feedback 0 1 2 3 4
6. Shows mother how to hold the child and applies alcohol rub to hands 0 1 2 3 4
7. Checks Vaccine Vial Monitor (VVM) and expiry date of vaccine and
draws 0.5ml 0 1 2 3 4
8. Cleans the outer middle part of the thigh/left arm with damp cotton wool and
discards it 0 1 2 3 4
9. Holds the part tightly between the thumb and forefinger of left hand and gently
pushes the needle deep into the muscle at an angle of 900/450 0 1 2 3 4
10. Removes and discards solo shot after injecting vaccine, presses the area with
dry clean cotton wool ball and discards. 0 1 2 3 4
11. Tells mother not to apply anything to the site but to give baby paracetamol
syrup according to age in case of fever 0 1 2 3 4
12. Commends the mother for bringing her child for immunization 0 1 2 3 4
13. Washes, dries hands and records procedure 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE……………………………………….
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: CHECKING THE WEIGHT OF A CHILD AT CWC
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Establishes rapport and explains procedure to mother 0 1 2 3 4

2. Washes, dries hands assists mother to remove baby’s clothing and puts the
pants on 0 1 2 3 4
3. Ensures weighing scale is functioning 0 1 2 3 4
4. Hangs baby to the scale and reads the weight 0 1 2 3 4
5. Removes baby from the scale and removes pants 0 1 2 3 4
6. Gives baby to the mother to dress up and applies alcohol rub to hands 0 1 2 3 4
7. Plots the weight on the growth chart 0 1 2 3 4
8. Checks the weight against the previous one, explains the graph to the 0 1 2 3 4
mother on weight gain/loss and thank her
9. Records the weight in the registration book against the child’s name 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: HOME VISITING
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Presents map of the community 0 1 2 3 4

2. Enter home and greets according to custom 0 1 2 3 4
3. Introduces self and examiner, and explains purpose of the visit 0 1 2 3 4
4. Observes environment for cleanliness and safety 0 1 2 3 4
5. Ensures privacy and confidentiality 0 1 2 3 4
6. Identifies needs/concerns of the family 0 1 2 3 4
7. Set objectives with family 0 1 2 3 4
8. Discusses and helps find solution to family needs if possible 0 1 2 3 4
9. Educates on prevailing health issues 0 1 2 3 4
10. Expresses appreciation and informs family of next visit 0 1 2 3 4
11. Records findings 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..

RANK OF EXAMINER ……………………………………. DATE………………………………………..

CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: USING HOME VISIT BAG
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Equips bag with required items 0 1 2 3 4

2. Explains procedure to client 0 1 2 3 4
3. Places bag on a clean surface using a paper 0 1 2 3 4
4. Opens bag, removes and wears apron 0 1 2 3 4
5. Washes and dries hands 0 1 2 3 4
6. Removes necessary items and carries out the procedure 0 1 2 3 4
7. Wraps used items into polythene bag 0 1 2 3 4
8. Washes, dries hands and packs items into compartments 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE……………………………………….
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: VISIT A CLIENT WITH EPILEPSY
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Presents map of the community 0 1 2 3 4

2. Knocks, enters, greets and introduces self and examiner 0 1 2 3 4
3. Explains the purpose of visit 0 1 2 3 4

Enquires and counsels about:

4. The health of client and relatives 0 1 2 3 4

5. Drug treatment 0 1 2 3 4
6. Existing problems 0 1 2 3 4
7. Occupation / schooling 0 1 2 3 4
8. Causes, management and prevention of the disease 0 1 2 3 4
9. Personal and environmental hygiene 0 1 2 3 4
10. Diet 0 1 2 3 4
11. Prevention of home accidents 0 1 2 3 4
12. Refers problems beyond scope to the appropriate place 0 1 2 3 4
13. Counsels on regular check-ups, next visit and thanks them for their
co-operation 0 1 2 3 4
14. Records and report finding to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: HOME VISIT TO A CLIENT WITH LEPROSY
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Presents map of the community 0 1 2 3 4

2. Knock, enters on response, greets and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and asks about general health of the client 0 1 2 3 4
4. Observes environment for cleanliness/safety 0 1 2 3 4
5. Ensures privacy and confidentiality 0 1 2 3 4

Carries out the following procedures:

6. Tests for skin sensitivity 0 1 2 3 4
7. Test skin for healing/new patches 0 1 2 3 4
8. Dresses wounds if necessary 0 1 2 3 4

Interviews and counsels client on the following

9. Diet 0 1 2 3 4
10. Sleeping pattern and recreational activities 0 1 2 3 4
11. Drugs and regular continuation of treatment 0 1 2 3 4
12. Prevention of home accidents 0 1 2 3 4
13. Care of hands, feet and eyes 0 1 2 3 4
14. Relationship with family/ community members 0 1 2 3 4
15. Date of review and other concerns 0 1 2 3 4
16. Congratulates client, family and inform them on the next visit 0 1 2 3 4
17. Records and report findings to examiner 0 1 2 3 4
SCORE OBTAINED ……………………………………………………………………………………………
NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: VISIT TO A CLIENT WITH MENTAL DISORDER
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Presents map of the community 0 1 2 3 4

2. Knocks, enters, greets and introduces self and examiner 0 1 2 3 4
3. Explains the purpose of visit and ensure confidentiality 0 1 2 3 4
Enquires and counsels on:
4. Health of client and relatives 0 1 2 3 4
5. Drug treatment 0 1 2 3 4
6. Existing problem 0 1 2 3 4
7. Occupation/schooling 0 1 2 3 4
8. Diseases condition to family/and other tenant (if necessary) 0 1 2 3 4
9. Personal and environmental hygiene 0 1 2 3 4
10. Diet 0 1 2 3 4
11. Regular check-ups to hospital/visit by community psychiatric nurse 0 1 2 3 4
12. Refers problem beyond scope to the appropriate place 0 1 2 3 4
13. Informs client relatives about next visit and thanks them 0 1 2 3 4
14. Records and report findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: HOME VISIT TO A CLIENT WITH ELEPHANTIASIS
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Present map of the community 0 1 2 3 4

2. Knocks, enters, greets, and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and ask about general health 0 1 2 3 4
4. Observes the environment for cleanliness and safety 0 1 2 3 4

Interview and counsels client about:

5. Diet 0 1 2 3 4
6. Bowel movement 0 1 2 3 4
7. Sleep pattern 0 1 2 3 4
8. Drug and continuation of treatment 0 1 2 3 4
9. Date and review at the hospital 0 1 2 3 4
10. Relationship with family/community members 0 1 2 3 4
11. Personal and environmental health 0 1 2 3 4
12. Any special concerns 0 1 2 3 4
13. Prevention of mosquito bites 0 1 2 3 4
14. Care of leg 0 1 2 3 4
15. Congratulate client and family and informs them about next visit 0 1 2 3 4
16. Records and reports findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: HOME VISIT TO A PREGNANT WOMAN / HIGH RISK
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Presents map of the community 0 1 2 3 4
2. Knock, enters on response, greets and introduces self and examiner 0 1 2 3 4
3. Ask about general health 0 1 2 3 4
4. Observes environment for cleanliness/safety 0 1 2 3 4
Interview client:
5. Diet 0 1 2 3 4
6. Bowel movement 0 1 2 3 4
7. Rest and sleep pattern 0 1 2 3 4
8. Exercise 0 1 2 3 4
9. Birth preparedness plan 0 1 2 3 4
10. Health timing of pregnancy (family planning) 0 1 2 3 4
11. Danger signs of pregnancy per Ante Natal Care (ANC) booklet 0 1 2 3 4
12. Prevention of malaria with Sulpadoxine Pyrimethamine (SP) and Insecticide
Treated Bed net (ITN) 0 1 2 3 4
Examine and counsel on:
13. Washes, dries hands, checks vital signs and weight 0 1 2 3 4
14. Performs general physical examination (Head to toe) 0 1 2 3 4
15. Inspects and palpate abdomen (if possible) 0 1 2 3 4
16. Washes, dries hand and counsels client according to findings 0 1 2 3 4
17. Encourage early reporting when labour starts 0 1 2 3 4
18. Encourage male involvement 0 1 2 3 4
19. Counsels on regular attendance to antenatal clinic 0 1 2 3 4
20. Records and report findings to examiner 0 1 2 3 4

SCORE OBTAINED ………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ……………………
CENTRE……………………………………………………………….. DATE ………………………..
TASK: VISITING A CLIENT WITH CVA AT HOME
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Present map of the community 0 1 2 3 4
2. Knocks, enter, greets and introduces self and examiner 0 1 2 3 4
3. Explains the purpose of the visit and ensure confidentiality 0 1 2 3 4
4. Enquires about the general condition from care taker/relatives/client 0 1 2 3 4
5. Undresses the client with assistance from the care taker 0 1 2 3 4
6. Examines client from head to toe 0 1 2 3 4
7. Checks Blood Pressure (BP) and compares with the previous one (if available) 0 1 2 3 4
8. Counsels care taker according to findings 0 1 2 3 4
9. Counsel caretaker on personal hygiene with emphasis on pressure areas 0 1 2 3 4
10. Emphasize on frequent change of position (Bedridden) and exercise 0 1 2 3 4
11. Stresses on diet 0 1 2 3 4
12. Find out about medication and counsels 0 1 2 3 4
13. Ask of other concerns and counsels 0 1 2 3 4
14. Reminds them of regular check-ups, informs them about next visit and thanks
them 0 1 2 3 4
15. Records and report findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ……………………
CENTRE……………………………………………………………….. DATE ……………………….
TASK: HOME VISIT TO A CLIENT WITH BURULI ULCER
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Present map of the community 0 1 2 3 4

2. Knocks, enters, greets, and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and ask about general health 0 1 2 3 4
4. Observes the environment for cleanliness and safety 0 1 2 3 4
5. Ensures privacy and confidentiality 0 1 2 3 4
6. Dresses wound where necessary 0 1 2 3 4

Interview and counsels client about:

7. Health education on disease condition 0 1 2 3 4
8. Diet 0 1 2 3 4
9. Exercise 0 1 2 3 4
10. Sleep pattern and recreational activities 0 1 2 3 4
11. Drug and continuation of treatment 0 1 2 3 4
12. Date and review at the hospital 0 1 2 3 4
13. Relationship with family/community members 0 1 2 3 4
14. Personal and environmental health 0 1 2 3 4
15. Any special concerns 0 1 2 3 4
16. Prevention of mosquito bites 0 1 2 3 4
17. Congratulate client and family and informs them about next visit 0 1 2 3 4
18. Records and reports findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: VISITING THE DIABETIC AT HOME
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Presents map of the community 0 1 2 3 4

2. Knocks, enters, greets and introduces self and examiner 0 1 2 3 4
3. Explains the purpose of visit and ensure confidentiality 0 1 2 3 4

Enquires and counsels on:

4. Health of client and relatives 0 1 2 3 4
5. Occupation, general life style 0 1 2 3 4
6. Diet 0 1 2 3 4
7. What client knows and feels about condition 0 1 2 3 4
8. Drug treatment and exercise 0 1 2 3 4
9. Causes and management of disease 0 1 2 3 4
10. Alleviates their anxiety/fear about condition 0 1 2 3 4
11. Reminds client of regular check-ups, next visit, thanks client and
relatives 0 1 2 3 4
12. Records and report findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: VISITING THE AGED AT HOME
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Present map of the community 0 1 2 3 4
2. Knocks, enters, greets, and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and ask about general health 0 1 2 3 4
4. Observes the environment for cleanliness and safety 0 1 2 3 4
5. Ensures privacy and confidentiality 0 1 2 3 4

Interview and counsels client about:

6. Diet 0 1 2 3 4
7. Bowel movement, personal and environmental cleanliness 0 1 2 3 4
8. Mobility/Exercise and sleep pattern and recreational activities 0 1 2 3 4
9. Home help (care taker) 0 1 2 3 4
10. Prevention of home accidents 0 1 2 3 4
11. Good interpersonal relationship with family members 0 1 2 3 4
12. Any special concerns 0 1 2 3 4
13. Assist in providing any care required 0 1 2 3 4
14. Encourages initiation/continuation of any special activity 0 1 2 3 4
15. Congratulate client and care taker and informs them of next visit 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: HOME VISIT TO PEOPLE LIVING WITH HIV/AIDS (PLWHA)
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Present map of the community 0 1 2 3 4

2. Knocks, enters, greets, and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and ask about general health 0 1 2 3 4
4. Observes the environment for cleanliness and safety 0 1 2 3 4
5. Ask about general health of client 0 1 2 3 4

Interviews and counsels client on the following

6. Disease condition 0 1 2 3 4
7. Occupational/schooling 0 1 2 3 4
8. Diet 0 1 2 3 4
9. Personal hygiene 0 1 2 3 4
10. Sleep pattern and recreational activities 0 1 2 3 4
11. Bowel action/hydration 0 1 2 3 4
12. Drugs and regular continuation of treatment 0 1 2 3 4
13. Prevention of home accidents 0 1 2 3 4
14. Relationship with family and community members 0 1 2 3 4
15. Home help (care giver) 0 1 2 3 4
16. Other concerns and date for review 0 1 2 3 4
17. Congratulates client and family and informs them of next visit 0 1 2 3 4
18. Records and report findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ……………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: MALNOURISHED CHILD AT HOME
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Present map of the community 0 1 2 3 4

2. Knocks, enters, greets, and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and ask about general health 0 1 2 3 4
4. Ask about general health of client 0 1 2 3 4
5. Request for the child’s card and finds out about clinic attendance 0 1 2 3 4
6. Weighs and records the child’s weight 0 1 2 3 4
7. Compares weight with the previous one and counsel accordingly 0 1 2 3 4
8. Examines child from head to toe 0 1 2 3 4
9. Compares and discusses findings with parents/caretaker 0 1 2 3 4
10. Ask mother about type of food for the day and possibly looks at it 0 1 2 3 4
11. Finds out if child is eating well, and counsels on adequate diet and
proper feeding methods 0 1 2 3 4

Counsel on:
12. Personal and environmental hygiene 0 1 2 3 4
13. Regular attendance at C.W.C and reminds her about next visit 0 1 2 3 4
14. Any other concern 0 1 2 3 4
15. Congratulates mother, records and report findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: VISIT TO A CLIENT WITH HYPERTENSION AT HOME
RATING SCALE: 0 - This step was omitted

1 - The basic technique was not done well

2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Knocks, enters, greets and introduces self and examiner 0 1 2 3 4

2. Explains the purpose of the visit 0 1 2 3 4
3. Enquires about the general health of client and relatives 0 1 2 3 4
4. Examines client for oedema of feet, legs and sacral regions 0 1 2 3 4
5. Checks Blood Pressure (BP) and compares with the previous one
(if available) 0 1 2 3 4
6. Counsels on the need to take prescribed drugs accordingly 0 1 2 3 4
7. Reminds client about review 0 1 2 3 4
8. Counsel client on personal hygiene 0 1 2 3 4
9. Ask client for concerns and counsels 0 1 2 3 4
10. Thanks client and relatives and informs them about the next visit 0 1 2 3 4
11. Records and reports findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE ……………………………
TASK: HOME VISIT TO CLIENT WITH TUBERCULOSIS
RATING SCALE: 0 - This step was omitted
1 - The basic technique was not done well
2 - The technique was performed correctly but with hesitation
3 - The technique was performed correctly and without hesitation
4 - The technique, speed and style are excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Present map of the community 0 1 2 3 4
2. Knocks, enters, greets, and introduces self and examiner 0 1 2 3 4
3. Establishes rapport and ask about general health 0 1 2 3 4
4. Observes the environment for cleanliness and safety 0 1 2 3 4
Interview and counsels client about:
5. General health 0 1 2 3 4
6. Diet 0 1 2 3 4
7. Bowel movement 0 1 2 3 4
8. Sleep pattern and recreational activities 0 1 2 3 4
9. Drugs and continuation of treatment 0 1 2 3 4
10. Availability of treatment supporter 0 1 2 3 4
11. Date for review at the hospital 0 1 2 3 4
12. Relationship with family/community members 0 1 2 3 4
13. Personal and environmental hygiene 0 1 2 3 4
14. Occupation/schooling 0 1 2 3 4
15. Care of sputum container/sputum disposal 0 1 2 3 4
16. Prevention of spread of disease through health education 0 1 2 3 4
17. Any special problem 0 1 2 3 4
18. Congratulate client and family and informs them about next visit 0 1 2 3 4
19. Records and reports findings to examiner 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: GIVING A TALK TO A GROUP OF PEOPLE (TECHNIQUE)
RATING KEY: 0 - This step was omitted

1 - The basic technique of this step is done with errors

2 - The basic technique is done correctly but with hesitation
3 - The basic technique is done correctly
4 - The technique, speed and style excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING

1. Introduces self and topic 0 1 2 3 4

2. Explains relevance of the topic and objectives to the audience 0 1 2 3 4
3. Gives the talk in the form of discussion 0 1 2 3 4

Delivers the talk with:

4. Clarity 0 1 2 3 4
5. Audibility 0 1 2 3 4
6. Maintains eye contact 0 1 2 3 4
7. Controls audience 0 1 2 3 4
8. Uses teaching aids when necessary 0 1 2 3 4
9. Provides time for questions and contribution 0 1 2 3 4
10. Provides time for appropriate answers to questions 0 1 2 3 4
11. Asks for feedback 0 1 2 3 4
12. Summarizes the talk and thanks the audience 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: HOME VISIT TO A FAMILY WITH TWINS
RATING KEY: 0 - This step was omitted

1 - The basic technique of this step is done with errors

2 - The basic technique is done correctly but with hesitation
3 - The basic technique is done correctly
4 - The technique, speed and style excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATING
1. Knock and enter on response 0 1 2 3 4
2. Establishes rapport 0 1 2 3 4
3. Greets 0 1 2 3 4
4. Introduces self and examiner 0 1 2 3 4
5. Observes the environment 0 1 2 3 4
6. Ask client about general health of family 0 1 2 3 4
7. Remove apron, towel, soap dish, note book 0 1 2 3 4
8. Put on apron 0 1 2 3 4
9. Wash Hands 0 1 2 3 4
10. Examine 1st twin from head to toe 0 1 2 3 4
11. Wash hands 0 1 2 3 4
12. Examine 2nd twin from head to toe 0 1 2 3 4
13. Explains finding to mother 0 1 2 3 4
14. Assist in providing care when necessary 0 1 2 3 4
15. Give necessary health education 0 1 2 3 4
16. Encourage attendant at C.W.C for immunization 0 1 2 3 4
17. Ask about home help (if any) 0 1 2 3 4
18. Relationship of home help 0 1 2 3 4
19. Congratulates client and inform her of next visit 0 1 2 3 4
20. Record findings 0 1 2 3 4
21. Thanks mother and bid farewell 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: HOME VISIT TO A PRE-TER/NEW BORN BABY
RATING KEY: 0 - This step was omitted
1 - The basic technique of this step is done with errors
2 - The basic technique is done correctly but with hesitation
3 - The basic technique is done correctly
4 - The technique, speed and style excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATINGS
1. Knock and enters on response 0 1 2 3 4
2. Greets and introduce self and examiner 0 1 2 3 4
3. Establishes rapport and explains the purpose of the visit to mother 0 1 2 3 4
Ask about
4. The child’s health 0 1 2 3 4
5. Breast feeding 0 1 2 3 4
6. Provision of warmth 0 1 2 3 4
7. Prevention of infection 0 1 2 3 4
8. Sleep pattern of the child 0 1 2 3 4
9. Examines child from head to toe 0 1 2 3 4
10. Inspects and dress cord if necessary 0 1 2 3 4
11. Explains findings to the mother 0 1 2 3 4
12. Gives necessary health education 0 1 2 3 4
13. Encourages attendance at child welfare clinic 0 1 2 3 4
14. Congratulates client and family 0 1 2 3 4
15. Records findings and bids farewell 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: HOME VISIT TO THE HEANDICAPPED
RATING KEY: 0 - This step was omitted

1 - The basic technique of this step is done with errors

2 - The basic technique is done correctly but with hesitation
3 - The basic technique is done correctly
4 - The technique, speed and style excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATINGS
1. Knock and enters on response 0 1 2 3 4
2. Greets and introduce self and examiner 0 1 2 3 4
3. Establishes rapport and explains the purpose of the visit 0 1 2 3 4
4. Inquires about client’s general condition 0 1 2 3 4
5. Observes the environment 0 1 2 3 4
6. Asks about helper/care taker 0 1 2 3 4
7. Observes client’s personal hygiene 0 1 2 3 4
8. Gives necessary education on any problem identified 0 1 2 3 4
9. Encourages CBR and refer when necessary 0 1 2 3 4
10. Discusses future plan for client’s care 0 1 2 3 4
11. Records findings 0 1 2 3 4
12. Thanks client and bid farewell 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: PHYSICAL EXAMINATION OF A PREGNANT WOMAN AT THE
ANTENATAL CLINIC
RATING KEY: 0 - This step was omitted
1 - The basic technique of this step is done with errors
2 - The basic technique is done correctly but with hesitation
3 - The basic technique is done correctly
4 - The technique, speed and style excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATINGS
1. Establish rapport and asks the client to empty her bladder 0 1 2 3 4
2. Provides privacy, washes and dries hands 0 1 2 3 4
3. Assists client to undress and wear gown 0 1 2 3 4
4. Helps client to adopt dorsal position 0 1 2 3 4
5. Examines scalp and face 0 1 2 3 4
6. Examines neck, upper limbs and axillae 0 1 2 3 4
7. Examines breast and teaches client self-breast examination 0 1 2 3 4
8. Inspects abdomen and notes findings 0 1 2 3 4
9. Measures symphysio-fundal height and performs fundal palpation 0 1 2 3 4
10. Perform lateral palpation 0 1 2 3 4
11. Instructs client to bend her knees slightly and breathe slowly through the
mouth 0 1 2 3 4
12. Performs pelvic palpation and assesses head descent 0 1 2 3 4
13. Listen and counts foetal heart rate for one minutes 0 1 2 3 4
14. Examines the vulva 0 1 2 3 4
15. Instruct client to lie on her side and examines the back 0 1 2 3 4
16. Examines the lower limbs 0 1 2 3 4
17. Communicates findings to the client 0 1 2 3 4
18. Help her out of bed and assists her to re-dress 0 1 2 3 4
19. Observes infection prevention procedures 0 1 2 3 4
20. Thanks client, record and report findings 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..
CANDIDATE’S NUMBER …………………………………. SIGN. OF CAND ………………………
CENTRE……………………………………………………………….. DATE …………………………..
TASK: COUNSELLING A MOTHER AT ANTENATAL CLINIC
RATING KEY: 0 - This step was omitted
1 - The basic technique of this step is done with errors
2 - The basic technique is done correctly but with hesitation
3 - The basic technique is done correctly
4 - The technique, speed and style excellent
INSTRUCTION: For each of the observations circle the appropriate number on the scale that
best indicates level of performance.
COMPONENT TASK RATINGS
1. Offers mother a seat 0 1 2 3 4
2. Ensures privacy 0 1 2 3 4
Interviews and educates mother on:
3. Diet 0 1 2 3 4
Delivers the talk on:
4. Personal hygiene and general care 0 1 2 3 4
5. Preparation for breastfeeding 0 1 2 3 4
6. Immunization 0 1 2 3 4
7. Preparation for confinement 0 1 2 3 4
8. Family Planning 0 1 2 3 4
9. Any other problems 0 1 2 3 4
10. Compliments mother for attending A.N.C 0 1 2 3 4
11. Tells her of the next A.N.C 0 1 2 3 4

SCORE OBTAINED ……………………………………………………………………………………………

NAME OF EXAMINER……………………………………… SIGNATURE………………………………..
RANK OF EXAMINER ……………………………………. DATE………………………………………..