Tool and Forms
Program Tracking - updated daily or weekly
- Client Database The client database houses all biographical information about Ubuntu clients, both current and former. Location: Dropbox > M&E > Client Database > Client Database Newest Copy.
- Service Log A tab in the Client Database spreadsheet used to track all services provided clients during their time with Ubuntu. Services are added daily and reviewed both daily and monthly. Location: Dropbox > M&E > Client Database > Client Database Newest Copy.
- Adherence Tracking Tool The adherence spreadsheet is updated monthly with the date a client is due for treatment and the date they actually came for treatment. It is used to show adherence for clients both monthly and over a period of 3 years. Location: Dropbox > M&E > Adherence.
- IDT/MDT Minutes Each FSS, Nurse and Y&A Admin have their own teamwork account and are assigned to this particular project. They have been trained how to capture IDT minutes in the shared google spreadsheet so that everyone works off 1 document. Each time a case is discussed a new line in the sheet is completed to show a running history of discussions. FSS then submit cases discussed in their daily logs and this google doc is the source documentation for IDT services. Location: ubuntu.teamwork.com.
- Annual Screenings Spreadsheet Sheet houses outcomes of all data captured during annual client screening process. Location: Dropbox > M&E > Annual Screenings.
- Quarterly Milestones This document shows major milestones for each program department by quarter for the FY16 year. It should be updated by managers regularly. Location: ubuntu.teamwork.com.
- Clinic Triage Sheet Updated daily this spreadsheet tracks the flow of persons through the clinic. Staff triage patients based on their reason for visiting. Preference is given to HIV+ clients, TB+ clients, and visibly ill persons. This sheet also tracks all HIV and TB tests conducted on both clients and non-clients alike. Summaries are sent weekly. Location: Google Drive > Screenings & Forms 2015.
- Development plan Used by employee and supervisor to identify strengths and weaknesses in order to create a professional development plan.
- Observation Forms To be submitted on Teamwork monthly by managers
- In House Training Template To be submitted one week prior to presentation.
- Adherence Form
- Consent to Treatment Pick Up This form is used when clients initiate on treatment. It also captures persons designated to collect treatment on behalf of the client.
- Eye Care Client Agreement This form is used for clients receiving spectacles after an eye exam. It ensures that clients understand why they are receiving specs and that Ubuntu will not replaces them if lost/stolen/broken.
- Vaccination Consent Form
- Client Health Record This is used when clients visit the clinic for minor ailments. It is an ongoing record of their health complaints outside of ART visits.
- HIV Wellness Checklist This form is used annually when screening HIV+ clients ages 15+ for wellness.
- Minor Ailments for Non-Clients This form is used when a non-client or a closed client visits the clinic for treatment of a minor ailment. It is to be kept in the filing cabinet next to clinic reception. And reused if a patient comes again.
- Minor Ailment Observation Codes Used to code diagnosis and symptoms to keep notes brief and quick.
- Minor Ailment Tracking Form This is where we track non-clients seeking treatment for minor ailments at Ubuntu. The form looks at the types of ailments being treated by staff and allows us to see if persons are coming multiple times a month.
- Doctor Tick Sheet Used by the Doctor to record services provided to clients during visits.
- Clinical Monthly Stock Used by Clinical Administrator to check nurses rooms and doctors room for stock and to make sure all items are orderly.
- Physical Screening Physical screening form for children ages 0-18. HIV+ clients 15+ use only the HIV wellness form.
- Youth Support Group Booklets These booklets are to be used by the FSS to conduct youth, adherence, and disclosure support groups
- Nurse Stock Room Lists
- Case Closure Form Used by FSS/Caseworkers to close cases.
- Walk-In Form Counseling form used to document walk-in clients
- Home Assessment Used by FSS/Caseworker when conducting annual home assessments
- Adherence Form Used by FSS/Caseworker when conducting an adherence counseling session.
- Counselling Form Used by FSS/Caseworker when conducting a counseling session.
- BHS Used by FSS when conducting annual Mental Health Screenings.
- Home Visit Request Form FSS and Caseworkers submit an online form request for all home visits. Visits are then approved on the spreadsheet end of the form by the SPO and updates about the visit outcomes are completed on back end by the HHS Manager.
- Incentive Referral This form is submitted by FSS and Caseworkers who want to request a package of tangible items for a client. It is approved by the SPO on the back end of the form. The back end is also where details about when the item(s) were given and if it is to be a reoccurring package are captured.
- Household Stability Log Sheet
- Daily Logs and Gaps
- Programs Tracking Tool This is the workplan for the programs department for the FY16 year. It is to be updated by managers on an ongoing basis.
- Log Submission Sign Up Sheet Used by FSS daily to submit files of clients served/worked on that day.
- Ubuntu Passport Template used to print more Ubuntu Passports
- Services Register Used by staff for collecting names of persons served at a large event
- Counselling Room Sign Up Sheet Placed on the doors of both counseling rooms. FSS use the sheet to sign in the time of their counseling session.
- Teacher phone call log
- Youth Services The following program use the site to record attendance daily: EYP, ECD, JLP, FLP Jr/Sr., UP. ECD administrator captures all ECD and JLP online after teachers take roll in the classroom on paper sheets. FLP Jr and UP facilitators take attendance on paper print outs first then capture online the following day. FLP Sr. is captured on paper by classroom tutors and is then captured online by the FLP Sr. administrator. EYP is taken by EYP Facilitator and captured online by M&E Data Capturer by Wednesday.
- Ubuntu Pathways Interview Questions
- Ubuntu Pathways Interview Rubric
- Ubuntu Pathways Interview Plan
- ART telephone survey This form was administered to ART clients to better understand the way clients use their cellphones and can best be contacted. It was administered by the SPO.
- PMTCT Survey This is a survey administered by the M&E Manager for women who are in our PMTCT program (both pregnant or given birth). The survey explores how a women’s pre/post-natal experience at Ubuntu is different than their previous pregnancies.
- Adherence Support Checklist for Children (Operation Gqoqa) This survey was used to collect information on adherence amongst Ubuntu’s HIV+ children subset.
- Parental Skills Assessment Used in March at the beginning of our parenting skills classes. The form looks at the baseline knowledge of parents/caregivers when it comes to engaging, effective parenting practices.
- Client Satisfaction Survey This is administered by the SPO, M&E Manager or Clinical Administrator to clients throughout the year to better understand their interaction with Ubuntu.
- Global School-based Student Health Survey This is a CDC designed form looking at multiple aspects of a teenagers life, from drug/alcohol use, to family relations, to nutritional well being and mental health. It is administered annually to students in our FLP program.