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facility assessment form

Manchester United Kisumu Family Maternity & Health Facility Assessment

Project Overview

As Manchester United Kisumu Family, we are planning a national charity project supporting maternal health—focusing on the Maternity wing, Antenatal care, and drilling a borehole to support the hospital and community within Kisumu.

Facility Assessment Checklist

Please complete this assessment for each of the at least 5 candidate facilities near Kisumu town to help us select the most needy site.

Name of the hospital or health centre being assessed

Distance and travel time from Kisumu town

Maternity Wing Urgency & ConditionRequired

Rate from 1 (extremely poor condition) to 5 (good condition)

Antenatal Care NeedsRequired

Rate current antenatal service needs from 1 (critical need) to 5 (adequate)

Water Access & Borehole NeedRequired

Rate water availability and need for a borehole from 1 (severe shortage) to 5 (adequate water)

Community Impact PotentialRequired

Rate the potential benefit to the wider community from 1 (low) to 5 (high)

Describe specific challenges or infrastructure gaps observed at the facility

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