' Chinic Factlittes Form ~ Page 2
Number of windows aeeding repair (sroken glass, jammedjoren or shuc,
etc.)
Number of doors needing repair.
Does roofleak?
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Yes (describe)
No
heed Gee} feed Greed
Fleer natertal:
. Dire
Other (please speci‘ty)
Toilec factitstes for clinic:
reara eer saeses
Flush toilet in suilding
Chemical coilerc in building
Outhouse with pit etoilec
Qpen pit toilat ocurside
Yo toilet factlitias
Other (please spec:i7)
Clinic washing Zacilicies:
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Piped wacar with sink and drain in building
Sink and drain in building but 20 piped vacar
Ne sink and drain in building (please describe washing Facilisias)
Lighting source:
(
(
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Be Bed Bee fenced
10.
Conucrate
Wood
AC eleceric light
DC. eleceric Lights
Other light scurce (plaase dascrise)
No light scurce