Clanic Facilities Form - Page 2
Number of wiadows aeeding repair (broken glass, jammed oren or shut,
atc.)
Number of doors needing repair.
' Does root. leak?
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Yes (dasezribea)
No
ww a aoe eer)
Floor material:
1d.
Conerate
Wood
. Dirt
Other (please specity)
Toilac faci2tttas for clinic:
Flush toilet in building
Chemical coiler in building
Oushouse with pit tcoilec
Open pic coilet outside
Yo totlec facitliries
Ocher (please svec:=7)
Clinic washing fZacilicies:
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Piped wacear with sink and drain in building
Sink amd drain ia building 5ut ao piped varar
Nae sink and drain in building (please describe washing faciliséas)
Lighting source:
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AC eleceric light
DC ealeceric light
Other lighe source (plaase describe)
Ne Light source