Institution Name:

Type of Institution: Select Type Government Hospital Private Hospital Health Bureau Clinic Other (Specify)

Address:

Phone Number:

Email:

Number of Staff:

Number of Medical Staff:

Number of Administrative Staff:

Daily Patient Count:

Do you currently use any form of digital system in your institution?
Yes No

What hardware is currently available?
Computers (Number): Tablets/Handheld devices (Number): Printers/Scanners (Number): Other equipment:

Is there reliable internet access in your institution?
Yes No

What software tools are currently in use?
Electronic Health Records (EHR)
Billing/Accounting software
Inventory Management System
Patient Registration System
Other (Specify: )

How is patient data currently stored?
Paper records
Partially digital (Hybrid system)
Fully digital

How do you handle patient record confidentiality and data security?
Are there protocols in place? Yes
Do you use any form of data encryption or security software? Yes

How do you manage patient appointments?
Manually
Online booking system
Telephone booking

How do you manage administrative tasks (scheduling, payroll, inventory)?
Manual process
Digital system (Specify software: )

How do you manage financial tasks (billing, payments, procurement)?
Manual
Partially digital
Fully digital

Have staff been trained to use digital systems?
Yes
No
Partially

What kind of digital skills does your staff currently lack? Select Skill Computer literacy Digital health tools (EHR, telemedicine, etc.) Data management and analysis None

Would you be interested in staff training and capacity building in health IT?
Yes No

What areas of your institution would benefit the most from digitalization? Patient management Inventory management Financial management Public health reporting Staff training and development

Are you open to telemedicine and remote consultations for patients?
Yes No

What specific challenges do you hope digital solutions can address?

Do you have a dedicated IT department or personnel?
Yes No

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