CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C

MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES (FORM-2)
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD Cases Overall Cases Reported General Deaths Reported Remarks
ICD Code (A) (B) (C) (D) (E) (F) (G) (H)
[out of col. (B)] [out of col. (C)]

M F Tr Total M F Tr Total M F Tr Total M F Tr Total M F Tr Total M F Tr Total

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
(3+4+5) (7+8+9) (11+12+13) (15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

1 0 0 0 0 0 0 0 0
ACCIDENTAL INJURIES S 00- 0
99,T 00-14

2 0 0 0 0 0 0 0 0
ARSENICOSIS 0

3 0 0 0 0 0 0 0 0
ASTHMA J 45 0

4 0 0 0 0 0 0 0 0
BRONCHITIS J 40 0

5 0 0 0 0 0 0 0 0
BURNS 0

6 0 0 0 0 0 0 0 0
CANCER [BREAST] C 50 , D 24 0

7 0 0 0 0 0 0 0 0
CANCER [CERVIX] C 53, D 26 0

8 0 0 0 0 0 0 0 0
CANCER [LUNG] C 34, D 14.3 0

9 CANCER [ ORAL (LIP, ORAL 0 0 0 0 0 0 0 0

CAVITY AND PHARYNX)] C 00 - 0
14, D 10
10 0 0 0 0 0 0 0 0
CANCER [OTHERS(EXCLUDING 0
[Link]. 6 TO 9)] C 00-D 48

11 0 0 0 0 0 0 0 0
CEREBROVASCULAR ACCIDENT 0
I 60-69

12 0 0 0 0 0 0 0 0
DIABETES MELLITUS [TYPE 1] 0
E 10

13 0 0 0 0 0 0 0 0
DIABETES MELLITUS [TYPE 2] 0
E 11

14 0 0 0 0 0 0 0 0
EMPHYSEMAS J 43 0

15 0 0 0 0 0 0 0 0
HEART DISEASES [ISCHEMIC] 0
I 20-25

16 0 0 0 0 0 0 0 0
HEART DISEASES 0
[CONGENITAL] Q 20-28

17 0 0 0 0 0 0 0 0
HYPERTENSION I 10-15 0

18 0 0 0 0 0 0 0 0
MENTAL DISORDERS F 10-19, F 0
99

19 0 0 0 0 0 0 0 0
NEUROLOGICAL DISORDER 0
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0 0 0 0 0 0 0 0
[OTHER (EXCLUDING [Link]. 19)] 0
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0 0 0 0 0 0 0 0
DISEASES I 05-09,I 26-52,I 70- 0
99
22 0 0 0 0 0 0 0 0
RENAL FAILURE[ ACUTE] N 0
17

23 0 0 0 0 0 0 0 0
RENAL FAILURE[ CHRONIC] N 0
18

24 0 0 0 0 0 0 0 0
RHEUMATIC FEVER I 00-02 0

25 0 0 0 0 0 0 0 0
ROAD TRAFFIC ACCIDENTS V 0
01-89

26 0 0 0 0 0 0 0 0
RUBELLA 0

27 0 0 0 0 0 0 0 0
SNAKE BITE T 63.0 0

28 0 0 0 0 0 0 0 0
Obesity E66.9 0

29 0 0 0 0 0 0 0 0
SEVERE MENTAL DISORDER 0
F99

30 0 0 0 0 0 0 0 0
Others 0

31 0 0 0 0 0 0 0 0
Autoimmune Diseases 0

M= Male F= Female Tr= Transgender

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for Disease Definition and Type of Health Establishment. Signature of the Approving Authority
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularly latest by 20th of the succeeding month. Name of the Approving Authority
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of the succeeding month. Designation of the Approving Authority
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to verify the reported data. Official Email ID
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases Official Phone Number
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases
ICD Code (A) (B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD C
(C) (D) (E)
[out of col. (B)] [out of col. (C)]

F Tr Total M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
from Emergency OPD Cases Overall Cases Reported General Deaths Reported
(E) (F) (G)
[out of col. (C)]

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases
ICD Code (A) (B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD C
(C) (D) (E)
[out of col. (B)] [out of col. (C)]

F Tr Total M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
from Emergency OPD Cases Overall Cases Reported General Deaths Reported
(E) (F) (G)
[out of col. (C)]

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases
ICD Code (A) (B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD C
(C) (D) (E)
[out of col. (B)] [out of col. (C)]

F Tr Total M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
from Emergency OPD Cases Overall Cases Reported General Deaths Reported
(E) (F) (G)
[out of col. (C)]

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases
ICD Code (A) (B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD C
(C) (D) (E)
[out of col. (B)] [out of col. (C)]

F Tr Total M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
from Emergency OPD Cases Overall Cases Reported General Deaths Reported
(E) (F) (G)
[out of col. (C)]

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases
ICD Code (A) (B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD C
(C) (D) (E)
[out of col. (B)] [out of col. (C)]

F Tr Total M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
from Emergency OPD Cases Overall Cases Reported General Deaths Reported
(E) (F) (G)
[out of col. (C)]

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of Health Establishment:-
Complete postal Address and office phone number of Health Establishment:-

S
No
Name of Disease and General OPD Cases Emergency OPD Cases
ICD Code (A) (B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

Emergency OPD Cases IPD referred from General OPD Cases IPD referred from Emergency OPD C
(C) (D) (E)
[out of col. (B)] [out of col. (C)]

F Tr Total M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
from Emergency OPD Cases Overall Cases Reported General Deaths Reported
(E) (F) (G)
[out of col. (C)]

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) Month:-
ANNEXURE-C Year:-

MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES (FORM-2) Name of Health Establishment:- CHC MADAWARA

Month:- Year:-

IPD referred from General OPD Cases IPD referred from Emergency OPD Cases
S Name of Disease and General OPD Cases Emergency OPD Cases Overall Cases Reported General Deaths Reported Remarks
(D) (E)
No ICD Code (A) (B) (C) (F) (G) (H)
[out of col. (B)] [out of col. (C)]
M F Tr Total M F Tr Total M F Tr Total M F Tr Total M F Tr Total M F Tr Total

1 ACCIDENTAL INJURIES
2 ARSENICOSIS

3
ASTHMA

4
BRONCHITIS

5
BURNS

6
CANCER [BREAST]

7
CANCER [CERVIX]

8
CANCER [LUNG]

9 CANCER [ ORAL (LIP, ORAL

CAVITY AND PHARYNX)]
10 CANCER [OTHERS

11 CEREBROVASCULAR
ACCIDENT
12
DIABETES MELLITUS [TYPE 1]

13
DIABETES MELLITUS [TYPE 2]

14 EMPHYSEMAS
15 HEART DISEASES [ISCHEMIC]

16 HEART DISEASES
[CONGENITAL]
17
HYPERTENSION

18
MENTAL DISORDERS

19 NEUROLOGICAL DISORDER
[CHRONIC]
20 NEUROLOGICAL DISORDERS
[OTHER
21 OTHER CARDIO VASCULAR
DISEASES
22 RENAL FAILURE[ ACUTE]
23 RENAL FAILURE[ CHRONIC]
24 RHEUMATIC FEVER
25 ROAD TRAFFIC ACCIDENTS
26 RUBELLA
27 SNAKE BITE
28 Obesity
29 SEVERE MENTAL DISORDER
30 Others
31 Autoimmune Diseases

M= Male F= Female Tr= Transgender

Signature of the Approving Authority
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for Disease Definition and Type of Health Establishment.
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularly latest by 20th of the succeeding month. Name of the Approving Authority [Link] KUMAR
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of the succeeding month. Designation of the Approving Authority SUPERINTENDENT MADAWARA
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to verify the reported data. Official Email ID chcmadawara@[Link]
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases Official Phone Number
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases

7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of
Health
Complet
Establis
e postal
hment:-
Address
S Name of Disease and General OPD Emergency
and
No
ICD Code (A) Cases OPD Cases
(B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

IPD referred IPD referred

from General from
OPD Cases Emergency
(D) OPD Cases
[out of col. (E)
F Tr Total (B)]
M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
 Overall General
Cases Deaths
Reported Reported
(F) (G)

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of
Health
Complet
Establis
e postal
hment:-
Address
S Name of Disease and General OPD Emergency
and
No
ICD Code (A) Cases OPD Cases
(B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

IPD referred IPD referred

from General from
OPD Cases Emergency
(D) OPD Cases
[out of col. (E)
F Tr Total (B)]
M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
 Overall General
Cases Deaths
Reported Reported
(F) (G)

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of
Health
Complet
Establis
e postal
hment:-
Address
S Name of Disease and General OPD Emergency
and
No
ICD Code (A) Cases OPD Cases
(B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

IPD referred IPD referred

from General from
OPD Cases Emergency
(D) OPD Cases
[out of col. (E)
F Tr Total (B)]
M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
 Overall General
Cases Deaths
Reported Reported
(F) (G)

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27
CENTRAL BUREAU OF HEALTH INTELLIGENCE (CBHI) ANNEXURE-C
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS IN THE REPORTING UNIT DUE TO NON-COMMUNICABLE DISEASES
Month:- Year:-
Name of
Health
Complet
Establis
e postal
hment:-
Address
S Name of Disease and General OPD Emergency
and
No
ICD Code (A) Cases OPD Cases
(B) (C)

M F Tr Total M
1 2 3 4 5 6 7
(3+4+5)

1 0
ACCIDENTAL INJURIES S 00-
99,T 00-14

2 0
ARSENICOSIS

3 0
ASTHMA J 45

4 0
BRONCHITIS J 40

5 0
BURNS

6 0
CANCER [BREAST] C 50 , D 24

7 0
CANCER [CERVIX] C 53, D 26

8 0
CANCER [LUNG] C 34, D 14.3

9 CANCER [ ORAL (LIP, ORAL 0

CAVITY AND PHARYNX)] C 00 -
14, D 10
10 0
CANCER [OTHERS(EXCLUDING
[Link]. 6 TO 9)] C 00-D 48

11 0
CEREBROVASCULAR ACCIDENT
I 60-69

12 0
DIABETES MELLITUS [TYPE 1]
E 10

13 0
DIABETES MELLITUS [TYPE 2]
E 11

14 0
EMPHYSEMAS J 43
 15 0
HEART DISEASES [ISCHEMIC]
I 20-25

16 0
HEART DISEASES
[CONGENITAL] Q 20-28

17 0
HYPERTENSION I 10-15

18 0
MENTAL DISORDERS F 10-19, F
99

19 0
NEUROLOGICAL DISORDER
[CHRONIC] G 90-99

20 NEUROLOGICAL DISORDERS 0
[OTHER (EXCLUDING [Link]. 19)]
F 00-03,G 00-83
21 OTHER CARDIO VASCULAR 0
DISEASES I 05-09,I 26-52,I 70-
99
22 0
RENAL FAILURE[ ACUTE] N
17

23 0
RENAL FAILURE[ CHRONIC] N
18

24 0
RHEUMATIC FEVER I 00-02

25 0
ROAD TRAFFIC ACCIDENTS V
01-89

26 0
RUBELLA

27 0
SNAKE BITE T 63.0

28 0
Obesity E66.9

29 0
SEVERE MENTAL DISORDER
F99

30 0
Others

31 0
Autoimmune Diseases

M= Male F= Female

NOTES:-
1. CBHI Official Website [Link] and CBHI Data Entry Portal [Link] may be visited for D
2. It is to be ensured that data is entered online in CBHI Data Entry Portal [Link] every month regularl
3. This form, duly filled and signed in original, should be sent to the respective District Nodal Officer latest by 20 th of
4. One copy of this form, duly filled and signed, should be maintained at the reporting unit as CBHI teams will visit to
5. IPD referred from General OPD Cases should be less than or equal to General OPD Cases
6. IPD referred from Emergency OPD Cases should be less than or equal to Emergency OPD Cases
7. In case for any disease data is Zero the same may also be mentioned in the remark column as "ZERO"
 ANNEXURE-C
TO NON-COMMUNICABLE DISEASES (FORM-2)

IPD referred IPD referred

from General from
OPD Cases Emergency
(D) OPD Cases
[out of col. (E)
F Tr Total (B)]
M F Tr Total M F
8 9 10 11 12 13 14 15 16
(7+8+9) (11+12+13)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
 0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Tr= Transgender
[Link] may be visited for Disease Definition and Type of Health Establishment.
[Link] every month regularly latest by 20th of the succeeding month.
rict Nodal Officer latest by 20 th of the succeeding month.
ng unit as CBHI teams will visit to verify the reported data.

ency OPD Cases

rk column as "ZERO"
 Overall General
Cases Deaths
Reported Reported
(F) (G)

Tr Total M F Tr Total M F Tr Total

17 18 19 20 21 22 23 24 25 26
(15+16+17) (3+7) (4+8) (5+9) (19+20+21) (23+24+25)

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0
Signature of the Approving Authority
Name of the Approving Authority
Designation of the Approving Authority
Official Email ID
Official Phone Number
Remarks
(H)

27