ASHA Volunteer Enrollment Form

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ASHA Volunteer Enrollment Form

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• Certified course for volunteers and ASHA workers
• Onboarding process for trained volunteers and ASHA worker

Name of Volunteer

Full Name of Volunteer

Age

Gender

Male

Female

Whatsapp Number

Email

Aadhar Number

Name of Panchayat

Division/ Ward Number

Address HTML

Select Your Community Clinic

- Select -MBMM KothamangalamChazhikkattu Hospital ThodupuzhaKMRL Stadium StationSD TATA hospital Chottanikkara

Interested to work with Karkinos family as an associate

Yes

No

Introduction to cancer/risk factors/ cancer screening/Risk factors/dietary/lifestyle advice/explain the project

Done

Not Done

Risk assessment questionnaire

Done

Not Done

Hands on training of using the questionnaire/app

Done

Not Done

Oral visual examination: Theory

Done

Not Done

Oral Visual examination Practical half day, Offline

Done

Not Done

Common oral lesions Pictures/ Ready reckone

Done

Not Done

Clinical breast examination and breast self examination, Theory

Done

Not Done

Clinical breast examination practical, mannequin Half day offline

Done

Not Done

Referral system Karkinos/Governments practical aspects

Done

Not Done

Evaluation and retraining if needed offline Certification

Done

Not Done

Public awareness of cancer treatment/side effects/ palliative care /and follow up patient and family

Done

Not Done

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Login ID

Done

Not Done

Certificate number of the Karkinos course

Bank Name

Account Number

IFSC Code

Branch Name

Non disclosure clause

Bank Account

Submit

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