As an PCE surveyor I, ______________________(name), pledge to maintain the highest level of respect and integrity while conducting this survey. I will not lie, deceive, vandalize, or commit forgery while performing my role as an PCE surveyor. I am fully awar of the methodology and what is expected of me and it is my duty to report violations when they occur. I make this pledge in the spirit of honor and trust. Signature: _________________________________ How many times did you sector divided to find your first house? ______________________ Position of the household in the cluster Sl No VARIABLES 1 2 3 4 5 6 7 8 9 10 How many children younger than 5 years old are currently 0 PRESENT in the house?
How old in months is this child? (ONLY for the randomly
1 selected child for all remaining questions)
1b If >6m, Was this child provided Vitamin A? (Yes = 1; No= 0)
2 What is the gender of this child? (M/F)
Is a finger mark present from the last campaign? (Yes = 1; No=
3 0)
Child was Asleep
Child was Away from the home Newly Migrated after Team Visit Newly Born after Team Visit Reasons why child was not finger- Team did NOT visit the 4 marked: What was the reason for house Child or Parent Refused not getting the two drops? Vaccine from the Team (Answer Q5 & Q6) Team Missed the child
Vaccinated but NO Finger
Mark Others (specify)
Religious reason
The child was sick
Tired of too many campaigns Misconception or Negative Reasons for refusal: What was the Rumour 5 reason for refusing the two drops? Demand for other services Prefers vaccinations from a medical provider Security related concerns
Others (specify)
Is there an "R" present on the door
6 Yes = 1; No= 0 mark of this house?
Before the campaign that just
0, 1-3, 4 or more, DK-dont 7 ended, how many times did the know child receive OPV?
Is there a door mark present for this
campaign (date only)? *The 8 Yes = 1; No= 0 accurarcy of the door mark should not be assessed