Download Coverage Survey Household Questionnaire

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Household Survey to Measure Coverage of [list drug(s) here] Among [list survey population here ]
Interviewer Code: |__|__|__|
District: |__________________|
Sub-district: |_______________|
Subunit (EA/Village/Other_______________): |___________________________|
HH No: |__|__|__|
Date of interview (dd/mm/yyyy): |__|__|/|__|__|/|__|__|__|__|
Household Head:_______________________________
Survey population: ________________________________________________
[Drug 1]
#
First Name
Sex
(M/F)
Age
HH member
(Years) present (Y/N)
[Drug 2]
Offered the
Swallow the Reason Reason Offered the
Swallow the Reason
Reason
Reason not
Reason not
drug(s)?
drug(s)?
DID
NOT
DID
drug(s)?
drug(s)?
DID
NOT
DID
offereda
offereda
(Y/N/DK)
(Y/N/DK) swallowb swallowc (Y/N/DK)
(Y/N/DK) swallowb swallowc
1
2
3
4
5
6
7
8
9
10
a
Reason treatment was not offered
1= Underage
6= Didn't hear about MDA
2= Pregnant
7= Drug ran out
3= Breast feeding
8= Nobody came
4= Sick
9= Other
5= Absent
Y=”Yes”, N=”No”, DK = “Don’t Know”
b
Reason treatment was not swallowed
1= Fear of side effects
2= Bad taste
3= Not sick
4= Not enough information given
5= Other
c
Reason treatment was swallowed
1= Fear of disease(s)
2=To treat disease(s)
3= Because it was given/ free
4=Useful information from CDD
5=Other