PERIODIC ASSESSMENT PROTOCOL: DATA COLLECTION TOOL FORM 1, QUESTIONNAIRE FOR MOTHERS Type of health facility (change to appropriate Health Centre □ ………….………………1 administrative unit/division) Health Clinic □ ……………..…………….2 Hospital….………………..………………3 □ Other □ ………….…………….…………….4 Public / Private Public □ ………………………..……………1 Private □ ………….…………….………….2 For large facilities, indicate Ward/ Unit/Department , if applicable as above] ___________________________ Facility name ___________________________ Facility ID __ __ __ __ __ __ Data collector ID __ __ __ Date (dd/mm/yyyy) __ __/__ __/__ __ __ __ NOTE to data collectors: Remember to go through the Consent form before you begin! Are you a mother of any children younger than 24 months?
PERIODIC ASSESSMENT PROTOCOL: DATA COLLECTION TOOL FORM 1, QUESTIONNAIRE FOR MOTHERS Type of health facility (change to appropriate administrative unit/division) □ Health Centre ………….………………1 □ Health Clinic ……………..…………….2 □ Hospital….………………..………………3 □ Other ………….…………….…………….4 Public / Private □ Public ………………………..……………1 □ Private ………….…………….………….2 For large facilities, indicate Ward/ Unit/Department , if applicable as above] ___________________________ Facility name ___________________________ Facility ID __ __ __ __ __ __ Data collector ID __ __ __ Date (dd/mm/yyyy) __ __/__ __/__ __ __ __ NOTE to data collectors: Remember to go through the Consent form before you begin! Are you a mother of any children younger than 24 months?