A-7: CBS Checklist for Payam Assistants (PA) Supervisor/visitor’s name: Date of visit: REMARKS County: Payam: Name of the payam assistant 1) Does the payam assistant have an Yes No work plan for the current month? 2) Does the payam assistant have a list of the Key Informants (KI) indicating the location and Yes No the type of the KI? 3) Is the number of the key informants Yes No appropriate? 4) Is the selection of the Key Informants Yes No appropriate? 5) Does the payam assistant have map of Yes No distribution of the KI? 6) Does the distribution of the KI provide full Yes No coverage of the population of the payam? 7) Does the payam assistant (PA) keep a log Yes No book for contacts with key informant? 8) Do the key informants sign the log book Yes No when visited by the PA? 9) Did the PA carry out all planned visits to KI Yes No last month? 10) Did the PA conduct all planned community Yes No meetings last month? 11) Does the PA keep a line-list of the suspect Yes No AFP cases reported? 12) Is the above line-list properly filled? Yes No 13) Does the Payam Assistant (PA) have a copy Yes No of the monthly report for the previous month? 14) Does the PA know the name and have contact with the WHO disease surveillance Yes No staffs in his/her payam & the county (If any)? TOTAL YES PERCENT YES:
A-7: CBS Checklist for Payam Assistants (PA) Supervisor/visitor’s name: Date of visit: REMARKS County: Payam: Name of the payam assistant 1) Does the payam assistant have an work plan for the current month? Yes No 2) Does the payam assistant have a list of the Key Informants (KI) indicating the location and the type of the KI? Yes No 3) Is the number of the key informants appropriate? Yes No 4) Is the selection of the Key Informants appropriate? Yes No 5) Does the payam assistant have map of distribution of the KI? Yes No 6) Does the distribution of the KI provide full coverage of the population of the payam? Yes No 7) Does the payam assistant (PA) keep a log book for contacts with key informant? Yes No 8) Do the key informants sign the log book when visited by the PA? Yes No 9) Did the PA carry out all planned visits to KI last month? Yes No 10) Did the PA conduct all planned community meetings last month? Yes No 11) Does the PA keep a line-list of the suspect AFP cases reported? Yes No 12) Is the above line-list properly filled? Yes No 13) Does the Payam Assistant (PA) have a copy of the monthly report for the previous month? Yes No 14) Does the PA know the name and have contact with the WHO disease surveillance staffs in his/her payam & the county (If any)? Yes No TOTAL YES PERCENT YES:
Field-Guide-for-Community-Based-Surveillance.docx