B-6: Monthly Report by County Supervisors Name of County Supervisor: Reporting Month Implementing partner: County: State: - Visits to Payam Assistants Summary Date of Date of SN Name of PA score of Issues detected during the visit planned visit actual visit checklist 1 2 3 4 5 6 - Summary of checklist for supervising Payam Assistants Total PAs Number Number of visited in of “Yes” % Question from Checklist SN the Checklists answers Yes month filled-out from checklists 1 Up-to-date work plan 2 List of the Key Informants (KI) 3 Number of KI appropriate 4 Type of KI appropriate Map of distribution of the KI? 5 KI fully cover the population of the county 6 7 A log book for contacts with key informant 8 key informants sign the log book 9 PA carried out the planned visits to KI last month 10 PA conducted planned meetings last month 11 A line-list of the suspect AFP cases reported 12 Line-list properly filled Has the monthly report for the previous month 13
B-6: Monthly Report by County Supervisors Name of County Supervisor: Reporting Month Implementing partner: County: State: - Visits to Payam Assistants SN Name of PA Date of planned visit Date of actual visit Summary score of checklist Issues detected during the visit 1 2 3 4 5 6 - Summary of checklist for supervising Payam Assistants SN Question from Checklist Total PAs visited in the month Number of Checklists filled-out Number of “Yes” answers from checklists % Yes 1 Up-to-date work plan 2 List of the Key Informants (KI) 3 Number of KI appropriate 4 Type of KI appropriate 5 Map of distribution of the KI? 6 KI fully cover the population of the county 7 A log book for contacts with key informant 8 key informants sign the log book 9 PA carried out the planned visits to KI last month 10 PA conducted planned meetings last month 11 A line-list of the suspect AFP cases reported 12 Line-list properly filled 13 Has the monthly report for the previous month
Field-Guide-for-Community-Based-Surveillance.docx