ANNEX A: DATA COLLECTION FORM Supervision Area (SA):_________________________________ Interviewer:__________________________ Date:______________________ Drug: ________________________ Disease being assessed:___________________ Survey population: ______________________________ No. Village Respondent Type of Were you offered If not, why? A = Did you swallow If not, why? F=fear Response: _________ during the away at work/ ________ during the of side effects, Age Sex S = answering for last MDA? Show traveling, S=supply last MDA? Show N=not enough info, (M/F) him/herself, P = respondent example of ran out, D=distributor respondent example of O = other Proxy1, M drug never came, O = drug =mobile other 1. M F Yes No Yes No 2. M F Yes No Yes No 3. M F Yes No Yes No 4. M F Yes No Yes No 5. M F Yes No Yes No 6. M F Yes No Yes No 7. M F Yes No Yes No 8. M F Yes No Yes No 9. M F Yes No Yes No 10. M F Yes No Yes No 11. M F Yes No Yes No 12. M F Yes No Yes No 13. M F Yes No Yes No 14. M F Yes No Yes No 15. M F Yes No Yes No 16. M F Yes No Yes No 17. M F Yes No Yes No 18. M F Yes No Yes No 19. M F Yes No Yes No 20. M F Yes No Yes No Total Yes: No: Yes: No: 1The principal caretaker should respond on behalf of children <10 years; conversely, all children may respond for themselves when drugs are distributed in schools
ANNEX A: DATA COLLECTION FORM Supervision Area (SA):_________________________________ Interviewer:__________________________ Date:______________________ Drug: ________________________ Disease being assessed:___________________ Survey population: ______________________________ No. Village Respondent Type of Response: S = answering for him/herself, P = Proxy1, M =mobile Were you offered _________ during the last MDA? Show respondent example of drug If not, why? A = away at work/ traveling, S=supply ran out, D=distributor never came, O = other Did you swallow ________ during the last MDA? Show respondent example of drug If not, why? F=fear of side effects, N=not enough info, O = other Age Sex (M/F) 1. M F Yes No Yes No 2. M F Yes No Yes No 3. M F Yes No Yes No 4. M F Yes No Yes No 5. M F Yes No Yes No 6. M F Yes No Yes No 7. M F Yes No Yes No 8. M F Yes No Yes No 9. M F Yes No Yes No 10. M F Yes No Yes No 11. M F Yes No Yes No 12. M F Yes No Yes No 13. M F Yes No Yes No 14. M F Yes No Yes No 15. M F Yes No Yes No 16. M F Yes No Yes No 17. M F Yes No Yes No 18. M F Yes No Yes No 19. M F Yes No Yes No 20. M F Yes No Yes No Total Yes: No: Yes: No: 1The principal caretaker should respond on behalf of children <10 years; conversely, all children may respond for themselves when drugs are distributed in schools
SCT%20Guidelines%20for%20Implementation_revised%2016_Feb_2018.docx