Injuries Pregnancy-related conditions (please specify) Have been reports of any unusual increases of illnesses or rumours of outbreaks of any disease? (KI) Yes No If yes, describe: How many births have been reported during the last 7 days? (KI) Number of births total: _____________ Number of births with skilled attendant: _______________ H.4 Have you heard about mother’s or child deaths at delivery? Number or mother’s death: __________________ Number of child death: _______________ H.5 In the same site / village Where is the closest health facility to the In another location population/where displaced people are currently located? (KI, O) Less than 30 minutes If the health facility is in another location / village, how 1-2 hours long does it take to walk (KI) 2-4 hours More than 4 Are services provided at a cost? (KI) No, services are free Yes Fees for services are: Cannot pay Is the crisis-affected / displaced population the Too far health services at the facility? No drugs/doctor/nurse available Not permitted by health staff If no, why not? (KI) Can men and use health Other services without any restrictions considering local ______________ cultural practices? Can Women and girls access freely health services whenever needed without male authorisation? What type of health facility is closest to the crisis-affected / displaced people? (KI) Hospital PHCC PHCU Mobile clinic only Other please specify: – What is the name, location and type of facility for the Name: closest referral facility? (KI) Location: Type of facility: Hospital PHCC PHCU What type of provides health care in this facility? Type # staff # consultations /day
Injuries Pregnancy-related conditions (please specify) Have been reports of any unusual increases of illnesses or rumours of outbreaks of any disease? (KI) Yes No If yes, describe: How many births have been reported during the last 7 days? (KI) Number of births total: _____________ Number of births with skilled attendant: _______________ H.4 Have you heard about mother’s or child deaths at delivery? Number or mother’s death: __________________ Number of child death: _______________ H.5 Where is the closest health facility to the population/where displaced people are currently located? (KI, O) In the same site / village In another location If the health facility is in another location / village, how long does it take to walk (KI) Less than 30 minutes 1-2 hours 2-4 hours More than 4 Are services provided at a cost? (KI) No, services are free Yes Fees for services are: Is the crisis-affected / displaced population the health services at the facility? If no, why not? (KI) Can men and use health services without any restrictions considering local cultural practices? Can Women and girls access freely health services whenever needed without male authorisation? Cannot pay Too far No drugs/doctor/nurse available Not permitted by health staff Other ______________ What type of health facility is closest to the crisis-affected / displaced people? (KI) Hospital PHCC PHCU Mobile clinic only Other – please specify: What is the name, location and type of facility for the closest referral facility? (KI) Name: Location: Type of facility: Hospital PHCC PHCU What type of provides health care in this facility? Type # staff # consultations /day
1._revised_irna_template_24_february_2015.docx