Household Survey to Measure Coverage of [list drug(s) here] Among [list survey population here ] Interviewer Code: |__|__|__| District: |__________________| Sub-district: |_______________| Subunit (EA/Village/Other_______________): |___________________________| HH No: |__|__|__| Date of interview (dd/mm/yyyy): |__|__|/|__|__|/|__|__|__|__| Household Head:_______________________________ Survey population: ________________________________________________ [Drug 1] [Drug 2] Offered the Swallow the Reason Reason Offered the Swallow the Reason Reason Sex Age HH member Reason not Reason not # Name drug(s)? drug(s)? DID NOT DID drug(s)? drug(s)? DID NOT DID (M/F) (Years) present (Y/N) offereda offereda (Y/N/DK) (Y/N/DK) swallowb swallowc (Y/N/DK) (Y/N/DK) swallowb swallowc 1 2 3 4 5 6 7 8 9 10 cReason treatment was swallowed aReason treatment was not offered bReason treatment was not swallowed 1= Fear of disease(s) 1= Underage 6= Didn't hear MDA 1= Fear of side effects 2=To disease(s) 2= Pregnant 7= Drug ran out 2= Bad taste 3= Because it was given/ free 3= Breast feeding 8= Nobody came 3= Not sick 4=Useful information from CDD 4= Sick 9= 4= Not enough information given 5= Absent 5=
Household Survey to Measure Coverage of [list drug(s) here] Among [list survey population here ] Interviewer Code: |__|__|__| District: |__________________| Sub-district: |_______________| Subunit (EA/Village/Other_______________): |___________________________| HH No: |__|__|__| Date of interview (dd/mm/yyyy): |__|__|/|__|__|/|__|__|__|__| Household Head:_______________________________ Survey population: ________________________________________________ [Drug 1] [Drug 2] # Name Sex (M/F) Age (Years) HH member present (Y/N) Offered the drug(s)? (Y/N/DK) Reason not offereda Swallow the drug(s)? (Y/N/DK) Reason DID NOT swallowb Reason DID swallowc Offered the drug(s)? (Y/N/DK) Reason not offereda Swallow the drug(s)? (Y/N/DK) Reason DID NOT swallowb Reason DID swallowc 1 2 3 4 5 6 7 8 9 10 aReason treatment was not offered bReason treatment was not swallowed cReason treatment was swallowed 1= Underage 6= Didn't hear MDA 1= Fear of side effects 1= Fear of disease(s) 2= Pregnant 7= Drug ran out 2= Bad taste 2=To disease(s) 3= Breast feeding 8= Nobody came 3= Not sick 3= Because it was given/ free 4= Sick 9= 4= Not enough information given 4=Useful information from CDD 5= Absent 5=
Coverage%20Evaluation%20Guidelines%20Final%20Draft_DEC%202016_clean.docx