ANNEX 3: ASSIGNMENT [YEAR] [COUNTRY] MIS SHEET INTERVIEWER’S PAGE _______ OF _______ PAGES CLUSTER INTERVIEWER NAME INTERVIEWER COUNT OF NUMBER NUMBER BLOOD ----------------------------------------------------------------------- SLIDES HOUSEHOLD CHILDREN WOMEN TOTAL LINE LMIS ELIGIBLE NUMBER LINE NUMBER NAME OF CHILDREN OF TOTAL NUMBER OR HOUSEHOLD FINAL 6 MOS-5 ELIGIBLE TESTED FOR MALARIA ELIGIBLE OF ELIG. FINAL NUMBER ADDRESS HEAD RESULT YRS CHILD AND ANEMIA WOMEN WOMAN RESULT NOTES (1) (2) (3) (4)* (5) (6) (7) (8) (9) (10)* (11) Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N CODES FOR COLUMN (4)* CODES FOR COLUMN (10)* 1 COMPLETED 1 COMPLETED 6 DWELLING VACANT/ADDRESS NOT A DWELLING 2 NOT AT HOME 2 NO HH MEMBER AT HOME 7 DWELLING DESTROYED 3 POSTPONED 3 ENTIRE HH ABSENT FOR EXTENDED PERIOD 8 DWELLING NOT FOUND 4 REFUSED 4 POSTPONED 9 OTHER 5 PARTLY COMPLETED 5 REFUSED 6 INCAPACITATED 7 OTHER TOTAL NUMBER TOTAL NUMBER OF NUMBER OF NUMBER OF OF HOUSEHOLD CHILDREN ELIGIBLE CHILDREN TESTED WOMAN’S QUESTIONNAIRES FOR ANEMIA AND FOR ANEMIA AND MALARIA TESTING MALARIA
ANNEX 3: [YEAR] [COUNTRY] MIS INTERVIEWER’S ASSIGNMENT SHEET PAGE _______ OF _______ PAGES CLUSTER NUMBER INTERVIEWER NAME ----------------------------------------------------------------------- INTERVIEWER NUMBER COUNT OF BLOOD SLIDES HOUSEHOLD CHILDREN WOMEN NOTES LMIS NUMBER NUMBER OR ADDRESS NAME OF HOUSEHOLD HEAD FINAL RESULT TOTAL ELIGIBLE CHILDREN 6 MOS-5 YRS LINE NUMBER OF ELIGIBLE CHILD TESTED FOR MALARIA AND ANEMIA TOTAL ELIGIBLE WOMEN LINE NUMBER OF ELIG. WOMAN FINAL RESULT (1) (2) (3) (4)* (5) (6) (7) (8) (9) (10)* (11) Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N CODES FOR COLUMN (4)* CODES FOR COLUMN (10)* 1 COMPLETED 2 NO HH MEMBER AT HOME 3 ENTIRE HH ABSENT FOR EXTENDED PERIOD 4 POSTPONED 5 REFUSED 6 DWELLING VACANT/ADDRESS NOT A DWELLING 7 DWELLING DESTROYED 8 DWELLING NOT FOUND 9 OTHER 1 COMPLETED 2 NOT AT HOME 3 POSTPONED 4 REFUSED 5 PARTLY COMPLETED 6 INCAPACITATED 7 OTHER TOTAL NUMBER OF HOUSEHOLD TOTAL NUMBER OF WOMAN’S QUESTIONNAIRES NUMBER OF CHILDREN ELIGIBLE FOR ANEMIA AND MALARIA TESTING NUMBER OF CHILDREN TESTED FOR ANEMIA AND MALARIA
07%20MIS%20Supervisors%20Manual.docx