ANNEX 2: CLUSTER NAME OF ASSIGNMENT SHEET NUMBER SUPERVISOR’S SUPERVISOR’S NAME_____________________ PAGE ________ OF ___________ PAGES CHILDREN WOMEN INTER- VIEWER INTER- MIS LINE AND DATE VIEW NUMBER TOTAL NUMBER TESTED LINE NUMBER INTER-VIEW ASSIGNED OR NAME OF FINAL CHILDREN OF ELIG. FOR TESTED FOR TOTAL ELIGIBLE OF ELIG. FINAL NUMBER ADDRESS HOUSEHOLD RESULT 6 MOS-5 YRS CHILD ANEMIA PARASITEMIA WOMEN WOMAN RESULT NOTES (1) (2) (3) (4) (5)* (6) (7) (8) (9) (10) (11) (12)** (13) 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 (12) *CODES FOR COLUMN (6) **CODES FOR COLUMN (12) AND (16) 1 COMPLETED 6 DWELLING VACANT/ADDRESS NOT A DWELLING 1 COMPLETED 5 PARTLY COMPLETED 2 NO HH MEMBER AT HOME/NO COMPETENT RESPONDENT 7 DWELLING DESTROYED 2 NOT AT HOME 6 INCAPACITATED 3 ENTIRE HH ABSENT FOR EXTENDED PERIOD 8 DWELLING NOT FOUND 3 POSTPONED 7 OTHER 4 POSTPONED 9 OTHER 4 REFUSED 5 REFUSED NUMBER OF NUMBER OF NUMBER OF NO. OF CHILDREN NO. OF CHILDREN NO. OF CHILDREN ┌───┬───┐ ┌───┬───┐ ┌───┬───┐ ┌───┬───┐ ┌───┬───┐ ┌───┬───┐ HOUSEHOLDS HOUSEHOLD 6 MOS-5YRS TESTED FOR TESTED FOR │░░ │░░ │ │░░ │░░ │ WOMAN’S │░░ │░░ │ │░░ │░░ │ │░░ │░░ │ │░░ │░░ │ ANEMIA PARASITEMIA │░ ░│░ ░│ QUESTIONNAIRES │░ ░│░ ░│ QUESTIONNAIRES │░ ░│░ ░│ │░ ░│░ ░│ │░ ░│░ ░│ │░ ░│░ ░│ └───┴───┘ └───┴───┘ └───┴───┘ └───┴───┘ └───┴───┘ └───┴───┘
ANNEX 2: SUPERVISOR’S NAME_____________________ SUPERVISOR’S ASSIGNMENT SHEET CLUSTER NAME OF NUMBER PAGE ________ OF ___________ PAGES CHILDREN WOMEN MIS NUMBER NUMBER OR ADDRESS NAME OF HOUSEHOLD INTER- VIEWER AND DATE ASSIGNED INTER- VIEW FINAL RESULT TOTAL CHILDREN 6 MOS-5 YRS LINE NUMBER OF ELIG. CHILD TESTED FOR ANEMIA TESTED FOR PARASITEMIA TOTAL ELIGIBLE WOMEN LINE NUMBER OF ELIG. WOMAN INTER-VIEW FINAL RESULT NOTES (1) (2) (3) (4) (5)* (6) (7) (8) (9) (10) (11) (12)** (13) 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 (6) *CODES FOR COLUMN (12) **CODES FOR COLUMN (12) AND (16) 1 COMPLETED 2 NO HH MEMBER AT HOME/NO COMPETENT RESPONDENT 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 NUMBER OF ┌───┬───┐ HOUSEHOLDS │░░ │░░ │ │░ ░│░ ░│ └───┴───┘ NUMBER OF ┌───┬───┐ HOUSEHOLD │░░ │░░ │ QUESTIONNAIRES │░ ░│░ ░│ └───┴───┘ NUMBER OF ┌───┬───┐ WOMAN’S │░░ │░░ │ QUESTIONNAIRES │░ ░│░ ░│ └───┴───┘ NO. OF CHILDREN ┌───┬───┐ 6 MOS-5YRS │░░ │░░ │ │░ ░│░ ░│ └───┴───┘ NO. OF CHILDREN ┌───┬───┐ TESTED FOR │░░ │░░ │ ANEMIA │░ ░│░ ░│ └───┴───┘ NO. OF CHILDREN ┌───┬───┐ TESTED FOR │░░ │░░ │ PARASITEMIA │░ ░│░ ░│ └───┴───┘
07%20MIS%20Supervisors%20Manual.docx