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Name of respondent: Age / sex: Location: Respondent among common masses S.No. Questionnaire
01 0% 0, 01 02 03 Does TB disease occur in our !i""age/area# $es/No &o' do ou suspect ( one )as TB# *oug)/+e!er/B"ood in sputum -) do ou t)in. TB occurs# /"d sins / 0ad ) giene / organisms Do ou .no' ')ere free treatment and diagnosis faci"it a!ai"a0"e in our area# $es/ No &a!e ou )eard a0out D/TS as treatment for TB# $es/No


4f t)ere is an TB patient in our neig)0or)ood5 ')at 'i"" ou do# 1. $ou 'i"" a!oid )im %. $ou 'i"" )e"p )im in comp"eting Rx

Feed back of respondent about services in area:

Signature of Surveyor

Stamp of Clinic with Signature