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Post Campaign Evaluation (PCE) Methodology Questionnaire rev. May. 2017

Province:

Surveyor Code:

Lot Number:

1

2

3

District:

Cluster Number: (please, circle)

1

2

3

4

5

Tehsil:

Starting village/settlement

 

Ending:

UC:

Date of monitoring:

CBV?

Yes

No

As an PCE surveyor I,

vandalize, or commit forgery while performing my role as an PCE surveyor. I am fully awar of the methodology and what is expected of me and it is my duty to report violations when they occur. I make this pledge in the spirit of honor and trust. Signature:

How many times did you sector divided to find your first house?

(name),

pledge to maintain the highest level of respect and integrity while conducting this survey. I will not lie, deceive,

Position of the household in the cluster Sl No VARIABLES 1 2 3 4 5
Position of the household in the cluster
Sl No
VARIABLES
1
2
3
4
5
6
7
8
9
10
How many children younger than 5 years old are currently
0
PRESENT in the house?
How old in months is this child? (ONLY for the randomly
1
selected child for all remaining questions)
1b
If >6m, Was this child provided Vitamin A? (Yes = 1; No= 0)
2
What is the gender of this child? (M/F)
Is a finger mark present from the last campaign? (Yes = 1; No=
3
0)
Child was Asleep
Child was Away from the
home
Newly Migrated after
Team Visit
Newly Born after Team
Visit
Reasons why child was not finger-
Team did NOT visit the
4
marked: What was the reason for
not getting the two drops?
house
Child or Parent Refused
Vaccine from the Team
(Answer Q5 & Q6)
Team Missed the child
Vaccinated but NO Finger
Mark
Others (specify)
Religious reason
The child was sick
Tired of too many
campaigns
Misconception or Negative
Reasons for refusal: What was the
Rumour
5
reason for refusing the two drops?
Demand for other services
Prefers vaccinations from a
medical provider
Security related concerns
Others (specify)
6
Is there an "R" present on the door
mark of this house?
Yes = 1; No= 0
Before the campaign that just
7
ended, how many times did the
child receive OPV?
0, 1-3, 4 or more, DK-don’t
know
Is there a door mark present for this
8
campaign (date only)? *The
accurarcy of the door mark should
not be assessed
Yes = 1; No= 0
Observations: #FM but NV, #Fresh FM, #No
9
Response/Participation houses, Vaccination Card Observations,
Parent's comments, VNFM details, Compliments
Facilitator's Name:
Guide's Name:
Name of Monitor:
Monitor 's affiliation (WHO/UNICEF/NSTOP):
Signature of Monitor