MSSSKA-4.

0 Monitoring and Supervisory Form (Institutional)– March 20-23, 2023

Name & Designation Department of Monitor Contact number State Name District Urban Area/ Name of
of Monitoring Officer of monitor Name Block Name/PHC ward/ village
1.Health
2.Education
3. Social Welfare
3. Development partner
5.Others (Specify)
Monitoring site 1. Government school 2. Private aided/Private unaided school 3. Anganwadi Centre 4. Others (Specify)

Name of monitoring Code of monitoring site If monitoring site is government/private school, please fill in the below two points:
site: Total children Total attendance in the school on the day of monitoring visit:
enrolled in the school:

Date of visit (___ /___ /2023)

MONITORING SECTION: Circle the correct option based on your observations and interviews.
MSSSKA-4.0 Observations
1. Does the school/AWC has drugs and supplements (Albendazole tab/Vitamin A Capsules (Blue and Red), IFA (Syrup/Pink and blue tablets)/Zinc
/ORS/Td10 and Td16 vaccine?
1. YES 2. NO 3. if no please specify the details as applicable
2. Are all the drug and supplements available in sufficient quantity for all targeted age group children?
1. YES 2. NO 3. If No, specify the quantity of drugs - ______________
3. Are you conducting MSSSKA-4.0 today? 1. Yes, Ongoing now 2. Yes, already done
3. Yes, after lunch/ Mid-Day-Meal 4. No, will not administer today 5. Yes, after few hours
4. If NO, why is not happening at school/Anganwadi? Specify reason.
1. No information 2. Apprehension of Adverse events 3. Already administered all children and adolescents 4. Drugs not received
5. Drugs not in hand 6. Will administer on another day 7. Others specify_________
5. Does the school/AWC have the following provisions for MSSSKA-4.0? Circle all that apply.
1. IEC materials 2. reporting form 3. Drinking water 3. Others (specify)------------------------
6. Did the out-of-school (6-19 years children and adolescents) unregistered children in AWC (0-6 years) administered and distribute drug and
supplements in the at AWC? 1. YES 2.NO (Applicable only in Anganwadi Center)

7. Are teacher/AWW administering/administer albendazole tablets themselves to children/adolescents? Incase not able to observe, make note
1. YES 2. NO
8. Are AWW administering/administer Vitamin A Capsules (Blue and Red) to the children as per administration protocol? (Applicable only in Anganwadi
Center) 1. YES 2. NO
9. Whether children and adolescents are distributed appropriate dose of IFA supplements (IFA syrup for 6 months -5 years/Pink (WIFS Junior)
6-9 years and blue tablets 10-19 years by teacher/AWW as applicable? 1. Yes 2. No
10. Did the AWW provide/distribute Zinc and ORS to all children (0-5 years) and specially with diahorrea cases in AWC? 1. Yes 2. No
3. No such cases found (Applicable for AWC only)
11. Did the AWW measure weight and height for children between 0-6 years in AWC under POSHAN Abhiyaan?
1. Yes 2. No 3. Not applicable (applicable for AWC only)
12. Is vaccination camp happened in School / ? If No, mention date when it will be conducted.
1. Yes 2. No 3. Not applicable
Training Aspects
13. Have you or any other person from your school/AWW attended official training for MSSSKA-4.0? 1. YES 2. NO
14. If No, reasons for not attending training. Circle all that apply.
1. No information 2. Location was far away 3. Busy in other work
4. Not necessary because already attended such training in past 5. Others (Specify)________________

15. Did you receive any message (SMS, WhatsApp) about the MSSSKA-4.0? 1. YES 2.NO
Adverse Events
16. Is the teacher/AWW aware of the possibility of adverse events from deworming? 1. YES 2.NO 3. Don’t know
17. Did you witness any serious cases of adverse events in the school/AWC? 1. YES 2.NO
Community Awareness and IEC Materials
18. From where did you get information about the MSSSKA-4.0?
1. Departmental communication 2. Television 3. Radio 4. Newspaper 5. Banner
6. SMS/WhatsApp 7. Training 8. Others (Social Media/etc.) _______________________________________________
ADDITIONAL COMMENTS: (This space may be used for sharing the suggestion of Teacher/AWW for program improvement and monitor’s feedback on
any program gap and best practices observed on MSSSKA-4.0)