Surveypoint

Q01

IDENTIFICATION NO

Q02

Sr. No.

Q03

Name of the Research Investigator

Q04

STATE NAME

Q05

STATE NO

Q06

WARD NAME

Q07

WARD NO

Q08

AREA NAME

Q09

AREA CODE

Q10

CLUSTER/ BLOCKNUMBER

Q11

HOUSEHOLD NUMBER

Q12

Date of visit (DD/MM/YY)

Q13

Outcome of visit

HH found and Agreed to participate

HH found but Refused to participate

HH found by was asked to come later on

HH Locked

A01

Has any member of your household EVER been treated / diagnosed for tuberculosis (at any time)?

Yes

No

A02

Is the patient a usual resident of your household?

Yes

No

A03

Is anyone in your household currently having cough?

Yes

No

A04

Was the information confirmed with senior female member of the household?

Yes

No

A05

If yes, how many people in your household have cough at present?

A06

Beside the information you just provided, Did you or anyone in the household get diagnosed with TB/ or were told had TB in the last 6 months?

Yes

No

A07

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