Surveypoint

Q01

State

Q02

District

Q03

Block/Wards

Q04

Village/CEBs

Q05

Date of interview

Q06

Time interview started

Q07

Time interview ended

Q08

Scrutinized by

Q09

Date of scrutiny

Q10

Signature of the Facilitator/Investigator

Q11

Signature of the Supervisor

A01

Name of the Respondent

A02

Age

A03

Position

A04

Are you a resident of the village?

Yes

No

A05

If a non resident what is the distance of your village?

A06

For how long have you been working in this place?

A07

Total number of years of experience in the current occupation?

B01

What is the local name for diarrhea in this community?

B02

Do you know what rotavirus is?

Yes

No

B03

What is the local name for rotavirus in this community?

B04

What are the symptoms of diarrhea?

Report of more than 3 loose or watery stools in a 24 hours period.

Increased thirst

Restlessness, irritability

Decreased skin turgor

Dry mouth and tongue

Tears absent, Sunken eyes

Nausea

Vomiting

Fatigue

Blood in stool

None of the above

Others

B05

If a child has the following symptoms do you think, the child essentially has diarrhea

B05_1

Frequent Passage of stools

Yes

No

B05_2

Passage of watery stools by infants who are being breastfed

Yes

No

B06

When should one approach professional help for treating diarrhea (Prompt: “After how many loose stools, How many days?”)

B06_1

Number of stools

B06_2

Number of Days

B07

When does it becomes necessary to seek the help of a doctor?

Child becomes weak

Immediately as the child suffers from Diarrhoea

Child is not able to drink/ breast-feed properly

Blood in child’s stool

Child has fever

Restlessness/ irritable behavior

Sunken eyes

Dehydration

Others (specify)

Don’t Know

No response

B08

How do you check for the symptoms of dehydration in the child?

Child is thirsty

Child is not able to drink

Child is not able to suckle when given breastfeed

Sunken Eyes

Whitish tongue

Weak pulse

None of the above

Others

B09

What are the symptoms of severe dehydration?

Child becomes unconscious

Sunken Eyes

Not able to drink or drinking poorly

Skin after being pinched goes back very slowly

All of the above

None of the above

B10

What qualifies as severe persistent diarrhea?

1-3 days

4-7 days

8-10 days

11-15 days

15 days or more

Don’t Know

B11

What do you infer/diagnose if a child suffering from diarrhea, has blood in his/her stool?

Child has cholera

Child has dysentery

Blood in stool is common during diarrhea

B12

What is the next step that you should take in such a case?

B13

What are the major causes of diarrhoea?

Bacterial Infection

Parasites

Contaminated water

Poor diet of food/ improper diet

Food poisoning/ intolerance

Dehydration / loss of fluids

Bowel disorder

Intestinal diseases

Reaction to medicines

It is contagious

Bad spirit

Others (specify)

Don’t know

C01

Answer the following questions in the context of ORS and Zinc

C01A

ORS

C01A_1

What is the local name for diarrhoea in this community ?

C01A_2

Do you know what rotavirus is?

Yes

No

C01A_3

How many packets were bought last month?

C01A_4

What is the local name for rotavirus in this community?

C01B

Zinc

C01B_1

What is the local name for diarrhoea in this community ?

C01B_2

Do you know what rotavirus is?

Yes

No

C01B_3

How many packets were bought last month?

C01B_4

What is the local name for rotavirus in this community?

C02

Answer the following questions in the context of ORS and Zinc

C02A

ORS

C02A_1

Are you aware of it?

Yes

No

C02A_2

Do you provide it to patients with diarrhea? (Collect sample)

Yes

No

C02A_3

How many packets were bought last month?

C02A_4

What is your current stock at the store?

C02A_5

From where do you get your supply?

C02A_6

Do you preorder your supply?

Yes

No

C02A_7

When is the preordering done?

C02A_8

How frequently is preordering done?

C02A_9

Anm Template 1 -Form Fill

State

District

Block/Wards

Village/CEBs

Date of interview

Time interview started

Time interview ended

Scrutinized by

Date of scrutiny

Signature of the Facilitator/Investigator

Signature of the Supervisor

Name of the Respondent

Age

Position

Are you a resident of the village?

If a non resident what is the distance of your village?

For how long have you been working in this place?

Total number of years of experience in the current occupation?

What is the local name for diarrhea in this community?

Do you know what rotavirus is?

What is the local name for rotavirus in this community?

What are the symptoms of diarrhea?

If a child has the following symptoms do you think, the child essentially has diarrhea var statement=document.write(localStorage.getItem('total'));

Frequent Passage of stools

Passage of watery stools by infants who are being breastfed

When should one approach professional help for treating diarrhea (Prompt: “After how many loose stools, How many days?”) var statement=document.write(localStorage.getItem('total'));

Number of stools

Number of Days

When does it becomes necessary to seek the help of a doctor?

How do you check for the symptoms of dehydration in the child?

What are the symptoms of severe dehydration?

What qualifies as severe persistent diarrhea?

What do you infer/diagnose if a child suffering from diarrhea, has blood in his/her stool?

What is the next step that you should take in such a case?

What are the major causes of diarrhoea?

Answer the following questions in the context of ORS and Zinc var statement=document.write(localStorage.getItem('total'));

ORS var statement=document.write(localStorage.getItem('total'));

What is the local name for diarrhoea in this community ?

Do you know what rotavirus is?

How many packets were bought last month?

What is the local name for rotavirus in this community?

Zinc var statement=document.write(localStorage.getItem('total'));

What is the local name for diarrhoea in this community ?

Do you know what rotavirus is?

How many packets were bought last month?

What is the local name for rotavirus in this community?

Answer the following questions in the context of ORS and Zinc var statement=document.write(localStorage.getItem('total'));

ORS var statement=document.write(localStorage.getItem('total'));

Are you aware of it?

Do you provide it to patients with diarrhea? (Collect sample)

How many packets were bought last month?

What is your current stock at the store?

From where do you get your supply?

Do you preorder your supply?

When is the preordering done?

How frequently is preordering done?

What was the size of the last order

If a child has the following symptoms do you think, the child essentially has diarrhea

When should one approach professional help for treating diarrhea (Prompt: “After how many loose stools, How many days?”)

Answer the following questions in the context of ORS and Zinc

ORS

Zinc

Answer the following questions in the context of ORS and Zinc

ORS