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Asha Template 1 -Form Fill
Village Location
Q01
District Name
Q02
District Code
Q03
Block Name
Q04
Block Code
Q05
Village Name
Q06
Village Code
Q07
Name Of Asha
Q08
Asha Code
Q09
First Visit
Q09_1
Interviewer Name
Q09_2
Interviewer Id
Q09_3
Date Of Visit
Q09_4
Result Code
Interview Completed
Visit Rescheduled
Interview Incomplete
Refused
Other (Specify)
Q10
Second Visit
Q10_1
Interviewer Name
Q10_2
Interviewer Id
Q10_3
Date Of Visit
Q10_4
Result Code
Interview Completed
Visit Rescheduled
Interview Incomplete
Refused
Other (Specify)
Q11
Third Visit
Q11_1
Interviewer Name
Q11_2
Interviewer Id
Q11_3
Date Of Visit
Q11_4
Result Code
Interview Completed
Visit Rescheduled
Interview Incomplete
Refused
Other (Specify)
Demographic Characteristics
A01
What is your current age?
A02
What is your caste/category?
Scheduled caste
Scheduled tribe
Other backward caste
General
Other (specify)
A03
Can you read and write?
Yes, Read And Write
Yes, Read Only
Yes, Write Only
No
A04
What is the highest standard or class you completed?
A05
For how long have you been working as an ASHA?
A06
For how long you have been working in this village?
Home Based New Born Care Plus: Home Visits
B01
Do you have HBNC+ cards?
Yes
No
B02
How many blank HBNC+ cards do you have?
B03
How many children aged 0 to 3 months are there in your catchment area?
B04
How many children aged 0 to 3 months have you visited?
B05
How many children aged 3 to 6 months are there in your catchment area?
B06
How many children aged 3 to 6 months have you visited?
B07
How many children aged 6 to 9 months are there in your catchment area?
B08
How many children aged 6 to 9 months have you visited?
B09
How many children aged 9 to 12 months are there in your catchment area?
B10
How many children aged 9 to 12 months have you visited?
B11
How many children aged 12 to 18 months are there in your catchment area?
B12
How many children aged 12 to 18 months have you visited?
B13
How many times should you visit the within one year of age?
6/7 times in the first 42 days
When the child turns 3 months
When the child turns 6 months
When the child turns 9 months
When the child turns 12 months
Others
Home Based New Born Care Plus: Knowledge and Practice
C01
During your home visits for infants, what are the topics on which you provide counselling?
Exclusive breastfeeding
Continued breastfeeding
Childhood illness/complications
Immunization
Complementary feeding practices
Hand washing practices
Effective handling of the Child
Home management/case management of illness
Others (specify)
C02
For how many months, should a child be given only mother’s milk and not even water?
C03
At what age should complementary feeding be started?
C04
How many times is the 6 – 12 months old infant being fed each day?
Less than 3 times
3 to 4 times
More than or equal to 5 times
Don’t know
C05
How much quantity should be given to infants from 6 - 12 months in each feed?
Less than ½ Katori in each feed
½ to 1 katori in each feed
More than 1 Katori in each feed
Don’t know
C06
What are the critical occasions during which a mother should wash her hands?
After defecation by self
After cleaning the child after defecation
Before preparing food
Before eating
Before feeding child
Others (specify)
C07
What should be usually used to wash the hands?
Water
Mud
Ash
soap
Other (Specify)
C08
Please describe the vaccines which a child must get within 1st year of life along with the age at which it should be given.
C08_1
BCG 0
Yes
No
C08_2
Polio 0 dose
Yes
No
C08_3
OPV 1
Yes
No
C08_4
OPV 2
Yes
No
C08_5
OPV 3
Yes
No
C08_6
Hep B O
Yes
No
C08_7
Hep B 1
Yes
No
C08_8
Hep B 2
Yes
No
C08_9
Hep B 3
Yes
No
C08_10
DPT 1
Yes
No
C08_11
DPT 2
Yes
No
C08_12
DPT 3
Yes
No
C08_13
Measles
Yes
No
C08_14
Pentavalent 1
Yes
No
C08_15
Pentavalent 2
Yes
No
C08_16
Pentavalent 3
Yes
No
C09
Time for administration mentioned
C09_1
BCG 0
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_2
Polio 0 dose
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_3
OPV 1
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_4
OPV 2
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_5
OPV 3
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_6
Hep B O
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_7
Hep B 1
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_8
Hep B 2
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_9
Hep B 3
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_10
DPT 1
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_11
DPT 2
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_12
DPT 3
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_13
Measles
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_14
Pentavalent 1
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_15
Pentavalent 2
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C09_16
Pentavalent 3
At Birth
1½ months
2 ½ months
3 ½ months
9-12 months
Other
C10
Which part of the body is it administered?
C10_1
BCG 0
Hand
Thigh
Oral
C10_2
Polio 0 dose
Hand
Thigh
Oral
C10_3
OPV 1
Hand
Thigh
Oral
C10_4
OPV 2
Hand
Thigh
Oral
C10_5
OPV 3
Hand
Thigh
Oral
C10_6
Hep B O
Hand
Thigh
Oral
C10_7
Hep B 1
Hand
Thigh
Oral
C10_8
Hep B 2
Hand
Thigh
Oral
C10_9
Hep B 3
Hand
Thigh
Oral
C10_10
DPT 1
Hand
Thigh
Oral
C10_11
DPT 2
Hand
Thigh
Oral
C10_12
DPT 3
Hand
Thigh
Oral
C10_13
Measles
Hand
Thigh
Oral
C10_14
Pentavalent 1
Hand
Thigh
Oral
C10_15
Pentavalent 2
Hand
Thigh
Oral
C10_16
Pentavalent 3
Hand
Thigh
Oral
C11
A 6 month old child is having loose stools 4 times a day. What will you do in this condition?
Will give ORS
Ask the mother to take the child to doctor immediately
Will yourself take the child to doctor immediately
Zinc tablet/syrup
Give salt and sugar solution
Do nothing
Others (Specify)
Don’t know
C12
Do you have ORS packets available with you?
Yes
No
C13
How many packets of ORS do you have?
C14
How much quantity of water must be added to one packet of ORS?
1 litre of water
4-5 glasses of water
Others (specify)
C15
Do you have paediatric IFA syrup available with you for children?
Yes
No
C16
How many IFA syrup bottles do you have?
C17
Have you ever provided IFA syrup to children aged between 6 months to 1 year?
Yes
No
C18
How often should the IFA syrup be given to the child 6 months to 1 year of age?
Weekly
Bi-weekly
Monthly
Don’t Know
others (specify)
C19
What quantity of Paediatric IFA should be given to an infant in one dose?
1 ml
2 ml
5 ml
More than 5 ml
Don’t know
others (specify)
Supportive Supervision
E01
Who is your supervisor?
ANM
ASHA supervisor
None
Other (Specify)
Don’t Know
E02
How many total visits were made by your supervisor in the last 3 months?
E03
When did you receive the last supportive supervision visit? (Month / Year)
E04
What were the different activities undertaken during supportive supervision?
Review your HBNC+ records and cards for accuracy
Observe you during home visits
Provide you with direct feedback about your Performance
Provide you with technical resources and information to help you learn and do your job better
Assist you with problems or difficulties you are facing
Others(specify)
E05
How many completed HBNC+ cards have you submitted for the receipt of payment?
E06
For how many completed HBNC+ card have you received payment?
E07
How much amount did you receive for the completion of one HBNC+ visit?
Growth Monitoring
F01
Do you conducted growth monitoring during home visits?
Yes
No
F02
When you check the growth chart of a child, in which condition would you refer the infant to a health facility?
When the growth curve is in the red zone
Growth curve moving downwards or to the colour zone below
Don’t know
Others
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