Surveypoint

Q01

District Name

Q02

District Code

Q03

Block Name

Q04

Block Code

Q05

Village Name

Q06

Village Code

A01

Name of the Mother

A02

Name of the Child

A03

Age of the Child (in completed months)

A04

Respondent category

Mother of 0-6 month child

Mother of 6-11 month child

Mother of 12-23 month child

A05

Does this household have a BPL card/coupon?

Yes, Card seen

Yes, Card not seen

No Card

Don’t Know

A06

Do you have MCP Card? Display if yes.

Yes

No

A07

Has ASHA visited the child after the age of 3 months (Plus minus 7 days)?

Yes

No

A08

Was the child given breast milk in the last 24 hours.

Yes

No

A09

Do you give [CHILD NAME] any solid, semi-solid, mashed or soft foods to eat?

Yes

No

A10

Has the child ever been immunised?

Yes

No

A11

Have you given IFA syrup to the child at least bi-weekly in last two weeks?

Yes

No

A12

How many ORS packets do you have currently?

A13

Did (child name) suffer from diarrhoea in the last two weeks?

Yes

No

A14

Did the ASHA counsel you on handwashing practices?

Yes

No

A15

Did the ASHA weigh the child during her visit?

Yes

No

Back Check Template 5 -Form Fill