Surveypoint

Q01

CLUSTER CODE

Q02

STRUCTURE CODE

Q03

HOUSEHOLD ID NUMBER

Q04

DATE

Q05

TIME STARTED

Q06

TIME FINISHED

Q07

No of members in family

Q08

How many pregnancy (antenatal) care check up visits did you have in total during this pregnancy?

Q09

How many months pregnant were you when you first received antenatal care for this pregnancy?

Q10

During the whole pregnancy, for how many days did you take the tablets or syrup?

Q11

During this pregnancy, how many times did you get a tetanus injection?

Q12

When you gave birth, did the person conducting the delivery wear gloves during delivery?

Yes

No

Q13

Where did you give birth to (NAME)?

HOSPITAL

DISPENSARY

UHC/UHP/UFWC

CHC/RURAL HOSPITAL

PHC

SUB-CENTRE

ANGANWADI CENTRE/ ICDS CENTRE

OTHER GOVT. HEALTH FACILITY

NGO/CHARITABLE HOSPITAL/CLINIC

PRIVATE HOSPITAL

AYUSH HOSPITAL/ CLINIC

PRIVATE DISPENSARY

SKY CLINIC

OTHER PVT. HOSPITAL/ CLINIC

OTHER

Q14

Was [NAME] delivered by caesarean, that is, did they cut your belly open to take the baby out?

Yes

No

Q15

For this pregnancy, did you get any maternity financial benefit under the government scheme name Janani Surakashi Yojana (JSY)?

Yes

No

Q16

Did anyone check on your health within 48 hours after the delivery?

Yes

No

Q17

What was used to cut the cord?

NEW RAZOR BLADE

STERILE RAZOR BLADE

ANY RAZOR BLADE

SCISSORS

DON’T KNOW

OTHER

Q18

What was applied to the cord just after cutting the cord?

BUTTER/GHEE

ASH

OINTMENT

ANIMAL DUNG

OIL

COLD WATER

GENTIAN VIOLET

OTHER

Q19

Do you have an immunization card or MCP card where [CHILD NAME]’s vaccinations are written down?

YES, SAW CARD

YES, DID NOT SEE CARD

NO

Q20

DPT 1

Q21

Back Check Template 3 -Form Fill

CLUSTER CODE

STRUCTURE CODE

HOUSEHOLD ID NUMBER

DATE

TIME STARTED

TIME FINISHED

No of members in family

How many pregnancy (antenatal) care check up visits did you have in total during this pregnancy?

How many months pregnant were you when you first received antenatal care for this pregnancy?

During the whole pregnancy, for how many days did you take the tablets or syrup?

During this pregnancy, how many times did you get a tetanus injection?

When you gave birth, did the person conducting the delivery wear gloves during delivery?

Where did you give birth to (NAME)?

Was [NAME] delivered by caesarean, that is, did they cut your belly open to take the baby out?

For this pregnancy, did you get any maternity financial benefit under the government scheme name Janani Surakashi Yojana (JSY)?

Did anyone check on your health within 48 hours after the delivery?

What was used to cut the cord?

What was applied to the cord just after cutting the cord?

Do you have an immunization card or MCP card where [CHILD NAME]’s vaccinations are written down?

DPT 1

In the last 3 months, how many times have you or any family member met with an ASHA at your home to discuss a health issue?