Surveypoint

Q01

District

Q02

Block

Q03

Date

Q04

Name of the Facilitator

Q05

Scrutinized by

A01

Name of the Respondent

A02

Age

A03

Category of Pharmacist

Pharmacist at the Hospital

Private Pharmacist

A04

What is the name of your shop?

A05

How many years have you worked as a pharmacist?

A06

How old is this pharmacy?

B01

Private Pharmacist

B02

For cases related to infant diarrhea, who comes to buy medicine? Why him or her? What do you think?

B03

Do they come with a prescription? If not then what do you do?

B04

What do you prescribe? Why?

B05

Out of 10 how many cases are being prescribed by the doctors/health workers?

B05_1

Government Doctors

B05_2

Private doctor

B05_3

Rural Medical Practitioner

B05_4

No prescription

B06

What do most people ask for? Which medicine? Please give the exact name (local term). And also list how much it is bought on average at one time (mention units as well)

B06A

Quantity

B07

What are the other kinds of enquires do the people make about Diarrhea while buying the medicine? What are the questions that they ask? (Food, dosage, longevity of treatment, good doctor, causes, prevention etc.) What is your response to their queries?

B07A

Response

B08

What is the local name for diarrhea in this community?

B09

Do you know what rotavirus is?

Yes

No

B10

What is the local name for rotavirus in this community?

B11

Answer the following questions in the context of ORS and Zinc

B11A

Are you aware of it?

B11A_1

ORS

Yes

No

B11A_2

Zinc

Yes

No

B11B

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

B11B_1

ORS

Yes

No

B11B_2

Zinc

Yes

No

B11C

How many packets were bought last month?

B11C_1

ORS

B11C_2

Zinc

B11D

What is your current stock at the store?

B11D_1

ORS

B11D_2

Zinc

B11E

From where do you get your supply?

B11E_1

ORS

B11E_2

Zinc

B11F

Do you preorder your supply?

B11F_1

ORS

Yes

No

B11F_2

Zinc

Yes

No

B11G

When is the preordering done?

B11G_1

ORS

B11G_2

Zinc

B11H

How frequently is preordering done?

B11H_1

ORS

B11H_2

Zinc

B11I

What was the size of the last order

B11I_1

ORS

B11I_2

Zinc

B11J

Are regular inventories performed with documentation or records (check if an inventory was performed in the last 12 months)

B11J_1

ORS

Yes

No

B11J_2

Zinc

Yes

No

B11K

Are the quantity and value of expired items recorded

B11K_1

ORS

Yes

No

B11K_2

Zinc

Yes

No

B11L

Are the product quality problem reports are documented and maintained

B11L_1

ORS

Yes

No

B11L_2

Zinc

Yes

No

B11M

Is feedback provided to the QA officer

B11M_1

ORS

Yes

No

B11M_2

Zinc

Yes

No

B11N

What other diarrheal medicine apart from ORS and zinc is stocked?

B11N_1

ORS

B11N_2

Zinc

B12

Pharmacist at the Hospital

B13

What is the local name for diarrhoea in this community ?

B14

Do you know what rotavirus is?

Yes

No

B15

What is the local name for rotavirus in this community?

B16

Answer the following questions in the context of ORS and Zinc

B17

Are you aware of it?

B17_1

ORS

Yes

No

B17_2

Zinc

Yes

No

B18

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

B18_1

ORS

Yes

No

B18_2

Zinc

Yes

No

B19

How many packets were bought last month?

B19_1

ORS

B19_2

Zinc

B20

What is your current stock at the store?

B20_1

ORS

B20_2

Zinc

B21

From where do you get your supply?

B21_1

ORS

B21_2

Zinc

B22

Do you preorder your supply?

B22_1

ORS

Yes

No

B22_2

Zinc

Yes

No

B23

When is the preordering done?

B23_1

ORS

B23_2

Zinc

B24

How frequently is preordering done?

B24_1

ORS

B24_2

Zinc

B25

What was the size of the last order

B25_1

ORS

B25_2

Zinc

B26

Are regular inventories performed with documentation or records (check if an inventory was performed in the last 12 months)

B26_1

ORS

Yes

No

B26_2

Zinc

Yes

No

B27

Are the quantity and value of expired items recorded

B27_1

ORS

Yes

No

B27_2

Zinc

Yes

No

B28

Are the product quality problem reports are documented and maintained

B28_1

ORS

Yes

No

B28_2

Zinc

Yes

No

B29

Is feedback provided to the QA officer

B29_1

ORS

Yes

No

B29_2

Zinc

Yes

No

B30

What other diarrheal medicine apart from ORS and zinc is stocked?

B30_1

ORS

B30_2

Pharmacists Template -Form Fill

District

Block

Date

Name of the Facilitator

Scrutinized by

Name of the Respondent

Age

Category of Pharmacist

What is the name of your shop?

How many years have you worked as a pharmacist?

How old is this pharmacy?

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

For cases related to infant diarrhea, who comes to buy medicine? Why him or her? What do you think?

Do they come with a prescription? If not then what do you do?

What do you prescribe? Why?

Out of 10 how many cases are being prescribed by the doctors/health workers? var statement=document.write(localStorage.getItem('total'));

Government Doctors

Private doctor

Rural Medical Practitioner

No prescription

What do most people ask for? Which medicine? Please give the exact name (local term). And also list how much it is bought on average at one time (mention units as well)

Quantity

What are the other kinds of enquires do the people make about Diarrhea while buying the medicine? What are the questions that they ask? (Food, dosage, longevity of treatment, good doctor, causes, prevention etc.) What is your response to their queries?

Response

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?

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

Are you aware of it? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Do you provide it to patients with diarrhea? (Collect sample) var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

How many packets were bought last month? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

What is your current stock at the store? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

From where do you get your supply? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Do you preorder your supply? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

When is the preordering done? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

How frequently is preordering done? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

What was the size of the last order var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Are regular inventories performed with documentation or records (check if an inventory was performed in the last 12 months) var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Are the quantity and value of expired items recorded var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Are the product quality problem reports are documented and maintained var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Is feedback provided to the QA officer var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

What other diarrheal medicine apart from ORS and zinc is stocked? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Pharmacist at the Hospital var statement=document.write(localStorage.getItem('total'));

What is the local name for diarrhoea in this community ?

Do you know what rotavirus is?

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'));

Are you aware of it? var statement=document.write(localStorage.getItem('total'));

ORS

Zinc

Do you provide it to patients with diarrhea? (Collect sample) var statement=document.write(localStorage.getItem('total'));

Private Pharmacist

Out of 10 how many cases are being prescribed by the doctors/health workers?

Answer the following questions in the context of ORS and Zinc

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

Are regular inventories performed with documentation or records (check if an inventory was performed in the last 12 months)

Are the quantity and value of expired items recorded

Are the product quality problem reports are documented and maintained

Is feedback provided to the QA officer

What other diarrheal medicine apart from ORS and zinc is stocked?

Pharmacist at the Hospital

Answer the following questions in the context of ORS and Zinc

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

Are regular inventories performed with documentation or records (check if an inventory was performed in the last 12 months)

Are the quantity and value of expired items recorded

Are the product quality problem reports are documented and maintained

Is feedback provided to the QA officer

What other diarrheal medicine apart from ORS and zinc is stocked?