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USAID / BASICS
Rapid Integrated Health Facility Assessment
2. EXIT INTERVIEW - SICK CHILD
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{PRONUM} Province Number/Name ## (F9) {PRONAME} ____________________________
{FACNUM} Facility Number/Name ## (F9) {FACNAME} ____________________________
{FACTYPE} Facility type # (1=Hospital, 2=Health Center, 3=Health Station)
{FACSTAT} Facility status # (1=Public, 2=Private)
{INUM} Interviewer no. ## {CHILDAGE} Child's age ## {CHILDNUM} ID No. ##
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1. Did the health worker give you any oral
{HWGOM} medicines at the clinic today? ............. # (1=YES, 2=NO)
If NO, go to question 2
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Medicine How much How many How many All correct?
each time? times/day? days?
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(77=As Required, 88=Until Completed, 99=Don't Know) (1=YES, 2=N0)
{CHQ} Chloroquine #.# {CHTD} ## {CHD} ## {CHCOR} #
{ABQ} Antibiotic #.# {ABTD} ## {ABD} ## {ABCOR} #
{APQ} Aspirin/Paracet #.# {APTD} ## {APD} ## {APCOR} #
{ORSQ} ORS/RHF ## {ORSTD} ## {ORSD} ## {ORSCOR} #
{OTHQ} Other ## {OTHTD} ## {OTHD} ## {OTHCOR} #
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A. Caretaker knows how to give ALL essential
{KEYMED} medications correctly? .................... # (1=YES, 2=NO)
2. What will you do for your child when you return home?
(Code 1 all ticked responses)
{DK2} Doesn't know ............................... #
{CFBF} Continue feeding or breastfeeding the child #
{GMF} Give same quantity/more fluids to the child #
{CCMED} Complete course of medications/ORS/RHF ..... #
Bring the child back if he/she doesn't
{BCB} get better or gets worse ................... #
{OTHDO} Other (specify:________________________
B. Caretaker knows at least 2 aspects
{KEYHCM} of home case-management? ............ # (1=YES, 2=NO)
3. How will you know if the child becomes worse at home?
(Code 1 all ticked responses)
{DK3} Doesn't know ..................... #
{CUTD} Child unable to drink............. #
{FB} Fever begins or doesn't go away .. #
{CONV} Child has convulsions ............ #
{CUTE} Child unable to eat............... #
{DIFBR} Child has difficulty breathing ... #
{DIAC} Diarrhea continues................ #
{BLOOD} Blood in the stool................#
{CHEST} Child has chest indrawing ........ #
{VB} Vomiting begins or continues...... #
{OTHER3} Other............................. #
{SPEC3} Specify ________________
C. Caretaker knows at least 2 signs of
{KEYWHOME} child getting worse at home? ............... # (1=YES, 2=NO)
4. Which diseases will be prevented by the immunizations you
or your child has received? (Code 1 all ticked responses)
{DK4} Don't know # {MEAS} Measles #
{DIPHT} Diphtheria # {TB} Tuberculosis #
{TETAN} Tetanus # {POLIO} Polio #
{WCOUGH} Whooping cough # {OTHER4} Other #
{SPEC4} Specify _______________
5.a Do you know what might happen as a side effect
{SIDEFCT} after the immunization? .................... # (1=YES, 2=NO)
.b If YES, what were you told? (Code 1 all ticked responses)
{FEV} Fever ........ # {SWELL} Swelling............... #
{IRRIT} Irritability # {PAIN} Pain at injection site.. #
{OTHER5} Other ........ # {SPEC5} Specify _______________
6. How many vaccination visits does a child need in the first
year of life to complete the series of vaccinations?
{NBVV} # (1=Correct, 2=Incorrect, 9=Doesn't know)
7.a Did your child receive an immunization today?
{CIMMU} # (1=YES, 2=NO)
.b If NO,
{REFV} # (1=Referred for vaccination another day,
2=Was not given or referred for vaccination,
3=Up to date)
8. Do you have your child's vaccination card?
{CVCARD} # (1=Yes, 2=Lost, 3=Never received, 4=Left at home)
If the caretaker has the card, record the dates of ALL VACCINES GIVEN,
both today and in the past, and the child's birthdate and age.
{BIRTHD} Birthdate: <dd/mm/yy> {AGE} Age ## (months)
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IMMUNIZATION Received (1=YES, 2=NO)
{POLIO0} Polio-0 (birth) ... #
{BCG} BCG ............... #
{DPT1} DPT-1 ............. #
{POLIO1} Polio-1 ........... #
{DPT2} DPT-2 ............. #
{POLIO2} Polio-2 ........... #
{DPT3} DPT-3 ............. #
{POLIO3} Polio-3 ........... #
{MEASLES} Measles ........... #
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{KEYCVAC} D. Child is up to date? ....... # (1=YES, 2=NO)
9. Do you have your own vaccination card?
{MVCARD} # (1=Yes, 2=Lost, 3=Never received, 4=Left at home,
9=N/A:father is the caretaker)
IF YES, copy the caretaker's tetanus toxoid vaccinations
in the table below. If the caretaker's TT doses are recorded
on the child's vaccination card, copy them here also.
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IMMUNIZATION Received (1=YES, 2=NO)
{TT1} TT-1 #
{TT2} TT-2 #
{TT3} TT-3 #
{TT4} TT-4 #
{TT5} TT-5 #
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{KEYMVAC} E. Caretaker has received at least TT-2? .... # (1=YES, 2=NO)
{MIMMU} 10.a Did you receive a tetanus vaccination today? # (1=YES, 2=NO,
.b If NO, 9=N/A)
{MRTV} # (1=Referred for vaccination another day,
2=Was not given or referred for tetanus vaccination,
3=Up to date)
11.a Were you prescribed any oral medication
{ORALMED } at your last visit? ...................... # (1=YES, 2=NO)
.b If YES, were you able to get your
your medication?.......................... # (1=YES, 2=NO)
.c If YES, where did you get your medication?
(Code 1 all ticked responses)
{HF} This health facility .......#
[DVEND} Drug vendor.................#
{PHARM} Private pharmacy .......... #
{OTHFH} Other facility............. #
OTHSP11} Other (specify):______________________
.d If NO, why could you not get the medication?(Code 1 all ticked responses)
{NODRUG} No drugs available ........ #
{NOMON} No money/could not afford . #
{NOSOU} No source ................. #
{OTHER11} Other ..................... #
END OF INTERVIEW
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