2

2. EXIT INTERVIEW--WELL CHILD

Greet the caretaker and say that you would like to ask some questions about his/her visit to the health facility today.

A. Immunization

1 Do you have your child's EPI card (or Road to Health card) ? Y N

If NO, go to question 3.

2. If YES, may I see it? (Interviewer reviews to determine if up-to-date) Y N

3. Did the health worker tell you what vaccine you received? Y N

4. Which vaccines did you receive? (Check all that apply.)

____ Polio-O (birth)____ PoliO

____ BCG____ DPT-3

____ DPT-1____ Polio-3

____ Polio-1____ Measles

____ DPT-2

5. Did the health worker explain what side effects your baby might experience? Y N

6. What side effects might your baby experience from this vaccination? (Check all that apply.)

____Soreness

____ Fever

____Irritability

____ Other (specify) __________________________________________________

7. Did the heath worker tell you when to return for the baby's next vaccination? Y N

8. When should you return? Y N

B. Vitamin A

9. If 'EPI' card available, interviewer reviews for Vitamin A up-to-date.

C. Mebendazole

10. If 'EPI" card available, interviewer reviews for mebendazole up-to-date.

D. GM/P

11. Do you have a Road to Health card? Y N

12. If yes, may I see it? (Interviewer reviews for weight plotted today.) Y N

13. Did the health worker discuss your baby's growth with you today? Y N

14. Please tell me what this (point to today's RTH card) means? Y N

Growing well Y N

Growing but not well Y N

Losing growth velocity Y N

15. Did the health worker provide you nutritional advice today about…

Breastfeeding Y N

If yes, what (specify) __________________________________

Complementary feeding Y N

If yes, what (specify) __________________________________

Feeding during illness Y N

If yes, what (specify) __________________________________