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PART C: Household Survey SI 1

Date

District

Union Council

Interviewee’s relation to the child(ren) under 5

Interviewee’s name

Q1What is the source of drinking water for members of your household?

Q2 What kind of toilet facility do members of the household usually use?

Q3 How long have you lived in this house?

Q4 Does anyone in the household travel regularly outside the district for work or social reasons?

If Yes, Where do they travel?

Q5 a) Has anyone travelled outside the district in the past 2 months?

If Yes, Where did they go?

b) Have any guests travelled to & from the district in the past 2 months?

If Yes, Where did they go?

Q6 What language do you regularly speak in the household?

Q7 What is your ethnic/tribal identification?

Q8 How well can the mother/ father of the children in this household read?

Q9 What is the father’s occupation?

Q11 Of the sources you mentioned, which one(s) do you trust the most?

Q12 Do you take your child to a public or private facility?

Q13 How many minutes does it take to travel to the closest community health center, hospitals or clinic?

Q14 Did you know about the last polio campaign in your area before it started?

Q16 What is the preferred place for your child to receive OPV?

Q17 Did a FLW visit your house during the last campaign? if “NO” or “not sure” skip to the next question

Q19 a) Was there a female present on the team that visited your house to give polio drops?

Q18 Did you feel that the vaccinators that visited your house to give polio drops were of appropriate age?

b) If “no,” were you uncomfortable with only male vaccinators”?

Q20 Did you feel the vaccinators’ appearance/dress was appropriate?

Q21 Did you feel the vaccinators were able to converse in local language?

Q22 Did you feel the vaccinators were well informed about their work of giving polio drops?

Q22 What do you think are the symptoms of polio? (Do not read out the options)

Q23 What do you think causes polio? (Do not read out the options)

Q24 Are you concerned that your child can contract polio?

Q25 Do you think OPV is effective in preventing polio infection?

Q26 Do you think OPV is safe?

Q27 If the caregiver answers 2 or 3 in Q25 or Q26, ask: “Why is OPV unsafe or not effective ?” Do not read out answers, but mark all that apply

Causes fever

Comes from USA / western countries

Causes sterility

Its ingredients are haram/doubtful

Too many doses are unsafe

Other

Q28 Do you think your child needs multiple doses of OPV to fully protect him/her from polio?

Q29 Do traditional/religious leaders in your community support polio campaigns / OPV?

Q30 Do people in your household support children to receive OPV?

Q31 Are the people in your community supportive of polio campaigns / OPV?

Q32 Do you know of any relative or community member less than 15 years of age with weakness or paralysis?

Q34 a) How many children under 5 live in this household, under your primary care?

b) Did she/he receive OPV during the last campaign (recall)?

Q35 Did the FLW come to your house?

Q36 If the child was not at home then where was the child?

Q37 Did you or someone in your household refuse OPV for your child?

Q38 a) If Yes. Why?

Medical doctors, nurse, or other health care professionals

Spiritual healers or herbalists

Imams, pastors, or religious figures

Relatives or friends

Community traditional leaders or elders

Any additional comments?

Submit the Investigation Findings using below Form

ABC investigation Form

Polio OBR Survey