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Social investigation survey forms
Household
UCMO/AIC
FW/CM
Influencer
DHMT(Health/DHO)
supervisor/CCO
Communication Block officer
OBR Follow-up
Desk
Field
UCMO/AIC
Influencer
FLW
CM
CCO/CBO
Household survey
Surge Staff
SSICA
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Submit the Investigation Findings using below Form
Follow up - CCO interview
OBR Follow-up: CCO interview
Date
District
How knowledgeable is s/he about the polio situation, challenges, measures taken & impact in this area in general & village/settlement specifically?
Very knowledgeable
Somewhat knowledgeable
Needs improvement
What is his/her level of involvement in polio activities?
Good
moderate
Needs improvement
At least one name of influencer (name & contact no)? Verify with SM plan
Did the influencers identified participate in catch-up activities to reach missed children
– Select –
yes
no
Is there evidence of refusal caregiver engagement in CE plan?
– Select –
yes
no
Were you able to cover refusals in your area during last campaign?
– Select –
yes
No
What are the main reasons for refusals in your area?
Medical reasons
Religious reasons
Repeated campaigns/knocks
Misconceptions
Rumors regarding vaccine safety
What do you do in order to try to overcome these issues?
Counseling of refusal caregivers about the importance of Polio vaccination
Follow up of vaccination on mobile phones
Pre campaign social mobilization activities & influencer engagement
Repeated catch up visits
Home visit during evening hours
LEAs engagement
How knowledgeable is s/he about PMC & SMC & their reporting?
Very knowledgeable
Somewhat
Needs improvement
Comments
Was there adequate visibility of polio materials during the last campaign (e.g. street chalking, banners, posters at the health centre etc)?
Yes
No
Somewhat
Were any testimonials/videos regarding polio sent to you by DHMT?
Yes
No
Any additional comments or suggestions?
Submit Form
Polio OBR Survey
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