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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
CCO/CBO
Influencer
FLW
CM
Household
Surge Staff
SSICA
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Submit the Investigation Findings using below Form
Surge Staff Intra Campaign Activities
Surge Staff Intra Campaign Activities
Job Title
CCO
SCBO
Name
Date
Campaign Day
– Select –
Day 1
Day 2
Day 3
Day 4
Day 5
Catchup Day 1
Catchup Day 12
District
– Select –
Gujranwala
Faisalabad
Multan
DG khan
Bahawalpur
Attock
RYK
Chakwal
Okara
Tehsil/Town
UC
No of HH clusters taken
PCA identified?
Yes
No
Missed Area identified?
Yes
No
No. of PCA
Details of PCA ( if any)
No. of Missed Area
Details of Missed Area ( if any) Never
Is there any refusal in UC on that day? *
Yes
No
Was the refusal identified by monitor or UC staff?
Monitor
Team/AIC
No of Refusals identified by monitor
No of Refusals identified by team
Who covered the refusal?
Monitor
Team
AIC/UCMO
No of Refusals covered by monitor
Most common reason (s) for Refusal ( includes refusals identified by monitor & UC staff)
Religious
Medical
Misconceptions ( sterility, vaccine from USA/Israel etc)
Rumors regarding Vaccine Safety & Vaccine Hesitancy
Repeated knocks/campaigns
Lack of community/family support for OPV
Vaccinator behaviour / appearance
Does the UC have a SM plan?
Yes
No
Did you validate the activities mentioned in the SM plan in the field?
Yes
No
Are the activities described in the plan need based?
Yes
No
Did UCMO supervise AICs & validate their plan?
Yes
No
Details & comments regarding the plan & activities validated by you
Any remarks?
Any communication issues/challenges in the UC?
Yes
No
If yes, what were these issues/challenges?
Was this challenge addressed by you previously in your planning?
Yes
No
Were you able to address these issues?
Yes
No
If yes, how did you solve them?
Did people in the community know about the polio campaign in your area before it started?
– Select –
Yes
No
Are the people in your community supportive of polio campaigns / OPV?
– Select –
Yes
No
What is the risk perception of the community?
– Select –
High
Moderate
Low
Do people in your community travel often?
Yes
No
If yes, which common districts do they travel to?
Lahore
Rawalpindi
Islamabad
Chakwal
Okara
Multan
Bahawalpur
Bahawalnagar
Attock
Gujranwala
Sahiwal
RYK
DG khan
KPK
Balochistan
Sindh
Other (please describe below)
Any other district not mentioned above
Any comments or queries regarding campaign monitoring?
Submit Form
Polio OBR Survey
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