House to House Survey Form - 3

ASHA/AWW/Surveyor Name/Ph No.: Sub-Centre name: Name of ANM:

ASHA/AWW/ Name/Ph No.: Area Name and No as per Form 1: Date of Visit : dd/mm/yy

“First house visited today -House No.: Name: Address with landmark: Last house visited today -House No.: Name: Address with landmark:

Family Details Pregnant Woman Children 0 to 2 years - (if YES , go to form 5)

House Name of head of family Fathers name How many family Is there any “Is there any “Is there any child aged “Is there any child
number (as members are living woman pregnant Newborn/child aged between 1 month and 1 agedbetween 1 to
per inthis house? in the family ?(If less than 1 month yearin the family 2 Years in the family
(Include All adults &
chullah) children including new YES, go to form 4) in the family (if YES, go to form 5)” (if YES, go to form 5)”
borns) (if YES, go to form 5)”

A B C D E F G H

Yes / No Yes / No Yes / No Yes / No

Total TOTAL Total Yes Total Yes Total Yes Total Yes

Signature of ASHA/assessor: Verified by ASHA Facilitator (Signature): Verified by ANM (Signature): SHEET NUMBER :
 VILLAGE/ AREA - Pregnant Women Survey Listing Form-4
Name of ASHA/AWW/ Surveyor: Area Name and No as IN Form 3:
Name of ANM:
House Name of the pregnant A Husbands name Mobile / Telephone Number Is MCP Expectedd Tetanus Toxoid Vaccination Ante Natal Check Up FOR ANM ONLY
No as in woman g card ate of
Form 3 e available delivery/
TT-1 TT-2 TT-Booster (If 2 1stANC 2ndANC 3rdANC 4thANC TT due - ANC due
: Yes / LMP
doses of TT have Y/N -Y/N
i No
been given within
n
3 years of the
current
y
pregnancy)
e
a
r
A B sC D E F G H I J
Date/Y/N/DNK Date/Y/N/DNK Date/Y/N/DNK Date Date Date Date
Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

TOTALS

Signature of ASHA Verified by ASHA Facilitator (Signature): Verified by ANM (Signature):

 INFANTS/CHILDREN SURVEY LISTING RI Form 5
Name of ASHA/AWW/Surveyor: Area Name and No as per Form 3: Name of ANM:
H A S Is Vaccines at Vaccines at 6 weeks Vaccines at 10 Vaccines at 14 weeks Vaccines at 9 to 12For
o ge e MC birth weeks months Fully
u in x P Immu-
s yr M car Hepat OPV - BC G O P R f P O P R O P R f P Mea JE 1st PCV Vitam nized
e s /F d it is B Zero (At P e V I C P e V P e V I C sles dose Boost i n A (FI)
an avai birth dose birth V n V P V V n V V n V P V / MR er 1st child -
N d la dose (withi or - t - V - - t - - t - V - 1st dose has
o m ble: (Witin n 15 upto 1 a 1 - 1 2 a 2 a 3 - 2 dos e incentiv
on Yes 24 days 1 - 1 - 3 e been
a th / No hours of year 2 - 2 given
s s of birth) of age 1 to
Name of the father and ASHA
Name of the child birth) - 3
i mobile number
as
n early
as
F possi
o ble)
r
m

A B C D E F G H I J K L
Date/ Date/ Date/ Date/ Date/ Date/ Date/ Date Date Date/ Date/ Date/ Date/ Date/ Date/ Date/ Date/ Date/ Date/ Date/
Y Y Y/N Y/N Y/N Y/N Y /Y/ N / Y/N Y Y/N Y/N Y/N YY Y/N Y/N Y/N Y Y/N
/N /N /N /N /N /N /N

Yes Yes
/No /No

Yes Yes
/No /No

Yes Yes
/No /No

Yes Yes
/No /No

Yes Yes
/No /No
 Yes Yes
/No /No

Yes Yes
/No /No

Yes Yes
/No /No

Signature of ASHA/AWW/ Assessor Verified by ASHA/AWW Facilitator (Signature):

Booster and 2nd doses of For
Vaccines at 16 to 24 months of Complet
age ely
OPV DPT Vitam Measl JE Immuniz
Boost Boost in A es/ 2nd ed (CI)
er er MR dose child -
2nd has
dose incentive
been
given to
ASHA

M N
Date/ Date/ Date/ Date/ Date/
Y/N Y/N Y/ N Y/ N Y/N

Yes /No

Yes /No

Yes /No

Yes /No

Yes /No
Yes /No

Yes /No

Yes /No