You are on page 1of 1

Post Campaign Evaluation (PCE) Methodology Questionnaire rev. May.


Province: Surveyor Code: Lot Number: 1 2 3

District: Cluster Number: (please, circle) 1 2 3 4 5

Tehsil: Starting village/settlement Ending:

UC: Date of monitoring: CBV? Yes No

As an PCE surveyor I, ______________________(name), pledge to maintain the highest level of respect and integrity while conducting this survey. I will not lie, deceive,
vandalize, or commit forgery while performing my role as an PCE surveyor. I am fully awar of the methodology and what is expected of me and it is my duty to report
violations when they occur. I make this pledge in the spirit of honor and trust. Signature: _________________________________
How many times did you sector divided to find your first house? ______________________
Position of the household in the cluster
1 2 3 4 5 6 7 8 9 10
How many children younger than 5 years old are currently
PRESENT in the house?

How old in months is this child? (ONLY for the randomly

selected child for all remaining questions)

1b If >6m, Was this child provided Vitamin A? (Yes = 1; No= 0)

2 What is the gender of this child? (M/F)

Is a finger mark present from the last campaign? (Yes = 1; No=


Child was Asleep

Child was Away from the
Newly Migrated after
Team Visit
Newly Born after Team
Reasons why child was not finger- Team did NOT visit the
4 marked: What was the reason for house
Child or Parent Refused
not getting the two drops?
Vaccine from the Team
(Answer Q5 & Q6)
Team Missed the child

Vaccinated but NO Finger

Others (specify)

Religious reason

The child was sick

Tired of too many
Misconception or Negative
Reasons for refusal: What was the Rumour
reason for refusing the two drops?
Demand for other services
Prefers vaccinations from a
medical provider
Security related concerns

Others (specify)

Is there an "R" present on the door

6 Yes = 1; No= 0
mark of this house?

Before the campaign that just

0, 1-3, 4 or more, DK-dont
7 ended, how many times did the
child receive OPV?

Is there a door mark present for this

campaign (date only)? *The
8 Yes = 1; No= 0
accurarcy of the door mark should
not be assessed

Observations: #FM but NV, #Fresh FM, #No

9 Response/Participation houses, Vaccination Card Observations,
Parent's comments, VNFM details, Compliments

Facilitator's Name: ________________________________

Guide's Name: ______________________________

Name of Monitor: Monitor 's affiliation (WHO/UNICEF/NSTOP): Signature of Monitor