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

2017

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
Sl No VARIABLES
1 2 3 4 5 6 7 8 9 10
How many children younger than 5 years old are currently
0
PRESENT in the house?

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

1
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=

3
0)

Child was Asleep

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

Vaccinated but NO Finger

Mark
Others (specify)

Religious reason

The child was sick

Reasons for refusal: What was the
5
reason for refusing the two drops?
Tired of too many
campaigns
Misconception or Negative
Rumour
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
know
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