House to House Monitoring Format: SID (2016)

Encircle appropriate options. For (*) marked questions multiple responses are allowed

Name of Monitor:______Organization: Govt, / WHO / UNICEF / UNDP /Others______
Designation: ______Date of Monitoring: _____/_____/_____ Time: ______: to ______:
District: ______Block/Urban Area: ______Planning Unit: ______
Name of the Village/ Mohalla/ Area: ______Setting: Rural / Urban
Particulars / House-1 / House-2 / House-3 / House-4 / House-5
1 / Name of the selected child (0-23 months)
2 / Name of the father / mother
3 / Religion (H=Hindu / M=Muslim / O=Others) / H / M / O / H / M / O / H / M / O / H / M / O / H / M / O
4 / Sex of the selected child (M=Male / F=Female) / M / F / M / F / M / F / M / F / M / F
5 / Is Mother & Child Protection (MCP) / RI Card available with family? / Yes / No / Yes / No / Yes / No / Yes / No / Yes / No
6 / Date of Birth (In dd / mm / yy format. if not known, write “NA”)
7 / Age in completed months (Even if date of birth is known)
Write date in dd/mm/yy format from Immunization card for vaccine the child has received. If date is unknown, write ‘Y’ for dose received and “N” for missed due dose. Use ready reckoner to find out due vaccine(s) for the child.
8A / Hep B Birth dose
OPV-0 dose
8B / BCG
OPV 1
Hepatitis B1
DPT 1
Pentavalent 1
8C / OPV 2
Hepatitis B2
DPT2
Pentavalent 2
8D / OPV 3
IPV (Single dose IM in right thigh)
Hepatitis B3
DPT 3
Pentavalent 3
8E / Measles / MR 1st dose
JE Vaccine 1st dose
8F / OPV Booster
DPT 1st Booster
Measles / MR 2nd dose
JE Vaccine 2nd dose
9 / Was this child due for any dose in this SID round? (refer ready reckoner) / Yes / No / Yes / No / Yes / No / Yes / No / Yes / No
10 / If yes in Q-9, ascertain if the child received all / partial / none of due vaccine(s) in this SID round. Select “NA” if child was not Eligible for Vaccine in this SID (refer ready reckoner) / All / Partial /
None / NA / All / Partial /
None / NA / All / Partial /
None / NA / All / Partial /
None / NA / All / Partial /
None / NA
11 / Did the child receive vaccination for the first time in life in SID? / Yes / No / NA / Yes / No / NA / Yes / No / NA / Yes / No / NA / Yes / No / NA
12* / If child is partially vaccinated / received none of the due vaccines in this SID round, then ascertain reason(s) from codes below (Max - 4)
13 / Whether the Household had SID sticker?
14 / If Yes, whether color of the sticker displayed was correct as per child immunization status?

Codes for Q-12: 1) Not aware of need for immunization; 2) No one contacted 3) Did not know where / when to go for immunization 4) Has no time / no one to take child 5) Concern for loss of work or wages 6)Session inconvenient for time / location / long waiting time; 7) unaware of missed dose 8) Unfriendly vaccinator 9) Session not held 10) Vaccine was not available 11) Child was away from home 12) Sick child - care-giver did not opt vaccination 13) Sick child – HW did not vaccinate; 14) Caregiver did not opt for multiple injections 15) HW did not give multiple injections 16) Experienced minor illness: fever, pain, swelling 17) Experienced severe illness: hospitalization, death, disability 18) Fear of AEFI on hearsay; 19) Adverse media reports, 20) Family is resistant 21) Family has no definite reason 99) Others

Ready reckoner to assess whether a child has received due dose of vaccine as per age

Assess vaccination status of the selected child during Mission Indradhanush as per age and time interval between vaccines as below:

•There has to be at least 4 weeks interval between subsequent doses of DPT / Hepatitis B / Pentavalent vaccine after 1st dose.

•There has to be at least 4 weeks interval between two different live vaccines if not being given simultaneously (BCG / Measles / JE vaccines)

•There has to be an interval of at least 1 month between 2 doses of Measles, and 3 months between two doses of JE vaccines.

•There has to be at least six months gap between 3rd dose of DPT/Pentavalent and 1st DPT booster.

 If the child received due vaccine on a specific day write date (dd/mm/yy). If date is not known but child received vaccine - write “Y” and If missed vaccine write “N”.If the child not due for any vaccine for age or not meeting time interval between vaccines or vaccine not yet introduced in the state/district write “NA”.

Age (Completed months) / Ideally a child should have received age specific vaccines as per National Immunization Schedule
BCG / OPV / Hep-B / **IPV / DPT + Hepatitis-B / ***Pentavalent / Measles / MR / ****JE / DPT Booster-1 / OPV
Booster
0 / BCG / OPV-0
(up to 15 days) / Birth dose
(Within 24 hours) / NA / NA / NA / NA / NA / NA
1 / BCG / OPV-0
( up to 15 days) / Birth dose
(Within 24 hours) / NA / NA / NA / NA / NA / NA
2 / BCG / OPV-0,1 / Birth dose
(Within 24 hours) / NA / (DPT-1+Hepatitis-B-1) / Pentavalent-1 / NA / NA / NA / NA
3 / BCG / OPV-0,1,2 / Birth dose
(Within 24 hours) / NA / (DPT-1,2 + Hepatitis-B-1,2) / Pentavalent-1,2 / NA / NA / NA / NA
4 to 8 / BCG / OPV-0,1,2,3 / Birth dose
(Within 24 hours) / IM dose / (DPT-1,2,3 + Hepatitis-B-1,2,3) / Pentavalent-1,2,3 / NA / NA / NA / NA
9 to 15 / BCG / OPV-0,1,2,3 / Birth dose
(Within 24 hours) / IM dose / (DPT-1,2,3 + Hepatitis-B-1,2,3) / Pentavalent-1,2,3 / Measles -1 / JE - 1 / NA / NA
16 to 23 / BCG / OPV-0,1,2,3 / Birth dose
(Within 24 hours) / IM dose / (DPT-1,2,3 + Hepatitis-B-1,2,3) / Pentavalent-1,2,3 / Measles - 1,2 / JE - 1,2 / DPT Booster -1 / OPV
Booster

** IPV: IPV is never started in a child over one year of age.

•IPV will be given IM along with OPV-3 at 14 weeks / later but within 1 year of age in Assam

***Pentavalent vaccine will be administered to birth cohort (within 1 year of age) who has not started with DPT & Hepatitis-B and will replace primary series of DPT & Hepatitis-B.

****JE vaccine is given at 9 -12 months (1st dose) and at 16-24 months of age (2nd dose) in selected endemic districts (list is updated every year).