│_│_│ │_│_│ │_│_│ / …………………………………………. / ……………………………………….
Village / Supervisor’s name / Health Worker’s name
……………………….………………. / ………………………………………….. / ……………………………………….
This form should be completed by the nurse at the health centre who is responsible for supervising community health workers. The nurse should visit the health workers during SMC administration, at least once per transmission season, to obtain the information required by interviewing and observing the health workers at work.
- Direct observation of SMC administration
Does the community health worker have all material for SMC administration? / │_│ Yes / │_│ No
Does the community health worker have a register for recording information? / │_│ Yes / │_│ No
Does the community health worker have SMC administration cards? / │_│ Yes / │_│ No
Did the community health worker give information on SMC to the caregiver? / │_│ Yes / │_│ No
Did the community health worker explain that SMC is administered on three occasions* during the rainy season? / │_│ Yes / │_│ No
Did the community health worker check the child’s identity and age? / │_│ Yes / │_│ No
Did the community health worker check whether the child is well and eligible for SMC? / │_│ Yes / │_│ No
Did the community health worker give the right dose of SP + AQ to the child? / │_│ Yes / │_│ No
Did the community health worker keep the child under observation for at least 30 min after treatment? / │_│ Yes / │_│ No
Did the community health worker give the second and third dose to the caregiver? / │_│ Yes / │_│ No
Did the community health worker explain to the caregiver how to administer the second and third doses? / │_│ Yes / │_│ No
Did the community health worker give an appointment for the next course of SMC? / │_│ Yes / │_│ No
Did the community health worker fill in the SMC card correctly? / │_│ Yes / │_│ No
Did the community health worker record information correctly in the register? / │_│ Yes / │_│ No
Did the community health worker rinse spoons, syringes and cups used for SMC administration? / │_│ Yes / │_│ No
- Sensitization of caregivers
Did the community health worker explain the difference between SMC and community case management of malaria or integrated case management? ** / │_│ Yes / │_│ No
Did the community health worker inform the caregiver about the side-effects of SMC drugs? / │_│ Yes / │_│ No
Has the caregiver been told what to do if an adverse event occurs? / │_│ Yes / │_│ No
Did the community health worker tell the caregiver to seek treatment at any time if their child is sick? / │_│ Yes / │_│ No
Supervisors comments: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
*may be changed to four courses, as appropriate
**for areas where community case management or integrated community case management of malaria is being implemented