BHOMA Monthly CHW Survey

 

17 February 2011

V1.0

 

  1. How many households did you visit this month? (num_people_in_hh)

Constraint: < 2500

  1. Enter Integer
  1. In minutes, about how long did you spend on each visit? (visit_length)

Constraint: < 400

  1. Enter Integer
  1. Were you able to visit one third of the households in your area? (any_missed_hh)
    1. Yes
    2. No
  2. How many households were you unable to visit this month? (num_missed_hh)

ONLY if ‘any_missed_hh’ = n

  1. Enter Integer
  1. What is the main reason you were unable to visit them? (reason_missed)

ONLY if ‘any_missed_hh’ = n

Multiple Choice

  1. Too many households in your area to visit each month
  2. Difficulties with travel between households
  3. Each visit took too long
  4. Personal reason (you were ill, on leave, etc.)
  5. The household members were gone
  6. The household members refused a visit
  7. Other
  1. Enter other reason you were unable to visit households (reason_detail)

ONLY if ‘reason_missed’ = other OR personal

Not Required

  1. Enter Text
  1. How often did you use the phone to record information during a visit? (phone_use)
  1. Never
  2. Rarely
  3. Sometimes
  4. Most of the Time
  5. Always
  1. If you didn’t use a phone, why? (phone_use_detail)

ONLY if ‘phone_use’ != always

Not Required

  1. Enter Text
  1. Have you had any problems with the phone in the last month? (phone_problem)
    1. Yes
    2. No
  2. What problems have you had with the phone? (problem_detail)

ONLY if ‘phone_problem’ = y

Multiple Choice

  1. Lost
  2. Stolen
  3. Screen broken
  4. Keyboard broken
  5. Battery broken
  6. Unable to charge battery
  7. Other
  1. Enter other problem have you had with the phone? (other_reason_detail)

ONLY if ‘problem_detail’ = other

Not Required

  1. Enter Text
  1. Have you had a problem submitting forms in the last month? (any_network_problem)
    1. Yes
    2. No
  2. What problems did you have submitting forms? (network_problem)

ONLY if ‘any_network_problem’ = y

  1. No connectivity
  2. Poor network
  3. No credit
  4. Other
  1. How often did you have a problem submitting forms? (network_prob_freq)

ONLY if ‘any_network_problem’ = y

  1. Never
  2. Rarely
  3. Sometimes
  4. Most of the Time
  5. Always
  1. On a normal Day, how much of your time is spent traveling between households? (travel_time)

Not Required

  1. Less than 1 hour
  2. 1 to 3 hours
  3. 3 to 5 hours
  4. More than 5 hours
  1. On a normal Day, how much of your time is spent making follow-up visits from the list on the phone? (followup_time)

Not Required

  1. Less than 1 hour
  2. 1 to 3 hours
  3. 3 to 5 hours
  4. More than 5 hours
  1. On a normal Day, how much of your time is spent making routine household visits? (visit_time)

Not Required

  1. Less than 1 hour
  2. 1 to 3 hours
  3. 3 to 5 hours
  4. More than 5 hours
  1. In a normal Day, how much of your time is spent on health education?"

Not Required

  1. Less than 1 hour
  2. 1 to 3 hours
  3. 3 to 5 hours
  4. More than 5 hours
  1. In a normal WEEK, how much of your time is spent organizing community events? (events_time)

Not Required

  1. Less than 1 day
  2. 1 to 2 days
  3. 2 to 3 days
  4. More than 3 days
  1. In a normal WEEK, how much of your time is spent helping at the clinic? (clinic_time)

Not Required

  1. Less than 1 day
  2. 1 to 2 days
  3. 2 to 3 days
  4. More than 3 days
  1. What problems did you have with your medical kit? (med_kit_problem)

Multiple Choice

Constraint: Can’t select None and another answer

  1. Ran out of medications/ supplies I needed
  2. Never had access or never given a medication/ supply I needed
  3. Didn't know how to use a medication/ supply in the kit
  4. Unable to administer a medication/ supply in the kit
  5. Patient refused the medicine/ supply you had
  6. Lost medical kit or medication/ supply
  7. Other
  8. None
  1. Describe any other problems with your medical kit: (other_med_kit_problem)

ONLY if ‘med_kit_problem’ = other

Not Required

  1. Enter Text
  1. Describe the medicine or supply you need: (med_needed)

ONLY if ‘med_kit_problem’ = need_med

Not Required

  1. Enter Text
  1. How many RDT tests did you use from your medical kit in the last month? (num_rdt_tests)

Constraint: < 99

  1. Enter Integer
  1. Thank you!  Make sure to send in your data! (survey_over)