PART I

1. Name of household head ____________________________________

2. What is his/her principal source of income?

0. Unemployed
1. Civil servant (employed by government)
2. Employed by a private firm (Bank etc.)
3. Self-employed/business
4. Farming/fishing
5. Others specify __________________

3. Education level reached by household head (specify)
__________________________________________________________

4. Number of members in the household? ________________________

5. Who was the last person to get an injection in this household?
(Which household member?)

6. When (time) was this injection received?

7. For what reason was the injection given?

1. Therapeutic
2. Drip (infusion)
3. Contraception
4. Immunization

8. If it was therapy, what symptoms were being treated?
(Please note down the symptoms in local terms)
_________________________________________________________
_________________________________________________________

9. What medicine was injected? (use local term)
_________________________________________________________
_________________________________________________________

10. Where was the injection provided? (Use local categorization)
_________________________________________________________

11. Who provided the injection?
_________________________________________________________

12. Do you have any kind of relationship with the injection provider?

1. Yes
2. No

13. If yes, what is the nature of relationship?

1. Parent
2. Relative
3. Friend
4. Neighbour
5. Other __________________________________________

EQUIPMENT AT HOME

14. Do you keep needles and syringes in your home?

1. Yes
2. No

15. If yes, where did you obtain them?
_________________________________________________________

16. Do you keep injectables?

1. Yes
2. No

17. If yes, what type of injectables do you have?

1. Chloroquine
2. PPF
3. Others _________________________________________

18. Where did you obtain the injectables (1. Yes 2. No)

1. Government facility
2. Non-governmental facility
3. Private clinic
4. Pharmacy
5. Drug shop
6. Shop or market place
7. Drug pedlar or hawker
8. Friend, relative or neighbour

COMPLICATIONS

19. Has any member of family ever had any complications with injections?

1. Yes
2. No

20. If yes, what kind of injection complications (1. Yes 2. No)

1. Abscess
2. Allergy
3. Lameness

21. From where was that injection obtained? (find out the local categorization of facilities)

1. Governmental hospital
2. Government HC
3. Non-governmental HC
4. Private clinic
5. Non-formal facility
6. At home
7. Others (specify) ________________________________________

22. Who provided that injection?
__________________________________________________________

23. What do you think was the cause of the complication?

1. Provider
2. Bad injectable
3. Bad equipment
4. I do not know
5. Others specify ____________________________________________

HYPOTHETICAL TRACER CONDITIONS

24. What treatment should be given for the following illnesses? Please fill in Table I.

Table I: Treatment form for tracer conditions based on hypothetical questions

PART II: TWO WEEKS RECALL PERIOD
(PLEASE NOTE IF THERE IS CHANGE IN THE RESPONDENT)

1. Has anyone in this home been sick during the last two weeks?

2. In the last two weeks has anyone in this home received any form of injection?

1. Therapeutic
2. Immunization
3. Drip (infusion)
4. Contraception
5. None

3. If it was a therapeutic injection then fill in Table II.

4. If it was an immunization then fill in Table III.

Table II: Sickness and treatment in two weeks period

Table III: Immunization record