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Additional Form B - Block Level Summary of Convergence Activities

Additional Form B - Block Level Summary of Convergence Activities

This form is filled out each month by the block mobilization coordinators (BMC) working in high risk blocks and submitted to their respective district mobilization coordinator (DMC). It summarizes the results of convergence activities conducted by the community mobilization coordinators (CMCs) under his or her supervision, and reports on the BMC's work. There is one row for each CMC, showing the activities planned and held as per the district communication plan. It also has details of convergence activities such as routine immunization sessions planned, held and missed and reasons thereof, number of RI sessions with adequate availability of vaccines, children immunized against the 6 vaccine preventable diseases, number of families with whom counseling sessions were held on key behaviours, including hygiene & sanitation, breastfeeding, diarrhea management through ORS and zinc, use of iodised salt, etc. The last page of the form has the compiled block level data, hence only one form is filled for the entire block. The DMC assigns one BMC to fill this form on behalf of all BMCs working in the block and supports him in the process.
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PDF Form
Additional Form C - Community Level Summary of Convergence Activities

Additional Form C - Community Level Summary of Convergence Activities

The monthly reporting form filled by community mobilization coordinators (CMCs) working in high risk blocks, summarizing convergence activities organized/conducted by them such as routine immunization sessions planned, held and missed, and reasons thereof, number of RI sessions with adequate availability of vaccines, children immunized against the 6 vaccine preventable diseases, number of families with whom counseling sessions were held on key behaviours, including hygiene & sanitation, breastfeeding, diarrhea management through ORS and zinc, use of iodised salt, etc. The CMCs working in high risk blocks fill this out once a month, and give it to their supervising block mobilization coordinator (BMC) who uses it to monitor her work. Some information is summarized and passed up the hierarchy for analysis.
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PDF Form
House to House Microplan - Urdu Version

House to House Microplan - Urdu Version

This is an Urdu version of the house-to-house microplan, which is developed prior to the polio round by the Government and WHO-NPSP with support from partners at block, district and state levels. It gives a detailed plan of the house-to-house activity with team numbers, names of team members, supervisors, including influencers and routine immunization indicators. It includes tasks, responsibilities and deadlines.The more robust the microplan, the better the verification and the less chance of missed children.
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PDF Document
House to House Microplan

House to House Microplan

The microplan is developed prior to the polio round by the Government and WHO-NPSP with support from partners at block, district and state levels. It gives a detailed plan of the house-to-house activity with team numbers, names of team members, supervisors, including influencers and routine immunization indicators. It includes tasks, responsibilities and deadlines. The more robust the microplan, the better the verification and the less chance of missed children.
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PDF Document
IEC Monitoring Form

IEC Monitoring Form

A form filled out by monitors of each polio immunization round. It shows the visibility of the IEC (information, education & communication) materials such as posters and banners. There are also sections for monitoring the quality of the partnership meetings held and house to house visits by vaccination teams. This form is given to staff from UNICEF, NPSP (WHO), Rotary and CORE, who visit the field during polio campaigns, for the purpose of monitoring. Around 4000 of these forms are filled out during each round. They are then collected by state offices and analyzed to show where improvements and corrections are needed next time around.
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PDF Form
CMC Field Book - Bihar - Key Page in English

CMC Field Book - Bihar - Key Page in English

This is the main form duplicated many times in the CMC Field Book for Bihar. The field book is filled out by the Community Mobilization Coordinator as she/he goes house to house. It is used to record data for each household; including where there are children under five living, whether they’ve been vaccinated for polio or received routine immunization, if they were missed then why, where there are babies and pregnant women living and more. It also sets out a monthly work plan for the CMC, and has pages to summarize data that can be torn out and handed over for data collection. The Bihar version of the field book combines the routine immunisation and the supplementary immunisation sections on one page. In some cases, like on this page, pictures of faces are used to keep records, making it easier for CMCs who have low literacy.
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PDF Form
Monitoring Format for Routine Immunizaton Sessions

Monitoring Format for Routine Immunizaton Sessions

A format for monitoring routine immunization sessions in Uttar Pradesh. It has details of the monitor - which organization s/he belongs to, along with the date and time of the routine immunization session monitored. It has a set of pre-defined questions with multiple responses, such as whether the session was held, who mobilized beneficiaries tot eh session site and so on. While observing an RI session, the monitor needs to tick off the options, whichever is applicable.
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PDF Form
Monitoring & Evaluation Framework for Polio Convergence - Uttar Pradesh

Monitoring & Evaluation Framework for Polio Convergence - Uttar Pradesh

This is the monitoring and evaluation plan for convergence in the polio programme in all 66 high-risk blocks of Uttar Pradesh (in this case from June 2010 - May 2012). The comparative matrix outlines the objective programme statement with outcome, outputs and specific activities, monitoring indicators, how frequently these indicators are reviewed in Polio task force meetings, specific values in consecutive months, district and blocks which need improvements (worst performing district-wise blocks with data), qualitative feedback on these districts/blocks, responses undertaken/planned and remarks, if any. A colour code is assigned to worst performing blocks – red for blocks which appear in worst performing list for consecutive 4 months/rounds, brown for blocks appearing in worst performing list for consecutive 3 months/rounds and blue for blocks appearing in worst performing list for consecutive 2 months/rounds. A trend analysis is then charted out for these blocks – whether neutral, positive or negative, with comments and suggestions.
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XLSX Table
Migration Form

Migration Form

This form tracks where the children in migrant families are going when they miss out on polio vaccination. Community and block mobilizers speak to migrant parents when they return to Uttar Pradesh or Bihar. They find out where they have come from, and whether their children received the oral polio vaccine when they were interstate. The form is filled out by the BMC with inputs from the CMC. The results show which locations outside UP and Bihar should be targetted for extra polio vaccination efforts. The results are used to inform government policy.
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PDF Form
List of Indicators With Definitions

List of Indicators With Definitions

A list of indicators with definitions used by the Social Mobilisation network in Uttar Pradesh & Bihar in addition to Devinfo.
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PDF Document
BMC Diary

BMC Diary

It is the key recording, planning and monitoring tool used by the Block Mobilization Coordinator (BMC) . The diary record the work of the 10 - 15 CMCs under the BMC. It summarises the activities of the CMCs, records the results of the polio round including the round report and key indicators. It includes form B and checklists including a daily diary which covers the planning of the BMC.
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PDF Book
Feedback Format - Block Level

Feedback Format - Block Level

A format used by the Surveillance Medical Officer (SMO) of WHO-NPSP in Uttar Pradesh to share block level feedback at the daily evening meetings during a polio round. This is a filled-in format of a block in Meerut district in west Uttar Pradesh. The format has a set of 20 questions on issues/activities during a polio round, which the SMO fills in during/post his/her monitoring visits to different areas and vaccination teams in the block. The information in these block level formats feed into the consolidated feedback format at district level.
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JPEG Form
Feedback Format - District Level Summary

Feedback Format - District Level Summary

This form is filled out daily by the Surveillance Medical Officer of WHO-NPSP during a polio immunization round, summarizing the information provided in the block level feedback format. It is a snapshot of issues/activities which have come up during monitoring visits by the SMO in the district, and whether district level officers or Superintendent/Medical officer In-charge are present during the meeting. It lists out the departments which have supported vaccination teams in converting refusal houses to accept vaccination, any replacement of vaccinators, any issues related to high risk groups and high risk areas, teams not doing bi-phasic activity or leaving the area early, teams with a high number of houses which have refused vaccination, teams not tracking newborns, teams not doing previous day conversion, details of transit teams and cold chain issues and so on. All the issues are discussed during the daily evening de-briefing meetings held during an ongoing polio round for immediate corrective actions.
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JPEG Form
Feedback Report - District Level

Feedback Report - District Level

This report is consolidated from block level reports submitted by Field Monitors and prepared by Surveillance Medical Officers of WHO-NPSP. This is a sample report of Saharanpur district in west Uttar Pradesh. The SMO fills in this report daily during an ongoing polio immunization round. It has details of which high-risk groups and areas were covered by vaccination teams on that particular day, what issues have come up or were observed such as which teams closed work before time, or did not go out in the second half of the day (bi-phasic activity) converting refusal houses, new born tracking not done, false conversions reported, replacements in vaccination teams, vaccine distribution and cold chain issues, and so on. The report is shared during the daily evening de-briefing meeting at district level, basis which immediate corrective actions are taken.
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JPEG Form
The CMC Field Book - English Translation of Key Pages

The CMC Field Book - English Translation of Key Pages

These are the two forms in the CMC Field Book, that are duplicated many times. The community mobilization coordinator visits the 300-500 households she is responsible for, and fills out these forms for each of them. The first form lists each house, whether children in the house missed being vaccinated (X-1 means one child was missed, X-2 two children missed) or did receive the vaccine (P-2 means two children were vaccinated). Each child is named, their date of birth recorded, and details about their vaccination. The second form is for tracking pregnant women. When they are pregnant it shows whether they've received the TT (tentanus) shots, then the baby's date of birth, and then whether the baby receives the required routine immunization vaccinations.
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PDF Form
Form C - CMC Field Book Summary

Form C - CMC Field Book Summary

The monthly reporting form filled by community mobilization coordinators (CMCs), summarizing their on interpersonal communication activities, polio round activities, and routine immunization, including monitoring of vaccine and status of children and pregnant women. The CMC fills this out once a month, and gives it to her supervising block mobilization coordinator (BMC) who uses it to monitor her work. Some information is summarized and passed up the hierachy for analysis.
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PDF Form
Form B - Block Level Summary

Form B - Block Level Summary

This form is filled out each month by the block mobilization coordinator BMC. It summarizes the results of the community mobilization coordinators (CMCs) under his or her supervision, and reports on the BMC's work. There is one row for each CMC, showing the number of houses visited, the number missed by polio vaccinators (X houses), the number of vaccine refusals (XR) and the reasons. The BMC also reports on his or her activities; the number of CMCs and influencers visited, any routine immunization sessions organized, and then monitored, any CMCs appointed, training sessions given, resource maps prepared, partnership meetings attended etc. Form B is given each month to the supervising district mobilization coordinator (DMC).
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PDF Form
Form A - District Level Summary

Form A - District Level Summary

This form is filled out each month and after each polio immunization round by the district mobilization coordinator (DMC) on a computer, summarizing the information provided in form B by the block mobilization coordinators. It is a snapshot of the social mobilization activities in the district; the number of CMCs and BMCs, the number of children in the target age group, the number of vaccine refusals and the reasons, interpersonal communication work done, polio classes held in schools, details of mosque announcements, routine immunization sessions scheduled, training conducted and meetings attended. The form is sent to the state office, where it is analyzed, and presented back to the district in the form of a district profile and a power point presentation. It allows the DMC to assess the quality of the communication work done, and areas in need of improvement.
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PDF Form
Form A - District Level Summary - Excel Version

Form A - District Level Summary - Excel Version

This form is filled out each month and after each polio immunization round by the district mobilization coordinator (DMC) on a computer, summarizing the information provided in form B by the block mobilization coordinators. It is a snapshot of the social mobilization activities in the district; the number of CMCs and BMCs, the number of children in the target age group, the number of vaccine refusals and the reasons, interpersonal communication work done, polio classes held in schools, details of mosque announcements, routine immunization sessions scheduled, training conducted and meetings attended. The form is sent to the state office, where it is analyzed, and presented back to the district in the form of a district profile and a power point presentation. It allows the DMC to assess the quality of the communication work done, and areas in need of improvement.
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XLS Form
CMC Area Round Report

CMC Area Round Report

A CMC area round report filled in at the district level by the SMC during a polio round. It has details of all the BMC areas under the SMC with further details such as the total number of CMCs, number of booths and children vaccinated at booths. It also has report of A Team – total houses visited, total children under 5 years in the houses visited, children vaccinated and ‘X’ (refusal) houses with further break-up of reasons, followed by B Team report. The form also lists out children missed in the particular round. Page 2 of the form lists out segregated ‘X’ report – number of refusal houses generated and remaining in the different blocks of the district.
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PDF Form
The CMC Field Book

The CMC Field Book

A field book of forms and tables filled out by the Community Mobilization Coordinator as she/he goes house to house. It is used to record data for each household; including where there are children under five living, whether they’ve been vaccinated for polio or received routine immunization, if they were missed then why, where there are babies and pregnant women living and more. It also sets out a monthly work plan for the CMC, and has pages to summarize data that can be torn out and handed over for data collection. Primary message: polio vaccination, routine immunization, data collection
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PDF Book
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