Immunization Session Site Monitoring Format ( _ ) _ _ / _ _ _ / _ _ __ / _ /_ _ _ _

(Not to be filled by monitor)

Encircle appropriate options. For (*) marked questions, multiple responses may be applicable
State/UT: _______________________ District: _________________________ Date: _ _ / _ _ / _ _ Monitoring time: _ _ : _ _ to _ _ : _ _
Name of Block / Urban: _________________________Setting: Rural / Urban Planning Unit: ___________________ Sub center/Urban Health Post: _______________________
Village/Mohalla/Ward: ______________________________ Name of session site:_________________________ Session type: Fixed / Outreach / Mobile
Name of ANM: __________________________ Name of Supervisor: ______________________ Designation: ______________CMC area: Yes / No / Not applicable
Name of Monitor: __________________________ Organization: ITSU / WHO / UNICEF / UNDP / CORE / FM / SMNet / IFV / Others: _________ Designation:_____________
Name of Mentor / Govt Monitor : ___________________________ Department: ________________ Designation:__________ Type of Monitoring: RI / IMI / Others____________
If joint monitoring is undertaken, whether both monitors were present through-out monitoring of this session. Yes / No
1 Is the session being held? Yes / No
2* If session is not being held - select reason(s): a) Early closure as per district timings b) ANM not available at session site c) Vaccine / logistics not available d) Others
If session not being held (Q1 – “No”) note reasons in Q2; proceed with house-to-house monitoring in this session area and then proceed for planned monitoring under RI monitoring. If it is IMI
monitoring – inform Medical Officer and proceed to a new IMI session / new area for house to house monitoring as per plan. Finally visit health facility to assess Q-49 – 50.
Session details

3 Is the session being held at same location as per micro-plan? Yes / No

a) Slum with migration b) Nomads c) Brick kilns d) Construction site e) Other migratory high risk area f) Non migratory (settled HRA)
4* If polio HRA, type of HRA/HRG
g) Hard to reach area (tribal, forest, hilly area, riverine etc)
5 Location of the session as per microplan: a) District Hospital b) CHC c) PHC d) UPHC e) Sub Centre f) Urban Health Post g) ICDS Centre h) HRG site (fixed) i) HRG site (by mobile team) j) Others
6 Vaccines / logistics delivered by? a) Alternate Vaccine Delivery b) ANM c) ASHA d) AWW e) Others :______________________________
7* Mobilizers found working today: a) ASHA b) AWW c) Link workers d) CMC e) NCC f) NYK g) NSS h) PRI i) Education Dept j) Religious leaders k) Others l) none m) Not met
8* Which mobilizers are same as per micro plan? a) ASHA b) AWW c) Link workers d) CMC e) NCC f) NYK g) NSS h) PRI i) Education Dept j) Religious leaders k) Others l) none m) NA
9 Is record of headcount count survey (register/format/paper) available at the session site? (Look for physical record) Yes / No / Headcount survey not conducted
Survey / Duelist
Headcount

Has ANM updated vaccination status of beneficiaries in RCH register / records following previous session?
10 Yes / No / Not applicable
(Not applicable when it is No / Headcount survey is not done )
Is updated due list available?
11 Yes / No / Due list not available
[Updated = New born may have been included, children (<2yrs) / Pregnant women rolling over for missed or next antigen as applicable following last session ]
12* Encircle vaccine / diluent avalable at this session : BCG / BCG Diluent / bOPV / RVV / PCV / IPV / Pentavalent / DPT / Measles / Measles diluent / MR / MR diluent / JE / JE diluent / TT
Vaccine and Open

13* Partially used vaccine vials from previous session received at the session today? a) bOPV b) Pentavalent c) DPT d) IPV e) TT f) PCV g) None
Vial Policy

14* Which of these open vials present at the session today had no date & time marked on them? a) BCG b) bOPV c) RVV d) IPV e) Penta f) DPT g) Measles h) MR i) JE j) TT k) PCV l) None m) NA
15* Any partially used vials received today supplied beyond 28 days of opening as per date/time marked on the vial? a) bOPV b) Pentavalent c) DPT d) IPV e) TT f) PCV g) None h) NA
16* Encircle if any partially used vial of vaccines not applicable under open vial policy has been supplied to this session: a) BCG b) Measles c) MR d) JE e) RVV f) No vial supplied
17* Encircle syringes not available at the session : a) AD (0.1 ml) Syringes b) AD (0.5 ml) syringes
Logistics other than

18* Which of the following is available at the session site : a) Paracetamol b) Vitamin A c) Spoon for Vitamin-A d) Red & Black bag
Vaccine

19 Is the number of 5ml reconstitution syringes equal to or greater than the total number of BCG + Measles/MR + JE vials supplied? Yes / No
20 Blank MCP/RI card available at the session? Yes / No (If “No” encircle “not applicable” in Q-21)
21 If MCP/ RI card available, does it have counterfoil for ANM for tracking missed doses? Yes / No / Not applicable
22 Working status of available hub cutter a) Working b) Not working c) Hub cutter not available
 23* Is ANM using any of these vaccines after 4 hours of reconstitution / opening the vial? a) BCG b) Measles c) MR d) JE e) RVV f) None g) NA

Supervision
practices
injection
ANMs

and 24* Observe ANMs injection practices & encircle: a) not cutting syringe hub immediately b) touching the needle c) post injection–applying thumb/finger/cotton d) no unsafe practices e) not observed

25 Has any supervisor visited the session today: a) Health Supervisor b) Medical Officer c) Others (specify): ………………… d) None
26 Is this IMI session site located at the same place where RI session is held? (From RI microplan / interview ANM): Yes / No / Don't know
IMI specific Questionnaires

a) Vacant sub Centre / health post b) Areas with last 3 or more consecutive missed RI sessions c) Polio High Risk Areas
27* Reason why IMI session is planned? d) Areas with low RI coverage (measles outbreaks, cases of diphtheria & neonatal tetanus in last 2 years
e) Small villages, hamlets, basas (field huts) clubbed with another village for not having independent RI sessions f) Others ……………...

No. of days this ANM has been assigned to work in IMI as per microplan/ANM duty roster? (Find out from ANMs session a) 1 b) 2 c) 3 d) 4 e) 5 f) 6 g) 7 h) more than 7 days
28
wise micro-plan) i) session wise microplan not available with ANM / not aware

29 Place of posting of this ANM? a) same sub center / urban health post b) different sub center / urban health post in the same block / planning unit c) different block / urban planning unit
30 If mobilizer (other than ASHA/AWW) is assigned to this session, ask if he/she is aware of incentive for mobilization of children @ Rs 150/= per session: Yes / No / NA
Communication Questionnaire
31 Status of frontline worker on BRIDGE IPC skill training: ANM – Y / N / Not available; ASHA – Y / N / Not available; AWW – Y / N / Not available
BRIDGE Training
and IEC visibility

Did you see any of the following IEC material related to Immunization displayed at session site (multiple responses possible):
32* a) Poster –RI: Yes / No b) Poster – IMI: Yes / No c) Banner –RI: Yes / No d) Banner – IMI: Yes / No e) Wall painting- RI: Yes / No f) Wall painting - IMI: Yes / No
g) Any other: Yes / No, If Yes- Specify: …………………… h) No IEC material displayed
33 Does any of the displayed IEC material has tagline (“Paanch Saal Saat Baar”): Yes / No (Skip Q33 if No IEC material displayed as per Q32)

Observe immunization of two children and record if ANM is giving key messages On child - 1 On child – 2
ANM providing key messages

34 Explain what vaccine(s) will be given and the disease(s) prevented Done / Not done / Not observed Done / Not done / Not observed

35 Explain potential side effects following immunization (fever/pain/swelling, etc.) and how to deal with them Done / Not done / Not observed Done / Not done / Not observed
36 Explain when to come for the next visit Done / Not done / Not observed Done / Not done / Not observed
37 Explain to keep the immunization card safe and to bring it along for the next visit Done / Not done / Not observed Done / Not done / Not observed
38 Ask the caregivers to wait with child for 30 min after vaccination Done / Not done / Not observed Done / Not done / Not observed
Conduct exit interview with 2 caregivers Caregiver 1 Caregiver 2
Interview with caregiver

1) Mother, 2) Grandmother, 3) Father, 4) Grandfather, 5)Uncle or 1) Mother, 2) Grandmother, 3) Father, 4) Grandfather, 5)Uncle or
39* Who brought the child to the session site/ Who is caregiver?
Aunt, 6) elder siblings, 7) neighbor, 8) mobilizer, 9)others Aunt, 6) elder siblings, 7)neighbor, 8)mobilizer, 9)others

ASHA / AWW / ANM / CMC / link worker ASHA / AWW / ANM / CMC / link worker
40* Who visited you to invite for vaccination to the session site?
Influencer as per microplan / Others / None / NA Influencer as per microplan / Others / None / NA
 Caregiver-1 Caregiver-2
ANM- Y/N Religious leader- Y/N Wall painting- Y/N ANM- Y/N Religious leader- Y/N Wall painting- Y/N

What is your source of information for ASHA- Y/N Poster/banner- Y/N Mobile SMS- Y/N ASHA- Y/N Poster/banner- Y/N Mobile SMS- Y/N
immunization services?
AWW- Y/N Radio-Y/N Social Media- Y/N AWW- Y/N Radio-Y/N Social Media- Y/N
41* Allow caregiver to respond spontaneously for
multiple responses; and then probe for CMC- Y/N Miking- Y/N Mothers’ meeting-Y/N CMC- Y/N Miking- Y/N Mothers’ meeting-Y/N
remaining options and select responses Community meeting-
accordingly. Neighbors-Y/N Rallies- Y/N Community meeting-Y/N Neighbors-Y/N Rallies- Y/N
Y/N
PRI- Y/N AV show / Street play - Y/N Others- Y/N PRI- Y/N AV show / Street olay - Y/N Others- Y/N

Influencers- Y/N TV- Y/N None Influencers- Y/N TV- Y/N None

Whether you are aware of all vaccine/s which

42 are given to your child in this visit (match Yes / No / NA Yes / No / NA
Caregiver Interview

responses with MCP card?

Whether you know when the next visit is due
43 for your child (Please confirm answer through Yes / No / NA Yes / No / NA
MCP card)?

Did ANM ask you to carry MCP card during

44 Yes / No / NA Yes / No / NA
next visit?
Did your child develop any discomfort
45 following previous / today’s vaccination? Yes / No / NA Yes / No / NA
(pain, fever, rash, swelling etc)
a) Gave PCM or cold sponge as instructed by ANM a) Gave PCM or cold sponge as instructed by ANM
b) Consulted ANM/ Informed ASHA/Visited Govt health facility b) Consulted ANM/ Informed ASHA/Visited Govt health facility
What all actions were taken by you in case of c) Visited Private Health facility c) Visited Private Health facility
46*
discomfort (Multiple response possible) d) Visited Quack d) Visited Quack
e) did not take any action e) did not take any action
f) /Others f) /Others
How many visits are required to get your
child completely immunized till 5 years age?
47 Yes/ No Yes/ No
Please tick Yes if caregiver response is
seven.
a) Line listing of households (survey for enlisting of beneficiaries) @ Rs.100 / session Yes / No / NA
Is ASHA aware of incentives in RI
ASHA Incentive

programme? b) Preparation of due list of children/pregnant women for immunization to be updated on monthly basis @Rs.100 /session Yes / No / NA

48 c) Mobilization of children @ Rs 150/= per session Yes / No / NA

(Select “NA” when ASHA could not be
interviewed) d) Full Immunization @ Rs 100 per child who has received all due doses within first year Yes / No / NA
e) For Complete Immunization, @ Rs 50/= per child who has received all doses due up to the second year Yes / No / NA
At Planning Meet Medical Officer in charge to ascertain reasons for monitored session not held. Respond Q-49 and/or 50 as applicable.
unit
49 Why ANM was not available at session site? a) On leave b) Vacant post c) Assigned other work d) Started late e) Others (specify) :
50 Reason for non-availability of vaccines/logistics? a) Not issued b) Not picked up c) Picked up but not delivered d) Others (specify) :