New Vaccine Post-Introduction Evaluation - libdoc.who.int - World ...

Appendix 2.2: Questionnaire — health facility
Date of interview: __________________________________
Name of interviewer: ____________________________
This questionnaire was conducted at:
Region:_______________________________________________________________________________________
District:_______________________________________________________________________________________
Health-facility name:_____________________________________________________________________________
Type of health facility (check one):
Health Centre/Clinic Health Post/Outpost Other (specify) _________________________
Name(s) and title(s) of person(s) interviewed (please list all persons that you interviewed):
EPI Senior Nurse/Health-care worker responsible for vaccinations (or their deputy) should be interviewed
Name:___________________________________________
Name:___________________________________________
Name:___________________________________________
Title: ________________________________________
Title: ________________________________________
Title: ________________________________________
Contact details of most senior person:
Telephone:________________________________________
E-mail address: ________________________________
Denotes Suggested Key Finding (see Appendix 3).
Documents to request at beginning of interview: (check appropriate boxes)
Introduction plan for new vaccine
Document / data
Training materials/reference documents utilized during new
vaccine training
Vaccine management guidelines
Media campaign/social mobilization/education materials
(brochures, posters, pamphlets, etc.)
Vaccine stock records
Supervisor’s book/site visit reports
Injection safety/waste-management policy document
Wastage reports
AEFI protocol/reporting form
AEFI logbook/registry
Sample child health card/immunization card
Immunization logbooks, monitoring forms, tally sheets,
vaccine registries
Document
received
Document reported
to exist but not
available at time of
interview
Document
unavailable
WHO/IVB/10.03
35