Nepal

1006* ASK YOUR RESPONDENT TO SHOW YOU ITEMS OBSERVED REPORTED, NOT
REQUIRED FOR VACCINATION SERVICES NOT SEEN AVAILABLE
01 Blank/unused individual child vaccination cards or booklets 1 2 3
02 Tally sheets 1 2 3
04* FCHV report forms (HMIS 9.1) 1 2 3
05* Immunization and outreach clinic programme report (HMIS 9.2) 1 2 3
06* Monthly progress report (HMIS 9.3) (IF SHP, HP , PHC) 1 2 3
07* Hospital monthly progress report (HMIS 9.4) (IF PUBLIC HOSPITAL) 1 2 3
08* Immunization register 1 2 3
1007* Does this facility routinely store any vaccines, or are ROUTINELY STORE SOME VACCINES. . . . . . 1
all its vaccines either picked up from another facility
RECEIVE ALL VACCINES FROM HIGHER
or delivered when services are being provided? CENTER AND STORES FOR SHORT TIME. 3 1014
STORES NO VACCINES. . . . . . . . . . . . . . 2 1014
1008 ASK TO BE TAKEN TO THE AREA WHERE VACCINES ARE
REFRIGERATOR OBSERVED. . . . . . . . . . . . . . 1
STORED. ASK TO SEE THE VACCINE REFRIGERATOR.
REFRIGERATOR NOT OBSERVED. . . . . . . . . 2 1014
1009 Do you maintain a cold-chain temperature monitoring chart? YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1012
1010 May I see the cold-chain temperature monitoring chart? OBSERVED. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
REPORTED NOT SEEN. . . . . . . . . . . . . . . . . . . 2 1012
1011 CHECK WHETHER THE TEMPERATURE RECORD WAS YES, COMPLETED . . . . . . . . . . . . . . . . . . . . . . 1
COMPLETED TWICE DAILY FOR EACH OF THE PAST 30 DAYS, NO, NOT COMPLETED . . . . . . . . . . . . . . . . . . . 2
INCLUDING WEEKENDS AND PUBLIC HOLIDAYS.
1012* Please tell me if each of the following vaccines is available
in the facility today. If available, I would like to see it.
IF AVAILABLE, CHECK TO SEE IF AT LEAST ONE IS VALID
(NOT EXPIRED, VVM UNCHANGED, NOT FROZEN)
(May be available on vaccination days only?)
(A) OBSERVED
AVAILABLE
AT LEAST
ONE VALID
AVAILABLE
NONE VALID
REPORTED
AVAILABLE
NOT SEEN
(B) NOT OBSERVED
NOT
AVAILABLE
TODAY
DK /
NEVER
AVAILABLE
01 DPT+HepB+Hib [PENTAVALENT] 1 2 3 4
5
02* ORAL POLIO VACCINE/ IPV 1 2 3 4
5
03 MR VACCINE AND DILUENT 1 2 3 4
5
04 BCG VACCINE AND DILUENT 1 2 3 4
5
05* PNEUMOCOCCAL CONJUGATE VACCINE (PCV 13) 1 2 3 4
5
06* JAPANESE ENCEPHALITIS VACCINE (JE VACCINE) 1 2 3 4
5
1013 WHAT IS THE TEMPERATURE IN THE VACCINE BETWEEN +2 AND +8 DEGREES. . . . . . . . . . 1
REFRIGERATOR? ABOVE +8 DEGREES. . . . . . . . . . . . . . . . . . . . 2
BELOW +2 DEGREES. . . . . . . . . . . . . . . . . . . . 3
THERMOMETER NOT FUNCTIONAL. . . . . . . 4
NO THERMOMETER . . . . . . . . . . . . . . . . . . . . . 5
1014* How many vaccine carriers or cold boxes do you have? ONE 1
TWO OR MORE SETS. . . . . . . . . . . . . . . . . . . . 2
ASK TO SEE THE VACCINE CARRIERS. REPORTED NONE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1015B
RESPONSE FROM KNOWLEDGEABLE RESPONDENT
IS ACCEPTABLE.
1015* How many sets of ice packs or cool water packs do you have? ONE SET. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
TWO OR MORE SETS. . . . . . . . . . . . . . . . . . . 2
ASK TO SEE THE ICE PACKS. NO ICE PACKS, USE PURCHASED ICE. . . . . . 3
REPORTED RESPONSEACCEPTABLE NO ICE PACKS. . . . . . . . . . . . . . . . . . . . . . . . . . 4 1015B
NOTE: 4-5 ICE PACKS MAKE ONE SET
Appendix C • 269