Name of Payam Assistant: _______________________ Name of County Supervisor: ______________________ Signature: ________________________________ Signature: __________________________ A-3: Information to be kept in the Payam Assistant’s Logbook Logbook information for contacts with KIs during the month State: County: Payam: Date of contact Name of KI Location of contact Reason of contact* Follow-up action Signature of KI * Reason for contact can be: a) Routine visit by PA, b) Report of suspect case by KI, or c) Other Logbook information for meetings conducted/attended during the month State: County: Payam: Date of meeting Meeting Location Purpose of Meeting Type of attendees Number attended Main issues discussed Follow-up actions
A-7: CBS Checklist for Payam Assistants (PA) Supervisor/visitor’s name: Date of visit: REMARKS County: Payam: Name of the payam assistant 1) Does the payam assistant have an work plan for the current month? Yes No 2) Does the payam assistant have a list of the Key Informants (KI) indicating the location and the type of the KI? Yes No 3) Is the number of the key informants appropriate? Yes No 4) Is the selection of the Key Informants appropriate? Yes No 5) Does the payam assistant have map of distribution of the KI? Yes No 6) Does the distribution of the KI provide full coverage of the population of the payam? Yes No 7) Does the payam assistant (PA) keep a log book for contacts with key informant? Yes No 8) Do the key informants sign the log book when visited by the PA? Yes No 9) Did the PA carry out all planned visits to KI last month? Yes No 10) Did the PA conduct all planned community meetings last month? Yes No 11) Does the PA keep a line-list of the suspect AFP cases reported? Yes No 12) Is the above line-list properly filled? Yes No 13) Does the Payam Assistant (PA) have a copy of the monthly report for the previous month? Yes No 14) Does the PA know the name and have contact with the WHO disease surveillance staffs in his/her payam & the county (If any)? Yes No TOTAL YES PERCENT YES:
B-2: Information to be kept in the County Supervisor’s Logbook/Diary Logbook information for contacts with PAs during the month State: County: Payam: Date of contact Name of PA and/or other persons Location of contact Reason of contact* Follow-up action Signature of PA * Reason for contact can be: a) Routine visit by PA, b) Report of suspect case by KI, or c) Other Logbook information for meetings conducted/attended during the month Date of meeting Meeting Location Purpose of Meeting Type of attendees Number attended Main issues discussed Follow-up actions Other information:
B-6: Monthly Report by County Supervisors Name of County Supervisor: Reporting Month Implementing partner: County: State: - Visits to Payam Assistants SN Name of PA Date of planned visit Date of actual visit Summary score of checklist Issues detected during the visit 1 2 3 4 5 6 - Summary of checklist for supervising Payam Assistants SN Question from Checklist Total PAs visited in the month Number of Checklists filled-out Number of “Yes” answers from checklists % Yes 1 Up-to-date work plan 2 List of the Key Informants (KI) 3 Number of KI appropriate 4 Type of KI appropriate 5 Map of distribution of the KI? 6 KI fully cover the population of the county 7 A log book for contacts with key informant 8 key informants sign the log book 9 PA carried out the planned visits to KI last month 10 PA conducted planned meetings last month 11 A line-list of the suspect AFP cases reported 12 Line-list properly filled 13 Has the monthly report for the previous month