MICS 6 - Form for vaccination records at Health Facility
Name and year of survey
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Under-five child information panel: HF
HF1. Cluster number: _ _ _
HF2. Household number: _ _
HF3. Child's name and line number:
Name ____ _ _ _
HF4. Mother's/caretaker's name and line number:
Name ____ _ _
HF5. Name and number of field staff recording at facility:
Name ____ _ _ _
HF6. Interviewer's name and number:
Name ____ _ _ _
HF7. Day/month/year of interview
_ _ / _ _ / 201 _
HF8. Record the time:
Hours : minutes
_ _ : _ _
_ _ : _ _
HF9. Child's day, month and year of birth: Copy from UB2 in the under-five's background module of the questionnaire for children under five
_ _ / _ _ / 201 _
HF10. Write the name of health facility: ____ (Go to HF11)
HF15. Result of health facility visit
[] 01 Record available at facility copied
[] 02 Record available at facility not copied (specify)
[] 03 Records not available at facility
[] 96 Other (specify) ____
[] 02 Record available at facility not copied (specify)
[] 03 Records not available at facility
[] 96 Other (specify) ____
[p. 2]
Immunisation: HF
HF11. Record day, month and year of birth as written on vaccination record/card
_ _ / _ _ / 201 _
HF12.
(a) Copy dates for each vaccination from the documents.
(b) Write '44' in day column if documents show that vaccination was given but no date recorded
(b) Write '44' in day column if documents show that vaccination was given but no date recorded
BCG
Date of immunisation Day/month/year _ _ / _ _ / 201 _
HepB (at birth)
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Polio (OPV) (at birth)
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Polio (OPV) 1
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Polio (OPV) 2
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Polio (OPV) 3
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Polio (IPV)
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Pentavalent (DTPHibHepB) 1
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Pentavalent (DTPHibHepB) 2
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Pentavalent (DTPHibHepB) 3
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Pneumococcal (Conjugate) 1
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Pneumococcal (Conjugate) 2
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Pneumococcal (Conjugate) 3
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Rotavirus 1
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Rotavirus 2
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Rotavirus 3
Date of immunisation Day/month/year _ _ / _ _ / 201 _
MMR/MR 1
Date of immunisation Day/month/year _ _ / _ _ / 201 _
MMR/MR 2
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Yellow Fever
Date of immunisation Day/month/year _ _ / _ _ / 201 _
Td Booster 1
Date of immunisation Day/month/year _ _ / _ _ / 201 _
HF13. For each vaccination not recorded enter '00' in day column.
HF8. Record the time:
Hours : minutes
_ _ : _ _
_ _ : _ _
[p. 3]
Data collector's observations ________
Supervisor's observations ________