1. Booth Activity Monitoring form - Polio NID/SNID
Round: _________ Date ________ District: _________________ Setting: Rural / Urban; Name of Block/Urban Area ___________________ Planning Unit: _________________________
Name of Monitor: ____________________________ Organization: Govt / ITSU / WHO / UNICEF / UNDP / CORE / / IPE - SMNet / IFV / Others: ___________________
If monitor from WHO: SMO / SRTL / OSA - OSD / RTL / NPSU / IPE-FM / EM
Booth No. No: No: No: No: No:
Monitoring start time
Is the booth easily accessible to the community? Y / N Y / N Y / N Y / N Y / N
Does the booth have IEC materials (like banners or posters) displayed
prominently?
Y / N Y / N Y / N Y / N Y / N
Number of team members found working 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4
Number of team members following Covid-19 appropriate behaviour 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4
Whether Covid-19 appropriate behaviour being followed by the caregivers at the booth? 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4
No. of children observed while polio vaccine was administered (Max-5) _____ / NA _____ / NA _____ / NA _____ / NA _____ / NA
No. of children given polio vaccine with dropper not touching the child’s
mouth
_____ / NA _____ / NA _____ / NA _____ / NA _____ / NA
Number of team members not same as in micro plan (i.e. replaced team
members)
0 / 1 / 2 / 3 / 4 0 / 1 / 2 / 3 / 4 0 / 1 / 2 / 3 / 4 0 / 1 / 2 / 3 / 4 0 / 1 / 2 / 3 / 4
No. of vaccinators that attended the vaccinator training conducted prior to
this round?
0 / 1 / 2 / 3 / NA 0 / 1 / 2 / 3 / NA 0 / 1 / 2 / 3 / NA 0 / 1 / 2 / 3 / NA 0 / 1 / 2 / 3 / NA
Did the booth receive the vaccine supply as per requirement? Y / N Y / N Y / N Y / N Y / N
Any unused/partially used polio vaccine vial with VVM in unusable stage?
If yes, remove and give replacement
Y / N Y / N Y / N Y / N Y / N
Does the team have correct knowledge about VVM? (ask to indicate and
explain the VVM)?
Y / N Y / N Y / N Y / N Y / N
Is the team marking the left little finger of children prominently? If no,
demonstrate.
Y / N Y / N Y / N Y / N Y / N
Is the team marking the tally sheet correctly after each child is vaccinated? Y / N Y / N Y / N Y / N Y / N
Does the number of used vials tally with the number of children
vaccinated?
Y / N Y / N Y / N Y / N Y / N
2. Booth No. No: No: No: No: No:
Monitoring start time
Interview of Booth Workers
Are the vaccinators aware of any community mobilizer / volunteer working
in the booth area?
Y / N Y / N Y / N Y / N Y / N
Interview of Parents: Interview 5 parents/caregivers who have brought children to the booth
How did you learn about the booth activities? (1st
respondent, 2nd
respondent, list all applicable numbers) 1-Miking; 2-Drum beating: 3-TV; 4-
Radio; 5-Newspaper; 6-poster/leaflets; 7-banner/hoarding; 8-
mosque/temple announcement; 9-relative/ neighbour / friend; 10-health
worker or Anganwadi worker; 11-CMC; 12-Any other
1 2 1 2 1 2 1 2 1 2
3. Migratory High -Risk Areas and Mobile Population Monitoring Form – Polio NID/SNID
Round__________ Date __________________State ______________________District________________________
Setting: Rural/Urban; Name of Block/Urban Area _________________________ Planning Unit: _______________________
Name of Monitor: ____________________ Organization: Govt / ITSU / WHO / UNICEF / UNDP / CORE / / IPE-SMNet / IFV / Others: _________
If monitor from WHO: SMO / SRTL / OSA - OSD / RTL / NPSU / FM-IPE / EM
Instructions for Migratory sites
Visit migratory population sites such as urban/ peri-urban slums including agricultural & industrial labour settlements, nomadic population settlements,
brick kilns, construction sites, and other such areas
Walk through different geographical areas of the migratory settlement to conduct this survey. Check finger marking of 0-5 years age group in each site.
In settlements with <100 households check 10-15 children and in larger settlements with >100 households check at least 20-25 children. Repeat
activity if >10% children are unvaccinated as evidenced by no finger marking.
Name of site/ location monitored
Time of visit by monitor
Circle category of site (code given below) 1 / 2 / 3 / 4 / 5 / 6 1 / 2 / 3 / 4 / 5 / 6 1 / 2 / 3 / 4 / 5 / 6
Is this site a part of micro plan? Y / N Y / N Y / N
If Yes, Record Team No & Name of supervisor
Has the team visited this site? Y / N Total Y / N Total Y / N Total
Children less than 5 years checked
(Put a tally mark for each child checked)
Denominator
Unvaccinated children less than 5 years found
(Put a tally mark for each unvaccinated child) Numerator
Operational Components: Monitors should try to meet the team working in the area and observe their activities.
No. of team members found working 1 / 2 / 3 / 4 / Team Not met 1 / 2 / 3 / 4 / Team not met 1 / 2 / 3 / 4 / Team not met
Is the team carrying a copy of its micro-plan with RI
component included in the format?
Y / N Y / N Y / N
If yes, is information on routine Immunization filled
completely in micro-plan format?
Y / N Y / N Y / N
Workload of teams: No. of houses being covered
by this team
< 150 / 150-200 / > 200 < 150 / 150-200 / > 200 < 150 / 150-200 / > 200
Team Composition: Are the first two vaccinators
same as mentioned in micro plan?
Both / One / None Both / One / None. Both / One / None.
Number of vaccinators below 18 years of age Both / One / None Both / One / None Both / One / None
ASHA involvement: Is ASHA worker identified in
this area?
Y / N / NA / Not Known Y / N / NA / Not Known Y / N / NA / Not Known
If ASHA worker is identified, is she working with the
team?
Y / N Y / N Y / N
Anganwadi involvement: Is Anganwadi worker
identified in this area?
Y / N / NA / Not Known Y / N / NA / Not Known Y / N / NA / Not Known
If Anganwadi worker is identified, is she working
with the team?
Y / N Y / N Y / N
Training: Number of vaccinators trained before this
round
Both / One / None / NA Both / One / None / NA Both / One / None / NA
Team Performance: Is team checking and
vaccinating children found outside of houses?
Y / N Y / N Y / N
Supervision: Is supervisor crosschecking work of
this team in the field?
Y / N Y / N Y / N
VVM Status: The status of VVM of
unused/partially used vaccine vial
Usable / Non-usable Usable / Non-usable Usable / Non-usable
1- Slums with migration; 2 – Nomads; 3 – Brick kiln; 4 – Construction site; 5 – Others, 6 – Settled non-migratory HRAs such as Urban Slums, Hard to
Reach Area, VPD outbreak areas, Unserved/ Vacant sub centre, Underserved / Vaccine Hesitancy / Refusal Area and others
4. Transit Site Monitoring Form – Polio NID/SNID
SIA round:_______ Date:__________ District:_____________________ Name of Block/Urban:__________________ ; Setting: Rural / Urban
Planning Unit: _________________ Name of monitor: _____________________ Organization: Govt / ITSU / WHO / UNICEF / UNDP / CORE /
IPE - SMNet / IFV / Others: __________ If monitor from WHO: SMO / SRTL / OSA - OSD / RTL / NPSU / IPE - FM / EM
Instructions for Transit sites *
Monitor should observe at least 10 children at each transit point discreetly. Put a tally mark for each child passing through the transit
point. In the next row, put a tally mark for each child whose finger mark is checked by the transit point team.
Name of transit site:
Railway station /
bus terminus / bazaar /
mela / other
Railway station /
bus terminus / bazaar /
mela / other
Railway station /
bus terminus / bazaar /
mela / other
Time of visit by the monitor
Are adequate numbers of teams deployed at this
site?
Y / N Y / N Y / N
Are the shift timings appropriate? Y / N Y / N Y / N
Are all the deployed members present at this site? Y / N Y / N Y / N
Number of team members found working 1 / 2 / 3 / 4 1 / 2 / 3 / 4 1 / 2 / 3 / 4
Number of team members below 18 years of age 1 / 2 / 3 / None 1 / 2 / 3 / None 1 / 2 / 3 / None
No. of children < 5 yrs that passed through the site
(denominator)
No. of children < 5 yrs that were checked for finger
marking by transit point teams (numerator)
No. of children observed when polio vaccine was
administered (denominator)
No. of children given polio vaccine with dropper not
touching the child’s mouth (numerator)
Status of VVM of unused/partially used vaccine vial Usable / Non-usable Usable / Non-usable Usable / Non-usable
Has supervisor cross-checked the work of this team
any time during the day?
Y / N Y / N Y / N
.
5. House to House Activity Monitoring Form - Polio NID/SNID
SIA round:_________ Date:_________ District:_____________________ Setting (encircle): Rural / Urban; Name of Block/Urban:________________________ Planning Unit: ___________________________
Name and exact address of the village / urban locality: ____________________________________ Team No.: _____ Supervisor’s name: ______________________________
Name of monitor: ________________________________ Organization: Govt / ITSU / WHO / UNICEF / UNDP / CORE / IPE - SMNet / IFV / Others: ___________________
If monitor from WHO: SMO / SRTL / OSA - OSD / RTL / NPSU / IPE-FM / EM Time of visit by monitor: _____
1) Assessment of completeness of house-to-house immunization activity: Visit 10 “P” or unmarked houses of team’s work of one day Is this area identified as high risk: Yes / No
S. No. 1 2 3 4 5 6 7 8 9 10
1. House number put by the team on the house
(For unmarked house write 0)
2. Religion of the family: H=Hindu, M=Muslim, O=Other
3. Does the family have a child born after the last SIA round Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
4. If yes, is the child immunized by the team in this round Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA Y / N / NA
5. Number of children <5 years vaccinated during this round
6. Number of children <5 years NOT vaccinated during this round >0 >0
7. Number of children <5 years NOT vaccinated at booth
[Write/select NA if no booth activity is planned in the district/area]
8. Mention reason if one or more eligible children found not
vaccinated at polio booth. (multiple options allowed).
[Skip if response to Q7 = NA]
Select appropriate reason(s) [Multiple options allowed]:
1) Booth not conducted 2) Not aware of booth activity 3) Booth far
away 4) Booth found closed 5) Vaccine was not available at the booth
6) Caregiver busy 7) Child was not present on booth day 8) Child sick
9) Fear of COVID-19 infection, 10) Others
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
1 / 2 / 3
4 / 5 / 6
7 / 8 / 9 / 10
2) Check missed areas (clusters of houses and field huts etc. missed by the teams in areas supposed to have been covered)
S. No. & Name of Area 1 2 3 4
Type of area Urban / Rural / Field hut / Other Urban / Rural / Field hut / Other Urban / Rural / Field hut / Other Urban / Rural / Field hut / Other
No of houses missed (circle) <20 / 20-50 / >50 / Team day area <20 / 20-50 / >50 / Team day area <20 / 20-50 / >50 / Team day area <20 / 20-50 / >50 / Team day area
Is missed area part of micro-plan? Y / N Y / N Y / N Y / N
6. 3) Operational Components: Monitors should try to meet the team working in the area and observe their activities at approximately 5 houses.
House number put up by the team
No. of children observed when polio vaccine was administered (denominator)
No of children administered polio vaccine with dropper not touching child’s mouth (numerator)
Microplanning formats: Is the team carrying a copy of
its micro-plan with RI component included in the format?
Y / N / Team not met
ASHA involvement: Is ASHA worker identified in this area? Y / N / NA / Not Known
If ASHA worker is identified, is she working with the team? Y / N
If yes, is information on Routine Immunization filled completely in microplan format? Y/ N Anganwadi involvement:
Is Anganwadi worker identified in this area?
If Anganwadi worker is identified, is she working with the team?
Y / N / NA / Not Known
Y / N
Workload of teams: No. of houses being covered by this team < 150 / 150-200 / > 200
Team Composition:
No. of team members: 1 / 2 / 3 / 4
Are first two vaccinators same as mentioned in micro plan? Both / One / None
Number of vaccinators below 18 years of age? Both / One / None
Training: Number of vaccinators trained before this round Both / One / None / NA
Team Performance: If met with team, assess questions below:
Is the team maintaining distance while interacting with caregiver at the households? Yes / No
Is team checking and vaccinating children found outside of houses? Y / N
Supervisor performance: Supervisor found wearing face mask/face cover? Yes / No / Not met
VVM status: The status of VVM of vaccine being used (encircle one): Usable / Non-usable
Manufacturer of vaccine: Bharat Biotech / BIBCOL/ Haffkine / Panacea / GSK / Novartis /
Sanofi/ Others ________________________
7. Bi-phasic Activity Monitoring Form – Polio NID/SNID, West Bengal
SIA round:_______ Date:_______ District:_______________________ Block/Urban:_____________________ Setting (encircle): Rural / Urban; Planning Unit: ________________________
Name and exact address of the village / urban locality: ____________________________________ Name of monitor: __________________________ Time of visit by monitor: ______
Organization: Govt / ITSU / WHO / UNICEF / UNDP / CORE / IPE - SMNet / IFV / Others: _________________ If monitor from WHO: SMO / SRTL / OSA - OSD / RTL / NPSU / IPE-FM / EM
1. Assess team’s efforts to convert X houses to P. Team Number _______ Is this team working in a pre-identified HR GP / Ward? Y / N
House number / date put by team on the house during first visit X- X- X- X- X- X- X- X- X- X-
Has the team re-visited household in afternoon for X to P
conversion? Circle “Y” for yes and “N” for no Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
If yes, are there unimmunized children in the household even
after re-visit? Circle “Y” for yes and “N” for no Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N
Did the team conduct biphasic activity in this team area?
(Based on monitor’s visits to X houses in team’s area)
Y / N If yes, did the team visit all monitored X houses Y / N
2. Assess supervisor’s efforts to convert X houses to P.
Name of Supervisor
Has the supervisor made any efforts to convert X houses to P? Y / N
3. Assess Medical Officer’s efforts to convert X houses to P
Name of Medical Officer
Has the Medical Officer made any efforts to convert X houses to P? Y / N
If yes, is the Medical officer carrying any medicine kit? Y / N
4. Assess efforts to support X-to-P conversions during biphasic activity.
Is this team working in a pre-identified HR GP / Ward? Y / N
No. of team members found working 1 / 2/ 3 / 4 / 5 / 6
Is there a NGO designated to work in this area? Y / N
If Yes, is the NGO member accompanying the team? Y / N
If Yes, is the NGO member making an effort to convert X houses to P? Y / N
Is NGO worker carrying any Appeal (Muslim religious leaders)/ Leaflet (IEC) for explaining the family? Y / N
8. Is the NGO worker cross checking the register after the team has identified all children in household? Y / N
Is there an influencer assigned to this team as per micro plan? Y / N
If yes, is the influencer visiting all X houses with the team during bi-phasic activity? Y / N
Is the influencer known to the team? Y / N
Is the influencer making an effort to convert X houses to P? Y / N
Was there UNICEF supported poster or IEC displayed in the areas? Y / N
9. Polio NID/SNID – End of Round Survey (ERS) of Children - Completeness of the Activity
Instructions:
Conduct this survey on the day after completion of house-to-house activities. Visit high risk migratory population sites such as urban/peri urban slums, nomadic population settlements, brick kilns,
construction sites, and other HR rural / urban areas. Also visit transit/congregation sites like markets (haats & bazaars), bus stands, railway stations, melas, religious congregations etc
Walk through all geographical parts of the areas to conduct this survey. Check finger marking of around 20 children in 0-5 years age group. At least 5 children
should be in the 0 - 2 years age group. Only children with polio indelible ink finger marks should be considered “vaccinated”.
SIA round:____________ Date:__________ District:_____________________ Setting (encircle): Rural / Urban; Name of Block/Urban:________________________
Planning Unit: _________________ Name and exact address of the village / urban locality: ____________________________________ Team No.:_____ Supervisor’s name:____________________
Name of monitor: __________________________ Stakeholder/Organization: Govt / ITSU / WHO / UNICEF / UNDP / CORE / / IPE - SMNet / IFV / Others: ___________________
If monitor from WHO: SMO / SRTL / OSA - OSD / RTL / NPSU / FM-IPE / EM
Record the details in the format given below. Vaccinate any unvaccinated child found. (Put a tally mark for each child)
Type of site Children checked in urban/peri-urban slums, nomadic population, construction site and brick kilns and other HR
areas
Children checked at markets (haats & bazaars), bus
stands, railway stations, melas etc
Time of visit by monitor at the site→
Name of Site/Location monitored
Circle category of site (as per code
given below)
1 / 2 / 3 / 4 / 5 / 6 1 / 2 / 3 / 4 / 5 / 6 1 / 2 / 3 / 4 / 5 / 6
Railway station / bus terminus /bazaar /mela
/religious congregation / Others
Is this site/ area part of microplan? Y / N Y / N Y / N Y / N
Has the team visited this site/area Y / N Total Y / N Total Y / N Total Y / N Total
Children (less than 2 years) checked
Unvaccinated children (less than 2
years) found
Children (2 years to 5 years) checked
Unvaccinated children (2 years
months to 5 years) found
1. Slums with migration; 2 – Nomads; 3 – Brick kiln; 4 – Construction site; 5 – Others
6 - Settled non-migratory HRAs such as Urban Slums, Hard to Reach Area, VPD outbreak areas, Unserved/ Vacant sub-centre, Underserved / Vaccine Hesitancy / Refusal Area and others
