UNIVERSITY OF GONDAR

School of nursing
Community Based Training Program (CBTP)

Part I

A. Data collection formats

A.1. General Information collection format
I. General
1. Geographical location of the study community
Kebele_____________
2. Range of estimated altitude in meters: ____________________
3. Number of: a) Streams_______ b) Ponds_______
4. Do people use irrigation? 1. Yes ________ 2. No_________
5. Total population__________
- Male ___________
- Female _________
II. Economy
1. Mean of generating income
1. Trading
2. Civil servant
3. Handicraft__________
4. Selling fuel wood & charcoal _____________
5. Daily labour _______________
6. Other (specify)_______________
III. Social and other services
1. Educational facilities indicate the number of:
1. Kindergarten _________ 2. Primary school________
3. Junior secondary school ______ 4. Senior secondary school____
7. Other educational facilities (specify)____________
2. Literacy status (estimated number of literate members of the community) _______
3. Number of Churches______
4. Number of mosques_______
5. Other religious centers (specify) ________
6. Community health post: 1. Yes ______ 2. No________
7. If yes, number of: Functioning ________ Non- functioning_________
8. Distance to the nearest
1. Health station _________
2. Health center____________
3. Hospital _________________
4. Drug vendor shops _________
IV. Communications and Power
List all formal and informal organizations present in the Kebele.
1. Formal 1. _________________________________________________
2. _________________________________________________
3.__________________________________________________

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2. Informal 1._________________________________________________________
2. ________________________________________________________
3.________________________________________________________
V. Culture
1. What is / are the staple diet? ______________________________________________
2. Is / are there food taboo/s in the study community? 1. Yes _____ 2. No______
3. If yes, identify the prevailing food taboos? _________________________________
4. For whom are these food items considered taboos? _________________________
5. Common language: 1. Amharic 2. Tigrigna 3. Others (specify) __________
6. What are the major problems prevailing in the study community?
__________________________________________________________
___________________________________________________________
7. What do people feel would be done to solve these problems?
__________________________________________________________
__________________________________________________________
8. What do they think is the community’s contribution to solve their own problems?
__________________________________________________________
___________________________________________________________

Part II
I. ENVIRONMENTAL HEALTH SURVEY
1. Waste Disposal
1. What is the source of waste in your community? (Select all that apply)
Residential/Domestic/Household
Commercial
Industrial
Other (specify) ________________

2. Is there any scheduled program to collect the waste?

 Yes  No
3. What is the final disposal method used for disposing collected waste?
Sanitary land field  Dumping in the river  Burning 
Other_______________
Composting
4. Do you have latrine facility?
 Yes  No
5. If yes, which type?
 Pit  VIP  Flush Other ________
6. If Pit, how far is it from the house?
_____________________________________________________
7. What is the status of ownership of excreta disposal?
 Owned by the family  Shared or communal  Other _______________________

8. If there is no latrine, is there adequate space for construction of a new one?

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  Yes  No
9. Is latrine construction affordable for the family?
 Yes  No

10. What is the waste disposal system of your latrine?

 Closed  Drained to pipes and then to river  clearing the septic tank

2. Water Supply

1. What is the source of your water supply?

 Tap  Well  Stream/River  Others _____________________
2. If you use well,
 Is it protected?  Yes  No
 What is the distance from the toilet? (In meters)_________
Do you employ any method of water purification?
□ Yes □ No
1. If Yes, Which of the following?
□ Boiling □ Traditional filtration □ Standard filtration
□ Other________________________
2. How much is your daily consumption in liters?
_________________________________________
3. Housing Conditions
1. Number of rooms (Excluding kitchen & toilet) __________________

No. of * Ventilation ** Illumination * Cleanses

rooms
1
2
3
4
5
6
*1. Good * 2. Fair * 3. Bad
** 1. Adequate ** 2. Inadequate

2. Type of floor
□ Cement □ Soil □ Wood □ Others
3. Are there cracks on the floor? □ Yes □ No
4. What is the frequency of House Cleaning?
___________________________________________
5. Are there any livestock around the house? □ Yes □ No
6. If yes, are they living together with people?

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 □ Yes □ No, they have separate quarters
7. Type of kitchen
□ Separate room attached to the main house
□ Separate room but detached from the main house
□ No kitchen at all

4. Food Sanitation

1. Which of the following procedures do you implement during food preparation?

(select all that apply)
□ Washing hands
□ Washing vegetables
□ Proper and adequate cooking
□ Material cleaning frequently
□ Preventing contamination
□ Other_____________________________

2. What method do you use to preserve food?

□ Refrigerator □ Other
Other__________________________
□ Drying
5. Vector and Insect control

1. Is there any stagnant water in your locality?

□ yes □ No
2. Is there any method you are applying to control insects?
□ yes □ No
3. If yes, which of the following?
□ Bed nets
□ Insecticides
□ Fumigation
□ Draining stagnant water
□ Insect repellent
□ Other______________________________
4. Do you encounter problems of rodent infestation in your house?
□ yes □ No
5. If yes, what methods do you take for prevention or eradication?
□ Poison
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 □ Mouse traps
□ Cats
□ Other_________________________________

II NUTRITIONAL ASSESMENT
Number of family members’ ___________________________
Income _________________
1. Maternal Education: - - Cannot read and write _________
- Read and write _______
- Grade completed _______
2. What is your staple food?
Injera □ Bread □ Vegetables and fruits □ Inset □ Others (specify) _________
3. Do you get diary food? □ Yes □ No
4. Do you get fatty and proteincious foods? □ Yes □ No
5. How many times do you eat daily?
Once□ Twice □ 3 x/day □ four times/day others (specify) __________
6. Is there any death related to lack of food in this year?
□ Yes □ No
CHILD NUTRITION
1. Do you breastfeed the child? □ Yes □ No
2. Did the child receive supplementary food? □ Yes □ No
3. If yes, at what age you start supplementary feeding?
o < 4 month □ 7-12 month □
o 4-6 month □ after 12-month □
4. For how long you keep on breastfeeding?
o < 6-month
o 6-8 month
o 9-12 month
o ≥12-months
5. How frequently you feed your child per day?
Once □ Twice □ 3 times □ more than 3x
6. What combination of food do you use to feed your child?
o Food made of cereals only _____________
o Food made of cereals and legumes combined _______
o Milk alone ___________
o Milk cereals and legumes combined _______
o From family dish only ___________
7. Do you use to feed fruits and vegetable to your child?
□ Yes □ No
7. Do you expose the child to sunlight?
□ Yes □ No
IV. PARASITOLOGICAL SURVEY
Name________________ Age_____________ Sex_____ House No._________
Educational Status____________ Religion____________ Ethnic group_______

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What are the ways of exposure to river water in your locality?

Drinking water source

Washing

Swimming
Others

Anthropometric Measurements Recording Form For < 5 Children

Reporting Team _______ Woreda ______ Kebele _____

Ser. Name of Child House. Age Sex Weight Length MUAC

No No in kg in cm. in cm.

IV. Pregnancy and Delivery Practices

(Only for Women who had at least one pregnancy)
1. Age (in years) at first marriage :( if even married) _____________________
2a. Age (in years) at first pregnancy: _______________
2b Age (in years) at last pregnancy;________________
3. Total number of pregnancies: __________________
3.1 Number of Live Births: ___________________
3.2 Number of Abortions: __________________
3.3 Number of StillBirths: __________________
4. Number of live births __________
4.1 Number of Male alive __________
4.2 Number of Female Alive__________
4.3 Number of Male dead ___________
4.4 Number of Female dead_________
Check that the values for question 3 = 3.1+3.2+3.3 and

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 4.1+4.2+4.3+4.4= 3.1
5. Where did you deliver your last child?
1. at home 2. In the Community Health Post
3. in a health station 3. In a health centre 4.In a hospital
5. Other (specify) _________________________
6. If the delivery was at home, who attended the delivery?
1. TBA (Trained) 2. Neighbours, family members
3. TBA (un-trained) 4. Health personnel
5. Other (specify) ________________________________
7. Did you have any health problem(s) during in the last pregnancy?
7.1 Pregnancy 1. Yes____ 2. No _____
If yes, mention the problem(s) 1.Bleeding 2.Fever 3.Abortion 4) body swelling 5.Others
(specify)______________
7.2Labour and Delivery 1.Yes____ 2. No _____
If yes, mention the problem(s) 1.Still birth 2.Prolonged labour 3.excessive bleeding 4.Retaind
placenta 5.Others (specify) ________________
7.3 Puerperium 1. Yes____ 2. No _____
If yes, mention the problem
1. Excessive bleeding 2.Fever 3.Urinary incontinence 4.Problems associated with
breastfeeding (breast pain, absent or decreased milk production…) 5.Others (specify)
________________________

10. Do you go to the nearby health facility during pregnancy?

1. Yes_____ 2. No_____
11. If yes to question 10, mention when:
1. While getting Sick 2. For regular check-up 3.Other (specify) _____
11a) if you were going for regular checkups how frequently were you doing it?
Every _________month
____________week
12. Do you make any special preparation before pain starts that would make delivery easier?
1. Yes_____ 2. No______
13. If yes to question 12, mention the type of preparation you make:
_______________________________________________________
14. Are there prohibited foods during puerperium? 1. Yes_____2. No_____
15. If yes to question 14 list: ________________________________________
________________________________________________________________
16. Are there recommended foods during puerperium?
1. Yes 2. No
17. If yes to question 16 list: ______________________________________________
V. Child Care Practices
(Only for women who had at least one delivery-if more than one child include only the last)
Age of the child__________
Sex __________
1. When do you wash the child after birth?

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 ____________________________________________________
2. When do you start breast-feeding the child after birth?
_____________________________________________________
2a) did the breastfeeding include the colostrum?
1. Yes 2. No
3. Is the child given other feeds immediately after birth?
1. Yes 2. No
4. If yes to question 3, what?
1. Water 2. Butter
3. Water & Butter 4. Other (specify) ___________________
5. For how long have you breastfeed?
1. Still breastfeeding 2. For < 3 months
3. For 3 to 4 months 4. For 5 months
5. For 6 months 6. For > 6 months
6. At what age do you start additional food for your baby?
1. < 4/12 2.4-6/12 3.7-12/12 4.> 12/12

What is the first additional food you introduce?

1. Pulses and Nuts 2. Milk and milk products
3. Eggs 4. Meat
5. Fruits and vegetables 6. Cereals (specify) __________________
7. Others ______________________________________________
8. How is weaning done?
1. Gradually 2. Abruptly
9. If abruptly to question 8, why? ____________________________________________
10. Are there forbidden foods for an infant?
1. Yes ___ 2. No _____
10. If yes mention the food items that are forbidden
_______________________
11. If yes question 10, why? _________________________________________________
12. Are there recommended foods for an infant?
1. Yes ___ 2. No _____
13. If yes to question 12, list the foods: _______________________________________
14. If yes to question 12, why do you recommend these types of foods?__________
_____________________________________________________________
15. Do you use bottle for feeding?
1. Yes ___ 2. No _____
16. Does your under five child attend children's clinic for check-up (if more than one child
refer to the youngest one)?
1. Yes ___ 2. No _____
17. If yes to question 16, where? ________________________________________
18. Which of the following do you practice in the family?
1. Uvula cutting 2. Extraction of milk tooth
3. Female circumcision
4. Application of cow dung in the umbilical cord of a new bon
5. Starvation therapy (for managing diarrhoea)
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 6. None ____________________
7. Other (specify) ___________________________________
19. Did any of your under five children has health problem during the last two weeks?
1. Yes ___ 2. No _____
20. If yes to question 19, what is the sex, age and type of ailment?

Sex Ailments
Ser 1. Male Age 1.Fever
No. 2. Female 2. Diarrhoea
3. Cough
4. Others (specify)

HIV/AIDS Awareness among Reproductive age Women

1 Have you ever heard about HIV/AIDS?
Yes_______________ No_______________
2 If yes what are the ways of transmission?

Mother to child 1
Sexual Intercourse 2
Blood and blood products 3
Others (specify) - 4
__________________
________________
3 Is it possible to prevent HIV?
Yes_______________ No_______________
4 If yes what are these methods?

Abstinence 1
Being faithful 2
Safe sex 3
Condom use
STI treatment 4
Safe transfusion 5
Safe infant feeding 6
Others (specify) - 7
_________________
________________

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5 Have you ever been tested for HIV?
Yes_______________ No_______________
6 If no specify why?
Sure of being negative 1
Fear of positive result 2
do not know where to get the service 3
Accessibility 4
could not afford 5
Others (specify) 6
EXPANDED PROGRAMME IMMUNIZATION FORMAT
Part I: EPI Coverage
Date ________________ Woreda _______ Keftegna/Kebele ____________
Name
Child No.
Sex
Immunization given (at
least once) Yes
Birth date & year No
Immunization given by*
Birth date & year
Vaccination Yes
Card No
DPT 1 Date From card
DPT 2 Date From card
DPT 3 Date From card
Polio 1 Date From card
Polio 2 Date From card
Polio 3 Date From card
Measles Date From card
Measles (2nd Date From card
BCG Date From card
TT 1 Date From card
TT 2 Date From card
TT 3 Date From card
TT 4 Date From card
TT 5 Date From card
IUCD Date From card
DEPO Date From card
IMPLANON Date From card
OPVo
OPV1, penta1, Date From card
rota1,PCV1
OPV2, penta2, Date From card
rota2,PCV2

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OPV3, Date From card
penta3, ,PCV2,
IPV
Other (specify
it )
TT-refer to the mother
Part II: Reasons for Immunization Failure (to be used with part I)
Child No.
1. Unaware of Immunization
2. Unaware of need to return
3. Fear of side-effect reactions
4. Place and time of immunization
unknown
5. Wrong ideas about
contraindication
6. Rumours about adverse effect
7. No faith in immunization
8. Mother busy
9. Time of immunization
inconvenient
10. Family problem
11. Child sick on day of immunization
12. Vaccination site too far to go
13. Have to wait a long time
14. Health staff rude & impolite
15. Vaccine not available
16. Vaccinator absent
17. Mother ill
18. Others specify
Note: Ask only one question at a time,
As ‘Why was the child not immunized’ or ‘why was the child unable to complete his/her
vaccination?’ and put a check mark (√) on the appropriate response
_________________ ________ _______________ ________________
Name of student signature and Date Team and class
______________ ________________
Name of Supervisor Signature and Date

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