Protocol for using the Home Visit Summary Form (FORM 2)
•
Enter the name of your State, LGA, Ward and Reporting period: reporting period is in month and year (e.g.
March 2013)
1.
First Visits: identify and separate first visits forms from follow up visit forms, count the number of first
visits and record in the space provided.
2.
Follow up visits: Count the number of follow up visits and record in the space provided.
3.
Total number of households visited in the month: Add 1 and 2: this should add to the total number of
forms filled for the months. Count the forms to confirm, record in the space provided
4.
Households with pregnant women: Refer to Question 2 on the form 1. Count the number of forms with
at least one pregnant woman, record in the space provided.
5.
Households with children under 5: Refer to Question 2 on the form 1. Count the number of forms with at
least one child under the age of 5 and record in the space provided
6.
Households with LLIN: Refer to Question 3 on the form 1, count the number of forms where LLIN was
ticked Yes and record in the space provided
7.
Households with LLIN already hung: Refer to Question 3 on the form 1, option b. Count all the forms
where at least one LLIN is hanging and record in the space provided
8.
Households assisted to hang LLIN: Refer to Question 4 on the form 1, count all the forms where option
(a) was ticked and record in the space provided
9.
Total number of individuals in household visited: Refer to option (b) on question 2 on form 1, add the
numbers in all the forms and record in the space provided
10. Individuals reached with messages on LLIN: Refer to option (c) in question 4, identify and select all the
forms where option c was ticked, go to question 2, remove option (c) [total no of children under 5] from
(b) [total no of people physically present in the household] and record the figure in a paper for all the
forms. Add up the values and record in the space provided in form 2.
11. Individuals reached with messages on ANC & IPT: Refer to option (e) in question 7, form 1: identify and
select all the forms where option (e) was ticked, go to question 2, remove option (c) [total no of children
under 5] from (b) [total no of people physically present in the household] and record the figure in a paper
for all the forms. Add up the values and record in the space provided.
12. Individuals reached with messages on prompt care seeking: Refer to option f in question 7: identify and
select all the forms where option (f) was ticked, go to question 2,remove option (c) [total no of children
under 5] from (b) [total no of people physically present in the household] [b-c] and record the figure in a
paper for all the forms . Add up the values and record in the space provided.
13. No of pregnant women referred for ANC: Refer to option (c) in question 6. Add the values on all the
forms and record in the space provided.
14. No of CU5 referred for treatment: Refer to option (a) in question 5. Add the values on all the forms and
record in the space provided.
15. No of pregnant women referred for treatment: refer to option (b) in question 5. Add the values on all the
forms and record in the space provided.
16. No of other household members referred for treatment: refer to option (c) in question 5. Add the values
on all the forms and record in the space provided.