MOSQUITO NET USAGE SURVEY

DISTRIBUTION DETAILS

Location: .... I1.(1lJ.J.~. ~'.1'1A:.............. .........SlIb-location: Y\9.yt]...... v.~ ................ .

. pate of Original Distribution: .. ..Iw. /1.:/If.?.. ))ate of this Review: .......'1.11111 ............ ..

· To' the Householder In the past, you received mosquito nets for free in a community distribution. We are conducting a random review of 50 households to assess lIet usage and net condition. We would like to ask for your permission to enter your home to gather this infonnation. Information is gathered anonymously: your personal details are not recorded.

'. From the householder:

·T agree to allow you enter III)' home in my presence for rt few minutes for the purpose of ,lssessing

the use and cond ition of Ill)' mosquito nets. . ' .

.' . Signature of member ofhousehold: ..~..rJ.Ct

- -

MOSQUITO NET USAGE SURVEY

DISTRIBUTION DETAILS

jLo,,,Uon ... . Na.'.'~~f..->. ~... .......,.............Sub-loc.Hon' .~b.....................

. pate of Original Distribution: .. lf/.c/I??.. Date of this Review: ......Y/..I/IJ ............

·To' the Householder .In the past, you receivcd mosquito nets for fre~in a community distribution. We are conducting a random rcview of 50 houscholds to assess net usage and net condition. We would like to ask for your permission tb enter yonr home to gather this information. Information is gathered anonymously: your pcrsonal dctails lIrc not recordcd.

From thc householder: T ngree to allow you cnter my home inmy prescnce for a few minutes for the purpose of ilssessing

· the use and condition of my mosquito nets. . . f) .t1 . . .. . . S' .. f I J 'P-{11Y \ c.J { U . Ignature of membcr 0 househo (I: .............,.. ••••••......J..••.~.............................

- /) l. How many nets are thcre in thc household? \ ~ .Total number of SLEEPING SPACES

y.

Number WITH NETS

Number WITHOUT NETS

Numbcr Of AMFNets

. [\ \ .-, /. I \ \ ' I

~ - ( 2. Arc the AMF nets bcing used at night? (please circlc one) ~S NO 3. Are thc AMF nets being used correctly? ([llcasecircle one) ES NO .Please ask the householder to demonstrate how the nets are llsed at D1 . .

4. What is the condition of the AMF ncts? PlcJse select: Vcry Good «2 holes oi' < 2cm). OK (fewer than 10 sma ll holes), Poor (marc than to small holes or 1 big hole)

Condition of AMF

Nct

Who slcpt under the AMF ncts last night'?

Net 1 'VCr- 1A~C { Net 2 tMA ZLl Net 3 (\r f\ 2C Net 4

Nct 5

Condition ofAMF

Net

Who slept Llndcr . the AMF nets last night?

Net 6

Net 7

Net 8

Net 9

Net 10 ,

· CERTIFICATION

I certify the information in this form is correct.

Reviewer's name alld position: ..).~.'?.....~\Il.~(. ..It..Y..~. Reviewer's organisatioIl: ......c;,Ce~.\.. ...O\J~.~.~.~...................

.,~

. / G M i n

Aga inst M,llariil Foundation ~:y_'Yw ·.Agai nstMalmia.coJll Page I of 1 100% % lll'jiIl7l/S hllY lIelS. rhey end lip uver heads and beds (lnd l l'e demonstrate rhat ho.\ happened

MOSQUITO NET USAGE SURVEY

DJSTRIBUTlON DETAILS

ILociltion: ·~:~·~····I ···T ··SUb-IO'"tiO"' ~~J.&;:." ... """."..... I1.'iL(}.J- · ; pilte of Original Distribution: .. j~~..."t./lf!..... Date of this Review: ..V .llll .................

. To' the Householder ,In the past, you received mosquito nets for free in a community distribution. We are conducting a random review of 50 households to assess net usage and net condition. We would like to ask for your permission to enter your home to gather this information. Information is gathered anonymously:

. your personal details are not recorded.

' From the householder: '1 agree to allow YOll enter my home in my presence for a few minutes for the purpose of llssessing the use and condition of my mosquito nets.. r{} f;,.,' . .

.. . . , . . [.>O(r~e ~ " . .Signilture of member of household: .................................~~ .................. .

1. How many nets arc there in the household? ) \ \ l lj lJ'

Total number of Number Number Number SLEEPING SPACES WITH NETS WITHOUT NETS Of AMF Nets

"1\ t ~ /' \ ) ( 3 -: ( ( C

2. Are the AMF nets being used at night? (please circle one) NOgs 3. Are the AMP nets being used correctly? (pJeasecircIe one) YE NO .P lcase ask the household« to demoost"te how the nets ace used at· .

4. What is the condition of the AMF nets? Please se lect: Very Good «2 hoks of < 2cm), OK (fewer than 10 small h0Ics). Poor (more than 10 smail holes or I big hole)

Condition ofAMF

Who slept under the AMP nets last

Net 1

Net 2

Net3

Net 4

Net 5

Condition of AMF

Net

Who slept under ' the AMP nets last night?

Net 6

Net 7

Net 8

Net 9

Net 10

CERTIFICATION

I certify the information in thi s form is correct.

Reviewer's name and POsition:?0£A.P.....(e.J1Jt.tk.&..t&t\-.k.... Reviewer's organisation: ...G..Ct.k0..:1.. ....m.lYl/W!.:Y~, ...................

Against Malaria Foundation ~w,f\gainstMa\~ja,com Page \ of 1

f 00% ofoUI'jilnds buy nelS. Ihey end up over heads and beds alld tre demonslraie rhar hilS happened

Kongohun_Mandeima Followup 2010_2011Mandeima_Mandeima Followup 2010_2011