surveytypenamelabellabel::Englishchoice_filterhintrequiredconstraintconstraint_messagerelevantdefaultappearancecalculationmedia::imagerepeat_countnotenote1 2.1 2015-16Handout 2.1, Survey form for Revised Microplanning of Sub Centerpp.jpgselect_one districtdistrict Districtyesselect_one_external blockblockBlockdistrict = ${district}yesselect_one_external phcphc ()PHC (Sector)district = ${district} and block = ${block}yesselect_one_external subcenterSub_Center Name of Sub Centerdistrict = ${district} and block = ${block} and phc = ${phc}yesbegin groupsc_InformationSub Centerfield-listintegersc_population Total Population of Sub Centeryesintegersc_villages Total Number of Villages Under Sub Centeryesintegersc_awc Number of Anganwadi Centeryesintegersc_min_awc Number of Mini Anganwadi Centeryesintegernumber_of_ASHA Number of ASHAyesintegersc_Village_Habitation Total Number of Session in a Monthyesend groupbegin repeatSession_No Session ${sc_Village_Habitation}begin groupgroup1field-listtextname_of_Village_Habitation/ Name of Village / Habitationyesselect_one yes_noHRA High Risk AreayesintegerpopulationPopulationyesend groupbegin groupexpected Annual Estimationfield-listintegerexpected_pw Pregnant Womenyes(${population}*.0247)+(${population}*.0247*.1)integerexpected_0_1_year0-1 0-1 Year Childrenyes${population}*.0247end groupselect_one sessionfreq Frequency of Sessionyesfield-listselect_one month5month5 Month of first Session of the Yearyes${freq}=5select_one month6month6 Month of first Session of the Yearyes${freq}=6select_one day2Session_day2 Day of Immunizationyes${freq}=2select_one day3Session_day3 Day of Immunizationyes${freq}=3select_one day4Session_day4 Day of Immunizationyes${freq}=4select_one day5Session_day5 Day of Immunizationyes${freq}=5select_one day6Session_day6 Day of Immunizationyes${freq}=6begin groupgroup2select_one placesession_place Place of Immunizationyestextname_of_vaccinator Name of Vaccinatoryestextname_of_social_mobilizer Name of Social Mobilizeryesselect_one yes_noAVD AVD ?Vaccine Distribution Through AVDyesselect_one AVDtype_of_AVDType of AVDyes${AVD} = "Yes"textName_of_Person Name of Personyes${AVD} = "Yes"decimaldistance_from_vaccine_depot Distance from Vaccine Depot (KM)yesend groupend repeat

choiceslist_namenamelabellabel::Englishimagedistrict districtAjmerAjmerdistrictAlwarAlwardistrictBanswaraBanswaradistrictBaranBarandistrictBarmerBarmerdistrictBharatpurBharatpurdistrictBhilwaraBhilwaradistrictBikanerBikanerdistrictBundiBundidistrictChittorgarhChittorgarhdistrictChuruChurudistrictDausaDausadistrictDholpurDholpurdistrictDungarpurDungarpurdistrictGanganagarGanganagardistrictHanumangarhHanumangarhdistrictJaipur_I Jaipur IdistrictJaipur_II Jaipur IIdistrictJaisalmerJaisalmerdistrictJaloreJaloredistrictJhalawarJhalawardistrictJhunjhunuJhunjhunudistrictJodhpurJodhpurdistrictKarauliKaraulidistrictKotaKotadistrictNagaurNagaurdistrictPaliPalidistrictPratapgarhPratapgarhdistrictRajsamandRajsamanddistrictSawai_Madhopur Sawai MadhopurdistrictSikarSikardistrictSirohiSirohidistrictTonkTonkdistrictUdaipurUdaipur

yes_noYesYesyes_noNoNo

session1Dailysession2Weeklysession3 2 ()Fortnightlysession4Monthlysession5 Once in two monthssession6 4 Quarterly

day2Each_Thursday Every Thursday2day2Each_Monday Every Monday2day3I_III_Thursday I & III Thursday3day3II_IV_Thursday II & IV Thursday3day3I_III_Monday I & III Monday3day3II_IV_Monday II & IV Monday3day4First_Thursday- I Thursday4day4Second_Thursday- II - Thursday4day4Third_Thursday- III - Thursday4day4Fourth_Thursday- IV - Thursday4day4First_Monday-I - Monday4day4Second_Monday-II - Monday4day4Third_Monday-III - Monday4day4Foutrh_Monday-IV - Monday4day5First_Thursday- I Thursday5day5Second_Thursday- II - Thursday5day5Third_Thursday- III - Thursday5day5Fourth_Thursday- IV - Thursday5day5First_Monday-I - Monday5day5Second_Monday-II - Monday5day5Third_Monday-III - Monday5day5Foutrh_Monday-IV - Monday5day6First_Thursday- I Thursday6day6Second_Thursday- II - Thursday6day6Third_Thursday- III - Thursday6day6Fourth_Thursday- IV - Thursday6day6First_Monday-I - Monday6day6Second_Monday-II - Monday6day6Third_Monday-III - Monday6day6Foutrh_Monday-IV - Monday6

month5JanuaryJanuary5month5FebruaryFebruary5month6JanuaryJanuary6month6FebruaryFebruary6month6MarchMarch6

AVDPVT_Jeep Pvt JeepAVDPVT_Motor_Cycle PVT Motor CycleAVDGovt_Jeep Govt. VehicleAVDOthersOthers

placeawc AWCplacesub_centerSub CenterplacePHC PHCplaceCHC. CHCplaceSchoolSchoolplaceOthersOthers

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