Acoll Name
Island Name
Ciinic Name
Clinic Locacion
interviewer Name
QUESTIONNAIRE FOR CLINIC XcY HOLDER
1.
What is the total number of health workers in the clidic serving
area including clinic personnel, tradicional sealers, [midwives,
vetarinarians,
dencists, ete.
clinic personnel.
2.
Inelude clinic kay hoJder and other
Who conducts deliveries in the clinic serving area?
(Check
apply below and report the number of individuals of each tyod
worker who conduct deliveries?)
$ many as
of health
Number of dealch Workers
Who Do Deliveries
{ ]
Clinic Personnel
{ ]
_
{ ]
Traditional YWidwives
Others (please specify)
For each health worker in che clinic serving area, record the foMlowing infornmation.
Start with che clinic kev holder.
LYFORMATION ON CLINIC KEY dOLDER
3.
4.
Primary occupation of clinic key potsesDoes this person work in the clinic?
[]
[ ]
Yes
Ne
3.
Hours ver week spent in clinic work.
6.
age
7.
Sex: