monitoring and evaluation package for community-based ... · web viewwhen you see a client for the...

Monitoring and Evaluation Package for Community-Based Provision of Family Planning Services:

Tools for Community Health Workers

June 2011

Cover Photo: © 2002 Kingston Namun/Mark Munguas, Courtesy of Photoshare

The contents of this report are the responsibility of project partners and do not necessarily reflect the views of USAID or the United States Government. Financial assistance was provided by USAID under the terms of GPO-A-00-08-00001-00, Program Research for Strengthening Services (PROGRESS).

2


Tools for Community Health Workers

June 2011

3


Tools for Community Health WorkersWhat is included in this package?This package contains sample monitoring and evaluation tools that have been developed based on program experiences from community-based access (CBA) programs that offer family planning (FP) and reproductive health (RH) services in Uganda, Kenya, Nigeria, and Zambia.

How to use the tools These tools can be adapted for use by community health workers (CHWs), their supervisors, and

program managers for recording FP/RH service delivery data for CBA programs. Forms used to gather data must be functional for the users and facilitate the accurate collection, tracking, and use of data.

Why use these tools? Ensure service delivery data is used for decision-making by either the CHW or the CBA program

staff. Data from CBA programs must be supplied to existing health management information systems in a

seamless manner so that program managers are aware of the need for services and can ensure that service providers and commodities are always available to meet demand.

The following sample tools are provided in this package along with a description of each tool’s purpose and instructions for completion. It is recommended that when possible, the instructions provided with the forms be photocopied onto the back side of the form so users have easy access to that information.

Table of Contents

1. Client List 5

2. Activity Planner 7a. Option 1: Monthly Planner 8b. Option 2: Weekly Planner 9

3. Client Tracking Form 11

4. Client Reminder Card 14

5. Referral Form 15

6. CHW Services Tracking Form 18

7. CHW Stock Tracking Form 21a. Option 1: CHW/supervisor shared responsibility (based on CHW 22

distribution records and inventory of CHW’s supply)b. Option 2: Supervisor-only (based on inventory of CHW’s supply) 24

4

1. Client List

Purpose: The Client List is used by CHWs to help keep track of their clients. The master list provides CHWs and their supervisors an at-a-glance summary of how many clients the CHW has, when they were initially seen, and which FP method the client is using. The identification numbers are assigned in sequence to each client when the CHW adds a new client to the list. The client numbers are beneficial because the CHWs can use them to keep their client tracking forms in order.

How to use this form:

Instruct CHWs to:

– keep a list of all their clients on a single sheet.

– add a client to their list at the time of their first visit with the client; write the client’s full name, the date of their initial visit with the client, and the method that the client chooses.

– keep the client list with their client tracking forms.

– keep all client records confidential.

Instruct supervisors to:

– review the CHW’s client list and compare it with their client tracking forms to ensure that the CHWs are performing as expected (e.g., adding clients to the list at their initial visit, using the client numbers to help keep their files in order).

5

Client List Name of CHW: _________________________________________________________

No. Name Start Date/Method

#1 ___________________ ______________________

#2 ___________________ ______________________

#3 ___________________ ______________________

#4 ___________________ ______________________

#5 ___________________ ______________________

#6 ___________________ ______________________

#7 ___________________ ______________________

#8 ___________________ ______________________

#9 ___________________ ______________________

#10____________________ ______________________

#11____________________ ______________________

#12____________________ ______________________

#13____________________ ______________________

#14____________________ ______________________

#15____________________ ______________________

#16____________________ ______________________

#17____________________ ______________________

#18____________________ ______________________

#19____________________ ______________________

#20 ____________________ ______________________

#21____________________ ______________________

#22____________________ ______________________

#23____________________ ______________________

#24____________________ ______________________

#25 ____________________ ______________________

#26____________________ ______________________

#27____________________ ______________________

#28____________________ ______________________

#29____________________ ______________________

#30____________________ ______________________

No. Name Start Date/Method

#31 ___________________ _____________________

#32 ___________________ _____________________

#33 ___________________ _____________________

#34 ___________________ _____________________

#35 ___________________ _____________________

#36 ___________________ _____________________

#37 ___________________ _____________________

#38 ___________________ _____________________

#39 ___________________ _____________________

#40 ___________________ _____________________

#41 ___________________ _____________________

#42 ___________________ _____________________

#43 ___________________ _____________________

#44 ___________________ _____________________

#45 ___________________ _____________________

#46 ___________________ _____________________

#47 ___________________ _____________________

#48 ___________________ _____________________

#49 ___________________ _____________________

#50 ___________________ _____________________

#51 ___________________ _____________________

#52 ___________________ _____________________

#53 ___________________ _____________________

#54 ___________________ _____________________

#55 ___________________ _____________________

#56 ___________________ _____________________

#57 ___________________ _____________________

#58 ___________________ _____________________

#59 ___________________ _____________________

#60 ___________________ _____________________

6

2. Activity Planner

Purpose: The Activity Planner is used by CHWs to help them keep track of appointments with clients and any key community activities they may wish to record. Any calendar or day planner can serve as an activity planner so long as the CHW finds that the format is functional and easy-to-use.

How to use the planner:

Instruct CHWs to:

– use the planner to record all the client visits and events that they are planning to conduct, for example:

√ record in the planner the name and location of clients that the CHW plans to meet for an initial visit on the date agreed upon with the client.

√ write the client’s name, ID number, and method on the date that the CHW and the client agree upon for their next visit.

√ use the calendar to help calculate the date of the client’s next visit (varies depending on the method that the client is using and when they may need reassurance or resupply).

√ record in the planner the community activities that the CHW plans to attend or organize.

– keep all records containing client information confidential.


– review a CHW’s activity planner at regular intervals to ensure that the CHW is performing as expected (e.g., scheduling follow-up and re-supply visits with clients at appropriate intervals, keeping a schedule that is realistic – not overbooking so that the CHW can meet her/his obligations to clients without neglecting other issues).

7

Sample Monthly Planner

Sun Mon Tue Wed Thu Fri Sat1 2 3 4 5 6

7 8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23 24 25 26 27

28 29 30 31

2010

Activity Planner – March

Sample Weekly Planner

Activity Planner – February 28-March 6, 2010 Week 1

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Feb 28 Mar 01 02 03 04 05 06Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

7 am

8 am

9 am

10 am

11am

12 pm

1 pm

2 pm

3 pm

4 pm

5 pm

6 pm

February 2010S M T W Th F S

1 2 3 4 5 6

7 8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23 24 25 26 27

28

March 2010S M T W Th F S

1 2 3 4 5 6

7 8 9 10 11 12 13

14 15 16 17 18 19 20

21 22 23 24 25 26 27

28 29 30 31

April 2010S M T W Th F S

1 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 27 28 29 30

Instructions for Using the Activity Planner select the planner format that works best for you (either weekly or monthly). use the planner to record all the client visits and events that you are planning, for example:

– write the name of a client that you plan to meet for an initial visit on the date that you agree to meet (i.e., someone a you met in the market or at a community health talk who invites you to come to their house for an initial visit).

– write the name and ID number of the client on the date that you and the client agree upon for their next visit; you may also want to make other brief notes about the visit, such as what method the client uses so that you can be sure to have ample supplies ready for your visits with clients.

– use the calendar to help calculate the date of a client’s next visit, for example:√ count 13 weeks from the date of the current visit to figure out the

reinjection date for a DMPA user (count 8 weeks for NET-EN users); for first-time DMPA/NET-EN users you may want to visit earlier than their scheduled reinjection date to answer questions and reassure the client about side effects that they may be experiencing

√ count 8 weeks from the date of the current visit to figure out the date of a resupply visit for a pill user who is given 3 packs of pills (although the pills will last 12 weeks, the client should have access to her resupply before she is completely out of pills)

√ count 4 weeks from the date of the current visit to figure out the date of a resupply visit for a condom user who was given 30 condoms (the client estimated that s/he would need about 6 condoms/week)

√ count 8 weeks from the date of the current visit to work out a date for a follow-up visit for a client who has been using LAM for two months (since the birth of her infant) but wants to choose another method before LAM runs out.

√ for clients using methods that do not require resupply, such as beads, select a date to follow up with the client that makes sense for their situation; for example, make plans to revisit a new bead user a few weeks after their initial visit to talk with them about any questions they may have about how to use the method.

– write the community activities that you plan to attend or organize on the date they are scheduled to occur (e.g., health talks in the village square for community members or for adolescents at the secondary school).

bring your activity planner to every meeting with your supervisor. keep all records that include information about clients in a safe place where no one else will see them.

3. Client Tracking Form

Purpose: The Client Tracking Form is used by CHWs to collect information about new clients, to monitor continuing clients, and to keep a record of any concerns or complications that may occur. For the CHW, it functions as a client register or activity log to record the family planning method dispensed and to manage his/her clients’ scheduled visits. Supervisors use this information to manage and report on the activities of the CHWs they oversee. When use and continuation data from the tracking forms are compiled, the information is used to assess the effectiveness the CBA program.


Instruct CHWs to:

– use one form for each client to record all the visits made.

– record on the client’s form each time they provide services.

– bring all client tracking forms to any meeting with his/her supervisor.

– keep forms in numeric order by client number so that you can easily locate a client’s tracking form to look up and record information.



– review each client tracking form at regular intervals to ensure that the CHWs are performing as expected (e.g., recording complete and accurate information, scheduling and conducting follow-up and re-supply visits with clients at regular intervals, screening for and administering reinjections and other methods as appropriate, documenting adverse events or complications from using a method, and referring clients who experience problems).

– based on your observations from reviewing the tracking forms and asking any necessary clarification questions, provide performance feedback to the CHW.

– record the date at the bottom of the form each time you review it.

– compile the information collected from the Client Tracking Forms to verify the information provided by a CHW on the CHW Services Tracking Form and the CHW Stock Tracking Form each month.

Printing and Copying

Depending on the situation and the available resources, consider pre-printing the client tracking sheets in a book or register format so that information gathered and recorded by CHWs is created in triplicate and can serve multiple purposes. For example, after a specific data collection period, the first copy could be used by the project team to compile program data, the second copy could be kept on file by the CHW’s supervisor at the district/local health facility in the catchment area where the client lives, and the third could be retained by the CHW in his/her register.

Remove or cross out (strike-through) any identifying information about individual clients from forms used for project monitoring and evaluation purposes (e.g., the names of the client and client’s spouse, contact information). This information is confidential and should only be available to the client’s health care providers (i.e., the CHW, his/her immediate supervisor, other facility-based health care providers who may be providing health services to the client).

Client Tracking FormName of client: ___________________________________________________ Client’s date of birth: _______________________ Sex: M / F (Circle one) Client #: __________

Name of client’s village: ____________________________________________ Client contact information (mobile #): ________________________________________________________________

Name of client’s spouse: ___________________________________________ No. of children: ____________ Date of last birth: __________________

Never used FP Current FP user, specify method: ____________________ Other methods used previously: ____________________________________________________________________

Date of client visit(dd/mm/yyyy)

DMPA Oral PillsType: _____________

Condoms CHW notes, include information about: Problems giving an injection Client comments, concerns, events (e.g., side effects) Referrals made

Date injection

scheduled

Date injection

given

Date of next scheduled

visitQty

Date of next scheduled

visitQty

Name of CHW: ___________________________________________________ Sub location/neighborhood: _______________________________ Supervisor: ______________________________

Signature of CHW: _______________________________________________________ Signature of CHW supervisor: _______________________________________________________________

Date 1: ___________________ Date 2: ___________________ Date 3: ___________________ Date 4: ___________________ Date 5: ___________________ Date 6: ___________________

Instructions for Using the Client Tracking Form use one form for each client; complete the information at the top during the first visit. write in the chart the date and what you do during each visit/contact with the client; record every visit on

a separate line in the chart. bring all of your client tracking forms to every meeting with your supervisor. keep all client records in a safe place where no one else will see them.

Explanation of Each Field on the Client Tracking Form Name of client: The full name of the client. Client’s date of birth: The day, month, and year the client was born. Sex M/F: Circle whether the client is male (M) or female (F). Client #: The number assigned by you to each new client; also recorded on your client list. Name of client’s village: The name of the village the client lives in most of the time. Client’s contact information: If the client has a mobile phone, record the number. Also write any other

information that might be useful for contacting the client; such as, keeps a stall in the market on Tuesday. Name of client’s spouse (or partner): If you meet with the client’s spouse/partner, write their name so

that you can call them by name during other visits. Number of children: The number of living children the client has. Date of last birth: The date on which the client last gave birth. FP status at time of initial visit: If the client has never used a method previously, check/tick the Never

used FP box. If the client is already using a method, write which method. Write which other methods the client has used in the past.

Name of CHW: Your full name, include all three names. Sub location: The name of the location or area to which you are assigned to provide community services. Supervisor: The name of your supervisor. Share the name of your supervisor with any client who is

interested in knowing that information. Date of client visit: The date you come in contact with the client for a family planning visit; indicate the

date in the correct DD/MM/YYYY format. Date injection scheduled: The date that the next injection is due should be recorded in this field; indicate

the date in the correct DD/MM/YYYY format. Date injection given: The date that the injection was actually delivered should be recorded in this field;

indicate this date in the correct DD/MM/YYYY format. Oral pills (Type of pill): The brand name of the pills that were dispensed to the client. Date of next scheduled visit: The date that you and the client agree upon for re-supply of pills or

condoms. Decide whether you will visit the client or he/she will visit you. Also write client’s name and number on your appointment/activity planner.

Qty: Indicates the number of pill packs or condoms you are providing to the client on this visit. CHW Notes:

– Record any problems associated with the method. Specify the type of problem experienced – for example, needle stick, soreness/infection at injection site – and what action(s) were taken.

– Record any comments, concerns, or events the client may talk about (i.e., questions about methods, counseling about LAM or beads, problems with side effects, plans for a pregnancy).

– Record the purpose of the referral and to which facility the client was referred. Signature of CHW, supervisor, and dates: You should sign the form to verify that what you have written

about the client is correct. Your CHW supervisor should sign the form to verify that they have reviewed the services you provided. Your supervisor should record the date each time that they review the form.

4. Client Reminder Card

Purpose: The Client Reminder Card is used by CHWs to help their clients keep track of their next appointment date. At the end of each visit, a CHW should schedule the next visit with the client and write the date of the next visit on a reminder card. If the client is using injectables, the CHW should also write the type of injectable and the date it was administered.

Some clients may also have their own personal health booklets/records that they carry with them when visiting health care providers. If a client has their own booklet/record, make notes about the method, services delivered, and date scheduled for the next visit in the client’s record rather than on a reminder card.

How to use the card:

Instruct CHWs to:

– ask the client if they would like a reminder card; some clients may be using contraception without the knowledge of their partner and do not wish to have a written record.

– write the appointment date for the follow-up visit with the client on a reminder card or small piece of paper.

– give the reminder card to the client and tell the client to put it somewhere safe to help remind him/her when to come back for their next visit.

– if the client received an injection, also note on the card which type of injection the client received; encourage the client to take the card with them if they visit the clinic so that providers at the clinic will know what type of FP method the client is using.

Client Reminder CardDate of Next Visit: ______________________

Type of injection: ______________________ Date given: _______________

5. Referral Form

Purpose: The Client Referral Form is used by CHWs to share basic information about a client with the clinic staff and request services that the CHW believes are required to meet the client’s needs. The Client Referral Form is also used by clinic staff to let the CHW know how they responded to the request for services. There are two parts to the form, Part A which the CHW uses to describe the request for their client and Part B which the clinic staff uses to describe what services they provided to address the client’s needs. The client is responsible for taking the form to the clinic and returning Part B of the form to the CHW. Part A of the form is maintained by the clinic in the client’s record and can be tallied along with other services provided at the facility. Part B of the form is maintained by the CHW as part of their client’s individual record and is summarized on the client’s tracking form.

If feasible, it may be desirable to create referral forms in triplicate. In this situation, the CHW completes Part A, keeps a copy, and gives the client two copies to take to the referral facility. The referral facility completes Part B and then keeps a copy for their records and sends a copy back to the CHW.


Instruct CHWs to:

– use the form to obtain clinic services for clients who have needs that the CHW cannot meet.

– complete Part A of the form, give it to the client, and instruct the client to take with them to the clinic.

– record the referral on the client’s tracking form.

– follow up with the client about their visit to the clinic, record the results of the referral on the client’s tracking form, and file Part B of the form with the client’s tracking form.


Instruct facility clinicians to:

– accept the referral forms presented by clients of CHWs and review the request with the client.

– provide the services that the CHW requested or modify the services based on a discussion with the client.

– retain Part A of the referral form, file it with the client’s records, and document the services provided in the service log.

– complete Part B of the form, detach it, give it to the client, and instruct the client to return it to the CHW.

Client Referral Form – Part A (CHW completes. Client takes to the clinic and shares with the provider. Clinic keeps for their records.)

Date: …………………………………………

Dear Health Worker/Staff of Health Facility: ………………………………………………………………………………………………

I am referring: Mr/Mrs/Ms ………………………………………………………….……………………………………… (Client’s Name)

Village: …………………………………….………………………………………………………………………………………….……..

Nearest school/church/crossroad: ……………………………………………………………………………..…………………………

To you for (please circle as appropriate)1. Contraceptive method (specify) ………………………………………………………….………………………………………

2. Side effect management (specify) ………………………………………………………………………………………………

3. Mother Health Services (specify) ……………………………………………………………………………………………….

4. STI Management (specify) …………….…………………………………………………………….…………………………..

5. Others (specify) ……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………

CHW Name: …………………………………………………………………………………………………..……………………………

Signature: …………………………………….…………………. Sub location: …………………………………..……………….………--------------------------------------------------------------------------------------------------------------------------

Client Referral Form – Part B(Clinic staff competes. Detached and returned to the CHW by client after clinic visit. CHW keeps in the client’s record.)

Date: ……………………………………………

Client’s Name: Mr/ Mrs/ Ms ………………………………………………………………………………………………………………….

has received services at this health facility as per the referral.

Name of health facility: ……………………………………………………………………………………………………………………….

Name of service provider: ……………………………………………… Signature: ……………………………………………………..

Service provided (in brief): …………………………………………………..………………………………………………………………

…………………………………………………..………………………………………………………………………………………………

…………………………………………………..………………………………………………………………………………………………

…………………………………………………..………………………………………………………………………………………………

Explanation of each field of the client referral form

Part A: This section to be completed by the CHW agent and retained by the clinic

Instructions for Using the Referral Form use the form to obtain clinic services for clients’ needs that you cannot meet. complete Part A of the form, give it to the client, and tell the client to take with them to the clinic. record the referral on the client’s tracking form. follow up with the client about their visit to the clinic; record the results of the referral on the client’s

tracking form and keep Part B of the form with the client’s tracking form. keep all client records in a safe place where no one else will see them.

Explanation of Each Field on the Referral FormPart A: To be completed by the CHW to send with the client to the clinic. Date: The date when the referral was made. Dear Health Worker/Staff of Health Facility: Name of health facility to which you are referring the client. I am referring Mr/Mrs/Ms: Name of the client being referred. Village: Name of village where clients stays most of the time. Nearest school/church/crossroad: Name of church, school, crossroad, or other landmark nearest to where

client lives. To you for: Circle reason for referral from the options provided. If reason is not in the options, write the

reason under ‘others’. Give as much additional information as necessary. CHW Name: Write your name. Signature: Sign your name. Sub location: The name of the location or area to which you are assigned to provide community services.

Part B: To be completed by the clinic staff and returned to the CHW agent after the client has received clinic services. Date: The date when the client reported to the facility for referral services. Client’s Name: Name of the client who was referred and received services. Name of health facility: Name of the health facility where the client received the services. Name of service provider: Name of the health care worker who provided the services. Signature service provider: Signature of the health care worker who provided the services. Service provided (in brief): A summary of the service(s) that was provided to the client during the visit.

Describe any additional follow-up services recommended to the client.

6. CHW Services Tracking Form

Purpose: The Services Tracking Form is the mechanism by which a CHW documents and shares her/his accomplishments with the larger health system. Each CHW records all program-related activities on the tracking form throughout the month, then summarizes the data, and submits it at the end of the month. CHWs give the tracking form to the CHW supervisor who is responsible for ensuring that the information is shared with the administrator of the health center who oversees the CHW program and is entered into the national health management and information system (HMIS) so that administrators at all levels of the health system can make programming decisions based on actual service data.

If feasible, it may be desirable to create the Services Tracking Form in duplicate. In this situation, the CHW keeps a copy and the supervisor keeps a copy.


Instruct CHWs to:

– use one form each month to record all their activities for the month.

– use the information tallied on the form or gathered from the other records that they keep and summarize it to fill in the various fields on the form.

– bring the completed form to the facility at the end of the month and submit it to the CBA supervisor for review.



– review the Services Tracking Form each month to ensure that the CHWs are performing as expected (e.g., recording complete and accurate information summarized from the form and other records).

– based on your observations from reviewing the summary form and asking any necessary clarification questions, provide feedback to the CHW.

– compile data from all the CHWs that you supervise and report the information in a timely manner through the established HMIS to ensure access to accurate data for management/decision-making purposes (e.g. using the Services Tracking Form for CHW Program).

CHW Services Tracking Form

CHW name: _______________________________________________ Today’s date (dd/mm/yyyy): ______________________________

Health facility name: _________________________________________ Supervisor name/initials: _________________________________

Family Planning Services

MethodsNew Users

Ticks TotalContinuing Users

Ticks Total

Total New & Continuing

Users1. Depo 2. Pills (COCs) 3. Emergency Contraceptive Pills (ECPs)4. CycleBeads5. LAM (breastfeeding method) 6. Male Condoms (sole method)7. Female Condoms (sole method)8. Dual method (male or female

condoms used with another method)

Activities Ticks Total Provided9. FP/RH Referrals

10.Counseling about FP methods

11.Counseling about other RH issues12.Group FP/RH health talksWrite topics of talks and # of participants:

Maternal Child Health ServicesActivities and Community Observations Ticks Total Number1. Household or client visits2. Pregnant women served3. Children under 5 served4. Children under 5 with FEVER 5. Pregnant women with FEVER 6. Children under 5 year referred for immunization7. Children under 5 years referred for other reasons8. Pregnant mothers referred9. Deliveries in health facility10. Deliveries at home11.Maternal deaths12.Other, describe:

Instructions for Using the CHW Services Tracking Form

Month/year reported: _______/_______

use the form to record your activities during the month and summarize your activities so that you can share your accomplishments at the end of each month.

complete the tracking form using the information that you 1) have recorded on the form (by counting the tick marks that you wrote on the tracking form during the month for each activity completed), or 2) written on your client list, your activity planner, and/or client tracking forms.

give the completed form to your supervisor at the end of the month.

Explanation of Each Field of the CHW Services Tracking Form

General Information

Month/year reported: Indicate the month and year that you are reporting (MM/YYYY format).CHW Name: Write your name.Today’s date: Write the date that you are completing the form (DD/MM/YYYY format).Health Facility Name: Write the name of the facility to which you are attached. Supervisor Name: Write the name of your supervisor. Supervisor will initial after reviewing the form.

Family Planning Services

The Methods section requires you to record the number of New Users and Continuing Users that you have served, by the method provided – DMPA, COC pills, emergency contraceptive pills, CycleBeads, LAM, male condoms, female condoms, and dual method – within the month specified.

The Activities section requires you to record the number of times during the month that you provided FP Referrals, Counseling about FP, Counseling about other RH issues, and Group FP/RH Health Talks.

After each client visit:Place a tick mark in the box(es) that match the services you provided. If the client is a new FP method user, place a tick mark in the box matching the method that they initiated and a tick mark in the box for counseling about FP methods. If the client is a continuing FP method user, place a tick mark in the box matching the method that they have been using. When you see a client for the first time who is using a family planning method that they previously received from another source (e.g., pharmacy, health care center), the client would be considered a Continuing User. If a client is using two methods, report their primary method (DMPA, pills, CycleBeads, or LAM) in the appropriate box and then also place a tick in the dual method box.

At the end of the month:Count the number of tick marks in each box and write it in the total column. For items 1–8, add the number of New Users to the number of Continuing Users and write the amount in the Total column. If there are no users or services to report, write 0 (zero) in the column. If you conduct health talks during the month, note the date, topic, location, and the number of participants.

Another way to gather this information is to look at your Client Tracking Forms and/or the information recorded on your activity planner, count the number of new and continuing users and activities, and report the information the appropriate space on the form.

Maternal/Child Health Services

Record any MCH information you have collected within the reporting period in a manner similar to the method used for tracking family planning services. [Note this section of the form is not addressed in the FPTRP materials or training, it is simply an example of the types of other data CHWs may be collecting as part of a community-based access project.]

7. CHW Stock Tracking Form – Option 1 and 2

Purpose: The Stock Tracking Form allows the CHW and the supervisor to monitor the status of commodities and helps to ensure that each CHW and the CBA program as a whole have access to a continuous supply of commodities for their clients. The form provides a summary of the commodities used during the month and supplies the information on quantities remaining for the purpose of re-stocking a CHW’s supply.

There are two versions of this form. Option 1 is designed to be completed primarily by the CHW with oversight from the supervisor. Option 2 gives complete responsibility for commodities tracking to the supervisor and is based on an inventory of the CHW’s supply, rather than records kept by the CHW during the month.

If feasible, it may be desirable to create Option 1 of the Stock Tracking Form in duplicate. In this situation, the CHW keeps a copy and the supervisor keeps a copy.


Instruct CHWs to:

– use one form per month to record all the stock that they use during the month.

– use the information tallied on the form or gathered from the other records that they keep and summarize it to fill in the various fields on the form.

– bring the completed form to the facility at the end of the month and submit it to the CBA supervisor for review.



– review the Stock Tracking Form each month to ensure that the CHWs are performing as expected (e.g., recording complete and accurate information summarized from the form and other records).

– based on your observations from reviewing the summary form and asking any necessary clarification questions, provide feedback to the CHW.

– re-supply the CHW with the commodities he/she requested, or you determine will be needed, to meet client demand during the coming month.

– ensure that replacement commodities are ordered and received at the health care facility on a regular basis to ensure that stock-outs are avoided in the CBA program.

– compile data from all the CHWs that you supervise and report the information in a timely manner through the established health management and information system (HMIS) to ensure access to accurate data for management/decision making purposes (e.g. by using the Commodities Tracking Form for CHW Program).

CHW Stock Tracking Form ┌ These columns to be completed by supervisor ┐

A B C D E FHow Much Product I Started With

How Much Product I Gave to Clients

How Much Product is Left in My Supply Now

Quantity CHW Needs for Next Month

Quantity CHW Received from Health Facility

Total Supply of Product Available after Re-supply

Write the number from column F on last month’s form.

Write the amount of product you give to each client. Example: If you give a client 3 pill packs, write 3 in the box.

Count how many you have left.

D=(B x 2) – C Double the number in column B then subtract the number in column C.

Should be the same amount as column D. If D is negative; do not provide new product.

F=C+EAdd the amounts in column C and column E. Write this number in column A on your next form.

Depo vials/ syringes

COC pill packets

EC pill packets

Cycle-Beads

Male condoms

Female condoms

CHW name: _______________________________________________ Today’s date (dd/mm/yyyy): ______________________________

Health facility name: _________________________________________ Supervisor name/initials: _________________________________Instructions for Using the CHW Stock Tracking Form – Form Option 1

use the form to summarize and report the commodities that you distributed/supplies that you used during the month and submit the completed form at the end of the month.

Month/year reported: ______/______

Form Option 1

complete the general information and columns A–C using the information that you have recorded on the form after each client visit

give the form to your supervisor to complete columns D–F.

Explanation of Each Field of the CHW Stock Tracking Form Option 1

General Information

Month/year reported: Indicate the month and year that you are reporting (MM/YYYY format).CHW Name: Write your name.Today’s date: Write the date that you are completing the form (DD/MM/YYYY format).Health Facility Name: Write the name of the facility to which you are attached. Supervisor Name: Write the name of your supervisor. Supervisor will initial after reviewing the form.

Summary of Commodity Status Columns A–C should be completed by the CHW as follows:

Column A – How Much Product I Started With: The amount of stock/product you have on hand in your supply at the beginning of the month. Copy the amount from Column F on last month’s form into the boxes in column A.

Column B – How Much Product I Gave to Clients: The amount of stock/product you gave to clients during the month. After each client visit, write in one of the small boxes in column B how much of each item you gave to the client during the visit.

Column C – How Much Product is Left in My Supply Now: Count the amount of stock/product you have remaining in your supply at the end of the month.

Columns D–F should be completed by the supervisor as follows:

Column D – Quantity CHW Needs for Next Month: Total the amounts in column B, multiply that quantity by 2, then subtract the amount in column C.

Column E – Quantity CHW Received from Health Facility: Re-fill the CHW’s supply with the amount of product specified in column D. If the solution to the equation is column D is a negative number, no additional product is needed. When re-filling the CHW’s supply, ensure that the items that are first to expire are at the top of the kit/bin so that they will be used first.

Column F – Total Supply of Product Available after Re-supply: Add the amounts in column C and column E. Instruct the CHW to write this amount in column A on the next month’s form.

CHW Stock Tracking Form

CHW name: _______________________________ Today’s date (dd/mm/yyyy): ___________―This form to be completed by supervisor during monthly visit with CHW. ―

A B C D E FAmount of Product Issued to CHW this Month

Amount of Product Left in Supply at End of Month

Quantity CHW Distributed this Month

Quantity CHW Needs for Next Month

Quantity CHW Received from Health Facility

Total Supply of Product Available after Re-supply

Record amount from column F on previous CHW stock tracking form.

Count how many the CHW has remaining in her/his supply.

A – B = C Subtract the amount in column B from the amount in column A.

D = (C x 2) – B Double the number in column C then subtract the number in column B.

Should be the same amount as column D. If D is negative; do not provide new product.

F = B + EAdd the amounts in column B and column E. Write this number in column A on the next form.

Depo vials/ syringes

COC pill packets

EC pill packets

Cycle-Beads

Male condoms

Female condoms

Health facility name: _________________________________________ Supervisor name/initials: _________________________________

Month/year reported: _______/_______Form Option 2

Instructions for Using the CHW Stock Tracking Form – Form Option 2 use the form to summarize and report the commodities distributed/supplies used by each of the CHWs that

you supervise at the end of the month. complete the form using the information gathered during the supervisor’s inventory of the CHW’s supply.

Explanation of Each Field of the CHW Stock Tracking Form Option 2

General Information

Month/year reported: Indicate the month and year that you are reporting (MM/YYYY format).CHW Name: Write the CHW’s name.Today’s date: Write the date that you are completing the form (DD/MM/YYYY format).Health Facility Name: Write the name of the facility to which you and the CHW are attached. Supervisor Name: Write your name and initial after completing the form and re-stocking the CHW’s supply.

Summary of Commodity Status Columns A–F should be completed by the supervisor as follows:

Column A – Amount of Product Issued to CHW this Month: The amount of stock/product the CHW had in her/his supply at the beginning of the month. Copy the amount from Column F on last month’s form into the boxes in column A.

Column B – Amount of Product Left in Supply at End of Month: Count the amount of stock/product remaining in the CHW’s supply at the end of the month.

Column C – Quantity CHW Distributed this Month: Subtract the amount in column B from the amount in column A.

Column D – Quantity CHW Needs for Next Month: Multiply the quantity in Column C by 2 then subtract the amount in column B.

Column E – Quantity CHW Received from Health Facility: Re-fill the CHW’s supply with the amount of product specified in column D. If the solution to the equation is column D is a negative number, no additional product is needed. When re-filling the CHW’s supply, ensure that the items that are first to expire are at the top of the kit/bin so that they will be used first.

Column F – Total Supply of Product Available after Re-supply: Add the amounts in column B and column E. Write this amount in column A on the next month’s form.

monitoring and evaluation package for community-based ... · web viewwhen you see a client for the...

Documents