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Annex B. Xerophthalmia field survey forms

The following field survey forms are modifications of those found useful in the Indonesian Nutritional Blindness Prevention Project. They are examples of the types of information and format that can be employed, but should be modified depending upon local conditions, interests, and abilities. They have been kept simple and include only those factors felt to be most relevant to an understanding of the xerophthalmia problem.

Clinical Examination Form

This form is primarily intended for children under the age of six. If older individuals are to be examined or other major causes of blindness exist or are of interest (e.g., trachoma, onchocerciasis, etc.), it should be modified and expanded. A full-scale paediatric or nutritional survey would include many additional measurements.

The ocular examination must be carried out by someone familiar with the clinical manifestations of xerophthalmia, preferably an ophthalmologist. The location and size of all corneal abnormalities should be carefully indicated in the circles provided.

The summation coding format maintains discrete information while economizing on punch-card columns. Simply circle the score for each abnormality present. add the scores for each section, and transfer the totals to the appropriate columns alongside. Where none of the abnormalities listed is present, the total is "O"; this should be entered in the appropriate space. At the completion of the examination, there should be a digit in each of the numbered spaces, even if it is "O".

Clinic Based Case Reporting Form

A simple line listing as shown here, is sufficiently detailed to monitor the number, types, and origin of cases presenting at treatment facilities. It has been kept short and simple to facilitate its use by overworked clinic personnel.

Clinical Examination Form

Data
Enumerator
Team
Ophthalmologist
Sample site

* Include only if not already part of a census/socioeconomic form.
** Collect only for those 6 years and under.

FIG. 5.A.b. Clinical Examination Form

FIG. 5.A.b. (cont.)

Historical data on corneal scars and destruction

FIG. 5.A b. (cont.)

Xerophthalmia case-reporting form

Clinical facility

FIG. 5.A.b. (cont)

Annex C. Diarrhoea/growth study illness surveillance form

Diarrhea/Growth Study Illness Surveillance Form

Study Number (1-3) 199

Name_______________________________
VTS Number (4-9)_____________________
Type of card (10) :
Card Number (11-13):___________________

* From D'Souza (5)

Annex D. Brief examination of child

Brief examination of child

Annex E. Birth report form

Birth report

Annex F. Death report form

Bith report

Annex G. Maternity history questionnaire

Maternity history questionnaire
Maternity history questionnaire (cont.)
Maternity history questionnaire (cont.)
Maternity history questionnaire (cont.)
Maternity history questionnaire (cont.)
Maternity history questionnaire (cont.)

References

1. Michael H. Alderman, Paul H. Wise. Robert P. Ferguson. H. T. Laverde and Anthony J. D'Souza, "Reduction of Young Child Malnutrition and Mortality in Rural Jamaica", Tropical Pediatrics and Environmental Child Health 7/11 (1978).
2. Warren L. Berggren, Douglas C, Ewbank and Gretchen G. Berggren, "Reduction of Mortality in Rural Haiti through a Primary Health Care Programme," New England Journal of Medicine, 304: No.22 (1981) pp. 13241330.
3. Henry S. Shyrock, Jacob S. Siegel and associates, The Methods and Materials of Demography(US Government Printing Office, Washington, DC. 1971).
4. World Fertility Survey, "Modifications to the WFS Core Questionnaires and Related Documents." Basic Documentation No. 10 (International Statistics institute, The Hague, 1977).
5. Stan D'Souza, The Demographic Surveillance System, Matlab, Comilla, Bankgladesh (International Centre for Diarrhoeal Disease Research, Dacca, Bangladesh. 1981).
6. J.M. Sullivan, S.H. Cochrane and W.D. Kalsbeek, "Procedures for Collecting and Analysing Mortality Date in LSMS," Paper prepared for the Living Standards Measurement Study (The World Bank, Washington DC, 1981) (draft!.
7. William D. Kalsbeek, "Statistical Precision and Household Sample Size in Surveys which Measure Mortality." Paper prepared for the Living Standards Measurement Study (The World Bank, Washington DC, 1981) (draft).
8. A. Sommer, Field Guide to the Detection and Control of Xerophthalmia, (World Health Organization, Geneva, 1978).
9. Philip L. Graitcer, A Manual for the Basic Assessment of Nutrition Status in Potential Crisis Situations. 2nd ed. (Centers for Disease Control, Public Health Service, US Department of Health and Human Services. Atlanta, Georgia, 1981).
10. J.V. Brown and R.M. Bateman, "Mother Infant Behavior Codes, Birth Through Three Months." Tech. Rep. 3. (Georgia State University, Atlanta, Georgia, 1975.)

Bibliography

Barclay, George W.. Techniques of Population Analysis. (John Wiley and Sons, New York, 1958).

Committee on Population and Demography. National Academy of Sciences, "Estimation of Childhood Mortality from Information on Children Ever Born and Children Surviving," from, Demographic Estimation: A Manual on Indirect Techniques, (National Academy of Sciences, Washington, DC 1980), chapter 4 (draft).

Linger, Joan W. A Handbook for Population Analysts. Part A.. Basic Methods and Measures. (Laboratories for Population Statistics, Chapel Hill, NC, 1974),

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