PEER WORKER DAILY DIARY

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PEER WORKER DAILY DIARY Powered By Docstoc
					NACP’s HIV/AIDS SERVICE PACAKGE FOR LONG
         DISTANCE TRUCK DRIVERS,
 CLEANERS/ATTANEDANTS AND ASSOCIATE
               POPULATIONS




    MONITORING AND EVALUATION TOOLS


              USER MANUAL

          (WORKING DOCCUMENT)
                         Table of Contents


1   Introduction                                 3



2   Indicators                                   4

     2.1 TARGET POPULATION CONTACTED             4
     2.2 STI SERVICES                            5
     2.3 VCT SERVICES                            5
     2.4 CONDOM AND LUBRICANT PROMOTION          6
     2.5 OTHER SBC ACTIVITIES                    6
     2.6 TRAININGS AND CAPACITY BUILDING         7

3   The M&E Tools (Indicators and Definitions)   8

     3.1 The Peer Educator Diary                 10
     3.2 The ORW Diary                           11
     3.3 The ORW Monthly Report                  13
     3.4 The Counselor Daily Log                 15
     3.5 The Counselor Monthly Report            16
     3.6 The STI Physician Daily Log             18
     3.7 The STI Physician Monthly Report        19
     3.8 Activity Report                         21
     3.9 The IA Progress Monthly Report          22
     3.10 The IA Progress Quarterly Report       25
     3.11 The Quarterly Review Report            25

4                                                26
    Annexes
1. Introduction


Monitoring and Evaluation (M&E) systems are a crucial part of good project
management, using strategic information to track project activities, identify problems,
and make data-based design, implementation, and management decisions. Ongoing M&E
information systems support better-informed program decisions in terms of the most
efficient allocation of relevant resources and the most effective activities and tasks. M&E
data are collected, analyzed and reported to inform managers of implementing agencies,
partners, donors as well as all relevant stakeholders at the grassroots level.



As managers learn lessons from project challenges and successes based on the M&E
system, implementation strategies, resource allocations, and realistic understandings of
achievable goals will be regularly adjusted. Indicators and other measures may need to be
revised, refined, or otherwise made more useful as results feedback tools, when and
where project evolution requires. Thus it is important to recognize that the M&E plan
will also be a living document, designed to continually support ongoing improvements to
project implementation through empirical feedback on results achieved, even as the goals
and targets may be modified over the life of the project. Thus information generated will
be essential to identify bottlenecks and barriers and make the required changes as well as
ascertain and maintain quality within all project activities and. Furthermore, information
will be interpreted in the context of further assessment activities, such as surveys, to
analyze the significance of program results. This document describes the various M&E
tools being used by various project staff in the project along with definitions of select
variables and tips on how best to utilize the information thus collected.

It must be noted that this shall remain a working document and therefore amenable to
changes necessitated by any operational issues that warrant re-definition, inclusion or
exclusion of certain indicators and variables over the life of the project. In such a case a
brief commentary will be included as to the circumstances and reasons.
2. Indicators

Based on the goals and objectives of the program, a comprehensive list of indicators has
been developed that covers all the strategies employed to attain truckers’ project goals. In
addition, these will be supplemented by periodic qualitative data and assessments as well
as monitoring quality of services which is described later.

Care has been taken to keep the list of indicators to a minimum to achieve timely and
essential data collection while maintain the effectiveness and quality of monitoring. The
various tools have been provided as an annex to this document.

    2.1 TARGET POPULATION CONTACTED (break down by staff cadre i.e. Peer Educator

    (PE), Outreach Worker (ORW), STI Doctor and Counselor)



 Population accessed by                                                     Frequency
                                                       Source of
 Project activities (total encounters and new                               of               Responsibility
                                                       verification
 clients identified)                                                        reporting
 Truck drivers                                         Daily logs:          -Weekly/         Staff
 Cleaners                                              - PE                 Monthly to       maintaining
 Workers/ mechanics                                    - ORW                IA supervisor    logs
 FSW                                                   - STI log
 MSW                                                   - Counselor log      - Monthly to     IA supervisor/
 Hijras (transgenders)                                                      FHI (MIAPR)      coordinator
 Religious leaders
 Formal Health providers                                                    - Quarterly to   FHI M&E unit
 Informal Health providers                                                  NACP
 Others
 TOTAL
 Access by outreach workers (with breakdown            ORW
 by age)                                               diary/monthly
                                                       reports
 Total clients accessed by all project staff (as per   Daily logs and
 new and old clients)                                  monthly reports of
                                                       all staff
2.2 STI SERVICES

                                                                                Frequency
                                                            Source of
        Access to STI services indicators                                           of         Responsibility
                                                           verification
                                                                                reporting
Total # consultations held (STI + PHC)                  -Daily STI log        -Weekly/         Staff
Total # of new clients* seen at clinic (STI + PHC)                            Monthly to IA    maintaining
# of clients revisiting clinic                                                supervisor       logs (STI
Total # of STI cases       Anal STIs                                                           clinician)
diagnosed                  Urethral Discharge
                           Testicular Swelling
                           Genital Ulcers
                           Others                       -Monthly STI          - Monthly to     IA supervisor/
                           Female STIs                  report                FHI (MIAPR)      coordinator
                           Total
# of new clients* treated for STI
                                                                              - Quarterly to   FHI M&E unit
# clients referred         Counseling
                                                                              NACP
                           Advanced STI care
                           HIV/AIDS care and
                           support
                           Others
                           Total
# clients referred by project staff to clinic
# days stock out of STI medicine                        Stock Register        Monthly          Supervisor
* New clients are clients registered for the first time at the DIC center



2.3 VCT SERVICES

                                                             Frequency
                                        Source of
 Access to STI services indicators                           of                      Responsibility
                                        verification
                                                             reporting
 Total # counseling sessions held       -Daily Counselor     -Weekly/                Staff maintaining logs
 # of clients referred by project       log                  Monthly to IA           (Counselor)
 staff                                                       supervisor
 # clients referred for testing/tests                                                IA supervisor/
 performed                              - Monthly                                    coordinator
 # HIV positive clients identified      Counselor report
 # HIV positive re-tested after                              - Monthly to FHI        FHI M&E unit
 window-period                                               (MIAPR)
 # clients referred for HIV/AIDS
 care and support                                            - Quarterly to
                                                             NACP
2.4 CONDOM AND LUBRICANT PROMOTION (break down by staff cadre i.e. PE, ORW,

Doctor and Counselors)

Indicators for    Condom      and      Lubricant                      Frequency
                                                   Source of
promotion                                                             of            Responsibility
                                                   verification
                                                                      reporting
# of condoms distributed                           -PE daily log      -Weekly/      All        staff
                                                   -ORW daily log     Monthly to    maintaining
# of lubricants distributed                        -STI daily log     IA            logs
                                                   -Counselor         supervisor
# of condom demonstrations performed               daily log
                                                                      - Monthly     IA supervisor/
# of clients provided with condoms                                    to    FHI     coordinator
                                                                      (MIAPR)
# of clients provided with lubricant
                                                                      - Quarterly   FHI M&E unit
                                                                      to NACP
# of condoms sold
# of lubricants sold                               - Stock Register   Monthly       Supervisor
# of days stock out of condoms
# of days stock out of lubricants                                     - Quarterly   FHI M&E unit
                                                                      to NACP


2.5 OTHER SBC ACTIVITIES (break down by staff cadre i.e. PE, ORW, Doctor and

Counselors)

                                                                      Frequency
                                                   Source of
Indicators for other SBC activities                                   of            Responsibility
                                                   verification
                                                                      reporting
Number of target population reached one-                              -Weekly/      All staff
on-one                                             - PE daily diary   Monthly to    maintaining
Number of target population reached by             - ORW daily log    IA            logs
group activity                                                        supervisor
# of theater performances
# of Focus group Discussions (FGD)
                                                                      - Monthly     IA supervisor/
# of social gatherings held
                                                   - Activity         to FHI        coordinator
# of IEC material distributed
                                                   reports            (MIAPR)
# of meetings of post-test club
                                                   - ORW daily log
# of meetings with partner organizations
                                                   -                  - Quarterly   FHI M&E unit
# of community group committees active
                                                   Supervisor/coor    to NACP
# supervisory visits/sessions conducted
                                                   dinator notes
# of demand creation meetings held
# sensitization/advocacy meetings held
# other activities held
2.6 TRAININGS AND CAPACITY BUILDING

Trainings                                                  Frequency
                                        Source of
                                                           of               Responsibility
                                        verification
                                                           reporting
# staff trained for first time          -       Activity   -Weekly/         All        staff
# staff receiving refresher training    reports            Monthly to IA    conducting
# trained to use SBC/IEC material       - Supervisor/      supervisor       trainings
# trained in HIV/AIDS                   coordinator
# trained in STI diagnosis/management   notes
# trained to demonstrate condom use                        - Monthly to     IA supervisor/
# trained for counseling                                   FHI (MIAPR)      coordinator
# other trainings held
# of PE identified                      - ORW daily log    - Quarterly to   FHI M&E unit
# of PE trained                         - ORW daily log    NACP
3. The M&E Tools (Indicators and Definitions

The M&E tools for the project consist of specific recording and reporting formats as
listed below:

Recording formats:

-STI forms

   1. Male health records
   2. Female Health record

-VCT Forms
These a series of forms designed to facilitate the counselor in maintaining proper records
and ensuring effective follow up in case of a returning client. The various forms, which
are self explanatory include;
    1. Oath of Confidentiality
    2. Screening Interview
    3. VCT Client Consent Form for HIV Testing
    4. VCT Pre-HIV Test Counseling Form
    5. VCT Post-HIV Test Counseling Form
    6. VCT Ongoing Care Counseling Form
    7. VCT HIV Antibody Test Report
    8. VCT Client Referral Form
    9. Client Consent for Release of Information

-ORW Daily Log

-STI Physician Daily Log

-Counselor Daily Log

-Peer Educator Diary

Reporting formats:

   -   ORW Monthly Report
   -   STI Physician Monthly Report
   -   Counselor Monthly Report
   -   IA Monthly Report
   -   IA Quarterly Report
   -   Activity reports
All tools will be updated on a daily basis or as when required by the personnel
responsible for undertaking the relevant activities. In addition, monthly formats have
been provided to compile all data on a monthly basis. Reports from individual staff will
be summarized into an IA Monthly Progress Report to be compiled by the IA
supervisor/coordinator and submitted to FHI. The following sections contain detailed step
by step instructions on filling each of these forms, while the whole system is represented
in the flow chart below:

Figure: M&E tools flow chart


                                       IA QUARTERLY
                                     PROGRESS REPORT
                                     (3rd MPR+ narrative)




                                       IA MONTHLY
                                     PROGRESS REPORT




                                                                        FINANCIAL
                             ORW            STI             COUNSELOR
                                                                         REPORTS
                           MONHTLY       MONTHLY             MONTHLY
                            REPORT        REPORT              REPORT

                                                                                    Activity
                                                                                    reports


         ?  PEER           ORW LOG          STI             COUNSELOR
           WORKER                           LOG                LOG
            DIARY
3.1 The Peer Educator Diary
The diary (still under preparation) will be a pictorial record of activities undertaken by
the Peer Educator (PE) on a daily basis or whenever contact with target group is made.
The use of pictorials is necessitated by the fact that most PEs are illiterate. Despite some
doubts as to the practicability of expecting PEs to keep records and make reports, the use
of the pictorial form will ensure accountability (specifically with regards to condom and
lubricant distribution) as well as developing ownership and involvement of the PEs. The
ORW supervising the PE will be responsible to make sure that entries are valid and
timely. He will collect the report after filling in the counter file for the specific period in
question taking the filled PE dairy page and leaving the counter file with the PE. He will
also make sure to collect all reports and compile in the ORW Monthly Report.


The initial forms will be pilot tested in the field for one quarter before a decision is made
as to include them as regular M&E tools.
3.2 The ORW Diary
The ORW diary is a diary that is to be filled in on a daily basis or whenever services are
delivered to target groups. It will provide the main information regarding out-reach
activities and is therefore a very important instrument. Each row in the ORW diary is for
a single contact episode. In case of a group session, ORWs will use a separate sheet for
EACH group session conducted. The final totals for a specific reporting period will
include data from all sheets combined (regular and for group sessions). The ORW will
provide input to the supervisor on a weekly basis in order for her/him to prepare weekly
bullets. A monthly report will be prepared by each ORW based on the information
collected in his diary


Indicator                      Definition/explanation                        Comments

Name of ORW                    Name of ORW maintaining diary

Project Site                   Name of the IA project site e.g.
                               Lahore/Karachi/Taxila etc.
Dates of work                  The period of data collection for the
                               particular sheet (e.g. May 16-20, 2006)
Date                           The date of particular encounter.             If more than one encounter
                                                                             takes place on the same day,
                                                                             please list them one after the
                                                                             other in the next rows.
Target Group                   Project target sub-group based according to   Use only one code as per
                               the codes given at the bottom of the page     your judgment (e.g. a
                                                                             mechanic may also be a sex
                                                                             worker)
Age                            Approximate age range of client/s according   In case of a group, use
                               to code given in the column head              separate sheet and note age
                                                                             range of each participant.
                                                                             PLEASE NOTE that a group
                                                                             consists of three or more
                                                                             individuals.
Contact History                Based on first time (1=new) or subsequent     If a client was approached
                               contact (2=old) with client                   by project staff or has
                                                                             visited a DIC in some other
                                                                             city, s/he will be marked as
                                                                             2=old
Topics Discussed               Mention main topics covered (e.g. causes of
                               HIV/ STI symptoms etc.)
SBC materials used             Tick if you have used any of the SBC tools
                               provided to you
# people given IEC materials   # of people you provided IEC material         DO NOT confuse with # of
                                                                             IEC materials given out
Condom/lubricant demo done     Tick if you demonstrated correct use of
                               condom/lubricant
# of condoms distributed        Put in the exact number of condoms you
                                gave out in the field
# of lubricants distributed     Put in the exact number of lubricants you
                                gave out in the field
Referrals made                  Tick in the appropriate column if a referral
                                is made.
# of PE identified              Fill in the number of potential PEs you have
                                identified
# of PEs trained                Fill in the number of PEs trained
PEs monitored                   Put in the name of the PE you have
                                monitored on that day
Feedback by target              The ORWs will enter any feedback from the
group/problems encountered in   field and any problems encountered during
the fieldwork                   that week. This information should be
                                updated on day to day basis.
Write down various questions    Note down any specific questions asked by
(with answers) asked by the     the target population regarding the
target populations              programme or knowledge specific

Supervisor’s Comments &
Suggestions after meeting
ORW/PE
3.3 The ORW Monthly Report
The ORW must compile his monthly statistics to report to the project coordinator for that
particular month along with information recorded by all peer educators under his
supervision. Data for the monthly report must be compiled individually by each ORW
from his daily diary AND any group sheets. The ORW monthly report from an individual
IA is the composite report of all ORWs (and the PEs under their supervision) functioning
at the project site.


Indicator                         Definition/explanation                           Comments

Project Site                      Name of the IA project site e.g.
                                  Lahore/Karachi/Taxila etc.
No of ORWs at the site            # of ORWs functioning at the particular site

Reporting Date                    The date of filling the form (e.g. August 1st
                                  2007)
Reporting Month                   The reporting month ( e.g. May 2007)

Target Groups accessed*           Project target sub-groups contacted              This will be sum total of
                                  according to the key given at the bottom of      each target sub-group
                                  the page of the ORW daily diary                  contacted by all out reach
                                                                                   workers i.e. ORWs and PEs
                                                                                   in that month
Age                               Sum total of number of individuals seen in
                                  each age range by all ORWs and PEs in that
                                  month
Contact History                   Total number of new and old clients              Sum of new and old clients
                                  contacted by all ORWs and PEs in that            should be equal to total of all
                                  month                                            target sub-groups accessed*
# of referrals made               Total number of people referred to the DIC       The proportion of people
                                  by all ORWs and PEs                              referred (clients referred
                                                                                   divided by all clients seen at
                                                                                   DIC) can give an idea of
                                                                                   performance of outreach
                                                                                   staff
# of one-to-one sessions          Sum total of all rows entered in the ORW         Total of # of people reached
                                  diary for the reporting period                   through one-on-one and
# of people reached through one   Same as above                                    group sessions should equal
to one session                                                                     the target group accessed
# of group sessions               Sum total of sheets used for group sessions      total*
                                  (each group session is recorded on a
                                  separate sheet)
# of people reached through       Sum total of all rows in all sheets filled for
group sessions                    group sessions conducted
# Condom /lubricants demo done    Sum total of number of rows ticked               This information can be
                                  (condom/lubricant demo done in ORW and           validated with the stock
                                  PE diaries) of all workers in that month         registers to monitor ORWs
# of condoms distributed          Sum total of all rows for # for condoms          and PE’s distribution of
                                  distributed in all ORW and PE diaries            condom and lubricants ( e.g.
# of clients given condoms      Sum total of number of rows having any       Are many people receiving
                                entry other than 0 for # for condoms         condoms or are only a few
                                distributed column in all ORW and PE         clients receiving many
                                diaries                                      condoms?) as well as to
# of lubricants distributed     Sum total of all rows for column # for       make projections for future
                                lubricants distributed in all ORW and PE     stock needs
                                diaries
# of clients given lubricants   Sum total of number of rows having any
                                entry other than 0 for # for lubricants
                                distributed column in all ORW and PE
                                diaries
# people given IEC materials    Sum total of rows # of people given IEC
                                materials column in all ORW and PE diaries
Feedback by target
group/problems encountered in
the fieldwork

Write down various questions
(with answers) asked by the
target populations

Supervisor’s Comments &
Suggestions after meeting
ORW/PE
3.4 The Counselor Daily Log
This log is the main recording tool for the counselor and shall be present in the Counselor
Office at all times. It records each individual encounter as and when it occurs and must
be updated at the end of each encounter.
Indicator                      Definition/explanation                            Comments

Name of counselor              Enter name of counselor
Project Site                   Name of the IA project site e.g.
                               Lahore/Karachi/Taxila etc.
Reporting Month                The reporting month ( e.g. May 2007)
Date                           The date of particular encounter.                 If more than one encounter
                                                                                 takes place, please enter next
                                                                                 encounter in the next row
New/Follow-up                  Based on first time (1=new) or subsequent         If a client has visited a DIC
                               contact (2=old) with client                       in some other city, s/he will
                                                                                 be marked as 2=old
Patient ID number              Enter the unique code assigned to a client at     Each client has a unique
                               the DIC                                           code that should be quoted
                                                                                 the next times/he visits
Referred by                    Enter the referring staff category if client is   Leave blank if walk-in
                               a referral (e.g. ORW,PE, doctor)
Sub population                 Project target sub-group according to the         Use only one code as per
                               key given at the bottom of the page               your judgment (e.g. a
                                                                                 mechanic may also be a sex
                                                                                 worker)
Risk Status                    Enter according to risk-status
                               (low/medium/high) based on the risk
                               assessment tool provided by FHI
Counseled for                  Enter the reason for counseling based on the      Multiple entries not allowed
                               code given below
Referred for                   Enter code as per instructions in column          The proportion of people
                               head in case of further referral                  referred (clients referred
                                                                                 divided by all clients seen at
                                                                                 DIC) can give an idea of
                                                                                 performance of outreach
                                                                                 staff
Test Results Delivered         Tick if ANY test results have been provided       This column will only be
                               to the client                                     filled for an old/follow-up
                                                                                 client
Condom/ lubricant/demo done    Tick if you demonstrated condom/lubricant

# of condoms distributed       Put in the exact number of condoms you
                               gave out
# of Lubricants Distributed    Put in the exact number of lubricants you
                               gave out
# IEC material                 Tick if any IEC material have been given

Comments                       Any client specific comments you would
                               like to make e.g. need for follow-up or
                               refusal of client to test for HIV despite the
                               assessed need
3.5 The Counselor Monthly Report
This is a compiled monthly report using information from the Counselor daily Log. It
will be completed at the end of each month and provided to the Supervisor/coordinator
for preparation of the IA Monthly Progress Report.
Indicator                            Definition/explanation                         Comments

Project Site                         Name of the IA project site e.g.
                                     Lahore/Karachi/Taxila etc.
Name of counselor                    Enter name of counselor

Reporting date                       Date of preparation of report

Reporting Month                      The reporting month ( e.g. May 2007)

Total # of counseling trainings to   Number of training facilitated by you with a
staff                                breakdown of number and cadres of staff
                                     trained
# of individuals referred by staff   Staff specific sum totals of column
for counseling                       “Referred by” in counselors daily log
Sub population*                      Sub-totals of different sub-group based on
                                     the key given at the bottom of the page

Type of counseling provided          Sub-totals of different categories of          Total counseling sessions
                                     counseling based on the key given at the       should equal to total of sub
                                     bottom of the page                             populations counseled*

# clients referred                   Total number of reason-specific referrals      The proportion of people
                                     done                                           referred (clients referred
                                                                                    divided by all clients seen at
                                                                                    DIC) can give an idea of
                                                                                    networking and linkages
                                                                                    developed by DIC
# of first ever visits               Sum total of “new=1” from the relevant
                                     column in counselor log
# of follow up visits                Sum total of “old=2” from the relevant
                                     column in counselor log
Condom lubricant/demo done           Sum total of number of rows ticked
                                     (condom/lubricant demo done in ORW and
                                     PE diaries) of all workers
# of condoms distributed             Sum total of all rows containing 1 or more     Sum total of all rows for # of
                                     in column “ # of condoms distributed” in       condoms distributed in
                                     Counselor Daily Log                            ORW and PE diaries of all
                                                                                    workers
# of clients given condoms           Sum total of number of rows containing 1 or
                                     more in column “ # of condoms distributed”
                                     in Counselor Daily Log
# of Lubricants Distributed          Sum total of all rows containing 1 or more
                                     in column “ # of lubricants distributed” in
                                     Counselor Daily Log
# of clients given lubricant    Sum total of number of rows containing 1 or
                                more in column “ # of lubricants
                                distributed” in Counselor Daily Log
# IEC materials                 Sum total of all rows ticked yes for column
                                IEC material given
# people given results          Sum total of column test results given ticked
                                as yes
# of HIV positive identified    Only HIV positives identified by DIC



In addition to the above counselors are requested to list up to four barriers that they faced
in fulfilling their duties and recommendations that may have with regards to rectifying
the situation


The counselor can also list major achievements that s/he thinks are worth reporting and
that can be a basis for best practices.


The counselor may also write down specific questions that were asked by target
populations. This source of information is important to assess effectiveness of messages
being delivered by out-reach, identify areas of information needs and possible changes to
IEC strategies.
3.6 The STI Physician Daily Log
This log is the main recording tool for the STI Physician and shall be present in the DIC
clinic at all times. It records each individual encounter as and when it occurs and must be
updated at the end of each encounter.
Indicator                      Definition/explanation                            Comments

Name of physician              Enter name of physician

Date                           Enter date of first entry on page

Project Site                   Name of the IA project site e.g.
                               Lahore/Karachi/Taxila etc.
Date                           The date of particular encounter.                 If more than one encounter
                                                                                 takes place on the same date,
                                                                                 please enter next encounter
                                                                                 in the next row
Patient ID number              Enter the unique code assigned to a client        Each client has a unique
                                                                                 code that should be quoted
                                                                                 the next times/he visits
New/Follow-up                  Based on first time (1=new) or subsequent         If a client has visited a DIC
                               contact (2=old) with client                       in some other city, s/he will
                                                                                 be marked as 2=old
Referred by                    Enter the referring staff category if client is   Write in others if the patients
                               a referral (e.g. ORW,PE, doctor)                  is a walk-in
Sub population                 Project target sub-group according to the         Use only one code as per
                               key given at the bottom of the page               your judgment (e.g. a
                                                                                 mechanic may also be a sex
                                                                                 worker)
Sex                            Enter M for male and F for female client

STI Diagnosis                  Enter diagnosis based on syndromic                Last column will be ticked if
                               approach. For STIs not listed here, enter the     the client is a woman
                               data in the ‘others’ column                       suffering from STI
Treatment given for STI        Enter treatment provided in case of STI only

Other medical conditions       Enter conditions other than STIs that the
                               patient is seeking treatment for
Referred for                   Enter as per codes provided in column head
                               in case of referral. If multiple referrals are
                               made then write them separately e.g. 2,4.
Investigations                 Enter any laboratory investigations ordered
                               either through DIC referral linkages or at
                               other places
Condom/lubricant demo done     Tick if you demonstrated the correct use of
                               condom and llubricants
# of condoms distributed       Put in the exact number of condoms you
                               gave out to the patient at that visit
# of lubricants Distributed    Put in the exact number of lubricants you
                               gave out to the patient at that visit
# IEC materials                Tick if you provided any IEC material to the
                               patient at that visit
3.7 The STI Physician Monthly Report
This is a monthly report for the STI clinic activities using information compiled from the
daily log for the STI physician. It will be completed at the end of each month and
provided to the project coordinator for preparation of the IA’s Monthly Progress Report.
This log will also be shared on monthly basis with the technical officer for STI at the FHI
Lahore office.
Indicator                            Definition/explanation                         Comments
Project Site                         Name of the IA project site e.g.
                                     Lahore/Karachi/Taxila etc.
Name of Doctor                       Enter name of the physician
Reporting date                       Date of preparation of report
Reporting Month                      The reporting month ( e.g. May 2007)
Total # of STI/PHC training to       Number of training facilitated by you with a
staff                                breakdown of number and cadres of staff
                                     trained
# of individuals referred by staff   Staff specific sum totals of column
for STI and PHC treatment            “Referred by” in physician daily log
Sub population treated for STIs      Totals of various STIs syndromes treated in
                                     various sub-groups
# clients referred                   Total number of reason-specific referrals      The proportion of people
                                     from the STI clinic done                       referred (clients referred
                                                                                    divided by all clients seen at
                                                                                    DIC) can give an idea of
                                                                                    networking and linkages
                                                                                    developed by DIC
# of first ever visits               Sum total of “new=1” from the relevant
                                     column in physician log
# of follow up visits                Sum total of “old=2” from the relevant
                                     column in physician log
Condom/lubricant lubricant done      Sum total of number of rows ticked
                                     condom/lubricant demo done daily
                                     physician log
# of condoms distributed             Sum total of all rows containing 1 or more     Sum total of all rows for # of
                                     in column “ # of condoms distributed” in       condoms distributed in
                                     physician Daily Log                            ORW and PE diaries of all
                                                                                    workers
# of clients given condoms           Sum total of number of rows containing 1 or
                                     more in column “ # of condoms distributed”
                                     in physician Daily Log
# of Lubricants Distributed          Sum total of all rows containing 1 or more
                                     in column “ # of lubricants distributed” in
                                     physician Daily Log
# of clients given lubricant         Sum total of number of rows containing 1 or
                                     more in column “ # of lubricants
                                     distributed” in physician Daily Log
# IEC material                       Sum total of all rows ticked yes for column
                                     IEC material given
In addition to the above physician are requested to list up to four barriers that they faced
in fulfilling their duties; recommendations that they may have in regards to rectifying the
situation; major achievements that s/he thinks are worth reporting and that can be a basis
for best practices; and specific questions that were asked by target populations. This
source of information is important in assessing effectiveness of messages being delivered
by out-reach, identifying areas of information needs and making possible changes to IEC
strategies.
3.8 Activity Report
This report will document all major SBC activities undertaken including trainings, social
mobilization and advocacy meetings, theater and other performances and particulars
about number and sub-groups of participants. It will also document barriers and
difficulties faced by the staff during their interactions with the community and in
particular with respect to the use of SBC material.
Indicator                        Definition/explanation                         Comments
Name of activity                 Name the activity (e.g. Training of peer
                                 workers/ demand creation meeting etc.)
Date (submission of report)      Date of report submission                      Preferably to be submitted
                                                                                within three days of activity
Submitted to                     Person report is submitted to
Submitted by                     Name of person submitting the report
Date (activity)                  Date when activity was conducted
Timings                          Timings of activity (e.g. 4 to 6 pm)
Duration                         Duration of activity (e.g. 2 hours)
Venue                            Name of venue where activity took place
Participation of population      Breakdown of participants as per codes
Key Messages                     Key messages delivered as per protocol
                                 provided
Type of activity                 Type of activity to be ticked as per choices
                                 provided in form
IEC/SBC material                 Use if IEC/SBC material along with specific
                                 feedback received from clients
Comments/questions by target     Specific questions or comments made by
population                       participants during activity
Comments by chief guest/others   Specific questions or comments made by
                                 chief guests or other stakeholders during
                                 activity
Issues pertaining to activity    Any issue like difficulties and barriers and
                                 good practices pertaining to the reported
                                 activity
3.9 The IA Progress Monthly Report
This report is the main reporting tool for IA project activities to be reported to FHI on a
monthly basis. It is developed after compiling the monthly ORW, Counselor and STI
Physician reports and supplemented by activity reports and financial reports.
Indicator                             Definition/explanation                          Comments

IA’s name                             Name of implementing agency
FCO number                            This is the cost code. For truckers project
                                      enter 16050
Report period                         Enter month/date/year of reporting period
Report compiled by                    Enter name of individual preparing report
                                      (project coordinator)
Access by out-reach workers (age      Breakdown of various age group accessed         The total of all age-groups
range and # accessed)                 by outreach workers only (to be compiled        should be equal to the
                                      from ORWs monthly report).                      column total in the target
                                                                                      population accessed by
                                                                                      ORWs
Total clients accessed by ALL         Total number of contacts made by all staff      To be compiled from ORW,
project staff (new and old clients)   (ORW, PE, Counselor and Clinician) as           STI and Counselor monthly
                                      coded ‘1=new’ and ‘2=old (first time)           reports.
Total # consultations held (STI +     Total sum of all clients seen at the DIC        From STI monthly report
PHC)                                  clinic
Total # of new clients seen at        Total number of clients (code=1) visiting the
clinic (STI + PHC)                    DIC clinic for the first time                   Total # of consultations
# of clients revisiting clinic        Total number of clients (code=2) visiting the   should be equal to total no of
                                      DIC clinic a second or more time                new and follow-up clients
Total # of STI cases diagnosed        Total number of STI cases diagnosed with
                                      breakdown (syndromic)
Total # of new clients treated for    # of clients coming for the first time at the
STI                                   clinic and being treated for STI (code=1 plus
                                      STI present)
Total # clients referred              # of clients referred from the DIC clinic to
                                      any site. Breakdown by reason
Total # clients referred by project   # of clients referred by outreach staff to
staff to clinic                       clinic. Breakdown by staff cadre
# days stock out of STI medicine      # of days of unavailability of STI medicine     From drug stock register
                                      stocks
Total # counseling sessions held      # of individual and group counseling            To be compiled for
                                      sessions held at DIC center (irrespective of    Counselor Monthly Report
                                      type of counseling)
# of clients referred by project      # of clients referred by outreach staff to
staff for counseling                  counselor. Breakdown by staff cadre
# clients referred for testing        # of clients referred by DIC staff (physician   To be compiled from STI
                                      and counselor) for testing of any kind          and Counselor Monthly
                                                                                      reports
# of HIV tests performed              # of clinical tests performed at DIC center     To be compiled for
                                      (for Karachi only)                              Counselor Monthly Report
# HIV positive clients identified     # of HIV positive clients identified through
                                      VCT
# clients referred for HIV/AIDS       # clients referred from DIC center for
care and support                      HIV/AIDS care and support of any kind
Indicator                           Definition/explanation                          Comments

# of condoms distributed            # of condoms distributed as per daily           To be compiled from ORW,
                                    logs/diaries of staff                           STI and Counselor Monthly
# of lubricants distributed         # of lubricants distributed as per daily        Report
                                    logs/diaries of staff
# of condom demonstrations          # of condom demonstrations performed as
performed                           per daily logs/diaries of staff
# of clients provided with          Total number of people provided with
condoms                             condoms by all staff

# of clients provided with          Total number of people provided with
lubricant                           lubricant by all staff
# of condoms sold                   # of condoms sold by collaborating              From retailer outlets
                                    retailers/outlets
# of lubricants sold                # of lubricants sold by collaborating
                                    retailers/outlets
# of days stock out of condoms      # of days of unavailability of condoms at       From stock register
                                    DIC center
# of days stock out of lubricants   # of days of unavailability of lubricant at
                                    DIC center

# of PEs identified                 Fill in the number of PEs identified            From ORW diary
# of PEs trained                    Put in the name of the PE trained               From ORW diary
Number of target population         # of one to one sessions conducted by out-      To be compiled from ORWs
reached one-on-one                  reach ( PE and ORW)                             monthly reports
Number of target population         # of group sessions conducted by out-reach (
reached by group activity           PE and ORW)
                                    (a group being two or more people)
# of theater performances           # of theater performance conducted by           To be compiled from activity
                                    outreach staff or any collaborating agency      reports and coordinator/
                                                                                    supervisor noted
# of Focus group Discussions        # of focus group discussions held with target
(FGD)                               population
# of social gatherings held         Social events organized (including award
                                    ceremonies, meetings, tea parties and others)
# of people given IEC materials     # of people given any kind of IEC materials

# of meetings of post-test club     post test club meetings are group support
                                    meetings of clients tested positive for HIV
# of meetings with partner          Enter # of meetings with organization the
organizations                       DIC collaborates with actively
# of meetings with stakeholders     Enter # meetings with stakeholders and
                                    approximate number attending
# of community group                Enter number of active group committees
committees active                   (having met at least once in the last month)
# supervisory visits/sessions       Total number of supervisory visits
conducted                           conducted by supervisor/ coordinator or FHI
                                    core team
# demand creation meetings held     Enter the number of demand creation
                                    activities/meetings conducted
Other activities held                  Mention any activity that does not fall in the
                                       above categories
# staff trained for first time         # of staff being trained for the first time
                                       within the project scope
# staff receiving refresher training   # of staff receiving refresher trainings of any
( and breakdown)                       kind
Total Amount Approved                  Enter the total value of contract in PKR
Amount expended this                   Enter the actual amount of money (not
month/quarter                          accrued) spent in the last month in PKR
Total Amount expended                  The amount of money spent to date in PKR
Balance amount                         Total budgeted amount minus the amount
                                       spent to date in PKR
3.10 The IA Progress Quarterly Report
The IA Quarterly Report is essentially the third monthly report in a quarter plus a
narrative section to be prepared by the supervisor/coordinator. The FHI team will then
compile the quantitative sections of the last three monthly reports to prepare the quarterly
report for each IA.


The narrative section must contain a brief summary of the project highlights, successes
achievements, and challenges in the last quarter. A detailed description of coordination
with other providers or organizations must also be provided with special emphasis on
referral networks and condom and lubricant distribution. Furthermore, the IAs are
required to provide details about development and use of SBC material and feedback
from the community regarding the same. The Quarterly report also warrants a detailed
description of any problems faced by the project staff and recommended solutions. A
detailed work plan for the next quarter must be attached to the Report.


Quarterly reports from all the IAs will be compiled to form the Project Quarterly report to
be submitted to the NACP


3.11 The Quarterly Review Report
This is a summary of the Project Quarterly Reports submitted to the NACP and sent to
the IA for sharing at stakeholder meetings and other management forums within the
organization.
5. Annexes
                      INFORMATION FLOW CHART


                                         NACP
Quarterly
Report

                                       FHI
                                     COUNTRY
                                      OFFICE
                                                             M&E
                                                            OFFICER
Compiled                                FHI                                Quarterly
Monthly Report                       PROGRAM                               review
                                      OFFICE



Monthly Report
                 IA   IA      IA    IA    IA     IA    IA      IA     IA
Weekly bullets                                                             Stakeholder
Daily records                                                              sharing


                           Outreach workers and Peer workers
                                             PEER    WORKER     DAILY        DIARY




       1                                                                                                                10
                     2             3          4         5            6           7           8               9
DATE       One on        Group     Target group   Condom/   Condom       Lube        IEC         Referred        Referred
           one           session   (1 to 10       lube      given        given       given       To doctor       To
           session                 above)         demo                                                           Counselor
                                   truck diver    done
                                   mechanic
                                   transgender
                                   sex worker
                                   ..
                                   …
                                                                             Outreach Worker Daily Diary


Name of ORW: ___________________________                               Project Site:________________                                  Dates of work__________________________
                           Age         Contact                                                         Condom /
                                                                        SBC             # people                           # of           # of                                   Peer educators
               Target    1=-14         History          Topic                                            Lube                                           Refer
    Date                                                               material        given IEC                       Condoms          Lubes
               group*    2=15-24     1= first time    discussed                                         demo                                           to DIC          #               #              #
                         3= 25+      2= old                             used            material                       distributed    distributed
                                                                                                         done                                                      identified       trained       supervised




   TOTAL


                                                                                                                                            Supervisor’s signature _____________________
              Code= 1-Truck drivers 2- cleaners; 3-Workers/Mechanics; 4- FSW (Female Sex Workers); 5- MSW(male Sex Workers); 6-Transgender/Hijrey;7-Religious leaders;8- Informal health care
               providers; 9-Formal Health care Providers; 10-others;




                                        HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
                                                                                   Daily Log for Counselor
               Name of the counselor:______________________ Site_____________________ Record dates:_______________________________

                                                                                      Referred for
                                                                                                       Test      Condom                            IEC
                                                                                   1=HIV testing
                                  Referred                                                            results     demo       # of      # of      material
                                                                                   2=STI treat
                      New=1         By1         Sub      Risk      Counseled                         delivered    done    condoms   lubricants    given
Date       Pt ID #                                                                 3=Care and                                                                          Comments
                      F-up=2                    pop2    status3      for4                                                   given     given
                                                                                   support
                                                                                                      (Y/N)      (Y/N)                            (Y/N)
                                                                                   4=other




Total




1
    1=ORW; 2=PE; 3=Clinican 4=other DIC Staff; 5= other SBC partners; 6= others.
2
  1-Truck drivers 2- cleaners; 3-Workers/Mechanics; 4- FSW (Female Sex Workers); 5- MSW(male Sex Workers); 6-Transgender/Hijrey;7-Religious leaders;8- Informal health care providers;
9-Formal Health care Providers; 10-others;
3
  L= low risk; M=Medium risk; H=High risk
4
  S=Supportive counseling; Gr=Group Counseling; PRT= Pre-test Counseling; POT=Post-test counseling.
                                     Monthly Report Format for Counselors


   Project Site: ________________________Counselor’s Name ________________________
   Reporting Date: _____________________ Reporting Month: ________________________
Total # of counseling trainings to staff            # of trainings

                                                    # of             PW
                                                    participants     ORW
                                                                     Doctors
                                                                     Others
# of individuals referred by staff for counseling   By ORW
                                                    By PE
                                                    By Doctor
                                                    Others
                                                    Total
Sub-population counseled                            Truck drivers
                                                    Cleaners
                                                    Workers/ mechanics
                                                    FSW
                                                    MSW
                                                    Hijras
                                                    Religious leaders
                                                    Others
Type of counseling provided (#)                     Supportive Counseling
                                                    Group Counseling
                                                    Pre-test Counseling
                                                    Post-test Counseling
                                                    Total
# of clients referred                               HIV Testing
                                                    STI management
                                                    HIV care and support
                                                    Others
                                                    Total
# of first ever visits
# of follow up visits
# condoms/lube demonstration done
# of condoms distributed
# of clients given condoms
# of lubes distributed
# of clients given lube
# of people given IEC material
# of people given their test results
# of HIV positives identified
                         Monthly Report Format for Counselors

Barriers/Problems faced by the Counselor              Recommendations




 Achievement/s of the Counselor/Notes from the meetings with supervisees
 __________________________________________________________________________
 __________________________________________________________________________
 __________________________________________________________________________
 __________________________________________________________________________



 Write down various questions (with answers) asked by the target populations:




                                    Signature of supervisor ____________________
                                                       Monthly Report Format for Counselors

                                             Physician: _________________________                          Date: _________________________________ Project site:
                                   ________________________
                                                                            STI Diagnosis                                                           Referred for
                                                                                                                                     Other       1= Counseling
                                                                                                                                                                           Invest     Cond                        IEC
                                                                                                           STI                      medical      2= Advanced                                     # of    # of
       Pt   New=1        Referred     Sub      Sex                                                                      Rx for                                               for      demo                      material
Date                                                   Ureth.    Test.     Gen.      Anal                   in                       cond.       STI care                                       cond    lubes
       ID   F-up=2         by5        pop6     M/F                                               Others                  STI                                                STI        done                      given
                                                       Disch     Swell     Ulcer     STIs                 woman                     (PHC/        3=HIV C&S                                      given   given
                                                                                                                                                                                      (Y/N)                      (Y/N)
                                                                                                                                     other)      4= Lab test
                                                                                                                                                 5=Other (specify)




            5
                1=ORW; 2=PE; 3=Counselor; 4=other DIC Staff; 5= other SBC partners; 6= others.

            6
              1-Truck drivers 2- cleaners; 3-Workers/Mechanics; 4- FSW (Female Sex Workers); 5- MSW(male Sex Workers); 6-Transgender/Hijrey;7-Religious leaders;8- Informal health care providers; 9-
            Formal Health care Providers; 10-others;
                                     Monthly Report Format for STIs

 Project Site: ________________________Doctor’s Name ________________________
 Reporting Date: _____________________ Reporting Month: _____________________
Total # of trainings     # of trainings
for staff
                         # of             PW
                         participants     ORW
                                          Counselors
                                          Others
# of individuals         By ORW
referred by staff for    By PE
treatment                By SBC partner
(STI and PHC)            Others
                         Total
Sub-population           Sub Population group          Ureth.   Test   Gen      Anal   Other    Female       PHC
treated for STIs                                       Disch    swel   Ulcer    STI             STI
                         Truck drivers
                         Cleaners
                         Workers/ mechanics
                         FSW
                         MSW
                         Hijras
                         Religious leaders
                         Others
                         Total
# of clients referred    Counseling
                         STI advanced care
                         HIV/AIDS Care and
                         Support
                         Lab test
                         Others
                         Total
# of first ever visits
# of follow up visits
# condoms/lube
demonstration done
# of condoms
distributed
# of clients given
condoms
# of lubes
distributed
# of clients given
lube
# of people given
IEC material



      HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
                             Monthly Report Format for STIs


  Barriers/Problems faced by the Physician                          Recommendations




Achievement/s of the Physician/Notes from the meetings with supervisees
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________



Write down various questions (with answers) asked by the target populations:




                                                 Signature of supervisor ____________________




HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
                                   Activity Performance Report

Name of the Activity: __________________________________________________________

Date (Submission of Report): _____________

Submitted To: _______________                             Submitted By:______________

Date (Activity) ______________                            Timings ____________________

Duration: ___________________                             Venue: _____________________

OBJECTIVE OF ACTIVITY:




PARTICIPATION OF POPULATION:

 Code1       Total #                                          Code= 1-Truck drivers; 2- cleaners;
                                                             3-Workers/Mechanics; 4- FSW
                                                             (Female Sex Workers); 5-MSW(Male
                                                             Sex Workers); 6-Transgender
                                                             /Hijrey; 7-Religious leaders; 8-
                                                             Informal health care providers; 9-
                                                             Formal Health care Providers; 10-
                                                             others.




KEY MESSAGES:
                         Yes                       No                        # if applicable
Abstinence
Faithfulness
Condoms
 Demonstration
 Distribution
 Demand created
Lubricants
 Demonstration
 Distribution
 Demand created
Other
(Specify/Describe)




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
TYPE OF ACTIVITY:

Mass Media:                                      Yes_____ No______

IEC/Community Outreach:                    Yes_____ No______
    a) Peer Education:                     Yes_____ No______
    b) Theatre, drama, edutainment:        Yes_____ No______ # _________
    c) Other IEC (Specify :______________________________): Yes_____ No______

Training:                                        Yes_____ No______
a) Training of Peer Educators:                   Yes_____ No______
                                                 # (training) ______ # (participants) _____

b) Training in Community Outreach:           Yes_____ No______
     c) Training on Mass Media SBC:          Yes_____ No______
     d) Training on SBC Strategy Development Yes_____ No______
     e) Other training (Specify :_______________________________): Yes_____ No______

IEC/SBC Material

              Material                   How it is used?                        Feedback




Comments/Questions by Target Population:




Comments by Chief Guest/others:




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
Notes from the debriefing meeting:

             Issues pertaining to activity                         Recommendations




   HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
IA’s Name: ________________________                FCO# ____________________________________
Report Period: _____________________               Report compiled by: _______________________

1. TARGET POPULATION CONTACTED
         Population        Target PE                  ORW       Couns       Clinic
 Truck drivers                                                                           Access by outreach
 Cleaners                                                                                      workers
 Workers/ mechanics                                                                  Age range      # accessed
 FSW                                                                                  < 14 years
 MSW                                                                                 15-24 years
 Hijras                                                                               25 + years
 Religious leaders
 Formal Health providers                                                             Total clients accessed by
 Informal Health providers                                                               ALL project staff
 Others                                                                              Total # of new clients
 TOTAL                                                                               Total # of old clients

2. STI SERVICES
Total # consultations held (STI + PHC)
Total # of new clients* seen at clinic (STI + PHC)
# of clients revisiting clinic
Total # of STI cases       Urethral Discharge
diagnosed                  Testicular Swelling
                           Genital Ulcers
                           Anal STIs
                           Others (male)
                           Female STIs
                           Total
# of male clients treated for STI
# of female clients treated for STI
# clients referred           Counseling
                             Advanced STI care
                             HIV/AIDS care and support
                             Lab test
                             Others
                             Total
# days stock out of STI medicine
# clients referred by project staff to clinic                    PE           ORW       Other        Total

* New clients are clients registered for the first time at the DIC center




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
3. VCT SERVICES
Total # counseling sessions held         Supportive        Group         Pre-test     Post-test        Total


# of clients referred by project staff        PE            ORW             Doctor        Other        Total

# clients referred for testing
# tests performed
# HIV positive clients identified
# of HIV positive retested after
window period
# clients referred for HIV/AIDS
care and support

4. CONDOM AND LUBE PROMOTION
Indicator                                                      Breakdown by staff
                                                   PE      ORW     Dr   CSL other              Total
# of condoms distributed
# of lubes distributed
# of condom demonstrations performed
# of clients provided with condoms
# of clients provided with lube
# of condoms sold
# of lubes sold

# of days stock out of condoms
# of days stock out of lubes
# retail outlets distributing condoms/lubes



# of PE identified
# of PE trained




     HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
5. OTHER SBC ACTIVITIES
Access by outreach                                             PE     ORW       Others        Total
Number of target population reached one-on-one
Number of target population reached by group activity
SBC Activities                                                # of sessions     # of people reached*
# of theater performances
# of Focus group Discussions (FGD)
# of social gatherings held
# of IEC material distributed                                       NA
# of meetings of post-test club
# of meetings with partner organizations
# meetings with stakeholders
# of community group committees active
# supervisory visits conducted                                                           NA
# of demand creation meetings held
# Other activities held (specify)
* Fill in approximate numbers


6. TRAININGS AND CAPACITY BUILDING
Trainings                                                           Staff cadre
                                      PE                  ORW       Doctor     Counselor       Others
# staff trained for first time
# staff receiving refresher training
# trained to use SBC/IEC material
# trained in HIV/AIDS
# trained in STI diagnosis/management
# trained to demonstrate condom use
# trained for counseling
# other trainings held



7. SUMMARY OF BUDGET EXPENDITURES

Total Amount Approved              Amount               Total Amount          Balance Amount
(PKR)                              Expended this        Expended (PKR)        (PKR)
                                   month/ quarter
                                   (PKR)




     HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
Briefly write down organization’s Technical/Management/Financial Assistance requirements over the
next month/quarter or any other comments:




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
                                         Narrative Report
Brief Summary of Project highlights/success/achievements of this quarter:




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
COORDINATION AND COLLABORATION
                   Details of collaboration
  Organization     (please describe nature e.g. referral to VCT/STI /PHC services, Condom
                   procurement, MoU signed etc)




MATERIAL DEVELEOPED (MANUALS/IEC MATERIAL/REPORTS)




SBC MATERIAL USED THIS QUARTER
       Material              How it is used?                             Reaction or Feedback




Themes/Key Messages given by project staff to Target Population this quarter
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________

Write down various questions (with answers) asked by the target populations:




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
Overall problems project staff met this quarter & how these have been/could be solved?

                  Problems                                            Solutions




   ANY OTHER COMMENTS/RECCOMENDATIONS




   PLEASE ATTACH TOUR WORKPLAN FOR THE NEXT QUARTER AND OTHER RELEVANT
   DOCCUMENTS




    HIV/AIDS Service Package for Long Distance Truckers, Cleaners/ Attendants and Associated Populations
                                             CLINIC
                                        Male Health Record


Referral #                    Registration No                    Date of Attendance
Name
Profession:                                            Age
Address:
Marital status
Referred by project staff? (Please Tick)                    Yes   □       No       □
Referred by sexual partner (i.e. contact tracing – please tick) Yes       □        No     □
New or Previous patient                                         New   □        Previous □

Present Complaints (Please circle all applicable):
1. Urethral Discharge                5. Scrotal Swelling         8. Vesicles
2. Anal Discharge                    6. Genital / Groin          9. Pustules
3. Penile Ulcer                         Itching                  10. Others ……………..
4. Anal Ulcer                        7. Burning urination
                                        /frequency
History of Present Illness:




Previous Illnesses (including STIs), treatments and surgeries:




Drug History:
1. Any medications used for    Yes/No       Details:
present problem
2. Drug Allergy                Yes/No       Details:

3. Illicit drug use            Yes/No       Details:




            Pt Registration #_____________________ Name: ________________________
Sexual History
Any sexual encounter in last month:      Yes        □         No    □
Male Partner                             Yes        □         No    □
Female Partner                           Yes        □         No    □

Sexual practice (Please Describe):


Total number of ever lifetime sexual partners (permanent and others):
Number of males: _____________                Number of females:____________________
Condom used in last 3 months (tick one box)
□ Every Time           □ Almost every time          □ Sometimes              □ Never
□ don’t know           □ No response                □ Not applicable

Condom Used correctly (if relevant): Yes □          No □      Don’t Know □       Not Applicable □

Partner/s has signs of STI (tick one):        Yes □ No □       Don’t know □
If yes please describe:



General Examination
Weight (kgs): ……………              B/P: …………. Temp( C 0):…….                   Pulse: ……….
Jaundice:        Yes      □      No          □      Pallor:         Yes      □       No      □
Lymph Nodes: …………………….                              Skin Lesions: ……………….
Local Examination (genital area)

Ulcer ……………………….. Yes/No                     Site: _____________Size: ______________ Single/Multiple,
Tender/Non Tender, Vesicular

Urethral discharge:     Yes    □             No     □
                        Watery           □         Milky        □
Scrotum:

Penis:

Epididymis:
Testis:
Vas deferens




            Pt Registration #_____________________ Name: ________________________
Anal Examination / Proctoscopy:




Systemic Examination
Chest:                                          CVS:


CNS:                                            Other:


Provisional Diagnosis




Laboratory Investigations
PRP     Yes □         No       □       Result: Positive □ Negative    □      Titer:

TPHA     Yes    □       No     □       Result: Positive □ Negative    □

Gram stain (urethral specimen): Yes    □       No        □    Result:_____________________

HIV antibody test:
Yes □ No □                                          Result: Positive □ Negative       □

Diagnosis



Treatment:




Other Management (4Cs etc)




            Pt Registration #_____________________ Name: ________________________
Follow-Up visits




         Pt Registration #_____________________ Name: ________________________
Implementing Partner/Location:
Type of Intervention: Sexually Transmitted Infections (STI)
Date:
Assessment team:

I. PREPAREDNESS FOR SERVICE DELIVERY

 Sub-category                                                     Scored   Max    Follow up actions          Resources/       Responsible    Expected
                                                                                  recommended                support needed   person(s)      completion
                                                                                                                                             date


 1.   The type, number and training of staff meets agreed
      requirements




 2.   Management functions meet agreed requirements




 3.   Facilities, supplies and educational or informational
      materials for delivering services meet agreed
      requirements


 Total                                                                            %

II. TECHNICAL AND PROGRAMMATIC IMPLEMENTATION (SERVICE DELIVERY)

                                                                                                               Resources/                     Expected
                                                                                         Follow up actions                     Responsible
 Sub-category                                                     Scored    Max                              support needed                  completion
                                                                                          recommended                            person
                                                                                                                                                date


 4.   The services are delivered according to agreed
      requirements




 5.   Client health, welfare and confidentiality is assured and
      protected wherever possible
 6.   Referral network of comprehensive quality services is
      established and functional wherever possible




 7.   Clients are satisfied with the facilities and services



                                                               Total                                  %

III. MONITORING AND EVALUATION (POST SERVICE DELIVERY)

                                                                                                                           Resources/                       Expected
                                                                                               Follow up actions                             Responsible
 Sub-category                                                           Scored      Max                                  support needed                    completion
                                                                                                recommended                                    person
                                                                                                                                                              date


 8.   The recording and reporting system is working well and
      the data are reliable




 9.   Processes for data use, supervision and feedback are
      in place




 10. Client utilization and coverage of services meets
     expectations



                                                               Total                                  %
Scoring Notes:                                                         Method Notes:
        NA: Not applicable          (0) No                              O= Observation                SI= Staff Interview
        (1) Yes, partially          (2) Yes                             R= Records Review             MI = Management Interview
            Red flag: serious deficiency, FHI senior                    CI= Client Interview          GI/StI =Gatekeeper/Stakeholder Interview
             management should be notified
I. PREPAREDNESS FOR SERVICE DELIVERY

1. The type, number and training of staff meets agreed                        Method         Score       Observations/rationale for score
requirements
a.   Written job descriptions for each position are available and staff        R/SI     NA   0       2
     understand their roles and responsibilities
b.   Staff are hired based on prior suitable experience and expertise           R       NA   0   1   2
     as evidenced by CV’s or equivalent
c.   All staff receive basic training appropriate for their work within        R/SI
     the first few weeks of recruitment and receive on-going
     mentoring, supervision and training to fulfill their responsibilities:
     •   Doctor                                                                         NA   0   1   2
     •   Midwives/nurse                                                                 NA   0   1   2
     •   Laboratory technician                                                          NA   0   1   2
     •   Administration staff                                                           NA   0   1   2
     •   Counselor                                                                      NA   0   1   2
     •   Peer educators, outreach workers                                               NA   0   1   2
d.   Dedicated time for training and continuing education is provided           SI      NA   0   1   2
     to all staff
e.   Performance reviews are conducted annually                                MI/SI    NA   0   1   2
f.   Written procedures exist for all services provided and staff are         O/MI/SI   NA       1   2
     trained in following procedures
g.   All relevant staff understand STI minimum standards                        SI      NA   0   1   2
h.   The number of staff hired/present as planned and are adequate              O       NA   0   1   2
     to meet the anticipated client service needs

2. Management functions meet agreed requirements                              Method         Score       Observations/rationale for score
a.   Organizational chart with clear lines of supervision and authority         O       NA   0       2
     as stated in SA is available and applied
b.   Regular staff meetings are held to discuss service quality-                SI
     related issues
c.   The monthly working schedule for clinic staff is up to date                R
d.   Staff are encouraged to take issues to management that could               SI
     affect the quality of STI services, patient care and staff safety
e.   The facility has a documented quality policy or equivalent                 O
2. Management functions meet agreed requirements                         Method         Score       Observations/rationale for score
    commitment to quality
f.   Staff receive ongoing mentoring, supervision and training to         SI/MI    NA   0   1   2
     fulfill their responsibilities
g.   Staff recruitment process follows FHI/national authorities           R/MI     NA   0   1   2
     recommended STI recruitment standards
h.   Staff are encouraged to take issues to management that could          SI      NA       1   2
     affect the quality of services, client care and staff safety
i.   Management staff routinely supervise that service delivery is       R/O/MI    NA       1   2
     according to the written procedures, including the provision of
     patient care and release of patient results
j.   Professional standards of conduct are expected and                  O/MI/SI   NA       1   2
     communicated to all staff
k.   All staff working in the program are paid on time and receiving      R/SI     NA   0   1   2
     their salary according to the SA
l.   Availability of STI SOP at the site as reference; SOP to be           O       NA   0   1   2
     readily available and accessible to all relevant staff
i.   Technical instructions/laboratory work instructions are available     O       NA   0   1   2
     in the laboratory area
j.   STI patient management guidelines using syndromic and                 O       NA   0   1   2
     laboratory approach are in the treatment and counseling room
k.   Institution conducts staff performance appraisal activities at       R/MI     NA   0   1   2
     least once every 6 months
a.   Client data is stored securely/confidentially at all times            O       NA       1   2


3. Facilities, supplies and educational or information materials         Method         Score       Observations/rationale for score
for delivering services meet agreed requirements
a.   The clinic has separate rooms for:                                    O
     •   Administration                                                            NA   0       2
                                                                                   NA
     •   Examination                                                                    0       2
                                                                                   NA
     •   Laboratory                                                                     0       2
                                                                                   NA
     •   Treatment and counseling                                                       0       2
                                                                                   NA
     •   Medical records storage                                                        0       2
b.   Visual and auditory privacy for clients                               O       NA       1   2

c.   Confidentiality in treatment/storage and access to medical            O       NA       1   2
3. Facilities, supplies and educational or information materials         Method         Score       Observations/rationale for score
for delivering services meet agreed requirements
     records to comply with local, national or regional requirements
d.   Signage and access to the facility does not lead to stigma           O/CI     NA   0   1   2
e.   The clinic is locked outside of stated opening hours                 O/SI     NA   0   1   2
f.   Clinic service hours comply with stated opening hours and days      O/CI/SI   NA   0   1   2
g.   Clinic has adequate water and electricity supply                      O       NA       1   2

h.   Clinic has backup power facility                                      O       NA   0   1   2
i.   Clinic is clean and well maintained                                   O       NA   0   1   2
j.   Clinic facilities and equipment pose no health and safety risk to     O       NA       1   2
     either clients or staff
k.   Procedures exist for the safe disposal of waste in accordance         O       NA       1   2
     with local/national standards
l.   Designated, experienced staff are available throughout stated       O/SI/CI   NA       1   2
     opening hours to provide a full range of agreed upon services
m. Clinic promotion activities are carried out as planned                 O/SI     NA   0   1   2
n.   There is a written policy for emergency cases displayed               O       NA   0   1   2
o.   Written procedures exist for all services provided and staff are    O/MI/SI   NA       1   2
     trained in following procedures
p.   Management staff regularly review that service delivery is           O/MI     NA       1   2
     according to the written procedures
a.   Medical equipment is according to standards, in good condition,       O       NA   0   1   2
     maintained, and stored correctly
b.   Administration equipment/furniture according to standards             O       NA   0   1   2
c.   Laboratory supplies are according to standards stored correctly       O       NA   0   1   2
     and used within manufacturer’s instructions for use
d.   Emergency equipment is according to standards and is suitable         O       NA   0   1   2
     and fit for use
e.   Laboratory reagents according to standards, stored correctly        O/R/SI    NA   0   1   2
     and used within manufacturer’s instructions for use
f.   Essential medication (as per clinic SoP) is on hand, within           O       NA       1   2
     expiry date and stored and dispensed correctly
g.   Sterile swab in the examination room (not hand-made by clinic         O       NA   0   1   2
     staff)
                                                                           O
h.   Clean gloves in the examination, lab, treatment rooms                         NA   0   1   2
3. Facilities, supplies and educational or information materials            Method        Score       Observations/rationale for score
for delivering services meet agreed requirements
                                                                              O
i.   Lab coats and face masks available to lab technicians and                       NA   0   1   2
     medical staff
                                                                              O
j.   First aid facilities available to staff including simple methods for            NA   0   1   2
     eye washing, covering of cuts and lesions etc
                                                                              O
k.   Adequate supply of all forms                                                    NA   0   1   2
                                                                              O
l.   pH paper (3.8-5.4) in the examination room                                      NA   0   1   2
                                                                              O
m. STI/HIV/AIDS IEC materials available in the treatment and                         NA   0   1   2
   counseling room and/or waiting area
                                                                              O
n.   Condoms available in the treatment and counseling room                          NA   0   1   2
                                                                              O
o.   Dildo/artificial penis available in the treatment and counseling                NA   0   1   2
     room

II. TECHNICAL AND PROGRAMMATIC IMPLEMENTATION (SERVICE DELIVERY):
Sub-category                                                                Method        Score       Observations/rationale for score
4. The services are delivered according to agreed requirements
a.   Insertion of Speculum performed correctly (FSW)                          O      NA   0   1   2

b.   Sample taken from vagina correctly (FSW)                                 O      NA   0   1   2

c.   Sample taken from endocervix correctly (FSW)                             O      NA   0   1   2

d.   Insertion of anoscopy performed correctly (MSM/TG)                       O      NA   0   1   2

e.   Sample taken from urethra correctly (MSM/TG)                             O      NA   0   1   2

f.   Sample taken from anus correctly (MSM/TG)                                O      NA   0   1   2

g.   Making correct smear from endocervix (FSW) or urethra/anus               O      NA   0   1   2
     (MSM/TG) for Methylene blue staining
h.   Use of sterilized speculum/anuscope                                      O      NA       1   2

i.   Re-sheathing of needles or finger-prick devices performed                O      NA       1   2
     correctly (if applicable)
j.   Examination with gloves                                                  O      NA       1   2

k.   Used speculum (FSW) or anoscopy (MSM/TG) put in container                O      NA   0   1   2
     with water, hypochlorite 1% and liquid soap
Sub-category                                                            Method        Score       Observations/rationale for score
l.   Correct diagnosis based on any 10% of records                        R      NA   0   1   2

m. Correct treatment based on any 10% of records                          R      NA   0   1   2

n.   All staff follow UP according to standard                           O/SI    NA           2

o.   Waiting time for examination acceptable (15-20 minutes)              O      NA   0   1   2

p.   Informed consent with client signature based on any 10% of           R      NA   0   1   2
     records
q.   Doctor/paramedic friendly, polite and explains procedure to         O/CI    NA   0   1   2
     patient before examination
r.   Patients receive an explanation about the STI they have, its        O/CI    NA   0   1   2
     transmission and prevention
s.   Patients able to have their questions satisfactorily answered in    O/CI    NA       1   2
     a language they understand before any procedures are
     performed
t.   Patient able to choose service and treatment options (if            O/CI    NA       1   2
     applicable)
u.   Patients receive condoms                                            O/CI    NA   0   1   2

v.   Patients receive an explanation about taking medication and         O/CI    NA   0   1   2
     side effects
w.   Laboratory technician correctly administers wet mount                O      NA   0   1   2

x.   Laboratory technician correctly uses microscope                      O      NA   0   1   2
     •   Wet mount
     •   Methylene blue smear
y.   Laboratory QA system in place (serology/microscopy)                 R/O     NA   0   1   2

z.   Serious adverse events are reported to FHI senior management        R/MI    NA       1   2
     (including death, anaphylaxis, etc.)
5. Client health, welfare and confidentiality is assured and             Method         Score       Observations/rationale for score
protected wherever possible
a.   Each room ensures the comfort of patients wherever possible           O       NA   0   1   2
b.   STI services are provided in rooms with visual and auditory           O       NA       1   2
     privacy
c.   Client given adequate time to understand the STI services and         O       NA   0   1   2
     to have their questions answered in a manner that they can
     understand
d.   Clinic has adequate water and electricity supply                      O       NA       1   2

e.   Clients have accessible drinking water and toilet facilities          O       NA   0   1   2
f.   Clinic is clean and well maintained                                   O       NA   0   1   2
g.   Clinic facilities and equipment pose no health and safety risk to     O       NA       1   2
     either clients or staff
h.   Client medical records are stored under secure and restricted         O       NA   0   1   2
     access

6. Referral network of comprehensive quality services is                 Method         Score       Observations/rationale for score
established and functional wherever possible
a.   Regular attendance of BCI coordination meetings                       MI      NA   0   1   2
b.   Meetings with referral partners held as planned (hospital, other      MI      NA   0   1   2
     clinics)
c.   Referral system is functioning                                      MI/CI     NA   0   1   2
d.   Monthly meetings held between clinic staff and outreach referral      SI      NA   0       2
     partners

7. Clients are satisfied with the facilities and services                Method         Score       Observations/rationale for score
a.   Easy to access services (time, location, cost)                        CI      NA   0   1   2
b.   Can access services without stigma or discrimination                  CI      NA   0   1   2
c.   Staff friendly, approachable                                          CI      NA   0   1   2
d.   Clients receive specific information on risks of HIV transmission     CI      NA   0   1   2
e.   Have good experiences with referral services                          CI      NA   0   1   2
f.   Staff provide information and answer questions in a way that          CI      NA   0   1   2
     clients can understand
g.   Complaint or report of serious professional misconduct              CI/SI/R   NA       1   2
III. MONITORING AND EVALUATION (POST SERVICE DELIVERY)

8. The recording and reporting system is working well and the              Method         Score       Observations/rationale for score
data are reliable
a.   All data collection by each level of staff is correct and complete.    R/O
     Data forms are available in project files:
     •   Patient register                                                            NA   0   1   2

     •   Medical record                                                              NA   0   1   2
b.   Data collection and monitoring tools are appropriately used by
     staff at all levels                                                    R/O      NA   0   1   2
c.   Reports are completed and submitted as scheduled
                                                                             R       NA   0   1   2
d.   Off-site clinical record audit conducted (if applicable)
                                                                            R/O      NA   0   1   2
e.   Off-site storage of clinical and medical records meets all local,
     regional and national requirements                                    R/SI/O    NA       1   2

9. Processes for data use, supervision and feedback are in                 Method         Score       Observations/rationale for score
place
a.   Consolidated data/results are discussed with staff during               SI      NA   0   1   2
     periodic meetings
b.   Project/site manager can explain how data is used for planning          MI      NA   0   1   2
     and management
c.   Feedback from patients is collected, shared and discussed in          MI/SI/R   NA   0   1   2
     regular meetings

10. Client utilization and coverage of services meets                      Method         Score       Observations/rationale for score
expectations
a.   Number of examinations with lab tests meeting monthly targets           R       NA   0   1   2

b.   Number of patients examined stable or increasing                        R       NA   0   1   2

c.   Number of FSW screenings meeting monthly targets                        R       NA   0   1   2

d.   Number of screenings of other target groups meeting monthly             R       NA   0   1   2
     targets



Implementing Partner/Location:
Type of Intervention: Voluntary Counseling and Testing (VCT)
Date:
Assessment team:

I. PREPAREDNESS FOR SERVICE DELIVERY

                                                                                                       Resources/                    Expected
                                                                                 Follow up actions                    Responsible
 Sub-category                                                     Scored   Max                       support needed                 completion
                                                                                  recommended                          person(s)
                                                                                                                                       date


 1.   The type, number and training of staff meets agreed
      requirements




 2.   Management functions meet agreed requirements




 3.   Facilities, supplies and educational or informational
      materials for delivering services meet agreed
      requirements


                                                          Total                         %

II. TECHNICAL AND PROGRAMMATIC IMPLEMENTATION (SERVICE DELIVERY)

                                                                                                       Resources/                    Expected
                                                                                 Follow up actions                    Responsible
 Sub-category                                                     Scored   Max                       support needed                 completion
                                                                                  recommended                           person
                                                                                                                                       date


 4.   The services are delivered according to agreed
      requirements




 5.   Client health, welfare and confidentiality is assured and
      protected wherever possible
 6.   Referral network of comprehensive quality services is
      established and functional wherever possible




 7.   Clients are satisfied with the facilities and services



                                                               Total                                  %

III. MONITORING AND EVALUATION (POST SERVICE DELIVERY)

                                                                                                                           Resources/                       Expected
                                                                                               Follow up actions                             Responsible
 Sub-category                                                           Scored      Max                                  support needed                    completion
                                                                                                recommended                                    person
                                                                                                                                                              date


 8.   The recording and reporting system is working well and
      the data are reliable




 9.   Processes for data use, supervision and feedback are
      in place




 10. Client utilization and coverage of services meets
     expectations



                                                               Total                                  %
Scoring Notes:                                                         Method Notes:
        NA: Not applicable          (0) No                              O= Observation                SI= Staff Interview
        (1) Yes, partially          (2) Yes                             R= Records Review             MI = Management Interview
            Red flag: serious deficiency, FHI senior                    CI= Client Interview          GI/StI =Gatekeeper/Stakeholder Interview
             management should be notified
I. PREPAREDNESS FOR SERVICE DELIVERY

1. The type, number and training of staff meets agreed                    Method         Score       Observations/rationale for score
requirements
a.   Written job descriptions for each position are available and staff    R/SI     NA   0       2
     understand their roles and responsibilities
b.   Staff are hired based on prior suitable experience and expertise       R       NA   0   1   2
     as evidenced by CV’s or equivalent
c.   Written procedures exist for all services provided and staff are     O/MI/SI   NA       1   2
     trained in following procedures
d.   All staff understand VCT minimum standards                             SI      NA   0   1   2
e.   The number of staff hired/present as planned and are adequate          O       NA   0   1   2
     to meet the anticipated client service needs
f.   VCT counselors received training from FHI, or other accredited         R       NA           2
     course; competency is demonstrated before services are
     provided by VCT counselors

2. Management functions meet agreed requirements                          Method         Score       Observations/rationale for score
g.   Organizational chart with clear lines of supervision as stated in      O       NA   0       2
     SA is applied
h.   Staff receive ongoing mentoring, supervision and training to          SI/MI    NA   0   1   2
     fulfill their responsibilities
i.   Staff recruitment process follows FHI/national authorities            R/MI     NA   0   1   2
     recommended VCT recruitment standards
j.   Staff are encouraged to take issues to management that could           SI      NA       1   2
     affect the quality of services, client care and staff safety
k.   Management staff routinely supervise that service delivery is        R/O/MI    NA       1   2
     according to the written procedures
l.   Professional standards of conduct are expected and                   O/MI/SI   NA       1   2
     communicated to all staff
m. All staff working in the VCT program are paid on time and               R/SI     NA   0   1   2
   receiving their salary according to the SA
n.   Availability of VCT SOP at the VCT site as reference; SOP to           O       NA   0   1   2
     be readily available and accessible to all VCT counselors
o.   VCT SOP and all other written procedures relating to services          O       NA   0   1   2
     are reviewed at least annually by management staff and
     suggestions for needed revisions are made to the appropriate
2. Management functions meet agreed requirements                         Method         Score       Observations/rationale for score
    owners/approvers of the procedures
p.   Availability of support group or clinical supervision program for     SI      NA   0   1   2
     VCT counselor through regular meeting
q.   Institution conducts staff performance appraisal activities at       R/MI     NA   0   1   2
     least once every 6 months
r.   Client data is stored securely/confidentially at all times            O       NA       1   2


3. Facilities, supplies and educational or information materials         Method         Score       Observations/rationale for score
for delivering services meet agreed requirements
a.   The clinic has separate rooms for:
     •   Administration/waiting/laboratory                                 O       NA   0       2
     •   Counseling                                                        O       NA   0       2
b.   Visual and auditory privacy for clients                               O       NA       1   2

c.   Signage and access to the facility does not lead to stigma           O/CI     NA   0   1   2
d.   The clinic is locked outside of stated opening hours                 O/SI     NA   0   1   2
e.   Service hours comply with stated opening hours and days (5          O/SI/CI   NA   0   1   2
     days per week)
f.   Clinic has adequate water and electricity supply                      O       NA       1   2

g.   Clinic has backup power facility                                      O       NA   0   1   2
h.   Clinic is clean and well maintained                                   O       NA   0   1   2
i.   Clinic facilities and equipment pose no health and safety risk to     O       NA       1   2
     either clients or staff
j.   Procedures exist for the safe disposal of waste in accordance         O       NA       1   2
     with local/national standards
k.   Designated, experienced staff are available throughout stated       O/SI/CI   NA       1   2
     opening hours to provide a full range of agreed upon services
l.   Availability of VCT SOP (testing algorithm, procedures,               O       NA   0       2
     management protocol etc.) at the point of service delivery and
     accessible to all VCT staff
m. Confidentiality in VCT areas as well as confidentiality and             O       NA   0       2
   restricted access to medical records and client information
n.   Management of occupational exposure information visible by            O       NA   0       2
     wall chart
3. Facilities, supplies and educational or information materials            Method        Score       Observations/rationale for score
for delivering services meet agreed requirements
o.   The institution has and distributes materials related to                O/SI    NA   0   1   2
     promotion of services and VCT networks
p.   Gov. approved test kits are used
                                                                              O      NA       1   2
q.   Test kits are within expiry date and are stored and used within
     the conditions specified by the manufacturer                             O      NA       1   2
r.   Test kits are in sufficient supply for anticipated use
                                                                              O      NA       1   2
s.   Sharps disposal container
                                                                              O      NA       1   2
t.   Gloves, N/S, anti-coagulate blood tubes, skin wipes/cotton and
     bandages are present in lab/blood work area                              O      NA   0   1   2
u.   Condoms are available in waiting room and counseling room
                                                                              O      NA   0   1   2
v.   Dildo/artificial penis available in the counseling room
                                                                              O      NA   0   1   2
w.   Appropriate IEC materials are available in the counseling room
     (VCT, prevention & referral services)                                    O      NA   0   1   2

x.   Counselors have phone access at site                                     O      NA   0   1   2
y.   Lab coats and face masks available to lab technicians and                O      NA   0   1   2
     medical staff
z.   First aid facilities available to staff including simple methods for     O      NA   0   1   2
     eye washing, covering of cuts and lesions etc
aa. Adequate supply of all forms                                              O      NA   0   1   2

II. TECHNICAL AND PROGRAMMATIC IMPLEMENTATION (SERVICE DELIVERY):

4. The services are delivered according to agreed requirements              Method        Score       Observations/rationale for score
a.   VCT counselor performs pre-test counseling to requirements:             O/SI
     •   Build rapport & introduce role to client, explain about                     NA   0   1   2
         service & record-keeping
     •   Ask about prior history of HIV testing                                      NA   0   1   2
     •   Explain confidentiality and privacy offered to client                       NA   0   1   2
     •   Assess clients knowledge about HIV/provides basic                           NA   0   1   2
         information about HIV and transmission
     •   Conduct clinical risk assessment & provide feedback on                      NA   0   1   2
         client risk
     •   Asks client about symptoms of STI/treatment for STI                         NA   0   1   2
4. The services are delivered according to agreed requirements              Method        Score       Observations/rationale for score
     •   Asks client about her/partner pregnancy                                     NA   0   1   2
     •   Reinforce information about window period & provide client                  NA   0   1   2
         details of date for retest
     •   Behavior change counseling following ABC model &                            NA   0   1   2
         condom/safe injecting education/demonstration
     •   Exploration of what client might do if test is positive, explain            NA   0   1   2
         ways of coping & suicide risk assessment if indicated
     •   Exploration of potential support from family & friends                      NA   0   1   2
     •   Basic information about the test, blood collection & result                 NA   0   1   2
         provision procedure
     •   Information provided for pregnant women (potential for HIV                  NA       1   2
         transmission, methods of PMTCT, etc)
     •   Provides clients with condoms as appropriate                                NA   0   1   2
     •   Specific prevention education for IDU                                       NA   0   1   2
b.   Testing according to requirements:                                      O/SI
     •   Before procedures are performed, clients have their                         NA           2
         questions satisfactorily answered in a language they
         understand
     •   Staff wear gloves for blood collection                                      NA           2
                                                                                     NA
     •   Bleed site is swabbed prior to blood collection and a                            0       2
         bandaid offered after blood collection
                                                                                     NA
     •   Disposal of needles or finger-prick devices performed                                    2
         correctly
                                                                                     NA
     •   Samples to be transported and packed according to SOP                            0       2
                                                                                     NA
     •   Testing performed according to national testing algorithm                                2
         (onsite lab only)
                                                                                     NA
     •   Lab supervisor (or equivalent) reviews all results for                           0       2
         accuracy before they are released to counselor and clients
                                                                                     NA
     •   Completed test result forms are transferred to client files                      0       2
                                                                                     NA
     •   HIV test result returned from laboratory correctly labeled                       0       2
         (confidential) and stored (offsite lab only)
                                                                                     NA
     •   National reporting forms are completed according to                              0       2
         national protocols
4. The services are delivered according to agreed requirements           Method        Score       Observations/rationale for score
                                                                                  NA
     •    Lab testing is subject to internal and external QA                                   2

c.   VCT counselor performs post-test counseling to requirements:         O/SI
     All types of results:
     •    All results are checked by counselor prior to provision to              NA   0   1   2
          client
     •    Results given simply and directly                                       NA   0   1   2
     •    Check for understanding/discuss meaning of result                       NA   0   1   2
     •    Assessed for type of support required (e.g. ongoing                     NA   0   1   2
          counseling, medical/treatment support etc.)
     •    Discussion of personal risk reduction strategy incorporating            NA   0   1   2
          ABC
     •    Refers client for assessment of other medical                           NA   0   1   2
          conditions/vaccinations that may contribute to a false
          positive/negative result
     •    Information provided for pregnant women/or partners                     NA   0   1   2
          (potential for HIV transmission, methods of PMTCT,
          referrals, etc)
     •    Provides clients with condoms as appropriate                            NA   0   1   2
     •    Patients are well informed about the meaning of "dual                   NA   0   1   2
          protection" [i.e. barrier methods that protect against both
          pregnancy and STIs including HIV]
     •    Patients have adequate access to affordable contraception               NA   0   1   2
     Negative result
     •    Checked for window period and subsequent exposure                       NA   0   1   2
     •    Client advised to re-test if necessary                                  NA   0   1   2
     •    Referral if necessary                                                   NA   0   1   2
     Indeterminate result
     •    Explained possibility that testing performed during window              NA   0   1   2
          period
     •    Referred to physician for investigation of other                        NA   0   1   2
          illness/indeterminate result
     •    Re-testing at this center in 12 weeks (4-6 if pregnant)                 NA   0   1   2
     •    Stress management and supportive counseling                             NA   0   1   2
4. The services are delivered according to agreed requirements         Method        Score       Observations/rationale for score
     Positive result
     •   Checked results and client details prior to provision                  NA   0   1   2
     •   Assessed client’s readiness for result                                 NA   0   1   2
     •   Provided and explained result, checked client                          NA   0   1   2
         understanding
     •   Provided brief information about follow-up and support                 NA   0   1   2
     •   Assessed client capacity to cope with result                           NA   0   1   2
     •   Assessed potential for harm to self/others                             NA   0   1   2
     •   Discussion on strategies for partner disclosure                        NA   0   1   2
     •   Coping management plan                                                 NA   0   1   2
     •   Discussion of follow up care/support & referrals made                  NA   0   1   2
         where necessary
     Follow up care counseling
     •   Counselor engaged client in discussion of priorities for               NA   0   1   2
         support
     •   Counselor assessed mood of client                                      NA   0   1   2
     •   Counselor assessed client’s capacity to adhere to risk                 NA   0   1   2
         reduction and partner disclosure
     •   Counselor engaged where appropriate in active problem                  NA   0   1   2
         solving to resolve client psychosocial issues
     •   Counselor explores treatment & other adherence support                 NA   0   1   2
     •   Client assessed for potential harm to self/others                      NA   0   1   2
d.   Serious adverse events are reported to FHI senior management       MI/R    NA       1   2
     (including major allergic reaction, suicide/threats to others,
     arrest of clients, professional misconduct, etc.)

5. Client health, welfare and confidentiality is assured and           Method        Score       Observations/rationale for score
protected wherever possible
a.   Each room ensures the privacy and comfort of patients               O      NA   0   1   2
     wherever possible
b.   VCT services are provided in rooms with visual and auditory         O      NA       1   2
     privacy; no other clients or non-VCT staff should be present in
     the room during counseling and provision of results unless at
     client request
5. Client health, welfare and confidentiality is assured and             Method           Score       Observations/rationale for score
protected wherever possible
c.   Clients are given the opportunity to bring family or friends with      O        NA   0   1   2
     them to appointments if they desire
d.   Informed consent freely given/signed                                   O        NA       1   2

e.   Client given adequate time to understand the VCT services and          O        NA   0   1   2
     to have their questions answered in a manner that they can
     understand
f.   Blood collected in separate private blood collection area (&           O        NA   0   1   2
     client can sit at table/desk)
g.   Clinic has adequate water and electricity supply                       O        NA       1   2

h.   Clients have accessible drinking water and toilet facilities           O        NA   0   1   2
i.   Clinic is clean and well maintained                                    O        NA   0   1   2
j.   Clinic facilities and equipment pose no health and safety risk to      O        NA       1   2
     either clients or staff
k.   Client medical and VCT records are stored under secure and             O        NA   0   1   2
     restricted access
l.   Designated, experienced staff are available throughout stated       O/SI/CI     NA       1   2
     opening hours to provide a full range of agreed upon services

6. Referral network of comprehensive quality services is                 Method           Score       Observations/rationale for score
established and functional wherever possible
a.   Availability of list of facilities and contact persons for client      R        NA   0   1   2
     referral needs updated in last 12 months
b.   Functioning referral system for HIV/AIDS case management            StI/MI/CI   NA   0   1   2
c.   Existing agreement letter/MOU with treatment service, hospital         R        NA   0   1   2
     or other community based services
d.   Referral forms on file (with client consent for release of             R        NA   0       2
     information) for counselor referrals to other supported services

7. Clients are satisfied with the facilities and services                Method           Score       Observations/rationale for score
a.   Easy to access services (time, location, cost)                         CI       NA   0   1   2
b.   Can access services without stigma or discrimination                   CI       NA   0   1   2
c.   Staff friendly, approachable                                           CI       NA   0   1   2
d.   Clients receive specific information on risks of HIV transmission      CI       NA   0   1   2
7. Clients are satisfied with the facilities and services                Method         Score       Observations/rationale for score
e.   Have good experiences with referral services                          CI      NA   0   1   2
f.   Staff provide information and answer questions in a way that          CI      NA   0   1   2
     clients can understand
g.   Complaint or report of serious professional misconduct              CI/SI/R   NA       1   2


III. MONITORING AND EVALUATION (POST SERVICE DELIVERY)

8. The recording and reporting system is working well and the            Method         Score       Observations/rationale for score
data are reliable
a.   Use of special code (anonymous identifier) in medical record          O       NA   0   1   2
     resume and in sample tube for referral
b.   Data collection and monitoring tools are appropriately used by
     staff at all levels                                                  R/O      NA   0   1   2
c.   Reports are completed and submitted as scheduled
                                                                           R       NA   0   1   2
d.   Off-site storage of clinical and medical records meets all local,
     regional and national requirements                                  R/SI/O    NA       1   2

9. Processes for data use, supervision and feedback are in               Method         Score       Observations/rationale for score
place
a.   A client satisfaction survey has been conducted and analyzed          R       NA   0   1   2
     within past 6 months
b.   VCT program manager routinely supervises and coordinates             SI/MI    NA   0   1   2
     with staff
c.   Project/site manager can explain how data is used for planning        MI      NA   0   1   2
     and management
d.   Feedback from clients is shared and discussed in regular            MI/SI/R   NA   0   1   2
     meetings

10. Client utilization and coverage of services meets                    Method         Score       Observations/rationale for score
expectations
a.   Number of VCT clients according to monthly target                     R       NA   0   1   2
b.   Targets for high risk group attendance achieved last three            R       NA   0   1   2
     months
c.   Rate of return: % of clients who are tested that receive their        R       NA   0   1   2
     final results>90%

				
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