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Guidelines
1. This survey is to collect data of children in your project who are suffering from ‘Chronic Diseases’. Chronic disease refers to a person suffering from one or more disease for period of three months or longer. Some chronic diseases can be cured, while others require lifelong treatment. We need you to provide information of all children in your project suffering from ‘Chronic disease’ only, children who require medicines long term or lifelong.
2. Do not skip any questions. All questions must be answered.
3. Please cross check with the child or parent before answering the questions.
4. If the project has more than one child, the questions has to be filled individually for each child.
5. Please submit the survey on or before the completion date specified in the mail.
6. Please call or mail the Health Specialist for clarifications or questions Cell:09600051331, email:[email protected]
 
 
Project Name
   
 
 
Project Number
   
 
 
District
   
 
 
Cluster
 
 
State
 
 
Project Coordinator Info
Project Coordinator Name : 
  : 
Phone : 
Email Address : 
 
Give the information of children who are down with chronic diseases in your project
Child Name Age Sex Name of the sickness Date of diagnosis Is the child being treated for the disease? If no, reasons for not being treated. Type of medical facility Name of the town/city where the hospital is located Present condition of the child Does the child require life long treatment Source of funding for the treatment What is the help required for the child
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
Child 9
Child 10
Child Name Age Sex Name of the sickness Date of diagnosis Is the child being treated for the disease? If no, reasons for not being treated. Type of medical facility Name of the town/city where the hospital is located Present condition of the child Does the child require life long treatment Source of funding for the treatment What is the help required for the child
Child 11
Child 12
Child 13
Child 14
Child 15
Child 16
Child 17
Child 18
Child 19
Child 20
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