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Federal Ministry of Health Public Health Institute and National Tuberculosis Programme National TB Prevalence Survey Daily Monitoring

Sheet Cluster ID ____ _____ _____ ______ State ___ Cluster name Date S/N Activity/ Achievements in the cluster Numb Remark er 1 Total number of households visited 2 3 4 5 6 7 8 9 10 Total number of household members listed Total survey eligible individuals Total number of Survey eligible individuals not present Total Number of Survey eligible individuals present Total giving consent Symptom screening interview Total # of subjects interviewed Chest X-Ray Total # of subjects screened Total number of TB Suspects Eligible for Sputum Sputum Sample collection Total number of samples collected Total # of spot samples collected Total # of Morning samples collected Health Seeking behavior Total eligible for HSB interviewed Other findings which needs urgent medical attention Referred by the chest physician Challenges faced Remedial actions taken Other issues which needs special consideration of the day

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11

12 13 14

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