BCS Program Monitoring Form

The Ghana GoodLife campaign, which ran from 2009-2014, was a unifying umbrella brand implemented under the Ghana Behavior Change Support (BCS) Project. BCS sought to increase demand and use of commodities and services as well as positive behaviors related to six key health areas: family planning, malaria, maternal and child health, nutrition, and water and sanitation.

BCS developed this monitoring form which tracked outputs at the community level and in the media, and helped in the collection of service statistics data when available.

Source: Johns Hopkins University Center for Communication Programs

Date of Publication: January 29, 2020

Fievre Ebola: Evaluation d’Etat de Sante du Voyageur [Ebola Traveler Evaluation Form]

This is a form used to determine whether someone entering or leaving the country is suspected of having Ebola. The form asks for all of the individual’s personal identification information and offers a series of questions that must be asked of the traveler regarding his own physical health/symptoms and the people he or she has been in contact with.

Source: Cote d'Ivoire National Institute of Health

Date of Publication: March 25, 2019

Fistula Care Informed Consent Form

This is a template for an informed consent form for obstetric fistula repair. The client reads the statements and discusses with the service provider or if she is not able to read, she listens as it is read and explained to her to her satisfaction that she understands the consequences of the procedure she will undergo, then she provides informed consent by signing.

Source: EngenderHealth

Date of Publication: March 25, 2019

Focus Group Participant Recruitment Screener

This is a sample Screener from the It All Adds Up to Cleaner Air Campaign. The screener allows the program to recruit the right kind of participants for a focus group discussion by asking certain questions. These questions help identify whether the participants are representative of the intended audience and match the criteria set for the test audience. Participants qualify or disqualify for the study based on their responses.

Source: US Department of Transportation

Date of Publication: March 25, 2019

Plague Case Investigation Report

This is a basic form for reporting individual cases of plague. It asks for information regarding patient history and the course of the illness. In addition, it offers space for laboratory results, the case status, and epidemiological information.

Source: US Centers for Disease Control and Prevention

Date of Publication: March 25, 2019