4. Name of States/Province/Region:
8. Please Choose Your Name:
9a. Type of site Visited:
10. Is it a Priority focal site?
11. Priority level for AFP surveillance
12. Is active case search done by the health facility focal person in the facility every week?
13.Is this Supervision occurring jointly with Government Staff?
14. When was the facility last supervised by District Staff?
15. When was the facility last supervised by WHO/Regional Staff?
15a.Was there a written feed back at the end of this supervision?
15b.Did you meet with the head of the health facility?
