NATIONAL SURVEY ON MALARIA ("ENPS, 2008")
WOMAN'S QUESTIONNAIRE
Republic of Senegal
Ministry of Health and Medical Prevention
Macro International
Research Center for Human Development ("CRDH")
REGION______
HEALTH DISTRICT ______
DISTRICT MUNICIPALITY/RURAL COMMUNITY ______
CLUSTER NUMBER ______
NAME OF HEAD OF CONCESSION ______
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER IN SAMPLE ______
NAME OF LOCALITY (DISTRICT MUNICIPALITY IN DAKAR, MUNICIPALITY, RURAL COMMUNITY) ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ENVIRONMENT ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL
(DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4) DETAILED ENVIRONMENT ______
NAME AND LINE NUMBER OF WOMAN ______
HOUSEHOLD SAMPLE (OF THE 30 IN CLUSTER)? (YES = 1, NO = 2) ______
HOUSEHOLD CHOSEN FOR ANEMIA/MALARIA TEST? (YES = 1, NO = 2) ______
(Repeat up to 3 visits)
DATE ______
NAME OF INTERVIEWER ______
RESULT ______
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT
DAY ______
MONTH ______
YEAR 200______
INTERVIEWER NUMBER______
RESULT CODE ______
TOTAL NUMBER OF VISITS ______
RESULT CODES:
1 COMPLETED
2 NOT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
8 OTHER (SPECIFY) ______
LANGUAGE OF QUESTIONNAIRE 1
LANGUAGE OF INTERVIEW ______
LANGUAGE CODES:
1 FRENCH
2 WOLOF
3 PULAR
4 SERER
5 MANDINKA
6 DIOLA
8 OTHER
INTERPRETER (YES = 1, NO = 2) ______
TEAM LEADER
NAME ______
DATE ______
SUPERVISOR
NAME ______
DATE ______
OFFICE EDITOR ______
KEYED BY ______
SECTION 1. SOCIODEMOGRAPHIC BACKGROUND OF RESPONDENT
INTRODUCTION AND CONSENT REQUEST
INFORMED CONSENT
Hello. My name is ______ and I am working for the Ministry of Health. We are carrying out a national survey of malaria. We would like you to participate in this survey. The information you give us will be useful to the government for planning health services. The interview usually takes between 10 and 20 minutes. The information that you provide us will remain strictly confidential and will not be shared with anyone other than members of our survey.
Participation in this survey is voluntary and if there is a question you do not wish to answer, let me know and I will go on to the next question. You can also stop the interview at any time. However, we hope that you will accept to participate in this survey because your opinion is very important to us.
Do you have any questions about the survey?
May I begin the interview now?
Interviewer's signature: ______
Date: ______
1 RESPONDENT AGREES TO ANSWER (Continue to 101)
2 RESPONDENT DECLINES TO ANSWER QUESTIONS (Skip to END)
MINUTES ______
102. How long have you been living on an ongoing basis in (NAME OF CURRENT CITY/TOWN OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEAR.
95 ALWAYS (Skip to 104)
96 VISITOR (Skip to 104)
103. Just before moving here, were you living in a big city, town, or in a village?
2 TOWN
3 RURAL
104. In what month and year were you born?
98 DK MONTH
YEAR ______
9998 DK YEAR
105. How old were you on your last birthday?
COMPARE AND CORRECT 104 AND/OR 105 IF INCONSISTENT.
106. Have you ever attended school?
2 NO (Skip to 110)
107. What is the highest level of studies you attended: primary, secondary, or higher?
2 SECONDARY
3 HIGHER
108. What is the last (YEAR/GRADE) you completed at this level?
PRIMARY ______ (Continue to 110)
SECONDARY OR HIGHER ______ (Skip to 111)
110. Now I would like you to read this sentence out loud to me; read as much as you can.
SHOW CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE:
Can you read part of the sentence?
2 CAN READ PARTS OF THE SENTENCE
3 CAN READ ENTIRE SENTENCE
4 NO CARD IN RESPONDENT'S LANGUAGE (SPECIFY LANGUAGE) ______
5 BLIND/VISUALLY IMPAIRED
2 CHRISTIAN
3 ANIMIST
4 WITHOUT RELIGION
6 OTHER (SPECIFY) ______
2 NO (Skip to 201)
02 PULAR
03 SERER
04 MANDINKA/SOCE
05 DIOLA
06 SONINKE/SARAKOLE
96 OTHER (SPECIFY) ______
201. Now I would like to ask you some questions about all the births you have had in your lifetime. Have you ever given birth?
2 NO (Skip to 206)
202. Do you have any sons or daughters to whom you gave birth who are currently living with you?
2 NO (Skip to 204)
203. How many sons live with you?
How many daughters live with you?
IF NONE, RECORD '00'.
DAUGHTERS AT HOME ______
204. Do you have any sons or daughters to whom you gave birth who are still living but do not live with you?
2 NO (Skip to 206)
205. How many sons are living but do not live with you?
How many daughters are living but do not live with you?
IF NONE, RECORD '00'.
DAUGHTERS ELSEWHERE ______
206. Have you ever given birth to a boy or girl who was born alive but who later died?
IF NO, PROBE: No baby who cried or showed other signs of life at birth but who did not survive?
2 NO (Skip to 208)
207. How many boys died?
How many girls died?
IF NONE, RECORD '00'.
DECEASED GIRLS ______
208. TOTAL UP THE ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL.
IF NONE, RECORD '00'.
TOTAL ______
I would like to be sure I understood correctly: you have had a TOTAL of ______ births in your life. Is that correct?
NO ______ PROBE AND CORRECT 201 - 208 AS NECESSARY
ONE OR MORE BIRTHS ______ (Continue to 211)
NONE ______ (Skip to 225)
211. Now I would like to make a list of all your births, whether they are still alive or not, starting with the 1st one that you had.
RECORD THE NAME OF ALL BIRTHS IN Q.212. RECORD TWINS/TRIPLETS ON SEPARATE LINES.
(IF MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE).
(Repeat questions 212 - 221 for up to 12 births)
212. What name was given to your (first/next) child?
01 (NAME) ______
213. Is (NAME) a single or multiple birth?
1 SINGLE
2 MULTIPLE
214. Is (NAME) a boy or a girl?
1 BOY
2 GIRL
215. In what month and year was (NAME) born?
PROBE: What is his/her birthdate?
MONTH ______
YEAR ______
1 YES
2 NO (Go to 220)
217. IF ALIVE:
How old was (NAME) on his/her last birthday?
RECORD AGE IN COMPLETED YEARS.
AGE IN YEARS ______
218. IF ALIVE:
Does (NAME) live with you?
1 YES
2 NO
219. IF ALIVE:
RECORD CHILD'S LINE NUMBER FROM HOUSEHOLD SCHEDULE
(RECORD '00' IF CHILD IS NOT LISTED IN HOUSEHOLD)
LINE NUMBER ______ (Skip to NEXT BIRTH)
How old was (NAME) when he/she died?
IF '1 YEAR', PROBE:
How old was (NAME) in months?
RECORD IN DAYS IF LESS THAN ONE MONTH; IN MONTHS IF LESS THAN 2 YEARS; OR IN YEARS.
1 DAYS ______
2 MONTHS ______
3 YEARS ______
221. Were there other live births between (NAME OF PRECEDING BIRTH) and (NAME)? Including babies who died after birth?
1 YES
2 NO
222. Have you had other live births since the birth of (NAME OF LAST BIRTH)?
IF YES, RECORD IN BIRTH TABLE.
2 NO
223. COMPARE 208 WITH NUMBER OF BIRTHS RECORDED IN THE TABLE ABOVE AND CHECK OFF:
NUMBERS ARE EQUAL ______ (Go to CHECK)
CHECK: FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED. ______
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED. ______
FOR EACH DECEASED CHILD: AGE AT TIME OF DEATH IS RECORDED. ______
FOR AGE AT TIME OF DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE THE EXACT NUMBER OF MONTHS. ______
NUMBERS ARE DIFFERENT ______ (PROBE AND CORRECT)
224. CHECK 215 AND RECORD THE NUMBER OF BIRTHS IN 2003 OR LATER.
IF NONE, RECORD '0'.
______
2 NO (Skip to 226A)
8 UNSURE (Skip to 226A)
226. How many months pregnant are you?
RECORD THE NUMBER OF COMPLETED MONTHS.
98 DK
226A. In your opinion, what are the benefits for a pregnant woman to sleep under a mosquito net soaked in insecticide?
B MORE EFFECTIVE AGAINST MOSQUITOS
C KILLS MOSQUITOS/OTHER INSECTS
D ELIMINATES MOSQUITOS/OTHER INSECTS
E BETTER FOR PREVENTING MALARIA
F BETTER FOR PREVENTING MISCARRIAGES/STILLBIRTHS
G WOMAN BETTER PROTECTED AGAINST ILLNESSES
H SAVES MONEY BECAUSE CHILD IS NOT SICK
X OTHER (SPECIFY) ______
Z DK
226B. In your opinion, what are the disadvantages for a pregnant woman to sleep under a mosquito net soaked in insecticide?
B BAD SMELL
C CAUSES IRRITATIONS/COUGH
D MAKES SICK
E MAKES NAUSEOUS
F PRODUCES DANGEROUS CHEMICAL
G PRODUCT USED CAN KILL FETUS/CAUSE MISCARRIAGE
H CAN SUFFOCATE/RESPIRATORY DIFFICULTIES
I INSECTICIDE USED NOT EFFECTIVE
J MOSQUITO NET GETS DIRTY QUICKLY
X OTHER (SPECIFY) ______
Z DK
ONE OR SEVERAL BIRTHS IN 2003 OR LATER ______ (Continue to 301)
NO BIRTHS IN 2003 OR LATER ______ (Skip to 435)
SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT
301. RECORD NAME AND SURVIVORSHIP OF LAST BIRTH IN 302.
Now I would like to ask you some questions about your last pregnancy that ended in a live birth, in the last 6 years (2003 or later).
302. CHECK 212 FOR NAME AND LINE NUMBER.
CHECK 216 FOR SURVIVORSHIP STATUS OF CHILD.
NAME: ______
LINE NUMBER ______
LIVING: ______ (Continue to 303)
DECEASED: ______ (Continue to 303)
303. When you were pregnant with (NAME) did you receive any antenatal care?
IF YES: Whom did you see?
Anyone else?
PROBE TO DETERMINE TYPE OF PERSON AND RECORD ALL PEOPLE SEEN.
A DOCTOR
B MIDWIFE
C NURSE/HEAD NURSE
OTHER PERSON
D VILLAGE MIDWIFE "MATRONNE"
E TRADITIONAL BIRTH ATTENDANT
F RELATIVE/FRIEND
X OTHER (SPECIFY) ______
Y NO ONE
304. During this pregnancy, did you take any medicine to prevent malaria?
2 NO (Skip to 401)
8 UNSURE/DK (Skip to 401)
305. What medication did you take?
RECORD ALL MENTIONED.
IF TYPE OF MEDICATION CANNOT BE DETERMINED, SHOW COMMON ANTIMALARIAL MEDICATIONS TO RESPONDENT.
B CHLOROQUINE
X OTHER (SPECIFY) ______
Z DK/NO ANSWER
[###translator's note: code Z "PDR" assumed to mean "pas de réponse", or "no answer"]
306. CHECK 305. MEDICATIONS TAKEN TO PREVENT MALARIA
CODE 'A' CIRCLED: ______ (Continue to 306A)
CODE 'A' NOT CIRCLED: ______ (Skip to 401)
306A. Did you get the (SP/Fansidar) medication for free, or did you pay money for it?
2 PAID MONEY
306B. How much money did you pay to get it?
RECORD IN CFA FRANCS.
9998 DK
307. How many times did you take SP/Fansidar during this pregnancy?
98 DK/NO ANSWER
308. CHECK 303: ANTENATAL CARE PROVIDED BY A HEALTH PROFESSIONAL DURING THIS PREGNANCY?
CODE 'A', 'B', OR 'C' CIRCLED: ______ (Continue to 309)
OTHER: ______ (Skip to 401)
309. Did you get the SP/Fansidar at an antenatal appointment, at a different visit to a health center, or from another source?
2 OTHER HEALTH CENTER
6 OTHER SOURCE (SPECIFY) ______
8 DK/NO ANSWER
401. RECORD THE LINE NUMBER, NAME, AND SURVIVORSHIP STATUS OF EACH BIRTH IN 2003 OR LATER IN THE TABLE. ASK THE QUESTIONS ABOUT EACH OF THESE BIRTHS. START WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ANOTHER QUESTIONNAIRE, BEGINNING IN THE FIRST COLUMN).
Now I would like to ask you some questions about the health of all your children who are under the age of 6 (born in 2003 or later). (We will talk about one child at a time).
LINE NUMBER ______
NEXT-TO-LAST BIRTH
LINE NUMBER ______
SECOND-TO-LAST BIRTH
LINE NUMBER ______
403. CHECK 212: RECORD THE NAME.
CHECK 216: RECORD SURVIVORSHIP STATUS.
LIVING ______ (Continue to 404)
DECEASED ______ (GO TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
404. Did (NAME) have a fever at any time in the last two weeks?
2 NO (RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
8 DK (RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
405. How many days ago did the fever start?
IF LESS THAN ONE DAY, RECORD '00'.
98 DK
406. Did you seek out any advice or treatment for the fever from any source?
2 NO (SKIP TO 411)
407. Where did you seek out advice or treatment?
Anywhere else?
PROBE TO IDENTIFY THE TYPES OF PLACES AND CIRCLE THE APPROPRIATE CODE(S).
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS A PUBLIC OR PRIVATE ESTABLISHMENT, RECORD THE NAME OF THE PLACE.
(NAME OF PLACE) ______
A GOVERNMENT HOSPITAL
B GOVERNMENT HEALTH CENTER
C GOVERNMENT RURAL HEALTH POST
D RURAL MATERNITY
E VILLAGE HEALTH CENTER
F COMMUNITY PHARMACY
G OUTREACH/MOBILE TEAM
H COMMUNITY HEALTH AGENT
I OTHER PUBLIC (SPECIFY) ______
PRIVATE MEDICAL SECTOR
J HOSPITAL/CLINIC/OFFICE
K PHARMACY
L PRIVATE DOCTOR
M RELIGIOUS DISPENSARY
N COMMUNITY HEALTH AGENT
O OTHER PRIVATE MEDICAL (SPECIFY) ______
OTHER SOURCE
P SHOP/MARKET
Q TRADITIONAL HEALER
R RELATIVE/FRIEND/NEIGHBOR
X OTHER (SPECIFY) ______
ONLY ONE CODE CIRCLED ______ (SKIP TO 410)
409. Where did you go first to seek advice or treatment?
USE LETTER CODE FROM 407.
410. How many days after the fever began did you start seeking out advice/treatment for (NAME)?
IF SAME DAY, RECORD '00'.
410A. Besides the fever, what other symptoms did (NAME) have?
B HEADACHE
C COUGH
D SPUTUM/NAUSEA
E SORE THROAT
F SKIN RASH
G DRAINAGE FROM EAR
H VOMITING
X OTHER (SPECIFY) ______
410B. When (NAME) had a fever, was he/she tested to see if he/she had malaria or not? The test consists of taking a few drops of blood from a finger or heel and analyzing it to know right away if (NAME) had malaria or not.
SHOW INSTRUMENTS USED.
2 NO (Skip to 411)
8 DK (Skip to 411)
410C. Were you told the results of the test done on (NAME)?
2 NO (SKIP TO 411)
8 DK (SKIP TO 411)
410D. What was the result of the malaria test done on (NAME)?
2 NEGATIVE
8 DK
411. Does (NAME) still have a fever?
2 NO
8 DK
412. Did (NAME) take any medication for the fever at any time?
2 NO (RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
8 DK (RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
413. What medication did (NAME) take?
Other medications?
RECORD ALL MENTIONED.
ASK TO SEE THE MEDICATION(S) IF TYPE OF MEDICATION IS UNKNOWN.
IF TYPE OF MEDICATION CANNOT BE IDENTIFIED, SHOW COMMON ANTIMALARIAL MEDICATIONS TO THE RESPONDENT.
A ACT: FALCIMON
B OTHER ACT
C SP/FANSIDAR
D CHLOROQUINE
E AMODIAQUINE
F QUININE
G OTHER ANTIMALARIAL
OTHER MEDICATIONS
H ASPIRIN
I ACETAMINOPHEN/PARACETAMOL
J IBUPROFEN
X OTHER (SPECIFY) ______
Z DK
414. CHECK 413:
ANY CODE A - G CIRCLED?
NO ______ (RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
415. Did you already have (NAME OF MEDICATION FROM 413) at home when (NAME) got sick?
ASK THE QUESTION SEPARATELY FOR EACH ANTIMALARIAL GIVEN IN 413.
IF YES, CIRCLE THE CODE FOR THIS MEDICATION.
IF NO FOR ALL MEDICATIONS, CIRCLE 'Y'.
A ACT: FALCIMON
B OTHER ACT
C SP/FANSIDAR
D CHLOROQUINE
E AMODIAQUINE
F QUININE
G OTHER ANTIMALARIAL
Y NO MEDICATION AT HOME
WAS ACT GIVEN ('A' OR 'B')?
CODES 'A' AND 'B' NOT CIRCLED ______ (SKIP TO 419)
417. How soon after the beginning of the fever did (NAME) start taking tablets of amonate/falcimon/arsucam?
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
4 FOUR OR MORE DAYS AFTER FEVER
8 DK
418. For how many days did (NAME) take the amonate/falcimon/arsucam tablets?
IF 7 OR MORE DAYS, RECORD '7'.
8 DK
418A. Did you get the medication ('A' or 'B') for free, or did you pay money to get it?
2 PAID MONEY
418B. How much money did you pay to get it?
RECORD IN CFA FRANCS.
9998 DK
WAS SP/FANSIDAR 'C' GIVEN?
CODE 'C' NOT CIRCLED ______ (Skip to 422)
420. How soon after the beginning of the fever did (NAME) start taking SP/Fansidar?
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
4 FOUR OR MORE DAYS AFTER FEVER
8 DK
421. For how many days did (NAME) take SP/Fansidar?
IF 7 OR MORE DAYS RECORD 7.
8 DK
WAS CHLOROQUINE 'D' GIVEN?
CODE 'D' NOT CIRCLED ______ (SKIP TO 425)
423. How soon after the beginning of the fever did (NAME) start taking chloroquine?
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
4 FOUR OR MORE DAYS AFTER FEVER
8 DK
424. For how many days did (NAME) take chloroquine?
IF 7 OR MORE DAYS RECORD 7.
8 DK
WAS AMODIAQUINE 'E' GIVEN?
CODE 'E' NOT CIRCLED ______ (SKIP TO 428)
426. How soon after the beginning of the fever did (NAME) start taking amodiaquine?
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
4 FOUR OR MORE DAYS AFTER FEVER
8 DK
427. For how many days did (NAME) take amodiaquine?
IF 7 OR MORE DAYS RECORD 7.
8 DK
WAS QUININE 'F' GIVEN?
CODE 'F' NOT CIRCLED ______ (SKIP TO 431)
429. How soon after the beginning of the fever did (NAME) start taking quinine?
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
4 FOUR OR MORE DAYS AFTER FEVER
8 DK
430. For how many days did (NAME) take quinine?
IF 7 OR MORE DAYS RECORD 7.
8 DK
WERE OTHER ANTIMALARIALS 'G' GIVEN?
CODE 'G' NOT CIRCLED ______ (RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, SKIP TO 435)
432. How soon after the beginning of the fever did (NAME) start taking other antimalarials?
1 NEXT DAY
2 TWO DAYS AFTER FEVER
3 THREE DAYS AFTER FEVER
4 FOUR OR MORE DAYS AFTER FEVER
8 DK
433. For how many days did (NAME) take other antimalarials?
IF 7 OR MORE DAYS RECORD 7.
8 DK
434. RETURN TO NEXT COLUMN IN 403 OR IF NO MORE BIRTHS, CONTINUE TO 435.
MINUTES ______
Note: (1): LIST OF REGISTERED ACT IN SENEGAL
(Table)
Laboratory: CIPLA
Commercial name: Falcimon (Adult, adolescent child)
International non-proprietary name: Artesunate + amodiaquine
Laboratory: Sanofil/Aventis
Commercial name: Arsucam (Adult, adolescent child)
Coarsucam (Adult, adolescent child)
International non-proprietary name: Artesunate + amodiaquine
Laboratory: Mepha
Commercial name: Artéquin
International non-proprietary name: Artesunate + Mefloquine
Laboratory: IPCA
Commercial name: Larimal FD 400 B/3 and B/6
International non-proprietary name: Artesunate + amodiaquine
Laboratory: Dafra Pharma
Commercial name: Co Arinate FDC (Adult, adolescent child)
Co Artesiane syrup fl/120ml
International non-proprietary name: Artesunate + SP
Artemether + lumefantrine
Laboratory: GVC
Commercial name: Lonart syrup fl/60 ml
Lonart suppo B/6
International non-proprietary name: Artemether + lumefantrine
Artemether + lumefantrine
Laboratory: Pfizer
Commercial name: Camoquin plus (Adult, adolescent child)
Dualkin
International non-proprietary name: Artesunate + amodiaquine
Artesunate + amodiaquine
Laboratory: Novartis
Commercial name: Coartem
International non-proprietary name: Artemether + lumefantrine
Laboratory: Stallion
Commercial name: Kesunate
International non-proprietary name: Artesunate + amodiaquine
Laboratory: Macleodes
Commercial name: Lumiter
International non-proprietary name: Artemether + lumefantrine
Laboratory: EGR
Commercial name: Cofantrine B/24cp
Cofantrine syrup 2fl/60ml
Cofantrine suppo B/6
International non-proprietary name: Artemether + lumefantrine
Artemether + lumefantrine
Artemether + lumefantrine
Laboratory: Beo Pharma
Commercial name: Artemin
Arimal FD
Duocotexcin
P-Alaxin
Coartema
International non-proprietary name: Artemether
Artesunate + amodiaquine
Dihydroartemisine + piperaquine
Dihydroartemisine + piperaquine
Dihydroartemisine + piperaquine
TO BE FILLED OUT ONCE THE INTERVIEW IS FINISHED
COMMENTS ON THE RESPONDENT: ______
COMMENTS ON PARTICULAR QUESTIONS: ______
OTHER COMMENTS: ______
OBSERVATIONS OF TEAM LEADER
______
NAME OF TEAM LEADER: ______
DATE: ______