PLEASE GIVE YOUR FEEDBACK
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COMPLETE ADDRESS
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THIS AREA IS THE PLACE WHERE -
IS THERE ANY FOGGING IN THE LOCALITY
IS THERE ANY DDT SPRAYING IN THE LOCALITY
IF YES , WHEN
IS THERE ANY DISTRIBUTION OF LLIN DURING LAST 3 YEARS
IF YES , HOW FREQUENTLY ARE YOU USING THE LLIN
IS THERE ANY IMPREGNATION OF BEDNET IN YOUR LOCALITY
IF YES , WHEN
IS THERE ANY LARVICIDAL SPRAY IN THE LOCALITY
IF YES , WHEN
IS THERE ANY CASE OF DENGUE IN THE LOCALITY
IF YES , PLEASE MENTION THE NAME & ADDRESS OF THE PATIENT
Sl No NAME OF THE PATIENT ADDRESS OF THE PATIENT
1
2
3
4
5
HAVE YOU COME ACROSS ANY AWARENESS MATERIALS/ADVERTISEMENT OF DENGUE
IF YES, PLEASE MENTION (TICK AT WHATEVER YOU HAVE COME ACROSS)
ANY OTHER INFORMATION RELATED TO DENGUE :
SUGGESTION, IF ANY :
NAME OF THE RESPONDENT :
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