Page 1

Under--five Child information Panel

All mothers/caretakers should be interviewed for these questionnaires, who have children under 5 years. Child index number should be the same to the one s/he is having as per family household at family module. Fill in all the questionnaires for one child then move to the data of the other child. All the children of the family under 5 years of age should be questioned.

UF1D. Line No.

UF6. Mother's/ caretaker's line number: _ _

UF9. Result of Interview for children under 5

UF10: Date of birth of the child

Probe: If the mother/caretaker knows the exact birth date, also enter the day; otherwise circle 98 for day.

Date of Birth:

UF11: How old was he/she at the last birthday
In completed years.

Page 2

Module of Birth Registration and Early Learning (MODBR): BR

BR11D. Line No.

BR1. Does (name) have a birth certificate? May I see it?

BR2. Has (name's) birth been registered with the civil authorities?

BR3. Why is (name's) birth not registered?

BR4. Do you know how to register your child's birth?

BR5. Is your child 3 years old or more?

BR6. Is your child in the nursery school or kindergarten?

BR7. Within the last seven days, about how many hours did (name) attend?

BR8. In the past 3 days, did you or any member of your household over 15 years of age engage in any of the following activities with (name):

Circle all that apply

Page 3

Module of Child Development: CE

Only for children under 5 years, question to be administered to each caretaker.

CE1D. Line No.

CE1. How many books are there in the household? Please include schoolbooks, but not other books meant for children, such as picture books
If ?none? enter 00

CE2. How many children's books or picture books do you have for (name)?
If ?none? enter 00

CE3. When the child is at home, which are the things he/she plays with?

CE4. Sometimes adults taking care of children have to leave the house to go shopping, wash clothes, or for other reasons and have to leave young children with others. Since last (day of the week) how many times was (name) left in the care of another child (that is, someone less than 10 years old)?
If 'none' enter 00

CE5. In the past week, how many times was (name) left alone?
If 'none' enter 00

Module of Vitamin A (MODOVA): VA

VA1D. Line No.

VA1 . Has (name) ever received a vitamin A capsule (supplement) like this one?

VA2. How many months ago did (name) take the last dose?

VA3. Where did (name) get this last does?

Page 4

Module of Breastfeeding: BF

BF1D. Line No.

BF1. Has (name) ever been breastfeed?

BF2. Is he/she still being breast--fed?

BF3. Since this time yesterday, did he/she receive any of the following:
More than one answer is allowed

BF5. Since this time yesterday, how many times did (name) eat solid, semi--solid, or soft foods other than liquids? (if 7 or more times record 7)

Page 5

Module of Care of illness (MODCA): CA

CA11D. Line No.

CA1. Did the child have diarrhea in the last two weeks?

CA2. During this last episode of diarrhea, did (name) drink any of the following:

CA3. During (name's) illness did he/she drink much less, about the same, or more than usual?

CA4. Did the child eat while being ill?

CA5. Has (name) had an illness with a cough at any time in the last two weeks?

CA6. While having the cough, did the child have breathing difficulties?

CA7. Were the symptoms due to a problem in the chest or a blocked nose?

CA8. Did you seek advice or treatment for the illness outside the home?

page 6

CA9. From where did you seek care? Anywhere else?

Circle all providers mentioned, but do not prompt with any suggestions. If source is hospital, health center, or clinic, write the name of the place below. Probe to identify the type of source and circle the appropriate code.

CA10. Was (name) given medicine to treat this illness?

CA11. What medicine was (name) given?
Circle all medicines given

Source and cost of supply for antibiotics for suspected pneumonia

CA11A. Check CA11: Antibiotic given?

CA11B. Where did you get the antibiotic?

CA11C. How much did you pay for the antibiotic?

CA12. Check UF11: Child aged under 3?

CA13. The last time (name) passed stools, what was done to dispose of the stools?

Page 7

CA14. Sometimes children have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take your child to a health facility right away?

Ask the following question (CA14) only once for each mother/caretaker.

Keep asking for more signs or symptoms until the mother/caretaker cannot recall any additional symptoms. Circle all symptoms mentioned, But do NOT prompt with any suggestions

Page 8

Immunization Module: IM

IM11D. Line No.

Mothers having children under 5 years, should be interviewed.

IM1. Is there a vaccination card for (name)?

A. Copy dates for each vaccination from the card.
B. Write '44' in day column if card shows that vaccination was given but no date recorded.
Date of immunization (DD/MM/YYYY)

IM9. In addition to the vaccinations and vitamin A capsules shown on this card, did (name) receive any other vaccinations ? including vaccinations received in campaigns or immunization days?

IM10. Has (name) ever received any vaccinations to prevent him/her from getting diseases?

Page 9

IM11. Has (name) ever been given a BCG vaccination against tuberculosis -- that is, an injection in the arm or shoulder that caused a scar?

IM12. Has (name) ever been given any "vaccination drops in the mouth" to protect him/her from getting diseases -- that is, polio?

IM13. How old was he/she when the first dose was given ? just after birth (within two weeks) or later?

IM21D. Line No.

IM14. How many times has he/she been given these drops?

IM15. Has (name) ever been given vaccination injections (in the bottom) to protect him/her from getting tetanus, white cough or diphtheria?

IM16. How many times?

IM17. Has (name) ever been given "Measles vaccination injections" or MMR -- that is, a shot in the arm at the age of 9 months or older -- to prevent him/her from getting measles?

IM19. Write down whether in the relevant campaigns, the child has taken the vaccines

Page 10
Anthropometry Module: AN
Only for child under 5 years (after the questionnaires are over for all the children, the person should measure and weigh all the children. Check the child line number on the household listing before recording measurements..

IM1D. Line No.

AN1. Child's weight in KG. i.e. 2 or 2,5

AN2A. Child's length or height

Check age of child in UF11:

[] Child under 2 years old. [Measure length (lying down).]
[] Child age 2 or more years. [Measure height (standing up).]

AN2B. Tallness (cm)

AN3. Measurer's identification code

AN4. Result of measurement