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MICS: Questionnaire for Children Under Five
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
[] 2 Not at home
[] 3 Refused
[] 4 Partially completed
[] 5 Incapacitated
[] 6 Other (specify) ____
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:
Year: _ _ _ _
UF11: How old was he/she at the last birthday
In completed years.
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Module of Birth Registration and Early Learning (MODBR): BR
BR1. Does (name) have a birth certificate? May I see it?
[] 2 Yes, not seen
[] 3 No
[] 8 DK
BR2. Has (name's) birth been registered with the civil authorities?
[] 2 No
[] 8 DK (go to BR4)
BR3. Why is (name's) birth not registered?
[] 2 Must travel to far
[] 3 Did not know it should be registered
[] 4 Did not want to pay fine
[] 5 Does not know where to register
[] 6 Other (specify) ____
[] 8 DK
BR4. Do you know how to register your child's birth?
[] 2 No
BR5. Is your child 3 years old or more?
[] No (go to BR8)
BR6. Is your child in the nursery school or kindergarten?
[] 2 No (go to BR8)
[] 8 DK (go to BR8)
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
[] B Father
[] X Other
[] Y No One
[] B Father
[] X Other
[] Y No One
[] B Father
[] X Other
[] Y No One
[] B Father
[] X Other
[] Y No One
[] B Father
[] X Other
[] Y No One
[] B Father
[] X Other
[] Y No One
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Module of Child Development: CE
Only for children under 5 years, question to be administered to each caretaker.
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
[] 10 Ten or more non--children's books
CE2. How many children's books or picture books do you have for (name)?
If ?none? enter 00
[] 10 Ten or more books
CE3. When the child is at home, which are the things he/she plays with?
[] B Objects and materials found outside the living quarters
[] C Homemade toys (dolls, cars)
[] D Toys that came from a store
[] Y No playthings mentioned
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
VA1 . Has (name) ever received a vitamin A capsule (supplement) like this one?
[] 2 No
[] 8 DK
VA2. How many months ago did (name) take the last dose?
[] 98 DK
VA3. Where did (name) get this last does?
[] 2 Sick child visit to health facility
[] 3 National immunization day campaign
[] 6 Other (specify) ____
[] 8 DK
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BF1. Has (name) ever been breastfeed?
[] 2 No (go to BF3)
[] 8 DK (go to BF3)
BF2. Is he/she still being breast--fed?
[] 2 No
[] 8 DK
BF3. Since this time yesterday, did he/she receive any of the following:
More than one answer is allowed
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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)
[] 8 DK
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Module of Care of illness (MODCA): CA
CA1. Did the child have diarrhea in the last two weeks?
[] 2 No (go to CA5)
[] 8 DK (go to CA5)
CA2. During this last episode of diarrhea, did (name) drink any of the following:
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
CA3. During (name's) illness did he/she drink much less, about the same, or more than usual?
[] 2 About the same
[] 3 More
[] 8 DK
CA4. Did the child eat while being ill?
[] 2 Much less
[] 3 Somewhat less
[] 4 About the same
[] 5 More
[] 8 DK
CA5. Has (name) had an illness with a cough at any time in the last two weeks?
[] 2 No (go to CA12)
[] 8 DK (go to CA12)
CA6. While having the cough, did the child have breathing difficulties?
[] 2 No (go to CA12)
[] 8 DK (go to CA12)
CA7. Were the symptoms due to a problem in the chest or a blocked nose?
[] 2 Blocked nose (go to CA13)
[] 3 Both
[] 6 Other (specify) ____ (go to CA13)
[] 8 DK
CA8. Did you seek advice or treatment for the illness outside the home?
[] 2 No (go to CA10)
[] 8 DK (go to CA10)
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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.
[] B Govt. Heath Center
[] C Govt. Health post
[] D Village health worker
[] E Mobile/outreach clinic
[] H Other public (specify) ____
[] J Private physician
[] K Private pharmacy
[] L Mobile clinic
[] O Other private medical (specify) ____
[] Q Shop
[] R Traditional practitioner
[] X Other (specify) ____
CA10. Was (name) given medicine to treat this illness?
[] 2 No (go to CA12)
[] 8 DK (go to CA12)
CA11. What medicine was (name) given?
Circle all medicines given
[] P Paracetamol/Panadol/Acetaminophen
[] Q Aspirin
[] R Ibuprofen
[] X Other
[] Z DK
Source and cost of supply for antibiotics for suspected pneumonia
CA11A. Check CA11: Antibiotic given?
[] No (Go to CA12)
CA11B. Where did you get the antibiotic?
[] 12 Govt. health centre
[] 13 Govt. health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 32 Shop
[] 33 Traditional practitioner
[] 98 DK
CA11C. How much did you pay for the antibiotic?
[] 9996 Free
[] 9998 DK
CA12. Check UF11: Child aged under 3?
[] No (go to CA14)
CA13. The last time (name) passed stools, what was done to dispose of the stools?
[] 02 Put/rinsed into toilet or latrine
[] 03 Put/rinsed into drain or ditch
[] 04 Thrown into garbage (solid waste)
[] 05 Buried
[] 06 Left in the open
[] 96 Other (specify) ____
[] 98 DK
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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
[] B Child becomes sicker
[] C Child develops a fever
[] D Child has fast breathing
[] E Child has difficulty breathing
[] F Child has blood in stool
[] G Child is drinking poorly
[] X Other (specify) ____
[] Y Other (specify) ____
[] Z Other (specify) ____
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Mothers having children under 5 years, should be interviewed.
IM1. Is there a vaccination card for (name)?
[] 2. Yes, not seen (go to IM10)
[] 3. No (go to IM10)
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?
[] 2 No (go to IM19)
[] 8 DK (go to IM19)
IM10. Has (name) ever received any vaccinations to prevent him/her from getting diseases?
[] 2 No (go to IM19)
[] 8 DK (go to IM19)
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IM11. Has (name) ever been given a BCG vaccination against tuberculosis -- that is, an injection in the arm or shoulder that caused a scar?
[] 2 No
[] 8 DK
IM12. Has (name) ever been given any "vaccination drops in the mouth" to protect him/her from getting diseases -- that is, polio?
[] 2 No (go to IM15)
[] 8 DK (go to IM15)
IM13. How old was he/she when the first dose was given ? just after birth (within two weeks) or later?
[] 2 Later
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?
[] 2 No (go to IM17)
[] 8 DK (go to IM17)
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?
[] 2 No
[] 8 DK
IM19. Write down whether in the relevant campaigns, the child has taken the vaccines
[] 2. No
[] 8. DK
[] 2. No
[] 8. DK
[] 2. No
[] 8. DK
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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..
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).]
AN3. Measurer's identification code
[] 2 Not present
[] 3 Refused
[] 6 Other (specify) ____