Mics Questionnaire for Children Under Five
Under-five child information panel: UF
UF3. Child's name and line number:
UF4. Mother's/caretaker's name and line number:
UF5. Interviewer's name and number:
UF6. Supervisor's name and number:
UF7. Day/month/year of interview
_ _ : _ _
Check respondent's age in HL6 in list of household members, household questionnaire:
If age 15-17, verify that adult consent for interview is obtained (HH33 or HH39) or not necessary (HL20=90). If consent is needed and not obtained, the interview must not commence and '06' should be recorded in UF17. The respondent must be at least 15 years old.
UF9. Check completed questionnaires in this household: Have you or another member of your team interviewed this respondent for another questionnaire?
[] 2 No, first interview (Go to UF10A)
UF10A. Hello, my name is (your name). We are from UNICEF in conjunction with the Consejo Nacional de Coordinación de Políticas Publicas (National Council for Public Policy Coordination). We are conducting a survey about the situation of children, families and households. I would like to talk to you about (child's name from UF3)'s health and well-being. This interview will take about 20 minutes. All the information we obtain will remain strictly confidential and anonymous. If you wish not to answer a question or wish to stop the interview, please let me know. May I start now?
UF10B. Now I would like to talk to you about (child's name from UF3)'s health and well-being in more detail. This interview will take about 20 minutes. Again, all the information we obtain will remain strictly confidential and anonymous. If you wish not to answer a question or wish to stop the interview, please let me know. May I start now?
[] 2 No/not asked (Go to UF17)
UF17. Result of interview for children under 5
[] 01 Completed
[] 02 Not at home
[] 03 Refused
[] 04 Partly completed
[] 05 Incapacitated (specify) ____
[] 06 No adult consent for mother/caretaker age 15-17
[] 96 Other (specify) ____
UB0. Before I begin the interview, could you please bring (name?s) Birth Certificate and DNI (National Identity Document)?
UB1. On what day, month and year was (name) born?
Date of birth
[] 98 DK day
_ _ Month
201 _ Year
Age (in completed years) _
UB2A. In which country was (name) born?
[] 2 Bolivia
[] 3 Brasil
[] 4 Chile
[] 5 Colombia
[] 6 Paraguay
[] 7 Peru
[] 8 Uruguay
[] 9 Venezuela
[] 96 Other (specify) ____
UB2B. Check columns HL14 and HL20 in the household members list, household survey. Is the interviewee the mother?
[] 2 No (HL14 does not equal HL20) (Go to UB2D)
UB2C. In which country you born?
[] 2 Bolivia
[] 3 Brasil
[] 4 Chile
[] 5 Colombia
[] 6 Paraguay
[] 7 Peru
[] 8 Uruguay
[] 9 Venezuela
[] 96 Other (specify) ____
UB2D. In which country was (name?s) mother born?
[] 2 Bolivia
[] 3 Brasil
[] 4 Chile
[] 5 Colombia
[] 6 Paraguay
[] 7 Peru
[] 8 Uruguay
[] 9 Venezuela
[] 96 Other (specify) ____
UB2E. In which country was (name?s) father born?
[] 2 Bolivia
[] 3 Brasil
[] 4 Chile
[] 5 Colombia
[] 6 Paraguay
[] 7 Peru
[] 8 Uruguay
[] 9 Venezuela
[] 96 Other (specify) ____
[] 2 Age 3 or 4
UB4. Check the respondent's line number (UF4) and the respondent to the household questionnaire (HH47):
[] 2 Respondent is not the same, UF4 does not equal HH47 (Go to UB6A)
UB5. Check ED4 in the education module in the household questionnaire: Is the child attending ECE in the current school year?
[] 2 Does not attend school, but has attended at some point (Go to UB8D)
[] 3 No, ED4 does not equal 0 or blank (Go to UB8D)
UB6A. Has (name) ever attended any early childhood education programme, such as educational institution, nursery, kindergarten, or preschool?
[] 2 Does not attend school, but has attended at some point
[] 3 No (Go to UB8C)
UB7. At any time since March, did (he/she) attend (programmes mentioned in UB6)?
[] 2 No
UB8C. What are the main reasons for which (name) does not attend to an educational institution, nursery, kindergarten or preschool?
[] B I do not need it, I would rather pay someone to take care of them at home
[] C I do not trust these educational institutions
[] D I am afraid the child will get sick often
[] E My child is too young
[] F My partner does not want it
[] H It is too far away or difficult to get there
[] I They were at capacity at the nearest institution
[] J The hours are incompatible with my work schedule
[] K I was not aware of the existence of institutions for children so young
[] Z DK
UB8D. You have mentioned that (name) DOES NOT attend an educational institution, nursery, kindergarten or preschool, What is or which are the main reasons?
[] B I do not need it, I would rather pay someone to take care of them at home
[] C I do not trust these educational institutions
[] D I am afraid the child will get sick often
[] E My child is too young
[] F My partner does not want it
[] H It is too far away or difficult to get there
[] I They were at capacity at the nearest institution
[] J The hours are incompatible with my work schedule
[] K I was not aware of the existence of institutions for children so young
[] Z DK
UB8D1. Check if any access related reason was reported in UB8C or UB8D
[] 2 No (UB8D=A-F OR UB8C=A-F)
UB8E. Do you believe that in any of the following cases (name) could attend an educational institution, nursery, kindergarten or preschool?
[A] If you had to work or got another job
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[C] If there was an option closer to home
[] 2 No
[] 8 DK
[D] If there was a form of transportation or easier access
[] 2 No (Go to end)
[] 8 DK (Go to end)
UB8G1. During the week, from Monday to Friday, how many days does (name) attend school?
UB8G2. You have mentioned that (name) is currently attending an educational institution, nursery, kindergarten or preschool. During the week, from Monday to Friday, how many days does (name) attend school?
UB8H. And, how many hours does (name) spend there on a typical day?
UB8I. Does (name) have lunch regularly in a school cafeteria, or does he take food from school for free?
[] 2 No
UB9. Is (name) covered by any health insurance?
[] 2 No (Go to end of module)
UB10. What type of health insurance is (name) covered by?
[] A Mutual health organization/community-based health insurance
[] B Health insurance through employer
[] C Social security
[] D Other privately purchased commercial health insurance
[] X Other (specify) ____
BR1. Does (name) have a birth certificate?
[] 1 Yes, seen (Go to end of module)
[] 2 Yes, not seen (Go to end of module)
[] 3 No
[] 8 DK
BR2. Has (name)'s birth been registered with the civil registry (el registro civil)?
[] 2 No
[] 8 DK
BR3. Do you know how to register (name)'s birth?
[] 2 No
Universal Allowance per Child: AUH
AUH00. Check the interviewee's list number (UF) in the UNDER-FIVE CHILD INFORMATION PANEL and the interviewee in the HOUSEHOLD QUESTIONNAIRE (HH47)
[] 2 Interviewee is not the person (UF4 does not equal HH47) (Go to AUH1A)
AUH0. Check TS2 in the HOUSEHOLD QUESTIONNAIRE if the household is on (Asignación Universal Por Hijo) Universal Child Allowance
[] 2 No (Go to AUH2)
[] 8 DK (Go to AUH2)
AUH1. You have told me that a member of the household is on Universal Child Allowance. May you remind me if (name) is a recipient?
[] 2 No (Go to AUH2)
[] 8 DK (Go to AUH2)
AUH1A. Is (name) a recipient of Universal Child Allowance?
[] 2 No
[] 8 DK
AUH2. Has (name) ever been a recipient of AUH (Universal Child Allowance)?
[] 2 No (Go to AUH8)
AUH3. Which were the reasons for (name) to stop receiving it?
[] B Did not present the certificate
[] C "ANSES" [a national health institution] did not accept or did not approve the health certificate
[] D The father/mother/tutor had a formal job/was in a dependent relationship/ "monotributista" [a small business owner]
[] E The father/mother/tutor had an income above the necessary requirements
[] F Had another plan/subsidy/program/pension
[] G Had problems with the identity documents (DNI, birth certificate)
[] H Another sibling was born
[] X Other (specify) ____
[] Z DK
AUH4. How long has it been since (name) stop receiving the AUH? If less than a month, record "1", otherwise, register the number of months.
[] 98 DK
AUH5. Did you try to get it again afterwards?
[] 2 No (Go to AUH7)
[] 8 DK (Go to end)
AUH6. Which were the reasons for which you failed to obtain it?
[] B ANSES did not accept/approve the certificate
[] C Had a formal job/was in a dependent relationship
[] D Had another plan/subsidy/program/pension
[] E Missing documents/documentation problems
[] F ANSES problems
[] G Was not informed of the reasons
[] H Was told to wait by anses
[] I Did not receive any answer
[] X Other (specify) ____
[] Z DK
AUH6A. Continue with the next module if any answer is registered in AUH6.
AUH7. What is the main reason that stopped you from re-applying [for the AUH]?
[] 2 DID NOT NEED IT/THERE ARE PEOPLE WHO ARE IN DEEPER NEED
[] 3COMPLICATED PAPERWORK
[] 4 PROBLEMS WITH ANSES'S SCHEDULES/TURNS
[] 5 THE ANSES OFFICE IS TOO FAR AWAY
[] 6 DID NOT THINK ABOUT IT
[] 96 Other (specify) ____
AUH7A. Continue with the next module if any answer is registered in AUH7.
AUH8. Did you ever re-apply for it (the AUH)?
[] 2 No (Go to AUH10)
[] 8 DK (Go to end)
AUH9. Why didn't you obtain it?
[] B ANSES did not accept/approve the certificate
[] C Had a formal job/was in a dependent relationship
[] D Had another plan/subsidy/program/pension
[] E Missing documents/documentation problems
[] F ANSES problems
[] G Was not informed of the reasons
[] H Was told to wait by anses
[] I Did not receive any answer
[] X Other (specify) ____
[] Z DK
AUH9A. Continue with the next module if any answer is registered in AUH9.
AUH10. Why didn't you re-apply for it?
[] 2 Has another plan/subsidy/program/pension
[] 3 Missing documentation/documentation problems
[] 4 Was told they couldn't apply (does not know the reason)
[] 5 Does not need it/there are people who need it more
[] 6 Paperwork/certificates are hard to get
[] 7 Lacks information/does not know how/where
[] 8 The ANSES office is too far away
[] 9 Did not think about it
[] 10 Stopped studying
[] 96 Other (specify) ____
[] 98 DK
AUH10A. Continue with the next module if any answer is registered in AUH10.
AUH11. In the last two years have you had any difficulty to receive or turn in health certificates?
[] 2 No (Go to end)
[] 8 DK (Go to end)
AUH12. What kind of difficulty?
[] E There are no health providers near the household
[] G Problems with schedules/turns in ANSES
[] H ANSES did not accept/the certificate/ID was not approved
[] J Difficulties by the guardian to take the child to medical controls/vaccination (due to lack of time, money, illness, etc.)
[] K Domicile change (their ID/certificate was not accepted)
[] L Lost their documentation (ID, DNI)
[] M Guardian died
[] N The guardian does not live at the household
AUH13. Did this difficulty cause the payment interruption?
[] 2 No
Early childhood development: EC
EC1. How many children's books or picture books do you have for (name)?
[] _ Number of children's book
[] 10 Ten or more books
EC2. I am interested in learning about the things that (name) plays with when (he/she) is at home.
Does (he/she) play with:
[A] Homemade toys, such as dolls, cars, or other toys made at home?
[] 2 No
[] 8 DK
[B] Toys from a shop or manufactured toys?
[] 2 No
[] 8 DK
[C] Household objects, such as bowls or pots, or objects found outside, such as sticks, rocks, animal shells or leaves?
[] 2 No
[] 8 DK
EC3. 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.
On how many days in the past week was (name):
[A] Left alone for more than an hour?
[B] Left in the care of another child, that is, someone less than 10 years old, for more than an hour?
If 'None' record '0'. If 'Don't know' record '8'.
_ Number of days left with another child for more than an hour
[] 2 Age 2, 3 or 4
EC5. In the past 3 days, did you or any household member age 15 or over engage in any of the following activities with (name):
A foster/step mother or father living in the household who engaged with the child should be coded as mother or father. Record all that apply. 'No one' cannot be recorded if any household member age 15 and above engaged in activity with child.
[A] Read books or looked at picture books with (name)?
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
[C] Sang songs to or with (name), including lullabies?
[] B Father
[] X Other
[] Y No one
[D] Took (name) outside the home?
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
[F] Named, counted, or drew things for or with (name)?
[] B Father
[] X Other
[] Y No one
[] 2 Age 3 or 4
I would like to ask you some questions about the health and development of (name). Children do not all develop and learn at the same rate. For example, some walk earlier than others. These questions are related to several aspects of (name)'s development.
EC6. Can (name) identify or name at least ten letters of the alphabet?
[] 2 No
[] 8 DK
EC7. Can (name) read at least four simple, popular words?
[] 2 No
[] 8 DK
EC8. Does (name) know the name and recognize the symbol of all numbers from 1 to 10?
[] 2 No
[] 8 DK
EC9. Can (name) pick up a small object with two fingers, like a stick or a rock from the ground?
[] 2 No
[] 8 DK
EC10. Is (name) sometimes too sick to play?
[] 2 No
[] 8 DK
EC11. Does (name) follow simple directions on how to do something correctly?
[] 2 No
[] 8 DK
EC12. When given something to do, is (name) able to do it independently?
[] 2 No
[] 8 DK
EC13. Does (name) get along well with other children?
[] 2 No
[] 8 DK
EC14. Does (name) kick, bite, or hit other children or adults?
[] 2 No
[] 8 DK
EC15. Does (name) get distracted easily?
[] 2 No
[] 8 DK
[] 2 Age 1, 2, 3, 4
UCD2. Adults use certain ways to teach children the right behavior or to address a behavior problem. I will read various methods that are used. Please tell me if you or any other adult in your household has used this method with (name) in the past month.
[A] Took away privileges, forbade something (name) liked or did not allow (him/her) to leave the house.
[] 2 No
[B] Explained why (name)'s behavior was wrong.
[] 2 No
[] 2 No
[D] Shouted, yelled at or screamed at (him/her).
[] 2 No
[E] Gave (him/her) something else to do.
[] 2 No
[F] Spanked, hit or slapped (him/her) on the bottom with bare hand.
[] 2 No
[G] Hit (him/her) on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.
[] 2 No
[H] Called (him/her) dumb, lazy or another name like that.
[] 2 No
[I] Hit or slapped (him/her) on the face, head or ears.
[] 2 No
[J] Hit or slapped (him/her) on the hand, arm, or leg.
[] 2 No
[K] Beat (him/her) up, that is hit (him/her) over and over as hard as one could.
[] 2 No
UCD3. Check UF4: Is this respondent the mother or caretaker of any other children under age 5 or a child age 5-14 selected for the questionnaire for children age 5-17?
[] 2 No (Go to UCD5)
UCD4. Check UF4: Has this respondent already responded to the following question (UCD5 or FCD5) for another child?
[] 2 No
UCD5. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?
[] 2 No
[] 8 DK/no opinion
[] 2 Age 2, 3 or 4
UCF2. I would like to ask you some questions about difficulties (name) may have.
[] 2 No
UCF3. Does (name) use a hearing aid?
[] 2 No
UCF4. Does (name) use any equipment or receive assistance for walking?
[] 2 No
UCF5. In the following questions, I will ask you to answer by selecting one of four possible answers. For each question, would you say that (name) has: 1) no difficulty, 2) some difficulty, 3) a lot of difficulty, or 4) that (he/she) cannot at all.
UCF6. Check UCF2: Child wears glasses?
[] 2 No, UCF2=2 (Go to UCF7B)
UCF7A. When wearing (his/her) glasses, does (name) have difficulty seeing?
UCF7B. Does (name) have difficulty seeing?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot see at all
UCF8. Check UCF3: Child uses a hearing aid?
[] 2 No, UCF3=2 (Go to UCF9B)
UCF9A. When using (his/her) hearing aid(s), does (name) have difficulty hearing sounds like peoples' voices or music?
UCF9B. Does (name) have difficulty hearing sounds like peoples' voices or music?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot hear at all
UCF10. Check UCF4: Child uses equipment or receives assistance for walking?
[] 2 No, UCF4=2 (Go to UCF13)
UCF11. Without (his/her) equipment or assistance, does (name) have difficulty walking?
[] 3 A lot of difficulty
[] 4 Cannot walk at all
UCF12. With (his/her) equipment or assistance, does (name) have difficulty walking?
[] 2 Some difficulty (Go to UCF14)
[] 3 A lot of difficulty (Go to UCF14)
[] 4 Cannot walk at all (Go to UCF14)
UCF13. Compared with children of the same age, does (name) have difficulty walking?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot walk at all
UCF14. Compared with children of the same age, does (name) have difficulty picking up small objects with (his/her) hand?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot pick up at all
UCF15. Does (name) have difficulty understanding you?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot understand at all
UCF16. When (name) speaks, do you have difficulty understanding (him/her)?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot be understood at all
UCF17. Compared with children of the same age, does (name) have difficulty learning things?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot learn things at all
UCF18. Compared with children of the same age, does (name) have difficulty playing?
[] 2 Some difficulty
[] 3 A lot of difficulty
[] 4 Cannot play at all
UCF19. The next question has five different options for answers. I am going to read these to you after the question. Compared with children of the same age, how much does (name) kick, bite or hit other children or adults?
Would you say: not at all, less, the same, more or a lot more?
[] 2 Less
[] 3 The same
[] 4 More
[] 5 A lot more
Breastfeeding and dietary intake: BD
[] 2 Age 3 or 4 (Go to end of module)
BD2. Has (name) ever been breastfed?
[] 2 No (Go to BD3A)
[] 8 DK (Go to BD3A)
BD3. Is (name) still being breastfed?
[] 2 No
[] 8 DK
CA1. In the last two weeks, has (name) had diarrhoea?
[] 2 No (Go to CA14)
[] 8 DK (Go to CA14)
CA2. Check BD3: Is child still breastfeeding?
[] 2 No or DK, BD3=2 or 8 (Go to CA3B)
CA3A. I would like to know how much (name) was given to drink during the diarrhoea. This includes breastmilk, Oral Rehydration Salt solution (ORS) and other liquids given with medicine. During the time (name) had diarrhoea, was (he/she) given less than usual to drink, about the same amount, or more than usual?
CA3B. I would like to know how much (name) was given to drink during the diarrhoea. This includes Oral Rehydration Salt solution (ORS) and other liquids given with medicine. During the time (name) had diarrhoea, was (he/she) given less than usual to drink, about the same amount, or more than usual?
If 'less', probe: Was (he/she) given much less than usual to drink, or somewhat less?
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Nothing to drink
[] 8 DK
CA4. During the time (name) had diarrhoea, was (he/she) given less than usual to eat, about the same amount, more than usual, or nothing to eat?
If 'less', probe: Was (he/she) given much less than usual to eat or somewhat less?
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Stopped food
[] 7 Never gave food
[] 8 DK
CA5. Did you seek any advice or treatment for the diarrhoea from any source?
[] 2 No (Go to CA7A)
[] 8 DK (Go to CA7A)
CA6. Where did you seek advice or treatment?
Probe: Anywhere else? Record all providers mentioned, but do not prompt with any suggestions. Probe to identify each type of provider. If unable to determine if public or private sector, write the name of the place and then temporarily record 'W' until you learn the appropriate category for the response.
(Name of place) ____
[] B Government health centre
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] O Other private medical (specify) ____
Other source
[] Q Shop/market/street
[] R Traditional practitioner
[] Z DK/Don't remember
CA7A. During the time (name) had diarrhoea, was (he/she) given:
[A] A fluid made from a special packet called [insert local name for ORS packet solution]?
[] 2 No (Go to CA12)
[] 8 DK
[B] A pre-packaged ORS fluid called [insert local name for pre-packaged ORS fluid]?
[] 2 No
[] 8 DK (Go to CA12)
CA8. Check CA7[A] and CA7[B]: Was child given any ORS?
[] 2 No, 'No' or 'DK' in both CA7[A] and CA7[B] (Go to CA12)
CA9. Where did you get the (ORS mentioned in CA7[A] and/or CA7[B])?
Probe to identify the type of source. If 'Already had at home', probe to learn if the source is known. If unable to determine whether public or private, write the name of the place and then temporarily record 'W' until you learn the appropriate category for the response.
(Name of place) ____
[] B Government health centre
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] O Other private medical (specify) ____
Other source
[] Q Shop/market/street
[] R Traditional practitioner
[] Z DK/don't remember
CA12. Was anything else given to treat the diarrhoea?
[] 2 No (Go to CA14)
[] 8 DK (Go to CA14)
CA13. What else was given to treat the diarrhoea?
Probe: Anything else? Record all treatments given. Write brand name(s) of all medicines mentioned.
(Name of brand) ____
[] B Antimotility (anti-diarrhoea)
[] G Other pill or syrup
[] H Unknown pill or syrup
[] M Non-antibiotic
[] N Unknown injection
[] Q Home remedy/herbal medicine
[] X Other (specify) ____
CA14. At any time in the last two weeks, has (name) been ill with a fever?
[] 2 No
[] 8 DK
CA16. At any time in the last two weeks, has (name) had an illness with a cough?
[] 2 No
[] 8 DK
CA17. At any time in the last two weeks, has (name) had fast, short, rapid breaths or difficulty breathing?
[] 2 No (Go to CA19)
[] 8 DK (Go to CA19)
CA18. Was the fast or difficult breathing due to a problem in the chest or a blocked or runny nose?
[] 2 Blocked or runny nose only (Go to CA20)
[] 3 Both (Go to CA20)
[] 6 Other (specify) ____ (Go to CA20)
[] 8 DK (Go to CA20)
CA19. Check CA14: Did child have fever?
[] 2 No or DK, CA14=2 or 8 (Go to CA30)
CA20. Did you seek any advice or treatment for the illness from any source?
[] 2 No (Go to CA22)
[] 8 DK (Go to CA22)
CA21. From where did you seek advice or treatment?
Probe "Anywhere else?". Record all providers mentioned, but do not prompt with any suggestions. Probe to identify the type of each provider. If unable to determine if public or private sector, write the name of the place and then temporarily record 'W' until you learn the appropriate category for the response.
(Name of place) ____
[] B Government health centre
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] O Other private medical (specify) ____
Other source
[] Q Shop/market/street
[] R Traditional practitioner
CA22. At any time during the illness, was (name) given any medicine for the illness?
[] 2 No (Go to CA30)
[] 8 DK (Go to CA30)
CA23. What medicine was (name) given?
Probe: Any other medicine? Record all medicines given. If unable to determine type of medicine, write the brand name and then temporarily record 'W' until you learn the appropriate category for the response
(Name of brand) ____
(Name of brand) ____
[] M Cotrimoxazole
[] N Other antibiotic pill/syrup
[] O Other antibiotic injection/IV
[] S Aspirin
[] T Ibuprofen
[] X Other (specify) ____
[] Z DK
CA24. Check CA23: Antibiotics mentioned
[] 2 No, antibiotics not mentioned (Go to CA30)
CA25. Where did you get the (name of medicine from CA23, codes L to O)?
Probe to identify the type of source. If 'Already had at home', probe to learn if the source is known. If unable to determine whether public or private, write the name of the place and then temporarily record 'W' until you learn the appropriate category for the response.
(Name of place) ____
[] B Government health centre
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] O Other private medical (specify) ____
Other source
[] Q Shop/market/street
[] R Traditional practitioner
[] Z DK/don't remember
[] 2 Age 3 or 4 (Go to CA32)
CA31. 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
CA32. In the past 12 months have you taken (name) for a health check up without being sick?
[] 2 No (Go to CA34)
[] 8 DK (Go to CA35)
CA33. In the past 12 months how many health check ups has (name) had?
[] 2 2 times (Go to CA35)
[] 3 3 times (Go to CA35)
[] 4 4 times (Go to CA35)
[] 5 5 to 9 times (Go to CA35)
[] 6 10 or more (Go to CA35)
CA34. What was the main reason for which you didn't take (name) for a check up?
[] 2 No money
[] 3 No transportation
[] 4 Applies for a turn but didn't receive
[] 5 Didn't think it was necessary
[] 6 Other (specify) ____
[] 8 DK
CA35. Verify UB2: Child's age?
[] 2 Age 3 or 4
CA36. In the past 12 months has (name) visited the ophthalmologist?
[] 2 No
[] 8 DK
CA37. In the past 12 months has (name) visited the dentist?
[] 2 No
[] 8 DK
UF13. Language of the Interview.
[] 6 Other language (specify) ____
UF14. Native language of the Respondent.
[] 6 Other language (specify) ____
UF15. Was a translator used for any parts of this questionnaire?
[] 2 Yes, parts of the questionnaire
[] 3 No, Not used
UF16. Tell the respondent that you will need to measure the weight and height of the child before you leave the household and a colleague will come to lead the measurement. Issue the anthropometry module form for this child and complete the Information Panel on that Form.
Check columns HL10 and HL20 in list of household members, household questionnaire: Is the respondent the mother or caretaker of another child age 0-4 living in this household?
[] No (Check HL6 and column HL20 in list of household members, household questionnaire: Is the respondent the mother or caretaker of a child age 5-17 selected for Questionnaire for Children Age 5-17 in this household?)
Interviewer's observations ________
Supervisor's observations ________
Anthropometry module information panel: AN
AN3. Child's name and line number:
AN5. Mother's/caretaker's name and line number:
AN6. Interviewer's name and number
AN7. Measurer's name and number:
AN8. Record the result of weight measurement as read out by the Measurer:
Read the record back to the Measurer and also ensure that he/she verifies your record.
[] 99.3 Child not present (Go to AN13)
[] 99.4 Child refused (Go to AN10)
[] 99.5 Respondent refused (Go to AN10)
[] 99.6 Other (specify) ____ (Go to AN10)
AN9. Was the child undressed to the minimum?
[] 2 No, the child could not be undressed to the minimum
[] 2 Age 2, 3, or 4 (Go to AN11B)
AN11A. The child is less than 2 years old and should be measured lying down. Record the result of length measurement as read out by the Measurer:
Read the record back to the Measurer and also ensure that he/she verifies your record.
AN11B. The child is at least 2 years old and should be measured standing up. Record the result of height measurement as read out by the Measurer:
Read the record back to the Measurer and also ensure that he/she verifies your record.
[] 999.4 Child refused (Go to AN13)
[] 999.5 Respondent refused (Go to AN13)
[] 999.6 Other (specify) ____ (Go to AN13)
AN12. How was the child actually measured? Lying down or standing up?
[] 2 Standing up
AN13. Today's date: Day/month/year:
AN14. Is there another child under age 5 in the household who has not yet been measured?
[] 2 No
AN15. Thank the respondent for his/her cooperation and inform your supervisor that the measurer and you have completed all the measurements in this household.
Interviewer's observations for anthropometry module ________