[Brcko District of BiH]

Under-five child information panel: UF

This questionnaire is to be administered to all mothers or caretakers (see Household Listing Form, column HL9 in the household questionnaire) who care for a child that lives with them and is under the age of 5 years (see Household Listing Form, column HL6 in the household questionnaire).

A separate questionnaire should be used for each eligible child.

UF1. Cluster number: _ _ _

UF2. Household number: _ _

UF3. Child's name:
Name ____

UF4. Child's line number: _ _

UF5. Mother's / caretaker's name:
Name ____

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

UF7. Interviewer name and number
Name ____ _ _

UF8. Day / month / year of interview _ _ / _ _ / _ _ _ _

Repeat greeting if not already read to this respondent:

We are from the Department of Health and Other Services of the Government of the Brcko District of Bosnia and Herzegovnia. We are working on a project concerned with family health and education. I would like to talk to you about (child?s name from UF3)'s health and well-being. The interview will take up to 20 minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

If greeting at the beginning of the household questionnaire has already been read to this person, then read the following:

Now I would like to talk to you more about (child's name from UF3)'s health and other topics. This interview will take up to 20 minutes. Again, all the information we obtain will remain strictly confidential.

May I start now?

UF9. Result of interview for children under 5
Codes refer to mother/caretaker.

UF10. Field edited by (name and number)

UF11. Data entry operator (name and number):

UF12. Record the time.

Age of child: AG

AG1. Now I would like to ask you some questions about (name)?s health.

In what month and year WAS (name) born?

Probe: what is his / her birthday? If the mother/caretaker knows the exact birth date, also enter the day; otherwise, circle 98 for day. Month and year must be recorded.

AG2. How old is (name)?

Probe: how old was (name) at his / her last birthday?

Record age in completed years. Record '0' if less than 1 year. Compare and correct AG1 and/or AG2 if inconsistent.

Birth registration: BR

BR0. Check cluster number in UF1

BR1. Does (name) have a birth certificate?

If yes, ask: May I see it?

BR2. Has (name)'s birth been registered with the registry office?

BR3. Do you know how to register your child's birth in the birth register?

Early childhood development: EC

EC1. How many children's books or picture books do you have for (name)?

EC2. I am interested in learning about the things that (name) plays with when he/she is at home.

If the respondent says "yes" to the categories above, then probe to learn specifically what the child plays with to ascertain the response

Does he/she play with:

[A] Homemade toys (such as dolls, cars, or other toys made at home)?

[B] Toys from a shop or manufactured toys?

[C] Household objects (such as bowls or pots) or objects found outside (such as sticks, rocks, animal shells or leaves)?

EC3. Sometimes adults taking care of children have to leave the house to go shopping, to the doctor or for other reasons and have to leave young children.

On how many days in the past week was (name):

If response is 'none' enter' 0'. If response is 'don't know' enter'8'

[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?

EC4. Check AG2: Age of child

EC5. Does (name) attend any organized learning or early childhood education programme, such as a private or public facility, including kindergarten or child care centre in the community?

EC6. Within the last seven days, about how many hours did (name) attend?

EC7. In the past 3 days, did you or any household member over 15 years of age engage in any of the following activities with (name):

If yes, ask: Who engaged in this activity with (name)? Circle all responses that apply.

[A] Read books to or looked at picture books with (name)?

[B] Told stories to (name)?

[C] Sang songs to (name) or with (name), including lullabies?

[D] Took (name) outside the home, compound, yard or enclosure?

[E] Played with (name)?

[F] Named, counted, or drew things to or with (name)?

EC8. I would like to ask you some questions about the health and development of your child. 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 your child's development.
Can (name) identify or name at least ten letters of the (Latin/Cyrillic) alphabet?

EC9. Can (name) read at least four simple, popular words?

EC10. Does (name) know the name and recognize the symbol of all numbers from 1 to 10?

EC11. Can (name) pick up a small object with two fingers, like a stick or a rock from the ground?

EC12. Is (name) sometimes too sick to play?

EC13. Does (name) follow simple directions on how to do something correctly?

EC14. When given something to do, can he/she do it independently?

EC15. Does (name) get along well with other children?

EC16. Does (name) bite, or hit other children or adults?

EC17. Does (name) get distracted easily?

Breastfeeding: BF

BF1. Has (name) ever been breastfed?

BF2. Is he/she still being breastfed?

BF3. I would like to ask you about liquids that (name) may have had yesterday during the day or the night. I am interested in whether (name) had the liquid even if it was combined with other foods.

Did (name) drink plain water yesterday, during the day or night?

BF4. Did (name) drink infant formula yesterday, during the day or night?

BF5. How many times did (name) drink infant formula yesterday, during the day or night?

BF6. Did (name) drink milk, such as powdered or fresh animal milk yesterday, during the day or night?

BF7. How many times did (name) drink tinned, powdered or fresh animal milk yesterday, during the day or night?

BF8. Did (name) drink juice or juice drinks yesterday, during the day or night?

BF9. Did (name) drink clear soup yesterday, during the day or night?

BF10. Did (name) consume vitamin or mineral supplements or any medicines yesterday, during the day or night?

BF11. Did (name) drink oral rehydration solution (ORS) yesterday, during the day or night?

BF12. Did (name) drink any other liquids yesterday, during the day or night?

BF13. Did (name) drink or eat sour-milk or yogurt yesterday, during the day or night?

BF14. How many times did (name) drink or eat sour-milk or yogurt yesterday, during the day or night?

BF15. Did (name) eat thin porridge or semolina porridge yesterday, during the day or night?

BF16. Did (name) eat solid or semi-solid (soft, mushy) food yesterday, during the day or night?

BF17. How many times did (name) eat solid or semi-solid (soft, mushy) food yesterday, during the day or night?

BF18. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?

Care of illness: CA

CA1. In the last two weeks, has (name) had diarrhoea?

CA2. I would like to know how much (name) was given to drink during the diarrhoea (including breastmilk).

During the time (name) had diarrhoea, was he/she given less than usual to drink, about the same amount, or more than usual?

If response is less, probe: was he/she given much less than usual to drink, or somewhat less?

CA3. 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 response is "less", probe: Was he/she given much less than usual to eat or somewhat less?

CA4. During the period of diarrhoea, was (name) given to drink any of the following:

Read each item aloud and record response before proceeding to the next item.

[A] A fluid for oral rehydration made from a special infusion called orosal, nelit or something similar?

[B] A pre-packaged ORS fluid for diarrhoea?

CA5. Was anything (else) given to treat the diarrhoea?

CA6. What (else) was given to treat the diarrhoea?

Probe: Anything else? Record all treatments given. Write brand name(s) of all medicines mentioned.

(Name) ____

CA7. During the last two weeks, has (name) had an illness with a cough?

CA8. When (name) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

CA9. Was the fast or difficult breathing due to a problem in the chest or a blocked or runny nose?

CA10. Did you seek any advice or treatment for the illness from any source?

CA11. From where did you seek advice or treatment?

Probe: Anywhere else? Circle all service providers mentioned, but do NOT prompt with any suggestions.

Probe to identify each type of source. If unable to determine if public or private sector, write the name of the institution/organisation.

(Name of institution/organisation) ____

CA12. Was (name) given any medicine to treat this illness?

CA13. What medicine was (name) given?

Probe: Any other medicine? Circle all medicines given. Write the name of every medicine mentioned.

(Names of medicines) ____

CA14. Check AG2: Child aged under 3?

CA15. The last time (name) passed stools, how were the stools disposed of?

Immunization: IM

If a health booklet/ immunization card is available, copy the dates in IM3 for each type of immunization recorded in the booklet/card. IM6-IM16 are for registering the vaccinations that are not recorded in the booklet/on the card. IM6-IM16 will only be asked when a card is not available.

IM1. Do you have a health booklet/vaccination card immunisations (name) received are recorded?

(If yes) May I see it please?

IM2. Did you ever have a health booklet/vaccination card for (name)?

IM3. Date of Immunization

BCG

Polio 1

Polio 2

Polio 3

Polio 4

Di-Te-Per1

Di-Te-Per2

Di-Te-Per3

Di-Te-Per4

HepB1 at birth

HepB2

HepB3

Hib1

Hib2

Hib3

Hib4 (only for RS and BD)

Mo-Ru-Pa (MMR)

IM4. Check IM3. Have all vaccines (BCG to MMR)been recorded?

IM5. In addition to what is recorded in this book/on this card, did (name) receive any other vaccinations?

Record 'Yes' only if respondent mentions vaccines listed in the table above.

IM6. Has (name) ever received any vaccinations to prevent him/her from contracting diseases?

IM7. Has (name) ever received a BCG vaccination against tuberculosis - that is, an injection in the arm or shoulder that usually causes a scar?

IM8. Has (name) ever received any "vaccination drops in the mouth" or injection to protect him/her from getting child paralysis (polio)?

IM10. How many times was the vaccine against child paralysis (polio) received?

IM11. Has (name) ever received a DPT vaccination - that is, an injection in the thigh or arm (shoulder) - to prevent him/her from getting tetanus, whooping cough, or diphtheria?

Probe by indicating that DPT vaccination is sometimes given at the same time as the polio vaccination

IM12. How many times was a DPT vaccine received?

IM13. Has (name) ever been given a Hepatitis B (infectious jaundice) vaccination - that is, an injection in the thigh or arm (shoulder) - to prevent him/her from getting Hepatitis B (infectious jaundice)?

Probe by indicating that the Hepatitis B vaccine is sometimes given at the same time as Polio and DPT vaccines

IM14. Was the first Hepatitis B (infectious jaundice) vaccine received within 24 hours after birth, or later?

IM15. How many times was a hepatitis B (infectious jaundice) vaccine received?

IM15A. Has (name) ever been given two vaccinations at the same time, - that is, two injections in the arm (shoulder) or one in the thigh and one in the arm (shoulder) - to prevent him/her from getting Haemophilus influenzae type B (Hib)?

IM15B. How many times was a Haemophilus influenza (Hib) vaccine received?

IM16. Has (name) ever received an MMR (Mo-Ru-Pa) injection - that is, a shot in the arm at the age of 12 months or older - to prevent him/her from getting measles, rubella or mumps?

UF13. Record the time.

UF14. Is the respondent the mother or caretaker of another child age 0-4 living in this household?

[] Yes [Indicate to the respondent that you will need to measure the weight and height of the child later. Go to the next questionnaire for children under five to be completed with the same respondent]
[] No [End the interview with this respondent by thanking them for their cooperation and tell them that you will need to measure the weight and height of the child]

Check to see if there are other woman's, man's or under-5 questionnaires to be administered in this household.

Move to another woman's, man's or under-5 questionnaire, or start making arrangements for anthropometric measurements of all children under 5 in the household.

Anthropometry: AN

After questionnaires for all children are complete, the measurer has to weigh and measure the length/height of each child.
Record weight and length/height in the questionnaire below, ensuring that you record the measurements on the correct questionnaire for each child. Check the child's name and line number on the household member listing form before recording the measurements.

AN1. Measurer's name and number:

AN2. Result of height / length and weight measurement

AN3. Child's weight

AN4. Child's length or height

Check age of child in AG2:

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

AN6. Is there another child in the household who is eligible for measurement?

End the interview with this household by thanking everyone for their cooperation. Collate all the questionnaires for this household and check that all the ID numbers have been recorded in the information panel on every questionnaire. On the household questionnaire, recoed the total number of completed women?s, men?s, and under-5 questionnaires.

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________