[Brcko Dostrict 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) 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 code
Name ____ _ _

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

Repeat greeting if not already read to this respondent:
We are from department of health and other services of the government of the Brcko district of Bosnia and Herzegovina. 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.

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. Control carried out by (name and number)

UF11. Data entry operator (name and number):

UF12. Record the interview start 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, 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 'none' enter' 0'. If '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 a 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 that apply.

[A] Read books to (name) 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 or yard?

[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, is (name) able to 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 item 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?

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 powdered or fresh animal milk?

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

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

BF10. Did (name) drink or eat 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 for 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 while he/she had 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 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 "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 continuing with 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. At any time in 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 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 place.
(Name of place) ____

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 brand name(s) of all medicines mentioned.
(Names of medicines) ____

CA14. Check AG2: Child aged under 3?
CA15. The last time (name) passed stools, what was done to dispose of the stools?

Immunization: IM

If a health booklet/ immunization card is available, copy the dates in IM3 for each type of immunization recorded in the booklet/on the card. IM6-IM16 are for registering 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

(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.

BCG

Polio 1

Polio 2

Polio 3

Polio 4

Di-Te-Per 1

Di-Te-Per 2

Di-Te-Per 3

Di-Te-Per 4

HepB1 at birth

HepB2

HepB3

Hib 1

Hib 2

Hib 3

Hib 4 (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 shown 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 the Haemophilus influenzae type B (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 interview end 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 administered to the same respondent]
[] No [End the interview with this respondent by thanking him/her for his/her cooperation and tell her/him 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.

Anthropometric data: AN

After questionnaires for all children are complete, the measurer weighs 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, record the total number of completed women?s, men?s and under-5 questionnaires.

Interviewer's observations ________

Controller?s observations ________

Supervisor's observations ________



Possession of documents questionnaire form: PD

PD1. Cluster number: _ _ _

PD2. Household number: _ _

PD3. Name of respondent:
Name ____

PD4. Line number of respondent: _ _

PD5. Interviewer name and number
Name ____ _ _

PD6. Day / month / year of interview _ _ / _ _ / _ _ _ _

Repeat greeting if not already read to this respondent:
We are from the Ministry for Human rights and refugees of Bosnia and Herzegovina. We are conducting a survey concerned with family health and education. I would like to talk to you about government issued documents that household members possess. This will take about 15 minutes. All the information we obtain will remain strictly confidential
.
If greeting has already been read to this person, then read the following:
Now I would like to talk to you more about government issued documents that household members possess. This will take about 15 minutes. Again, all the information you give me will remain strictly confidential.

May I start now?

PD7. Result of interview for possession of documents
PD8. Control carried out by (name and code)

PD9. Data entry operator (name and number):

PD10. Record the interview start time.

Possession of documents: PD

This module has to be administered to the respondent of the Household Questionnaire or another knowledgeable adult.

PD11. Check the Household Listing Form in the Household Questionnaire and record the following here:
PD12. Do all household members aged 18 and above have a unique ID number recorded in the UIN records in BiH?

PD13. How many household members aged 18 and above have a unique ID number recorded in the UIN records in BiH?

PD14. Check PD11[A] for number of household members younger than 18, if:
PD15. Do all households members younger than 18 years have a unique ID number recorded in the UIN records in BiH?

PD16. How many household members younger than 18 have a unique ID number recorded in the UIN records in BiH?

PD17. Do all households members aged 18 and above have an ID card for BiH citizens (valid for 10 years)?

PD18. How many household members aged 18 and above have an ID card for BiH citizens (valid for 10 years)?

PD19. Do all households members aged 18 and above have a BiH ID card for aliens?

PD20. How many household members aged 18 and above have a BiH ID card for aliens?

PD21. Do all households members aged 18 and above have ID card for BiH citizens - for displaced persons (valid for 2 years)?

PD22. How many household members aged 18 and above have ID card for BiH citizens - for displaced persons (valid for 2 years)?

PD23. Do all households members aged 18 and above have an official decision on DP status?

PD24. How many household members aged 18 and above have an official decision on DP status?

PD25. Do all households members aged 18 and above have an identification document for displaced persons?

PD26. How many household members aged 18 and above have an identification document for displaced persons?

PD27. Do all households members aged 18 and above have a BiH passport?

PD28. How many household members aged 18 and above have BiH passport?

PD29. Check PD11[A] for number of household members younger than 18, if:
PD30. Do all households members younger than 18 years have a BiH passport?

PD31. How many household members younger than 18 years have BiH passport?

PD32. Do any households members ages 18 and above have a passport from another country?

PD33. How many household members aged 18 and above have a passport from another country?

PD34. Check PD11[A] for number of household members younger than 18, if:
PD35. Do any households members younger than 18 years have a passport from another country?

PD36. How many household members younger than 18 years have a passport from another country?

PD37. Check PD12, if:
PD38. Do any households members aged 18 and above have a refugee card (issues in BiH)?

PD39. How many household members aged 18 and above have a refugee card (issues in BiH)?

PD40. Do any households members aged 18 and above have an international protection seeker card?

PD41. How many household members aged 18 and above have an international protection seeker card?

PD42. Do any households members aged 18 and above have confirmation of identity for stateless persons?

PD43. How many household members aged 18 and above have confirmation of identity for stateless persons?

PD44. Check PD11[C] for number of household members younger than 18, if:
PD45. Do all households members aged 50 and above have health insurance?

PD46. How many household members aged 50 and above have health insurance?

PD47. Do all households members aged 50 and above possess a health booklet?

PD48. How many household members aged 50 and above possess a health booklet?

PD49. Check PD11[C] and PD48 for number of household members younger than 18, if:
PD50. Are all household members aged 50 and above provided with health care services at the nearest health centre free of charge?

PD51. Are all household members aged 50 and above provided with health care services at the nearest hospital free of charge?

PD52. Record the interview start time.

Drug use questionnaire form: DU

This module has to be administered to the respondent of the Household Questionnaire or another knowledgeable adult.

DU1. Cluster number: _ _ _

DU2. Household number: _ _

DU5. Interviewer name and code
Name ____ _ _

DU6. Day / month / year of interview _ _ / _ _ / _ _ _ _

DU5. Is respondent:
DU6. Woman's line number: _ _

DU7. Man's line number: _ _

DU8. Check WB7 / MWB7 in the Women?s / Men?s questionnaire for this respondent:
DU9. Result of completion of form
Completed by interviewer
DU10. Result of completion of form
Completed by field editor
DU11. Control carried out by (name and number):
Name ____ _ _

DU12. Data entry operator (name and number):
Name ____ _ _

Drug use (self-administered): DU

Now we would like to ask you for information on the use of narcotic substances. again, all the information we obtain will remain strictly confidential. Please complete the following form and return it to the interviewer in the envelope provided to you.

DU13. Have you ever used any drugs (narcotic substances) in your life?
Circle only one code and follow the instructions.
DU14. When did you last take any of the following substances / drugs?
Circle only one code for each row.
Thank you for taking the time to answer these questions. Please place the completed form in the envelope provided to you and return the sealed envelope to the interviewer.