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 Instituto Nacional de EstadÃstica y Censos (INEC) [lit. National Institute for Statistics and Censuses]. 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 15 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 15 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 (provided by the Registro Civil [lit. Civil Registry]) and vaccination card from (name's) Seguro Social [lit. Social Insurance].
UB1. On what day, month and year was (name) born?
Date of birth
[] 98 DK day
_ _ Month
201 _ Year
Age (in completed years) _
[] 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 UB6)
UB5. Check ED10 in the education module in the household questionnaire: Is the child attending ECE in the current school year?
[] 2 No, ED10 does not equal 0 or blank (Go to UB9)
UB6. Has (name) ever attended any early childhood education programme, such as such as Interactivo [lit. Interactive, an early childhood education program], Transición [lit. transition, a preschool program], or Preparatoria [High School]?
[] 2 No (Go to UB9)
UB7. At any time since [insert month of beginning of school year], did (he/she) attend (programmes mentioned in UB6)?
[] 2 No (Go to UB9)
UB8A. Does (he/she) currently attend (programmes mentioned in UB6)?
UB8B. You have mentioned that (name) has attended an early childhood education programme this school year. Does (he/she) currently attend this programme?
[] 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?
[] B Health insurance through employer
[] C Social security
[] D Other privately purchased commercial health insurance
[] X Other (specify) ____
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
[D] Electronic devices such as tablets or smartphones?
[] 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
[] 2 Age 2 (Go to end of module)
BD4. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?
[] 2 No
[] 8 DK
BD5. Did (name) drink Suero Oral [lit. Oral Serum/ Oral Rehydration Solution] yesterday, during the day or night?
[] 2 No
[] 8 DK
BD6. Did (name) drink or eat vitamin or mineral supplements or any medicines yesterday, during the day or night?
[] 2 No
[] 8 DK
BD7. Now I would like to ask you about all other liquids that (name) may have had yesterday during the day or the night.
Please include liquids consumed outside of your home.
Did (name) drink (name of item) yesterday during the day or the night:
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[C] Caldo liviano (solo el caldo, sin arroz, fideos u otra cosa) [lit. Clear soup (just the broth, no rice, noodles, or other)]?
[] 2 No
[] 8 DK
[D] Infant formula, such as Nan, Nido, Efamil?
[] 2 No (Go to BD7[E])
[] 8 DK (Go to BD7[E])
[D1] How many times did (name) drink infant formula?
Number of times drank infant formula _
[E] Milk from animals, such as fresh, tinned, or powdered milk?
[] 2 No (Go to BD7[O])
[] 8 DK (Go to BD7[O)
[E1] How many times did (name) drink milk?
Number of times drank milk _
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No (Go to BD7[E])
[] 8 DK (Go to BD7[E])
[X1] Record all other liquids mentioned.
BD8. Now I would like to ask you about everything that (name) ate yesterday during the day or the night. Please include foods consumed outside of your home.
Think about when (name) woke up yesterday. Did (he/she) eat anything at that time?
If 'Yes' ask: Please tell me everything (name) ate at that time. Probe: Anything else?
Record answers using the food groups below.
What did (name) do after that? Did (he/she) eat anything at that time?
Repeat this string of questions, recording in the food groups, until the respondent tells you that the child went to sleep until the next morning. For each food group not mentioned after completing the above ask: Just to make sure, did (name) eat (food group items) yesterday during the day or the night.
[A] Yogurt made from animal milk?
[] 1 Yes
[] 2 No (Go to BD8[B])
[] 8 DK (Go to BD8[B])
[A1] How many times did (name) eat yogurt?
Number of times ate yogurt _
[B] Any baby food, such as Cerelac, Nestum or Nutrivida?
[] 2 No
[] 8 DK
[C] Bread, rice, noodles, porridge, or other foods made from grains?
[] 2 No
[] 8 DK
[D] Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?
[] 2 No
[] 8 DK
[E] White potatoes, white yams, cassava, or any other foods made from roots?
[] 2 No
[] 8 DK
[F] Any dark green, leafy vegetables, such as Spinach, Watercress or Broccoli?
[] 2 No
[] 8 DK
[G] Ripe mangoes or ripe papayas or [insert locally available vitamin A-rich fruits]?
[] 2 No
[] 8 DK
[H] Any other fruits or vegetables, such as banana, apple, plantain, tomato, onion?
[] 2 No
[] 8 DK
[I] Liver, kidney, heart or other organ meats?
[] 2 No
[] 8 DK
[J] Any other meat, such as beef, pork, lamb, goat, chicken, duck or sausages made from these meats?
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[L] Fish or shellfish, either fresh or dried?
[] 2 No
[] 8 DK
[M] Beans, peas, lentils or nuts, including any foods made from these?
[] 2 No
[] 8 DK
[N] Cheese or other food made from animal milk?
[] 2 No
[] 8 DK
[O] Gallo pinto? [a traditional Central-American dish which basically consists of rice and beans]
If yes: What was in the rice and beans?
Probe: Was there anything else in the dish?
Name additional ingredients mentioned previously until the interviewee determines that there was not anything else in the dish
If the interviewee mentions rice, record "Yes" for BD8[C]
If the interviewee mentions beans, record "Yes" for BD8[M]
If the interviewee mentions any other vegetable, or eggs, sausages, cheese or cream, record "Yes" for BD8[K], BD8[N], BD8[J], BD8[H], respectively?
[] 2 No
[] 8 DK
[X] Other solid, semi-solid, or soft food?
[] 2 No (Go to BD9)
[] 8 DK (Go to BD9)
[X1] Record all other solid, semi-solid, or soft food that do not fit food groups above.
BD9. How many times did (name) eat any solid, semi-solid or soft foods yesterday during the day or night?
_ Number of times
[] 8 DK
[] 2 Age 3 or 4 (Go to end)
IM2. Do you have a Vaccination Book, immunisation records from a private health provider or any other document where (name)'s vaccinations are written down?
[] 2 Yes, has only other document
[] 3 Yes, has card(s) and other document (Go to IM5)
[] 4 No, has no cards and no other document
IM3. Did you ever have a Vaccination Book or immunisation records from a private health provider for (name)?
[] 2 No
[] 2 Has no cards and no other document available, IM2=4 (Go to IM11)
IM5. May I see the card(s) (and/or) other document?
[] 2 Yes, only other document seen
[] 3 Yes, card(s) and other document seen
[] 4 No cards and no other document seen (Go to IM11)
IM6.
(b) Write '44' in day column if documents show that vaccination was given but no date recorded
Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) (DTPHibHepB) 1
Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) (DTPHibHepB) 2
Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) (DTPHibHepB) 3
Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) (DTPHibHepB) 4
Inactivated Polio Vaccine, via Intramuscular Injection (IPV) 1
Inactivated Polio Vaccine, via Intramuscular Injection (IPV) 2
Inactivated Polio Vaccine, via Intramuscular Injection (IPV) 3
IM7. Check IM6: Are all vaccines (BCG to Td Booster) recorded?
[] 2 No
IM9. In addition to what is recorded on the document(s) you have shown me, did (name) receive any other vaccinations including vaccinations received during the campaigns, immunisation days or child health days just mentioned?
[] 2 No (Go to end)
[] 8 DK (Go to end)
IM10. Go back to IM6 and probe for these vaccinations.
Record '66' in the corresponding day column for each vaccine received. For each vaccination not received record '00' in day column.
When finished, go to end of module. (Go to next module)
IM11. Has (name) ever received any vaccinations to prevent (him/her) from getting diseases, including vaccinations received in a campaign, immunisation day or child health day?
[] 2 No
[] 8 DK
[] 2 At least one yes
IM14. Has (name) ever received a BCG vaccination against tuberculosis - that is, an injection in the arm or shoulder that usually causes a scar?
[] 2 No
[] 8 DK
IM15. Did (name) receive a Hepatitis B vaccination - that is an injection on the outside of the thigh to prevent Hepatitis B disease - within the first 24 hours after birth?
[] 2 Yes, but not within 24 hours
[] 3 No
[] 8 DK
IM19. The last time (name) received the polio drops, did (he/she) also get an injection to protect against polio?
Probe to ensure that both were given, drops and injection.
[] 2 No
[] 8 DK
IM20. Has (name) ever received a Pentavalent vaccination - that is, an injection in the thigh to prevent (him/her) from getting tetanus, whooping cough, diphtheria, Hepatitis B disease, and Haemophilus influenzae type B?
Probe by indicating that Pentavalent vaccination is sometimes given at the same time as the polio drops.
[] 2 No (Go to IM22)
[] 8 DK (Go to IM22)
IM21. How many times was the Pentavalent vaccine received?
[] 8 DK
IM22. Has (name) ever received a Pneumococcal Conjugate vaccination - that is, an injection to prevent (him/her) from getting pneumococcal disease, including ear infections and meningitis caused by pneumococcus?
Probe by indicating that Pneumococcal Conjugate vaccination is sometimes given at the same time as the Pentavalent vaccination.
[] 2 No (Go to IM24)
[] 8 DK (Go to IM24)
IM23. How many times was the Pneumococcal vaccine received?
[] 8 DK
IM26. Has (name) ever received a MMR/MR vaccine - that is, a shot in the arm at the age of 9 months or older - to prevent (him/her) from getting measles, mumps and rubella?
[] 2 No (Go to end)
[] 8 DK (Go to end)
IM26A. How many times was the MMR/MR vaccine received?
[] 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 CA7)
[] 8 DK (Go to CA7)
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 CCSS clinic
[] C EBAIS [lit. BASIC EQUIPMENT FOR INTEGRAL HEALTH SERVICES, a health service provided by the government]
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] M Mobile clinic
[] O Other private medical (specify) ____
Other source
[] Q Shop/market/street
[] R Traditional practitioner
CA7. During the time (name) had diarrhoea, was (he/she) given:
[A] A fluid made from a special packet called CCSS Suero Oral?
[] 2 No
[] 8 DK
[B] A pre-packaged ORS fluid called Pedialyte?
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[D] Rice water, Pipe [Coconut] Water, Starch or other (for example, Chamomile)?
[] 2 No
[] 8 DK
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 CA10)
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 CCSS clinic
[] C EBAIS [lit. BASIC EQUIPMENT FOR INTEGRAL HEALTH SERVICES, a health service provided by the government]
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] M Mobile clinic
[] O Other private medical (specify) ____
Other source
[] Q Shop/market/street
[] R Traditional practitioner
[] Z DK/don't remember
CA10. Check CA7[C]: Was child given any zinc?
[] 2 No, Ca7[C] does not equal 1 (Go to CA12)
CA11. Where did you get the zinc?
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 CCSS clinic
[] C EBAIS [lit. BASIC EQUIPMENT FOR INTEGRAL HEALTH SERVICES, a health service provided by the government]
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] M Mobile clinic
[] 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 (Go to CA16)
[] 8 DK (Go to CA16)
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 CCSS clinic
[] C EBAIS [lit. BASIC EQUIPMENT FOR INTEGRAL HEALTH SERVICES, a health service provided by the government]
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] M Mobile clinic
[] 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 CCSS clinic
[] C EBAIS [lit. BASIC EQUIPMENT FOR INTEGRAL HEALTH SERVICES, a health service provided by the government]
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public medical (specify) ____
[] J Private physician
[] K Private pharmacy
[] M Mobile clinic
[] 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 end)
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
UF12. Language of the Questionnaire.
UF13. Language of the Interview.
[] 6 Other language (specify) ____
UF14. Native language of the Respondent.
[] 2 English
[] 3 Some indigenous language
[] 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
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 ________