Mics Questionnaire for Children Under Five
Under-five child information panel: UF
UF1. Consulting room number: _ _ _
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 the Ministerio de Salud Publica (MSP) [Lit. Ministry of Public Health]. 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 35 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 35 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) ID and vaccination card? We will need to refer to those documents.
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 1 to 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 end)
UB6. Has (name) ever attended any early childhood education programme, such as Círculo Infantil [lit. Child's Circle, a public institution specializing in children's education during their early infancy], Jardín Infantil [lit. Child's Garden, similar to the previous one], Casita Infantil [lit Child's Little House, a kind of nursery], preschool, or Educa a tu hijo program [Lit. Educate your child Program, similar to homeschooling]?
[] 2 No (Go to end)
UB7. At any time since [insert month of beginning of school year], did (he/she) attend (programmes mentioned in UB6)?
[] 2 No (Go to end)
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 (Go to end)
UB8C. Which program has (name) attended??
[] 2 Child's garden
[] 3 Child's little house
[] 4 Preschool or jr. elementary
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 civil registry?
[] 2 No
[] 8 DK
BR3. Do you know how to register (name)'s birth?
[] 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) have difficulties concentrating or keeping their attention focused on activities or chores?
[] 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
Child functional capacity: UCF
[] 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 Oral Rehydration Salt solution (ORS) 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
[B1] 100% natural juice, made of mango, fruta bomba [papaya], or carrot?
[] 2 No
[] 8 DK
[B2] 100% natural juice, made of other fruit such as orange, guava, pineapple or cane juice?
[] 2 No
[] 8 DK
[B3] Any kind of packaged sweet drink or liquid, like soda, Tang, Piñata [similar to Tang], or any kind of preserved juice or sweet drink?
[] 2 No
[] 8 DK
[C] [Local name for clear broth/clear soup]?
[] 2 No
[] 8 DK
[D] Infant formula, such as [insert popular brands]?
[] 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[X])
[] 8 DK (Go to BD7[X])
[E1] How many times did (name) drink milk?
Number of times drank milk _
[] 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 [insert brand name of commercially fortified baby food, e.g. Cerelac, Gerber, Hero or Nestum]?
[] 2 No
[] 8 DK
[C] Bread, rice, crackers, wheat, corn, oats, chicoticos [similar to crisps], spaghetti, maccaroni, noodles, cereals 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] Swiss chard, watercress, spinach or any vegetable dark green leafy leaves?
[] 2 No
[] 8 DK
[G] Ripe mangoes or ripe papayas or [insert locally available vitamin A-rich fruits]?
[] 2 No
[] 8 DK
[H] Some other fruit or vegetable, such as plantain of fruit or banana, guava, orange, mamey or sapote, soursop, custard apple, melon, tamarind or lettuce, cabbage, string beans, beets, tomatoes, avocado?
[] 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, chickpeas, peanuts, sesame, soy yogurt, including any food made from these?
[] 2 No
[] 8 DK
[N] Cheese or other food made from animal milk?
[] 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 National Child Immunisation Record, 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 National Child Immunisation Record 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
HB1 (1 month, mother HBsAG positive)
HB2 (2 months, mother HBsAG positive)
HB3 (12 months, mother HBsAG positive)
DTP + HB + HIB (2 months) DTPHIBHB1
DTP + HB + HIB (4 months) DTPHIBHB2
DTP + HB + HIB (6 months) DTPHIBHB3
DTP + HB + HIB BOOSTER (18 months) DTPHIBHB_R
DTP1 (2 months, mother + HBsAG) DTP1
DTP2 (4 months, mother + HBsAG) DTP2
DTP3 (6 months, mother + HBsAG) DTP3
HIB1 (2 months, mother + HBsAG) HIB1
HIB2 (4 months, mother + HBsAG) HIB2
HIB3 (6 months, mother + HBsAG) HIB3
IPV1 POLIO INACTIVE (4 months) IPV1
IPV2 POLIO INACTIVE (8 months) IPV2
POLIO 1 (Campaign 55 from 1 to 7-2-2016 1st stage) OPV1
POLIO 2 (Campaign 55 from 28-3 to 3-4-2016 2nd stage) OPV2
POLIO 3 (Campaign 56 from 20 to 26-2-2017 1st stage) OPV3
POLIO 4 (Campaign 56 from 17 to 23-4-2017 2nd stage) OPV4
POLIO 5 (Campaign 57 from 26-2 to 3-3-2018 1st stage) OPV5
POLIO 6 (Campaign 57 from 23 to 28-4-2018 2nd stage) OPV6
POLIO 7 (Campaign 58 from 25-2 to 2-3-2019 1st stage) OPV7
POLIO 8 (Campaign 58 from 22 to 27-4-2019 2nd stage) OPV8
INFLUENZA (ANTI-FLU)1 (newborns older than 6 months, up to children 1 year, 11 months and 29 days old) (Campaign from 28-7 to 30-9-2017. 1st dose) IA1
INFLUENZA (ANTI-FLU)2 (newborns older than 6 months, up to children 1 year, 11 months and 29 days old)(2nd dose is applied within 4 to 6 weeks) (Campaign from 28-7 to 30-9-2017) IA2
INFLUENZA (ANTI-FLU)3 (newborns older than 6 months, up to children 1 year, 11 months and 29 days old) (Campaign from 9-7 to 3-11-2018. 1st dose) IA3
INFLUENZA (ANTI-FLU)4 (newborns older than 6 months, up to children 1 year, 11 months and 29 days old) (2nd dose is applied within 4 to 6 weeks) (Campaign from 9-7 to 3-11-2018) IA4
IM7. Check IM6: Are all vaccines (BCG to Anti-Flu shot) recorded?
[] 2 No
IM8. Did (name) participate in any of the following campaigns, national immunisation days or child health days:
[A] Anti-Polio, Campaign 55 from 1 to 7-2-2016 / 1st stage
[] 2 No
[] 8 DK
[B] Anti-Polio, Campaign 55 from 28-3 to 3-4-2016 / 2nd stage
[] 2 No
[] 8 DK
[C] Anti-Polio, Campaign 56 from 20 to 26-2-2017 / 1st stage
[] 2 No
[] 8 DK
[D] Anti-Polio, Campaign 56 from 17 to 23-4-2017 / 2nd stage
[] 2 No
[] 8 DK
[E] Anti-Polio, Campaign 57 from 26-2 to 3-3-2018 / 1st stage
[] 2 No
[] 8 DK
[F] Anti-Polio, Campaign 57 from 23 to 28-4-2018 / 2nd stage
[] 2 No
[] 8 DK
[G] Anti-Polio, Campaign 58 from 25-2 to 2-3-2019 / 1st stage
[] 2 No
[] 8 DK
[H] Anti-Polio, Campaign 58 from 22 to 27-4-2019 / 2nd stage
[] 2 No
[] 8 DK
[I] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, Campaign from 28-7 to 30-9-2017 / 1st dose
[] 2 No
[] 8 DK
[J] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, 2nd dose is applied within 4 to 6 weeks, Campaign from 28-7 to 30-9-2017, / 2nd dose
[] 2 No
[] 8 DK
[K] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, Campaign from 9-7 to 3-11-2018 / 1st dose
[] 2 No
[] 8 DK
[L] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, 2nd dose is applied within 4 to 6 weeks, Campaign from 9-7 to 3-11-2018 / 2nd dose
[] 2 No
[] 8 DK
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
IM12. Did (name) participate in any of the following campaigns, national immunisation days or child health days:
[A] Anti-Polio, Campaign 55 from 1 to 7-2-2016 / 1st stage
[] 2 No
[] 8 DK
[B] Anti-Polio, Campaign 55 from 28-3 to 3-4-2016 / 2nd stage
[] 2 No
[] 8 DK
[C] Anti-Polio, Campaign 56 from 20 to 26-2-2017 / 1st stage
[] 2 No
[] 8 DK
[D] Anti-Polio, Campaign 56 from 17 to 23-4-2017 / 2nd stage
[] 2 No
[] 8 DK
[E] Anti-Polio, Campaign 57 from 26-2 to 3-3-2018 / 1st stage
[] 2 No
[] 8 DK
[F] Anti-Polio, Campaign 57 from 23 to 28-4-2018 / 2nd stage
[] 2 No
[] 8 DK
[G] Anti-Polio, Campaign 58 from 25-2 to 2-3-2019 / 1st stage
[] 2 No
[] 8 DK
[H] Anti-Polio, Campaign 58 from 22 to 27-4-2019 / 2nd stage
[] 2 No
[] 8 DK
[I] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, Campaign from 28-7 to 30-9-2017 / 1st dose
[] 2 No
[] 8 DK
[J] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, 2nd dose is applied within 4 to 6 weeks, Campaign from 28-7 to 30-9-2017, / 2nd dose
[] 2 No
[] 8 DK
[K] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, Campaign from 9-7 to 3-11-2018 / 1st dose
[] 2 No
[] 8 DK
[L] Anti-Flu Campaign, applied to newborns older than 6 months, up to children 1 year, 11 months and 29 days old, 2nd dose is applied within 4 to 6 weeks, Campaign from 9-7 to 3-11-2018 / 2nd dose
[] 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 (Go to IM16)
[] 8 DK (Go to IM16)
IM15A. How many times did (name) get the HepB shot?
Probe and indicate that the HepB shot is applied after birth to every child, then after the first month, second month, and after 12 months in children whose mothers were HepB positive.
[] 8 DK
IM16. Has (name) ever received any vaccination drops in the mouth to protect (him/her) from polio?
Probe by indicating that the first drop is usually given at birth and later at the same time as injections to prevent other diseases.
[] 2 No (Go to IM19)
[] 8 DK (Go to IM19)
IM18. How many times were the polio drops received?
[] 8 DK
IM19. Has name received an injected vaccine to prevent Polio (IPV inactive Polio)?
Probe and indicate that the IPV shot is applied at 4 months of age, and since April, 2018, at 8 months of age.
[] 2 No (Go to IM20)
[] 8 DK (Go to IM20)
IM19A. How many times did (name) get the IPV shot?
[] 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 and indicate that the Pentavalent Vaccine is applied at 2, 4 and 6 months of age. Since April 2018, a booster shot is applied at 18 months of age to children whose mothers tested negative for HepB.
[] 2 No (Go to IM26)
[] 8 DK (Go to IM26)
IM21. How many times was the Pentavalent vaccine received?
[] 8 DK
IM26. Has (name) received a PRS vaccine; that is, a shot applied to the arm at 12 months of age to prevent measles, mumps and rubella?
[] 2 No
[] 8 DK
IM29. Did (name) ever had a Hib shot; that is, an injection in the thigh to prevent meningitis and pneumonia caused by Type-B Haemophilus Influenzae?
Probe and indicate that the Hib shot is applied at 2,4 and 6 months of age, and a booster shot at 18 months for children whose mother tested positive for Hep B..
[] 2 No (Go to IM31)
[] 8 DK (Go to IM31)
IM30. How many times did (name) get the Hib shot?
[] 8 DK
IM31. Did (name) ever get the DTP shot; that is, an injection in the thigh to prevent difteria, whooping cough, and tetanus?
Probe and indicate that the DTP shot is applied at 2,4 and 6 months of age, and a booster shot at 18 months for children whose mother tested positive for Hep B..
[] 2 No (Go to IM33)
[] 8 DK (Go to IM33)
IM32. How many times did (name) get the DPT shot?
[] 8 DK
IM33. Did (name) ever get the AM-BC shot; that is, an injection in the thigh to prevent Meningococcus B and C?
Probe and indicate that the AM-BC shot is applied at 3 and 5 months of age.
[] 2 No (Go to IM35)
[] 8 DK (Go to IM35)
IM34. How many times did (name) get the AM-BC shot?
[] 8 DK
IM35. Did (name) ever get the Anti-Flu shot; that is, an injection in the arm or thigh to prevent the flu or seasonal influenzae?
Probe and indicate that the Anti-Flu shot is applied in campaigns two times a year.
[] 2 No (Go to end)
[] 8 DK (Go to end)
IM36. How many times did (name) get the anti-flu shot?
[] 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 Polyclinic
[] C Family medic
[] D Relative/neighbor/friend medic
[] E Relative/neighbor/friend nurse
[] H Other medic (specify) ____
Other source
[] Q Shop/market/street
[] R Healer
CA7. 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
[] 8 DK
[B] A pre-packaged ORS fluid called [insert local name for pre-packaged ORS fluid]?
[] 2 No
[] 8 DK
[] 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 Polyclinic
[] C Family medic
[] D Relative/neighbor/friend medic
[] E Relative/neighbor/friend nurse
[] H Other medic (specify) ____
Other source
[] Q Shop/market/street
[] R Healer
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 Polyclinic
[] C Family medic
[] D Relative/neighbor/friend medic
[] E Relative/neighbor/friend nurse
[] H Other medic (specify) ____
Other source
[] Q Shop/market/street
[] R Healer
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 Polyclinic
[] C Family medic
[] D Relative/neighbor/friend medic
[] E Relative/neighbor/friend nurse
[] H Other medic (specify) ____
Other source
[] Q Shop/market/street
[] R Healer
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
[] P Azitromicin
[] 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 Polyclinic
[] C Family medic
[] D Relative/neighbor/friend medic
[] E Relative/neighbor/friend nurse
[] H Other medic (specify) ____
Other source
[] Q Shop/market/street
[] R Healer
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
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 ________