Name and year of survey


Under-five child information panel: UF

UF1. Cluster number: _ _ _

UF2. Household 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
UF8. Record the time:

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?

UF10A. Hello, my name is (your name). We are from Fiji Bureau. 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 30 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 number 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?

UF17. Result of interview for children under 5
Under-five's background: UB

UB0. Before I begin the interview, could you please bring (name)'s Birth Certificate, National Child Immunisation Record, and any immunisation record from a private health provider? We will need to refer to those documents.

UB1. On what day, month and year was (name) born?

UB2. How old is (name)?

UB3. Check UB2: Child's age?
UB4. Check the respondent's line number (UF4) and the respondent to the household questionnaire (HH47):
UB5. Check ED10 in the education module in the household questionnaire: Is the child attending ECE in the current school year?
UB6. Has (name) ever attended any early childhood education programme, such as Kindergarten?

UB7. At any time since [insert month of beginning of school year], did (he/she) attend (programmes mentioned in UB6)?

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?

UB9. Is (name) covered by any health insurance?

UB10. What type of health insurance is (name) covered by?

Birth registration: BR

BR1. Does (name) have a birth certificate?

BR2. Has (name)'s birth been registered with [the civil authorities]?

BR3. Do you know how to register (name)'s birth?

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.
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, 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'.

EC4. Check UB2: Child's age?
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] Read books or looked at picture books with (name)?

[B] Told stories to (name)?

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

[D] Took (name) outside the home?

[E] Played with (name)?

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

EC21. I would like to ask you about certain things (name) is currently able to do. Please keep in mind that children can develop and learn at a different pace. For example, some start talking earlier than others, or they might already say some words but not yet form sentences. So, it is fine if your child is not able to do all the things I am going to ask about. You can let me know if you have any doubts about what answer to give.
Can (name) walk on an uneven surface, for example a dumpy or steep road, without falling?

EC22. Can (name) jump up with both feet leaving the ground?

EC23. Can (name) dress (him/herself), that is, put on pants and a shirt without help?

EC24. Can (name) fasten and unfasten buttons without help?

EC25. Can (name) say 10 or more words like "mama" or "ball"?

EC26. Can (name) speak using sentences of 3 or more words that go together, for example " I want water" or "The house is big"?

EC27. Can (name) speak using sentences of 5 or more words that go together, for example "The house is very big"?

EC28. Can (name) correctly use any of the words "I," "you," "she," or "he," for example "I want water," or "He eats rice"?

EC29. If you show (name) an object (he/she) knows well, such as a cup or animal, can(he/she) consistently name it?
Prob: By consistently I mean that (he/she) uses the word to refer to the object, even if the word used not fully correct.

EC30. Can (name) recognise at least 5 letters of the alphabet?

EC31. Can (name) write (his/her) own name?

EC32. Does (name) recognise all numbers from 1 to 5?

EC33. If you ask (name) to give you 3 objects, such as 3 stones or 3 spoon, does (he/she) give you the correct amount?

EC34. Can (name) count 10 objects, for example 10 fingers or 10 blocks, without mistakes?

EC35. Can (name) do an activity, such as coloring or playing with ?lego? blocks without repeatedly asking for help or giving up too quickly?

EC36. Can (name) ask about familiar people other than parents when they are not there, for example "Where is Babu or Nani"?

EC37. Does (name) offer to help someone who seems to need help?

EC38. Does (name) get along well with other children?

EC39. The next two questions have five different options for answers. I am going to read theses to you after each the question?
How often does (name) seem to be very sad or depressed?
Would you say: daily, weekly, monthly, a few times a year or never?

EC40. 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?

Child discipline: UCD

UCD1. Check UB2: Child's age?
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.

[B] Explained why (name)'s behavior was wrong.

[C] Shook (him/her).

[D] Shouted, yelled at or screamed at (him/her).

[E] Gave (him/her) something else to do.

[F] Spanked, hit or slapped (him/her) on the bottom with bare hand.

[G] Hit (him/her) on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.

[H] Called (him/her) dumb, lazy or another name like that.

[I] Hit or slapped (him/her) on the face, head or ears.

[J] Hit or slapped (him/her) on the hand, arm, or leg.

[K] Beat (him/her) up, that is hit (him/her) over and over as hard as one could.

[L] Flick the ear

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?
UCD4. Check UF4: Has this respondent already responded to the following question (UCD5 or FCD5) for another child?
UCD5. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?

Child functioning: UCF

UCF1. Check UB2: Child's age?
UCF2. I would like to ask you some questions about difficulties (name) may have.
Does (name) wear glasses?

UCF3. Does (name) use a hearing aid?

UCF4. Does (name) use any equipment or receive assistance for walking?

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?
UCF7A. When wearing (his/her) glasses, does (name) have difficulty seeing?
UCF7B. Does (name) have difficulty seeing?

UCF8. Check UCF3: Child uses a hearing aid?
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?

UCF10. Check UCF4: Child uses equipment or receives assistance for walking?
UCF11. Without (his/her) equipment or assistance, does (name) have difficulty walking?

UCF12. With (his/her) equipment or assistance, does (name) have difficulty walking?

UCF13. Compared with children of the same age, does (name) have difficulty walking?

UCF14. Compared with children of the same age, does (name) have difficulty picking up small objects with (his/her) hand?

UCF15. Does (name) have difficulty understanding you?

UCF16. When (name) speaks, do you have difficulty understanding (him/her)?

UCF17. Compared with children of the same age, does (name) have difficulty learning things?

UCF18. Compared with children of the same age, does (name) have difficulty playing?

Breastfeeding and dietary intake: BD

BD1. Check UB2: Child's age?
BD2. Has (name) ever been breastfed?

BD3. Is (name) still being breastfed?

BD3A. Check UB2: Child's age?
BD4. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?

BD5. Did (name) drink Oral Rehydration Salt solution (ORS) yesterday, during the day or night?

BD6. Did (name) drink or eat vitamin or mineral supplements or any medicines yesterday, during the day or night?

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:

[A] Plain water?

[B] Juice or juice drinks?

[B1] 100% real juice made from mango, papaya or carrots?

[B2] 100% real juice made from any other fruits or vegetables such as sugar cane, oranges or pineapple?

[B3] Any packaged sweet-testing drink such as Frooti, Tang, Real, or any similar packaged sweet tasting juice drink?

[C] [Local name for clear broth/clear soup]?

[D] Infant formula, such as S26, or LACTOGEN or SMA?

[D1] How many times did (name) drink infant formula?

[E] Milk from animals, such as fresh, tinned, or powdered milk?

[E1] How many times did (name) drink milk?

[E2] Soya milk or almond milk?

[X] Any other liquids?

[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?

[A1] How many times did (name) eat yogurt?

[B] Any baby food, such as Heinz, Cerelac or Farex?

[C] Bread, rice, noodles, porridge, or other foods made from grains?

[D] Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?

[E] White potatoes or kumala, white yams or dalo, cassava, or any other foods made from roots?

[F] Any dark green, leafy vegetables, such as island cabbage, bok choy, rourou, broccoli, bele, tubua, bhaji?

[G] Ripe mangoes or ripe papayas?

[H] Any other fruits or vegetables, such as oranges, pineapples, water melon, bananas, coconuts and guava?

[I] Liver, kidney, heart or other organ meats?

[J] Any other meat, such as beef, pork, lamb, goat, chicken, duck or sausages made from these meats?

[K] Eggs?

[L] Fish or shellfish, , prawns, crabs, lobsters, octopus, either fresh or dried?

[M] Beans, peas, lentils or any foods made from theses such as pulses or daal elc, as well as nuts like peanuts, walnuts, chestnuts and almond, including any foods made from these?

[N] Cheese or other food made from animal milk?

[P] Vegetable Pakora?

[X] Other solid, semi-solid, or soft food?

[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?

Immunisation: IM

IM1. Check UB2: Child's age?
IM2. Do you have a Clinic Card ( Fiji Child Health Record), or immunisation records from a private health provider or any other document where (name)'s vaccinations are written down?

IM3. Did you ever have a Clinic Card/ Fiji Child Health Record or immunisation records from a private health provider for (name)?

IM4. Check IM2:
IM5. May I see the card(s) (and/or) other document?

IM6.

(a) Copy dates for each vaccination from the documents.
(b) Write '44' in day column if documents show that vaccination was given but no date recorded

HepB (at birth)

BCG ( at bith)

DTO-HepB-Hib1 ( at 6 weeks)

(OPV) 1 (at 6 weeks )

Pneumococcal 1( at 6 weeks)

Rotavirus 1( at 6 weeks)

Rotavirus 2

Rotavirus 3

DTO-HepB-Hib2 ( at 10 weeks)

(OPV) 2 (at 10 weeks )

Pneumococcal 2( at 10 weeks)

DTO-HepB-Hib3 ( at 14 weeks)

(OPV) 3 (at 14 weeks )

Pneumococcal 3 ( at 14 weeks)

Rotavirus 2

IPV ( at 14 weeks)

IM7. Check IM6: Are all vaccines (BCG to Td Booster) recorded?

IM8. Did (name) participate in any of the following campaigns, national immunisation days or child health days:
[A] 14 May- 30 October 2018/National Meningococcal (Men C) Immunization Campaign, Neisnvac

[B] April 2019-2020 Measles Campaign, MR

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 National Meningococcal (Men C), Immunization program/ Measles and Rubella Immunization Campaign just?

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 National Meningococcal (Men C), Immunization program/ Measles and Rubella Immunization Campaign just?

IM12. Did (name) participate in any of the following campaigns, national immunisation days or child health days:
[A] 14 May- 30 October 2018/National Meningococcal (Men C) Immunization Campaign, Neisnvac

[B] April 2019-2020 Measles Campaign, MR

IM13. Check IM11 and IM12:

IM14. Has (name) ever received a BCG vaccination against tuberculosis - that is, an injection in the arm or shoulder that usually causes a scar?

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?

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 the age of 6 weeks.
IM17. Were the first polio drops received in the age of 6 weeks or order?

IM18. How many times were the polio drops received?

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.
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.
IM21. How many times was the Pentavalent vaccine received?

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.
IM23. How many times was the Pneumococcal vaccine received?

IM24. Has (name) ever received a rotavirus vaccination - that is, liquid in the mouth to prevent diarrhea?
Probe by indicating that rotavirus vaccination is sometimes given at the same time as the Pentavalent vaccination.
IM25. How many times was the rotavirus vaccine received?

IM26. Has (name) ever received a MMR/MR vaccine - that is, a shot in the arm at the age of 12 months or older - to prevent (him/her) from getting measles, mumps and rubella?

IM26A. How many times was the MMR/MR vaccine received?

IM28. Issue a questionnaire form for vaccination records at health facility for this child. Complete the Information Panel on that Questionnaire

Care of illness: CA

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

CA2. Check BD3: Is child still breastfeeding?
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?
If 'less', probe: Was (he/she) given much less than usual to drink, or somewhat less?
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?
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?
CA5. Did you seek any advice or treatment for the diarrhoea from any source?

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) ____

CA7. During the time (name) had diarrhoea, was (he/she) given:

[A] A fluid made from a special packet called ORS packet solution?

[C] Zinc tablets?

[D] ORS homemade fluid made with coconut juice?

[E] ORS homemade fluid made with warm water, salt and sugar?

CA8. Check CA7[A] and CA7[B]: Was child given any ORS?
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) ____

CA10. Check CA7[C]: Was child given any zinc?
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) ____

CA12. Was anything else given to treat the diarrhoea?

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) ____

CA14. At any time in the last two weeks, has (name) been ill with a fever?

CA16. At any time in the last two weeks, has (name) had an illness with a cough?

CA17. At any time in the last two weeks, has (name) had fast, short, rapid breaths or difficulty breathing?

CA18. Was the fast or difficult breathing due to a problem in the chest or a blocked or runny nose?

CA19. Check CA14: Did child have fever?
CA20. Did you seek any advice or treatment for the illness from any source?

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) ____

CA22. At any time during the illness, was (name) given any medicine for the illness?

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) ____

CA24. Check CA23: Antibiotics mentioned
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) ____

CA30. Check UB2: Child's age?
CA31. The last time (name) passed stools, what was done to dispose of the stools?

UF11. Record the time.
UF12. Language of the Questionnaire.
UF13. Language of the Interview.
UF14. Native language of the Respondent.
UF15. Was a translator used for any parts of this questionnaire?
MICS plus consent

UF20. Check HH60: Was consent for MICS plus previously asked from this respondent?
UF21. Was consent for MICS plus previously asked from this respondent in any questionnaire ( WQ, MQ or 5-17Q)
UF22.We would like to continue to talk about you and your family over the next 11 months. We wish to call you on the phone every month for 10-15 minutes. Again, all the information you provide will be confidential and anonymous. Would you like to participate?

UF23. Please give me all phone numbers at which we can easily get in touch with you, starting with your preferred number.

UF24. Order

UF25. Telephone number

UF25A. Is this landline or mobile?

UF25B. Who does this phone belong to?

UF26. Is there any preferred or more convenient time of the day we could call you on this number?

UF27. Do you have another phone number?

AN1. Cluster number: _ _ _

Interviewer's observations ________

Supervisor's observations ________

Anthropometry module information panel: AN

AN1. Cluster number: _ _ _

AN2. Household number _ _

AN3. Child's name and line number:
AN4. Child's age from UB2:
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.
AN9. Was the child undressed to the minimum?
AN10. Check AN4: Child's age?
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.
AN12. How was the child actually measured? Lying down or standing up?
AN13.Day/month/year of measumrment:
AN14. Is there another child under age 5 in the household who has not yet been measured?

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 ________

Measurer's observations for anthropometry module ________

Supervisor's observations for anthropometry module ________