Indonesia 2011

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).
A separate questionnaire should be used for each eligible child.

UF1. Cluster number: _ _ _

UF2. Household number: _ _

UF3. Child's name:
Name ____

UF4. Child's line number: _ _

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

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

UF7. Interviewer name and number
Name ____ _ _

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

Repeat greeting if not already read to this respondent:
We are from Local Government/BPS would like to talk to you about (name)'s health and well-being. The interview will take about 20 minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

If greeting at the beginning of the household questionnaire has already been read to this woman, 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 about 20 minutes. Again, all the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

May I start now?

UF9. Result of interview for children under 5
Codes refer to mother/caretaker.
UF10. Field edited by (name and number)

UF11. Data entry clerk (name and number):

UF12. Record the time.

Age: AG

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

BR1. Does (name) have a birth certificate?
If yes, ask: May I see it?

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

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

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 tinned, powdered or fresh animal milk yesterday, during the day or night?

BF7. How many times did (name) drink tinned, powdered or fresh animal milk?

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

BF9. Did (name) drink clear broth/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 Oralit (sugar salt solution) 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 yogurt yesterday, during the day or night?

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

BF15. Did (name) eat thin 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?

Malaria: ML

ML1. In the last two weeks, has (name) been ill with a fever at any time?

ML2. At any time during the illness, did (name) have blood taken from his/her finger or heel for testing?

ML3. Did you seek any advice or treatment for the illness from any source?

ML4. Was (name) taken to a health facility during this illness?

ML5. Was (name) given any medicine for fever or malaria at the health facility?

ML6. What medicine was (name) given?
Probe: Any other medicine? Circle all medicines mentioned. Write brand name(s) of all medicines, if given.
(Name) ____

ML7. Was (name) given any medicine for the fever or malaria before being taken to the health facility?

ML8. Was (name) given any medicine for fever or malaria during this illness?

ML9. What medicine was (name) given?
Probe: Any other medicine? Circle all medicines mentioned. Write brand name(s) of all medicines, if given.
(Name) ____

ML10. Check ML6 and ML9: Anti-malarial mentioned (codes A-H)
ML11. How long after the fever started did (name) first take (name of anti-malarial from ML6 or ML9)?
If multiple anti-malarials mentioned in ML6 or ML9, name all anti-malarial medicines mentioned.
Immunization: IM

If an immunization card is available, copy the dates in IM3 for each type of immunization recorded on the card. IM6-IM17 are for registering vaccinations that are not recorded on the card. IM6-IM17 will only be asked when a card is not available.

IM1. Do you have a card where (name)'s vaccinations are written down?
(If yes) May I see it please?

IM2. Did you ever have a 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

DPT/HB 1

DPT/HB 2

DPT/HB 3

DPT1

DPT2

DPT3

HepB at birth

HepB1

HepB2

HepB3

Measles (or MMR)

Vitamin A (most recent)

IM4. Check IM3. Are all vaccines (BCG to Measles) recorded?
IM5. In addition to what is recorded on this card, did (name) receive any other vaccinations - including vaccinations received in campaigns or immunization days?
Record 'Yes' only if respondent mentions vaccines shown in the table above.
IM6. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day?

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" to protect him/her from getting diseases - that is, polio?

IM9. Was the first polio vaccine received in the first two weeks after birth or later?

IM10. How many times was the polio vaccine received?

IM10A. Has (name) ever received a combo vaccination (combination of DPT and Hepatitis B vaccines) - that is, an injection in the thigh or buttocks - to prevent him/her from getting tetanus, whooping cough, diphtheria and Hepatitis B?
Probe by indicating that combo vaccination is sometimes given at the same time as Polio vaccines
IM10B. How many times was a combo vaccine(combination of DPT and Hepatitis B vaccines) received?

IM11. Has (name) ever received a DPT vaccination - that is, an injection in the thigh or buttocks - 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 Polio
IM12. How many times was a DPT vaccine received?

IM13. Has (name) ever been given a Hepatitis B vaccination - that is, an injection in the thigh or buttocks - to prevent him/her from getting Hepatitis B?
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 vaccine received within 24 hours after birth, or later?

IM15. How many times was a hepatitis B vaccine received?

IM16. Has (name) ever received a Measles injection or an MMR injection - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles?

IM18. Has (name) received a vitamin a dose like (this/any of these) within the last 6 months?
Show common types of ampules / capsules / syrups

IM19. Please tell me if (name) has participated in any of the following campaigns, national immunization days and/or vitamin a or child health days:

[A] Polio and Measles Campaign, during July-August 2011

UF13. Record the time.
UF14. Is the respondent the mother or caretaker of another child age 0-4 living in this household?
[] Yes [Indicate to the respondent that you will need to measure the weight and height of the child later. Go to the next questionnaire for children under five to be 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 eligible children in the household.

Anthropometry: AN

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

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________