Under--five Child information Panel

This questionnaire is to be administered to all mothers or caretakers (see household listing, column HL8) who care for a child that lives with them and is under the age of 5 years (see household listing, column HL5). A separate questionnaire should be used for each eligible child.
Fill in the cluster and household number, and names and line numbers of the child and the mother/caretaker in the space below. Insert your own name and number, and the date.

UF1. Cluster number: _ _ _

UF2. Household number: _ _ _

UF3. Child's name: ____

UF4. Child's line number: _ _

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

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

UF7. Interviewer name and number: ____ _ _

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

UF9. Result of Interview for children under 5
Codes refer to mother/caregiver
Repeat greeting if not already read to this respondent:
We are from COSIT and MOH. We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will take about 20-30 minutes. All the information we obtain will remain strictly confidential and your answers will never be identified. Also, you are not obliged to answer any question you do not want to, and you may withdraw from the interview at any time. May I start now?
If permission is given, begin the interview. If the respondent does not agree to continue, thank him/her and go to the next interview. Discuss this result with you r supervisor for a future revisit.

UF10: Now I would like to ask you some questions about the health of each child under the age of 5 in your care, who lives with you now. Now I want to ask you about (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.
Date of Birth:

UF11: How old was (name) at his/her last birthday?
Record age in completed years.
Birth Registration and Early Learning Module: BR

BR1. Does (name) have a birth certificate? May I see it?
If certificate is presented, verify reported date in UF10. If no birth certificate is presented, try to verify date using another document (health card, etc.). Correct stated age in UF11, if necessary.

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

BR3. Why is (name's) birth not registered?

BR4. Do you know how to register your child's birth?

BR5. Check age of child in UF11: Child is under 3 or 4 years old?
BR6. Does (name) attend any organized education program, such as a private or government facility, including kindergarten or community child care?

BR7. Within the last seven days, about how many hours did (name) attend?

BR8. In the past 3 days, did you or any member of your household over 15 years of age engage in any of the following activities with (name):
If yes, ask: who engaged in this activity with the child-- the mother, the child's father or other adult member of the household (including the caretaker/ respondent)? Circle all that apply.








Vitamin Module: VA

VA1 . Has (name) ever received a vitamin A capsule (supplement) like this one?

VA2. How many months ago did (name) take the last dose?

VA3. Where did (name) get this last does?

Breastfeeding Module: BF

BF1. Has (name) ever been breastfeed?

BF1A. After how many hours after birth did breastfeeding start?

BF1B. Did (name) take colostrum?

BF2. Is he/she still being breast--fed?

BF3. Since this time yesterday, did he/she receive any of the following:
Read each item aloud and record response before proceeding to the next item









BF4. Check BF3H: Child received solid or semi--sold (mushy) food?
BF5. Since this time yesterday, how many times did (name) eat solid, semi--solid, or soft foods other than liquids? (if 7 or more times record 7)
BF5a. Check UF10: Year of birth is 2005 or 2005
BF6. Did you receive the infant formula share of your child (name) in the last month?

BF7. What do you do with infant formulas?

BF8. Do you prefer that the infant formula share of (name) to be continued, stopped, or replaced with other food items in the monthly PDS?

Care of illness module: CA

CA1. Has (name) had diarrhea in the last two weeks, that is, since (day of the week) of the week before last?
Diarrhea is determined as perceived by mother or caretaker, or as three or more loose or watery stools per day, or blood in stool.
CA2. During this last episode of diarrhea, did (name) drink any of the following: Read each item aloud and record response before proceeding to the next item.







CA3. During (name's) illness did he/she drink much less, about the same, or more than usual?

CA4. During (name's) illness, did he/she eat less, about the same, or more food than usual?
If "less", probe: much less or a little less?
CA5. Has (name) had an illness with a cough at any time in the last two weeks, that is, since (day of the week) of the week before last?

CA6. When (name) had an illness with a cough, did he/she breathe faster than usual with short, quick breaths or have difficulty breathing?

CA7. Were the symptoms due to a problem in the chest or a blocked nose?

CA8. Did you seek advice or treatment for the illness outside the home?

CA9. From where did you seek care? Anywhere else?
Circle all providers mentioned, but do not prompt with any suggestions. If source is hospital, health center, or clinic, write the name of the place below. Probe to identify the type of source and circle the appropriate code.
CA9A. Check CA9: Source is healthy facility?
CA9BB. Why did you choose the facility that you mainly go to?

CA9CC. When you last went to the facility that you mainly go to, were your child medical needs addressed or not?

CA10. Was (name) given medicine to treat this illness?

CA11. What medicine was (name) given?
Circle all medicines given
CA11A. Check CA9: Source is a health facility?
CA11B. Were you able to get all the prescriptions from the same facility?

CA12. Check UF11: Child aged under 3?
CA13. The last time (name) passed stools, what was done to dispose of the stools?

CA14. Sometimes children have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take your child to a health facility right away?
Ask the following question (CA14) only once for each mother/caretaker.
Keep asking for more signs or symptoms until the mother/caretaker cannot recall any additional symptoms. Circle all symptoms mentioned, But do NOT prompt with any suggestions
Immunization Module: IM

If an immunization card is available, copy the dates in IM2?IM7 for each type of immunization or vitamin A dose recorded on the card. IM10--IM17 are for recording vaccinations that are not recorded on the card. IM10--IM17 will only be asked when a card is not available.

IM1. Is there a vaccination card for (name)?

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.
Date of immunization (DD/MM/YYYY)














IM9. In addition to the vaccinations and vitamin A capsules shown on this card, did (name) receive any other vaccinations ? including vaccinations received in campaigns or immunization days?

IM10. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day?

IM11. Has (name) ever been given a BCG vaccination against tuberculosis -- that is, an injection in the arm or shoulder that caused a scar?

IM12. Has (name) ever been given any "vaccination drops in the mouth" to protect him/her from getting diseases -- that is, polio?

IM13. How old was he/she when the first dose was given ? just after birth (within two weeks) or later?

IM14. How many times has he/she been given these drops?

IM15. Has (name) ever been given "DPT vaccination injections" - that is, an injection in the thigh or buttocks - to prevent him/her from getting tetanus, whooping cough, diphtheria? (Sometimes given at the same time as polio)

IM16. How many times?

IM16A. Has (name) ever been given "HB vaccine injections" - that is, an injection in the thigh or buttocks - to prevent him/her from getting Hepatitis (use local term)?
Sometimes given at the same time as DPT and polio
IM16B. How many times?

IM17. Has (name) ever been given "Measles vaccination injections" or MMR -- that is, a shot in the arm at the age of 9 months or older -- to prevent him/her from getting measles?

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:




IM19D. Check UF11: Child age is 3 years or younger?
IM19E. Does your child's growth monitored using a growth monitoring chart?

IM19F. Was your child weighted regularly at the health facility during the last 6 months?

IM20. Does another eligible child reside in the household for whom this respondent is mother/caretaker?
If this is the last eligible child in the household, go on to anthropometry module.

Anthropometry Module: AN
After questionnaires for all children are complete, the measurer weighs and measures each child. Record weight and length/height below, taking care to record the measurements on the correct questionnaire for each child. Check the child's name and line number on the household listing before recording measurements.

AN1. Child's weight

AN2. Child's length or height
Check age of child in UF11:
[] Child under 2 years old. [Measure length (lying down).]
[] Child age 2 or more years. [Measure height (standing up).]
AN3. Measurer's identification code

AN4. Result of measurement

AN4A. Check the left shoulder (which is the normal location of the bcg injection) to identify BCG scar.

AN5. Is there another child in the household who is eligible for measurement?
Gather together all questionnaires for this household and check that all identification numbers are inserted on each page. Tally on the Household Information Panel the number of interviews completed.