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. Serial Number ___ _
Parish __ __
Constituency __ __
Enumeration District ___ ___ ___

UF2. Dwelling number: _ _ __
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
Data entry operator: ____ ____
Verifier: ____ ____

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?
Ask for "pink slip" if birth certificate is not available
BR2. Has (name's) birth been registered with registrar general's department (RGD)?

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 learning or early childhood education education programme, 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 household member 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? Circle all that apply.







Child development: CE

Question CE1 is to be administered only once to each caretaker.

CE1. How many books are there in the household? Please include schoolbooks, but not other books meant for children, such as picture books
If ?none? enter 00
CE2. How many children's books or picture books do you have for (name)?
If ?none? enter 00
CE3. I am interested in learning about the things that (name) plays with when he/she is at home.
What does (name) play with?

Code Y if child does not play with any of the items mentioned.

CE4. 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 with others. Since last (day of the week) how many times was (name) left in the care of another child (that is, someone less than 10 years old)?
If 'none' enter 00
CE5. In the past week, how many times was (name) left alone?
If 'none' enter 00
Breastfeeding Module: BF

BF1. Has (name) ever been breastfeed?

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)
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/mucus 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?
CA4A. Check CA2A: ORS packet used?
CA4B. Where did you get the (local name for ORS packet from CA2A)?

CA4C. How much did you pay for the (local name for ORS packet from CA2A)?

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

CA11. What medicine was (name) given?
Circle all medicines given
CA11A. Check CA11: Antibiotic given?
CA11B. Where did you get the antibiotic?

CA11C. How much did you pay for the antibiotic?

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--IM8 for each type of immunization or vitamin A dose recorded on the card. IM10--IM18 are for recording vaccinations that are not recorded on the card. IM10--IM18 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 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 Polio?

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)
DPT = Diphtheria, Pertousis, Tetanus
IM16. 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 12 months or older -- to prevent him/her from getting measles?
For child one and over
IM19. Please tell me if (name) has participated in any of the following campaigns, national immunization days and/or child health days:




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, end the interview by thanking the family.