Questionnaire form for child disability
[IPUMS: Commonly found in the household records]
Child disability questionnaire form: DA
DA1. Cluster number: _ _ _
DA2. Household number: _ _
DA3. Child's name:
Name ____
DA4. Child's line number: _ _
DA5. Mother's/caretaker's name:
Name ____
DA6. Mother's/caretaker's line number: _ _
DA7. Interviewer name and number:
Name ____ _ _
DA8. Day/month/year of interview _ _ / _ _ / _ _ _ _
Repeat greeting if not already read to this respondent:
We are from (country-specific affiliation). We are working on a project concerned with family health and education. I would like to talk to you about (name)'s health condition. This will take only a few minutes. All the information you give me will remain strictly confidential and your answers will never be shared with those outside of team.
If greeting at the beginning of the household questionnaire has already been read to this respondent, then read the following:
Now I would like to talk to you more about (child's name from DA3)'s health condition. This will take only a few minutes. Again, all the information you give me will remain strictly confidential and your answers will never be shared with those outside our team.
Now I would like to talk to you more about (child's name from DA3)'s health condition. This will take only a few minutes. Again, all the information you give me will remain strictly confidential and your answers will never be shared with those outside our team.
May I start now?
[] Yes, permission is given (Go to DA12 to begin the interview)
[] No, permission is not given (Complete DA9. Discuss this result with your supervisor)
[] No, permission is not given (Complete DA9. Discuss this result with your supervisor)
DA9. Result of interview for child disability
Codes refer to mother/caretaker
[] 01 Completed
[] 02 Not at home
[] 03 Refused
[] 04 Partly completed
[] 05 Incapacitated
[] 96 Other (specify) ____
[] 02 Not at home
[] 03 Refused
[] 04 Partly completed
[] 05 Incapacitated
[] 96 Other (specify) ____
DA10. Field edited by (name and number):
Name ____ _ _
DA11. Data entry clerk (name and number):
Name ____ _ _
Child disability: DA
To be administered to mothers or caretakers of children age 2-9 years.
DA12. Copy child's name and age from HL2 and HL6, from Household Listing Form.
____ Name
_ _ Age
_ _ Age
DA13. Compared with other children, does or did (name) have any serious delay in sitting standing, or walking?
[] 1 Yes
[] 2 No
[] 2 No
DA14. Compared with other children, does (name) have difficulty seeing, either in the daytime or at night?
[] 1 Yes
[] 2 No
[] 2 No
DA15. Does (name) appear to have any difficulty hearing (uses hearing aid, hears with difficulty or completely deaf)?
[] 1 Yes
[] 2 No
[] 2 No
DA16. When you tell (name) to do something, does he/she seem to understand what you are saying?
[] 1 Yes
[] 2 No
[] 2 No
DA17. Does (name) have difficulty in walking or moving his/her arms or does he/she have weakness and/or stiffness in the arms or legs?
[] 1 Yes
[] 2 No
[] 2 No
DA18. Does (name) sometimes have fits, become rigid, or lose consciousness?
[] 1 Yes
[] 2 No
[] 2 No
DA19. Does (name) learn to do things like other children his/her age?
[] 1 Yes
[] 2 No
[] 2 No
DA20. Does (name) speak at all (can he/she make him or herself understood in words; can he/she say any recognizable words)?
[] 1 Yes
[] 2 No
[] 2 No
DA21. Check DA12: Age of child
[] Child age 3 through 9 (Continue with DA22)
[] Child age 2 (Go to DA23)
[] Child age 2 (Go to DA23)
DA22. Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?
[] 1 Yes (Go to DA24)
[] 2 No (Go to DA24)
[] 2 No (Go to DA24)
DA23. Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?
[] 1 Yes
[] 2 No
[] 2 No
DA24. Compared with other children of the same age, does (name) appear in any way mentally backward, dull or slow?
[] 1 Yes
[] 2 No
[] 2 No
DA25. As part of this survey, others in our team may visit you again to collect more information on some of the topics we have just talked about, concerning (name). Such a visit may take place within the next (days/weeks/months).
May I proceed and note that you would be fine with such a visit, if it occurs at all? Again, you may change your mind and decline to speak to our team if and when the visit happens.
[] 1 Respondent has no objections to additional visit
[] 2 Respondent uncertain about additional visit/depends
[] 3 Refused additional visit
[] 2 Respondent uncertain about additional visit/depends
[] 3 Refused additional visit