[name of country]

Under-five child information panel: HF

This questionnaire form is to be used at health facilities to record information on the vaccinations of children age 0-4 years. A separate questionnaire form should be used for each eligible child.
The Questionnaire for Under Five Children must be completed for the child prior to completing this form. This panel should be completed before visiting the health facility.
This questionnaire form must be appended to the Questionnaire for Under Five Children for each child.

HF1. Cluster number: _ _ _

HF2. Household number: _ _

HF3. Child's name:

HF4. Child's line number: _ _

HF5. Mother's / Caretaker's name:

HF6. Mother's / Caretaker's line number: _ _

HF7. Interviewer's name and number:

HF8. Day / Month / Year of facility visit: _ _ / _ _ / _ _ _ _

HF9. Day, month and year of birth
(From AG1 in Questionnaire for Children Under-5)
HF10. Name of health facility:

HF11. Result of health facility visit

Immunization: HF

HF12. Record day, month and year of birth as written on vaccination record

HF13.

BCG

Polio at birth

Polio 1

Polio 2

Polio 3

DPT 1

DPT 2

DPT 3

HepB at birth

HepB 1

HepB 2

HepB 3

Measles (or MMR)

Yellow fever

Vitamin A (most recent)