MICS questionnaire form for vaccinations at health facility
[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:
Name ____
HF4. Child's line number: _ _
HF5. Mother's / Caretaker's name:
Name ____
HF6. Mother's / Caretaker's line number: _ _
HF7. Interviewer's name and number:
Name ____ _ _
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:
Name ____
HF11. Result of health facility visit
[] 01 Vaccination record seen
[] 02 Vaccination record not seen
[] 96 Other (specify)
[] 02 Vaccination record not seen
[] 96 Other (specify)
Immunization: HF
HF12. Record day, month and year of birth as written on vaccination record
_ _ / _ _ / _ _ _ _
HF13.
(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.
(b) Write '44' in day column if card shows that vaccination was given but no date recorded.
BCG
BCG
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Polio at birth
OPV0
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Polio 1
OPV1
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Polio 2
OPV2
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Polio 3
OPV3
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
DPT 1
DPT1
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
DPT 2
DPT2
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
DPT 3
DPT3
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
HepB at birth
H0
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
HepB 1
H1
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
HepB 2
H2
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
HepB 3
H3
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Measles (or MMR)
Measles
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Yellow fever
YF
Date of immunization day/month/year _ _ / _ _ / _ _ _ _
Vitamin A (most recent)
VitA
Date of immunization day/month/year _ _ / _ _ / _ _ _ _