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MICS questionnaire for children under five



Name of survey


Under-five child information panel: UF

This questionnaire is to be administered to all mothers or caretakers (see List of Household Members, column HL15) who care for a child that lives with them and is under the age of 5 years (see List of Household Members, column HL7B).
A separate questionnaire should be used for each eligible child.

UF1. Cluster number: _ _ _

UF2. Household number: _ _

UF3. Child's name: Name ____

UF4. Child's line number _ _

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

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

UF7. Interviewer's name and number:
Name ____ _ _

UF8. Day/month/year of interview
_ _ / _ _ / 201 _

Repeat greeting if not already read to this respondent:
We are from [insert country-specific affiliation]. We are conducting a survey about the situation of children, families and households. I would like to talk to you about (child's name from UF3)'s health and well-being. The interview will take about [insert number minutes]. All the information we obtain will remain strictly confidential and anonymous.

If greeting at the beginning of the household questionnaire has already been read to this person, then read the following:
Now I would like to talk to you more about (child's name from UF3)'s health and other topics. This interview will take about [insert number minutes]. Again, all the information we obtain will remain strictly confidential and anonymous.

May I start now?

[] Yes, permission is given (Go to UF12 to record the time and then begin the interview.)
[] No, permission is not given (Circle '03' in UF9. Discuss this result with your supervisor)

UF9. Result of interview for children under 5
Codes refer to mother/caretaker.

[] 01 Completed
[] 02 Not at home
[] 03 Refused
[] 04 Partly completed
[] 05 Incapacitated
[] 96 Other (specify) ____

UF10. Field editor's name and number: Name ____ _ _

UF11. Main data entry clerk's name and number: Name ____ _ _

UF12. Record the time.
Hour and minutes _ _ : _ _

Age: AG

AG1. Now I would like to ask you some questions about the development and health of (name).
On what day, 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. Month and year must be recorded.
Date of birth
_ _ Day
[] 98 DK day
_ _ Month
20 _ _ Year

AG2. How old is (name)?
Probe: How old was (name) at his / her last birthday? Record age in completed years. Record '0' if less than 1 year. Compare and correct AG1 and/or AG2 if inconsistent.
Age (in completed years) _

Birth Registration: BR

BR1. Does (name) have a birth certificate?
If yes, ask: may I see it?
[] 1 Yes, seen (Go to next module)
[] 2 Yes, not seen (Go to next module)
[] 3 No
[] 8 DK

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

[] 1 Yes (Go to next module)
[] 2 No
[] 8 DK

BR3. Do you know how to register (name)'s birth?

[] 1 Yes
[] 2 No

Early childhood development: EC

EC1. How many children's books or picture books do you have for (name)?

[] 00 None
[] 0 Number of children's books _
[] 10 Ten or more books

EC2. I am interested in learning about the things that (name) plays with when he/she is at home.
Does he/she play with:
If the respondent says "yes" to the categories above, then probe to learn specifically what the child plays with to ascertain the response.

[A] Homemade toys (such as dolls, cars, or other toys made at home)?
[] 1 Yes
[] 2 No
[] 8 DK

[B] Toys from a shop or manufactured toys?
[] 1 Yes
[] 2 No
[] 8 DK

[C] Household objects (such as bowls or pots) or objects found outside (such as sticks, rocks, animal shells or leaves)?
[] 1 Yes
[] 2 No
[] 8 DK

EC3. 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.
On how many days in the past week was (name):
If 'none' enter '0'. If 'don't know' enter '8'.

[A] Left alone for more than an hour?

_ Number of days left alone for more than an hour

[B] Left in the care of another child, that is, someone less than 10 years old, for more than an hour?

_ Number of days left with other child for more than an hour

EC4. Check AG2: Age of child.
[] Child age 0, 1 or 2 (Go to next module)
[] Child age 3 or 4 (Continue with EC5)

EC5. Does (name) attend any organized learning or early childhood education programme, such as a private or government facility, including kindergarten or community child care?

[] 1 Yes
[] 2 No
[] 8 DK

EC7. In the past 3 days, did you or any household member age 15 or over engage in any of the following activities with (name):
If yes, ask: Who engaged in this activity with (name)?
Circle all that apply.


[A] Read books to or looked at picture books with (name)?
[] A Mother
[] B Father
[] X Other
[] Y No one

[B] Told stories to (name)?
[] A Mother
[] B Father
[] X Other
[] Y No one

[C] Sang songs to (name) or with (name), including lullabies?
[] A Mother
[] B Father
[] X Other
[] Y No one

[D] Took (name) outside the home, compound, yard or enclosure?
[] A Mother
[] B Father
[] X Other
[] Y No one

[E] Played with (name)?
[] A Mother
[] B Father
[] X Other
[] Y No one

[F] Named, counted, or drew things to or with (name)?
[] A Mother
[] B Father
[] X Other
[] Y No one

EC8. I would like to ask you some questions about the health and development of (name). Children do not all develop and learn at the same rate. For example, some walk earlier than others. These questions are related to several aspects of (name)'s development.
Can (name) identify or name at least ten letters of the alphabet?

[] 1 Yes
[] 2 No
[] 8 DK

EC9. Can (name) read at least four simple, popular words?

[] 1 Yes
[] 2 No
[] 8 DK

EC10. Does (name) know the name and recognize the symbol of all numbers from 1 to 10?

[] 1 Yes
[] 2 No
[] 8 DK

EC11. Can (name) pick up a small object with two fingers, like a stick or a rock from the ground?

[] 1 Yes
[] 2 No
[] 8 DK

EC12. Is (name) sometimes too sick to play?

[] 1 Yes
[] 2 No
[] 8 DK

EC13. Does (name) follow simple directions on how to do something correctly?

[] 1 Yes
[] 2 No
[] 8 DK

EC14. When given something to do, is (name) able to do it independently?

[] 1 Yes
[] 2 No
[] 8 DK

EC15. Does (name) get along well with other children?

[] 1 Yes
[] 2 No
[] 8 DK

EC16. Does (name) kick, bite, or hit other children or adults?

[] 1 Yes
[] 2 No
[] 8 DK

EC17. Does (name) get distracted easily?

[] 1 Yes
[] 2 No
[] 8 DK

Breastfeeding and dietary intake: BD

BD1. Check AG2: Age of child.
[] Child age 0, 1 or 2 (Continue with BD2.)
[] Child age 3 or 4 (Go to care of illness module.)

BD2. Has (name) ever been breastfed?

[] 1 Yes
[] 2 No (Go to BD4)
[] 8 DK (Go to BD4)

BD3. Is (name) still being breastfed?

[] 1 Yes
[] 2 No
[] 8 DK

BD4. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?

[] 1 Yes
[] 2 No
[] 8 DK

BD5. Did (name) drink ORS (oral rehydration solution) yesterday, during the day or night?

[] 1 Yes
[] 2 No
[] 8 DK

BD6. Did (name) drink or eat vitamin or mineral supplements or any medicines yesterday, during the day or night?

[] 1 Yes
[] 2 No
[] 8 DK

BD7. Now I would like to ask you about (other) liquids that (name) may have had yesterday during the day or the night. I am interested to know whether (name) had the item even if combined with other foods.
Please include liquids consumed outside of your home.
Did (name) drink (name of item) yesterday during the day or the night:

[A] Plain water?

[] 1 Yes
[] 2 No
[] 8 DK

[B] Juice or juice drinks?

[] 1 Yes
[] 2 No
[] 8 DK

[C] [insert local name for clear broth/clear soup]?

[] 1 Yes
[] 2 No
[] 8 DK

[D] Milk such as tinned, powdered, or fresh animal milk?

If yes: How many times did (name) drink milk? If 7 or more times, record '7'. If unknown, record '8'.
[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank milk

[E] Infant formula?

If yes: How many times did (name) drink infant formula? If 7 or more times, record '7'. If unknown, record '8'.
[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank infant formula

[F] Any other liquids?
(Specify) ____

[] 1 Yes
[] 2 No
[] 8 DK

BD8. Now I would like to ask you about (other) foods that (name) may have had yesterday during the day or the night. Again, I am interested to know whether (name) had the item even if combined with other foods. Please include foods consumed outside of your home.
Did (name) eat (name of food) yesterday during the day or the night:


[A] Yogurt?
If yes: How many times did (name) drink or eat yogurt? If 7 or more times, record '7'. If unknown, record '8'.

[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank/ate yogurt

[B] Any [insert brand name of commercially fortified baby food, e.g., cerelac]?

[] 1 Yes
[] 2 No
[] 8 DK

[C] Bread, rice, noodles, porridge, or other foods made from grains?

[] 1 Yes
[] 2 No
[] 8 DK

[D] Pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?

[] 1 Yes
[] 2 No
[] 8 DK

[E] White potatoes, white yams, manioc, cassava, or any other foods made from roots?

[] 1 Yes
[] 2 No
[] 8 DK

[F] Any dark green, leafy vegetables?

[] 1 Yes
[] 2 No
[] 8 DK

[G] Ripe mangoes, papayas or [insert any other locally available vitamin A-rich fruits]?

[] 1 Yes
[] 2 No
[] 8 DK

[H] Any other fruits or vegetables?

[] 1 Yes
[] 2 No
[] 8 DK

[I] Liver, kidney, heart or other organ meats?

[] 1 Yes
[] 2 No
[] 8 DK

[J] Any meat, such as beef, pork, lamb, goat, chicken, or duck?

[] 1 Yes
[] 2 No
[] 8 DK

[K] Eggs?

[] 1 Yes
[] 2 No
[] 8 DK

[L] Fresh or dried fish or shellfish?

[] 1 Yes
[] 2 No
[] 8 DK

[M] Any foods made from beans, peas, lentils, or nuts?

[] 1 Yes
[] 2 No
[] 8 DK

[N] Cheese or other food made from milk?

[] 1 Yes
[] 2 No
[] 8 DK

[O] Any other solid, semi-solid, or soft food that I have not mentioned? (Specify) ____

[] 1 Yes
[] 2 No
[] 8 DK

BD9. Check BD8 (Categories "A" through "O").
[] At least one "Yes" or all "DK" (Go to BD11)
[] Else (Continue with BD10)

BD10. Probe to determine whether the child ate any solid, semi-solid or soft foods yesterday during the day or night.
[] The child did not eat or the respondent does not know (Go to Next Module.)
[] The child ate at least one solid, semi-solid or soft food item mentioned by the respondent (Go back to BD8 and record food eaten yesterday [A to O]. When finished, continue with BD11.)

BD11. How many times did (name) eat any solid, semi-solid or soft foods yesterday during the day or night?
If 7 or more times, record '7'.
_ Number of times
[] 8 DK

Immunization: IM

If an immunization (child health) card is available, copy the dates in IM3 for each type of immunization and Vitamin A recorded on the card. IM6-IM17 will only be asked if a card is not available.

IM1. Do you have a card where (name)'s vaccinations are written down?
If yes: May I see it please?
[] 1 Yes, seen (Go to IM3)
[] 2 Yes, not seen (Go to IM6)
[] 3 No card

IM2. Did you ever have a vaccination (child health) card for (name)?

[] 1 Yes (Go to IM6)
[] 2 No (Go to IM6)

IM3.
(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.


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

HEP0
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

HepB 1

HEP1
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

HepB 2

HEP2
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

HepB 3

HEP3
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Hib 1

HIB1
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Hib 2

HIB2
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Hib 3

HIB3
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Measles (or MMR or MR)

Measles
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Yellow fever

YF
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Vitamin A (first dose)

VitA1
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

Vitamin A (second dose)

VitA2
Date of immunization day/month/year _ _ / _ _ / _ _ _ _

IM4. Check IM3. Are all vaccines (BCG to Yellow Fever) recorded?
[] Yes (Go to IM19)
[] No (Continue with IM5)

IM5. In addition to what is recorded on this card, did (name) receive any other vaccinations - including vaccinations received in campaigns or immunization days or child health days?

[] Yes (Go back to IM3 and probe for these vaccinations and write '66' in the corresponding day column for each vaccine mentioned. When finished, skip to IM19.)
[] No/DK (Go to IM19)

IM6. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day or child health day?

[] 1 Yes
[] 2 No (Go to IM19)
[] 8 DK (Go to IM19)

IM7. Has (name) ever received a BCG vaccination against tuberculosis - that is, an injection in the arm or shoulder that usually causes a scar?

[] 1 Yes
[] 2 No
[] 8 DK

IM8. Has (name) ever received any vaccination drops in the mouth to protect him/her from polio?

[] 1 Yes
[] 2 No (Go to IM11)
[] 8 DK (Go to IM11)

IM9. Was the first polio vaccine received in the first two weeks after birth?

[] 1 Yes
[] 2 No

IM10. How many times was the polio vaccine received?

Number of times _

IM11. Has (name) ever received a DPT vaccination - that is, an injection in the thigh to prevent him/her from getting tetanus, whooping cough, or diphtheria?
Probe by indicating that DPT vaccination is sometimes given at the same time as Polio.
[] 1 Yes
[] 2 No (Go to IM13)
[] 8 DK (Go to IM13)

IM12. How many times was the DPT vaccine received?

Number of times _

IM13. Has (name) ever received a Hepatitis B vaccination - that is, an injection in the thigh to prevent him/her from getting Hepatitis B?
Probe by indicating that the Hepatitis B vaccine is sometimes given at the same time as Polio and DPT vaccines.
[] 1 Yes
[] 2 No (Go to IM15A)
[] 8 DK (Go to IM15A)

IM14. Was the first Hepatitis B vaccine received within 24 hours after birth?

[] 1 Yes
[] 2 No
[] 8 DK

IM15. How many times was the Hepatitis B received?

Number of times _

IM15A. Has (name) ever received a Hib vaccination - that is, an injection in the thigh to prevent him/her from getting haemophilus influenzae type B?
Probe by indicating that the Hib vaccine is sometimes given at the same time as Polio and DPT vaccines.
[] 1 Yes
[] 2 No (Go to IM16)
[] 8 DK (Go to IM16)

IM15B. How many times was the Hib vaccine received?

Number of times _

IM16. Has (name) ever received a measles injection (or an MMR or MR) - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles?

[] 1 Yes
[] 2 No
[] 8 DK

IM17. Has (name) ever received the yellow fever vaccination - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting yellow fever?
Probe by indicating that the Yellow Fever vaccine is sometimes given at the same time as the measles vaccine.
[] 1 Yes
[] 2 No
[] 8 DK

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:
[A] [Insert date/type of campaign A, antigens]

[] 1 Yes
[] 2 No
[] 8 DK

[B] [Insert date/type of campaign B, antigens]

[] 1 Yes
[] 2 No
[] 8 DK

[C] [Insert date/type of campaign C, antigens]

[] 1 Yes
[] 2 No
[] 8 DK

IM20. Issue a questionnaire form for vaccination records at health facility for this child. Complete the information panel on that questionnaire and go to next module.

Care of illness: CA

CA1. In the last two weeks, has (name) had diarrhoea?

[] 1 Yes
[] 2 No (Go to CA6A)
[] 8 DK (Go to CA6A)

CA2. I would like to know how much (name) was given to drink during the diarrhoea (including breastmilk).
During the time (name) had diarrhoea, was he/she given less than usual to drink, about the same amount, or more than usual?
If 'less', probe: Was he/she given much less than usual to drink, or somewhat less?
[] 1 Much less
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Nothing to drink
[] 8 DK

CA3. During the time (name) had diarrhoea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
If 'less', probe: Was he/she given much less than usual to eat or somewhat less?
[] 1 Much less
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Stopped food
[] 6 Never gave food
[] 8 DK

CA3A. Did you seek any advice or treatment for the diarrhoea from any source?

[] 1 Yes
[] 2 No (Go to CA4)
[] 8 DK (Go to CA4)

CA3B. From where did you seek advice or treatment?
Probe: Anywhere else? Circle all providers mentioned, but do not prompt with any suggestions. Probe to identify each type of source. If unable to determine if public or private sector, write the name of the place.
(Name of place) ____

Public sector
[] A Government hospital
[] B Government health centre
[] C Government health post
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public (specify) ____
Private medical sector
[] I Private hospital/clinic
[] J Private physician
[] K Private pharmacy
[] L Mobile clinic
[] O Other private medical (specify) ____
Other source
[] P Relative/friend
[] Q Shop
[] R Traditional practitioner
[] X Other (specify) ____

CA4. During the time (name) had diarrhoea, was (name) given to drink:

[A] A fluid made from a special packet called [insert local name for ORS packet solution]?

[] 1 Yes
[] 2 No
[] 8 DK

[B] A pre-packaged ORS fluid for diarrhoea [insert local name for pre-packaged ORS fluid]?

[] 1 Yes
[] 2 No
[] 8 DK

CA4A. Check CA4: ORS.
[] Child was given ORS ('Yes' circled in 'A' or 'B' in CA4) (Continue with CA4B.)
[] Child was not given ORS (Go to CA4C.)

CA4B. Where did you get the ORS?
Probe to identify the type of source. If unable to determine whether public or private, write the name of the place.
(Name of place) ____

Public sector
[] 11 Government hospital
[] 12 Government health centre
[] 13 Government health post
[] 14 Community health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
Private medical sector
[] 21 Private hospital/clinic
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
Other source
[] 31 Relative/friend
[] 32 Shop
[] 33 Traditional practitioner
[] 40 Already had at home
[] 96 Other (specify) ____

CA4C. During the time (name) had diarrhoea, was (name) given:

[A] Zinc tablets?

[] 1 Yes
[] 2 No
[] 8 DK

[B] Zinc syrup?

[] 1 Yes
[] 2 No
[] 8 DK

CA4D. Check CA4C: Any zinc?
[] Child given any zinc ('Yes' circled in 'A' or 'B' in CA4C) (Continue with CA4E)
[] Child was not given any zinc (Go to CA4F)

CA4E. Where did you get the zinc?
Probe to identify the type of source. If unable to determine whether public or private, write the name of the place.
(Name of place) ____

Public sector
[] 11 Government hospital
[] 12 Government health centre
[] 13 Government health post
[] 14 Community health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
Private medical sector
[] 21 Private hospital/clinic
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
Other source
[] 31 Relative/friend
[] 32 Shop
[] 33 Traditional practitioner
[] 40 Already had at home
[] 96 Other (specify) ____

CA4F. During the time (name) had diarrhoea, was (name) given to drink any of the following:
Read each item aloud and record response before proceeding to the next item.
[A] [Insert Government-recommended homemade fluid X]?

[] 1 Yes
[] 2 No
[] 8 DK

[B] [Insert Government-recommended homemade fluid Y]?

[] 1 Yes
[] 2 No
[] 8 DK

[C] [Insert Government-recommended homemade fluid Z]?

[] 1 Yes
[] 2 No
[] 8 DK

CA5. Was anything (else) given to treat the diarrhoea

[] 1 Yes
[] 2 No (Go to CA6A)
[] 8 DK (Go to CA6A)

CA6. What (else) was given to treat the diarrhoea?
Probe: Anything else? Record all treatments given. Write brand name(s) of all medicines mentioned.
(Name) ____

Pill or Syrup
[] A Antibiotic
[] B Antimotility
[] G Other pill or syrup (Not antibiotic, antimotility or zinc)
[] H Unknown pill or syrup
Injection
[] L Antibiotic
[] M Non-antibiotic
[] N Unknown injection
[] O Intravenous
[] Q Home remedy/herbal medicine
[] X Other (specify) ____

CA6A. In the last two weeks, has (name) been ill with a fever at any time?

[] 1 Yes
[] 2 No (Go to CA7)
[] 8 DK (Go to CA7)

CA6B. At any time during the illness, did (name) have blood taken from his/her finger or heel for testing?

[] 1 Yes
[] 2 No
[] 8 DK

CA7. At any time in the last two weeks, has (name) had an illness with a cough?

[] 1 Yes
[] 2 No (Go to CA9A)
[] 8 DK (Go to CA9A)

CA8. When (name) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

[] 1 Yes
[] 2 No (Go to CA10)
[] 8 DK (Go to CA10)

CA9. Was the fast or difficult breathing due to a problem in the chest or a blocked or runny nose?

[] 1 Problem in chest only (Go to CA10)
[] 2 Blocked or runny nose only (Go to CA10)
[] 3 Both (Go to CA10)
[] 6 Other (specify) ____ (Go to CA10)
[] 8 DK (Go to CA10)

CA9A. Check CA6A: Had fever?
[] Child had fever (Continues with CA10)
[] Child did not have fever (Go to CA14)

CA10. Did you seek any advice or treatment for the illness from any source?

[] 1 Yes
[] 2 No (Go to CA12)
[] 8 DK (Go to CA12)

CA11. From where did you seek advice or treatment?
Probe: Anywhere else? Circle all providers mentioned, but do not prompt with any suggestions. Probe to identify each type of source. If unable to determine if public or private sector, write the name of the place.
(Name of place) ____

Public sector
[] A Government hospital
[] B Government health centre
[] C Government health post
[] D Community health worker
[] E Mobile/outreach clinic
[] H Other public (specify) ____
Private medical sector
[] I Private hospital/clinic
[] J Private physician
[] K Private pharmacy
[] L Mobile clinic
[] O Other private medical (specify) ____
Other source
[] P Relative/friend
[] Q Shop
[] R Traditional practitioner
[] X Other (specify) ____

CA12. At any time during the illness, was (name) given any medicine for the illness?

[] 1 Yes
[] 2 No (Go to CA14)
[] 8 DK (Go to CA14)

CA13. What medicine was (name) given?
Probe: Any other medicine? Circle all medicines given. Write brand name(s) of all medicines mentioned.
(Names of medicines) ____

Anti-malarials:
[] A SP/Fansidar
[] B Chloroquine
[] C Amodiaquine
[] D Quinine
[] E Combination with Artemisinin
[] H Other anti-malarial (specify) ____
Antibiotics:
[] I Pill/syrup
[] J Injection
Other medications:
[] P Paracetamol/Panadol/Acetaminophen
[] Q Aspirin
[] R Ibuprofen
[] X Other (specify) ____
[] Z DK

CA13A. Check CA13: Antibiotic mentioned (codes I or J)?
[] Yes (Continue with CA13B)
[] No (Go to CA13C)

CA13B. Where did you get the (name of medicine from CA13)?
Probe to identify the type of source. If unable to determine whether public or private, write the name of the place.
(Name of place) ____

Public sector
[] 11 Government hospital
[] 12 Government health centre
[] 13 Government health post
[] 14 Community health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
Private medical sector
[] 21 Private hospital/clinic
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
Other source
[] 31 Relative/friend
[] 32 Shop
[] 33 Traditional practitioner
[] 40 Already had at home
[] 96 Other (specify) ____

CA13C. Check CA13: Anti-malarial mentioned (codes A - H)?
[] Yes (Continue with CA13D.)
[] No (Go to CA14)

CA13D. Where did you get the (name of medicine from CA13)?
Probe to identify the type of source. If unable to determine whether public or private, write the name of the place.
(Name of place) ____

Public sector
[] 11 Government hospital
[] 12 Government health centre
[] 13 Government health post
[] 14 Community health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
Private medical sector
[] 21 Private hospital/clinic
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
Other source
[] 31 Relative/friend
[] 32 Shop
[] 33 Traditional practitioner
[] 40 Already had at home
[] 96 Other (specify) ____

CA13E. How long after the fever started did (name) first take (name of anti-malarial from CA13)?
If multiple anti-malarials mentioned in CA13, name all anti-malarial medicines mentioned.

[] 0 Same day
[] 1 Next day
[] 2 2 days after the fever
[] 3 3 days after the fever
[] 4 4 or more days after the fever
[] 8 DK

CA14. Check AG2: Age of child.
[] Child age 0, 1 or 2 (Continue with CA15)
[] Child age 3 or 4 (Go to UF13)

CA15. The last time (name) passed stools, what was done to dispose of the stools?

[] 01 Child used toilet/latrine
[] 02 Put/rinsed into toilet or latrine
[] 03 Put/rinsed into drain or ditch
[] 04 Thrown into garbage (solid waste)
[] 05 Buried
[] 06 Left in the open
[] 96 Other (specify) ____
[] 98 DK

UF13. Record the time
Hours and minutes _ _ : _ _

UF14. Check List of Household Members, columns HL7B and HL15.
Is the respondent the mother or caretaker of another child age 0-4 living in this household?
[] Yes (Indicate to the respondent that you will need to measure the weight and height of the child later. Go to the next questionnaire for children under five to be administered to the same respondent.)
[] No (End the interview with this respondent by thanking her/him for her/his cooperation and tell her/him that you will need to measure the weight and height of the child before you leave the household. Check to see if there are other woman's, man's or under-5 questionnaires to be administered in this household.)

Anthropometry: 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 in the List of Household Members before recording measurements.


AN1. Measurer's name and number:
Name ____ _ _

AN2. Result of height / length and weight measurement:
[] 1 Either or both measured
[] 2 Child not present (Go to AN6)
[] 3 Child or mother/caretaker refused (Go to AN6)
[] 6 Other (specify) ____ (Go to AN6)

AN3. Child's weight:
_ _ . _ Kilograms (kg)
[] 99.9 Weight not measured

AN3A. Was the child undressed to the minimum?
[] Yes.
[] No, the child could not be undressed to the minimum.

AN3B. Check age of child in AG2:
[] Child under 2 years old (Measure length (lying down))
[] Child age 2 or more years (Measure height (standing up))

AN4. Child's length or height:
_ _ _ . _ Length/height (cm)
[] 999.9 Length/height not measured (Go to AN6)

AN4A. How was the child actually measured? Lying down or standing up?
[] 1 Lying down
[] 2 Standing up

AN6. Is there another child in the household who is eligible for measurement?
[] Yes (Record measurements for next child)
[] No (Check if there are any other individual questionnaires to be completed in the household)

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________

Measurer's observations ________