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name of survey

Under-five child information panel: HF

This questionnaire form is to be used at health facilities to record information on the vaccinations and Vitamin A supplementation for children age 0-2 years. A separate questionnaire form should be used for each eligible child.
The questionnaire for children under five 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 children under five 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: _ _ / _ _ / 201 _

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

HF11A. Field editor's name and number:

HF11B. Main data entry clerk's name and number:

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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

Hib 1

Hib 2

Hib 3

Measles (or MMR or MR)

Yellow fever

Vitamin A (first dose)

Vitamin A (second dose)