Macedonia

Under-five child information panel: UF

This questionnaire is to be filled with all mothers or guardians (see Household Listing Form, column HL9 in the Household Questionnaire) who take care for a child that lives with them and is less than 5 years old (see Household Roster Form, column HL6 in the Household Questionnaire).
A separate questionnaire should be used for each eligible child, with the correspondent parent/guardian.

UF1. Cluster number: _ _ _

UF2. Household number: _ _

UF3. Child's name:
Name ____

UF4. Child's row number: _ _

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

UF6. Mother's / guardian's row number: _ _

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

UF8. Day / month / year of interviewing _ _ / _ _ / _ _ _ _

Repeat the introduction if you haven't read it to this respondent already:
We are from Ipsos Strategic Puls. We are working on a project related to family health and education. I would like to talk to you about these issues. The interview will last about 30 minutes. All information obtained will remain strictly confidential and your answers will never be shared with anyone outside the project team.

If you have already read it to this woman at the beginning from the household questionnaire, then read the following:
I would like to talk to you more about (child's name from UF3)'s health and other issues. The interview will last about 30 minutes. All the information obtained will remain strictly confidential and your answers will never be shared with anyone outside the project team.

Can we start now?

UF9. Result of interview for children under 5
Codes refer to mother/guardian.
UF10. Editor in the field (name and number)

UF11. Data entered by (name and number):

UF12. Record the momentary time.

Age: AG

AG1. Now I would like to ask you some questions about the health of (name).
In what month and year WAS (name) born?
Probe: what is his / her birthday? If the mother/guardian knows the exact birth date, enter the day at the required place; otherwise, circle 98 for day. Month and year must be recorded.
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 the age with the given date and immediately correct AG1 and/or AG2 if the answers are not consistent.
Birth registration: BR

BR1. Does (name) have a birth certificate?
If the answer is "yes", ask: May I see it?

BR2. Has (name)'s birth been registered with the registry department?

BR3. Do you know how to report/register your child's birth?

Early childhood development: EC

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

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

[A] Homemade toys (such as dolls, cars, or other toys made at home)?

[B] Toys from a shop or manufactured toys?

[C] Household objects (such as bowls or pots) or objects found outside (such as sticks, rocks, animal shells or leaves)?

EC3. Sometimes adults that take care of children have to leave the house to go shopping, wash clothes, or for other reasons and then they have to leave young children alone.
On how many days during the past week was (name):
If 'none' enter' 0'. If 'don't know' enter'8'

[A] Left alone at home for more than an hour?

[B] Left in the care of another child (that is, someone under 10) for more than an hour?

EC4. Check AG2: Age of child
EC5. Does (name) attend any organized learning or early childhood education programme, like a private or government facility, including kindergarten or community child care center?

EC6. Within the last seven days, about how many hours did (name) attend such learning programmes, i.e. attended kindergarten or community child care center?

EC7. In the past 3 days, did you or any of your adult household members aged 15 or more engage in any of the following activities with (name):
If the answer is ? yes?, ask for each given activity: who engaged in this activity with (name)? Circle all that apply and remind the respondent that you are talking about the last 3 days.

[A] Read books to or looked at picture books with (name)?

[B] Told stories to (name)?

[C] Sang songs to (name) or with (name), including lullabies?

[D] Took (name) outside the home, compound, yard for a walk?

[E] Played with (name)?

[F] Named, counted, or drew things to or with (name)?

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

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

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

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

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

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

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

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

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

EC17. Does (name) get distracted easily?

Breastfeeding: BF

BF1. Has (name) ever been breastfed?

BF2. Is he/she still being breastfed?

BF3. I would like to ask you about liquids that (name) may have had yesterday during the day or the night. I am interested in whether (name) had the mentioned liquid even if it was combined with other foods.
Please include liquids consumed outside of your home.
Did (name) drink plain water yesterday, during the day or night?

BF4. Did (name) drink infant formula/substitution for mother's milk/artificial milk yesterday, during the day or night?

BF5. How many times did (name) drink infant formula?

BF6. Did (name) drink tetra pack milk, powdered or fresh animal milk yesterday, during the day or night?

BF7. How many times did (name) drink tetra pack, powdered or fresh animal milk?

BF8. Did (name) drink juice yesterday, during the day or night?

BF9. Did (name) drink clear soup yesterday, during the day or night?

BF10. Did (name) drink or eat vitamin or mineral supplements or any medicines yesterday, during the day or night?

BF11. Did (name) drink oral rehydration solution yesterday, during the day or night?

BF12. Did (name) drink any other liquids yesterday, during the day or night?

BF13. Did (name) drink or eat yogurt (sour milk) yesterday, during the day or night?

BF14. How many times did (name) drink or eat yogurt (sour milk) yesterday, during the day or night?

BF15. Did (name) eat any porridge yesterday, during the day or night?

BF16. Did (name) eat solid or semi-solid (soft, mushy) food yesterday, during the day or night?

BF17. How many times did (name) eat solid or semi-solid (soft, mushy) food yesterday, during the day or night?

BF18. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?

Care of illness: CA

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

CA2. I would like to know how much liquid (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?
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?
CA4. During the episode of diarrhoea, was (name) given to drink any of the following:
Read each item aloud and record response before proceeding to the next item.

[A] A fluid prepared from rehydration powder?

[B] A pre-packaged fluid for rehydration?

[C] Homemade rehydration fluid?

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

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

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

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

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

CA10. Did you seek any advice or treatment for the illness from anywhere/anybody?

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

CA12. Was (name) given any medicine to treat this illness?

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

CA14. Check AG2: Child aged under 3?

CA15. The last time (name) defaceted, how did you remove the stools?

Immunization: IM

If an immunization card is available, copy the dates in IM3 for each type of immunization recorded on the card. IM6-IM16B will only be asked when 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?

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

IM3. Date of Immunization

(a) Copy dates for each vaccination from the card.
(b) Write '44' in day column if card has a record that vaccination was given but no date has been entered.

BCG (tuberculosis)

DPT1 (diphtheria, tetanus, pertussis)

DPT2 (diphtheria, tetanus, pertussis)

DPT3 (diphtheria, tetanus, pertussis)

DPT4 (diphtheria, tetanus, pertussis)

DPT5 (pertusis)

Polio 1 (child paralysis)

Polio 2 (child paralysis)

Polio 3 (child paralysis)

Polio 4 (child paralysis)

MRP (measles/rubeola)

HepB at birth

HepB1 (hepatitis B)

HepB2 (hepatitis B)

HIB1 (hemofilus influenca B)

HIB2 (hemofilus influenca B)

HIB3 (hemofilus influenca B)

HIB4 (hemofilus influenca B)

IM4. Check IM3. Are all vaccines (BCG to HIB4) recorded?
IM5. In addition to what is recorded on this card, did (name) receive any other vaccinations - including vaccinations received in campaigns, during epidemic or immunization days?
Record 'Yes' only if respondent mentions vaccines shown in the previous table and record all extra mentioned according to the instructions on the right.
IM6. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day?

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

IM8. Has (name) ever received any "vaccination drops in the mouth or by spoon" to protect him/her from getting diseases - that is, polio?

IM10. How many times was the polio vaccine received?

IM11. Has (name) ever received a DPT vaccination - i.e. an injection in the thigh or upper arm - to prevent him/her from getting diphtheria, tetanus, whooping cough, or?
Probe by indicating that DPT vaccination is sometimes given at the same time as Polio
IM12. How many times was a DPT vaccine received?

IM13. Has (name) ever been given a Hepatitis B vaccination - i.e. an injection in the thigh or upper arm - to prevent him/her from getting Hepatitis B, i.e. ...?

IM14. Was the first Hepatitis B vaccine received within 24 hours after birth, or later?
Ask for a birth card in which this information should be recorded
IM15. How many times was a hepatitis B vaccine received?

IM16. Has (name) ever received a Measles injection or an MRP injection - i.e. a shot in the arm at the age of 12 months or older - to prevent him/her from getting measles/rubeola?

IM16A. Has (name) ever received the hemophilus influence B (meningitis/lung inflammation) vaccination - that is, a shot in the arm or thigh - to prevent him/her from getting hemophilus influence B?

IM16B. How many times has he/she got a hemophilus influenca vaccine?

IM19. Could you tell me please if (name) has been vaccinated in any of the following campaigns, national immunization days and/or vitamin A or child health days:

[A] Immunization week ? April

[B] Parotitis (MrP) ? Jan-Jun 2009

[C] Measles ? Since Sept 2010

IM20. Issue a Questionnaire for Vaccinations Occurring in Health Institutions for this particular child. Fill in the panel in that questionnaire and continue further on.

UF13. Record the momentary time.
UF14. Is the respondent the mother or guardian of another child aged under 5 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 and fill it in with the same respondent]
[] No [End the interview with this respondent by thanking him/her for his/her cooperation and tell her/him that you will need to measure the weight and height of the child]
Check to see if there are any other members - women, children between 2 and 9 years of age, or children under-5 for which additional questionnaires should be administered in this household.
Move to the next questionnaire for women, for child disability, or for children under-5, or, if there aren?t any, start making arrangements for anthropometric measurements of all eligible children in the 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 separate child. Check the child's name and row number on the household roster before recording measurements.

AN1. Measurer's name and number:

AN2. Result of height / length and weight measurement

AN3. Child's weight

AN4. Child's length or height
Check age of child in AG2:
[] Child aged under 2. [Measure length (lying down).]
[] Child aged 2 or more. [Measure height (standing up).]
AN6. Is there another child in the household who is eligible for measurement?

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________