MICS questionnaire for children under five
Questionnaire for children under five
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.
UF5. Mother's/caretaker's name:
UF6. Mother's/caretaker's line number: _ _
UF7. Interviewer's name and number:
Repeat greeting if not already read to this respondent:
We are from the national statistical office of Mongolia and are conducting a survey about the situation of children, families and households. I would like to talk to you about (name)'s health and well-being nearly 20 minutes.According to the article 5, paragraph 4 of the Mongolian state law on confidentiality of an individual and article 22, paragraph 3 of the law on statistics all the information we obtain will remain strictly confidential.
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 20 minutes Again, all the information we obtain will remain strictly confidential and anonymous.
[] No, permission is not given (Circle '03' in UF9. Discuss this result with your supervisor)
Date and result of the interview:
Number of times visited
UF8. Year/month/day of interview
HH9. Result of the interview* _ _
Codes refer to mother/caretaker.
[] 02 Not at home
[] 03 Refused
[] 04 Partly completed
[] 05 Incapacitated
[] 96 Other (specify) ____
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.
_ _ Day
[] 98 DK day
_ _ Month
20 _ _ Year
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.
BR1. Does (name) have a birth certificate?
If yes, ask: may I see it?
[] 2 Yes, not seen (Go to next module)
[] 3 No
[] 8 DK
BR2. Has (name)'s birth been registered with the civil authorities?
[] 2 No
[] 8 DK
BR3. Do you know how to register (name)'s birth?
[] 2 No
AG1. Now I would like to ask you some questions about (name).
On what day, month and year was (name) born?
Probe: What is his / her birthday? If the child's birth date is known, record it in day part; if not known, circle 98 for day. Month and year must be recorded.
20 _ _ Year
_ _ Month
_ _ Day
[] 98 DK day
Probe: How old was (name) at his / her last birthday? Record age in completed years. Record '0' if less than 1 year. Must compare and correct AG1 and/or AG2 if inconsistent.
BR1. Does (name) have a birth certificate?
If yes, ask: may I see it?
[] 2 Yes, not seen (Go to next module)
[] 3 No
[] 8 DK
BR2. Has (name)'s birth been registered with khoroo/bag?
[] 2 No
[] 8 DK
BR3. Do you know how to register (name)'s birth?
[] 2 No
Early childhood development: EC
EC1. How many children's books or picture books do you have for (name)?
[] 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.
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 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 alone or leave in the care of another child.
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?
[B] Left in the care of another child whose under 10, for more than an hour?
EC4. Check AG2 for age of child.
[] Child age 2, 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?
[] 2 No
[] 8 DK
EC5A. Check AG2 for age of child.
[] Child age 3 or 4 (Continue with EC7)
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, probe: Who engaged in this activity with (name)?
Circle all that apply.
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
[] B Father
[] X Other
[] Y No one
EC7N. 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 colours?
[] 2 No
[] 8 DK
EC7M. Can (name) recognize simple shapes such as triangles, rectangles and circles?
[] 2 No
[] 8 DK
EC8. Can (name) identify or name at least ten letters of the alphabet?
[] 2 No
[] 8 DK
EC9. Can (name) read at least four simple words?
[] 2 No
[] 8 DK
EC10. Does (name) know the name and recognize the symbol of all numbers from 1 to 10?
[] 2 No
[] 8 DK
EC11. Can (name) pick up a small object with two fingers, like a stick or a rock from the ground?
[] 2 No
[] 8 DK
EC11A. Can (name) hold objects with his/her thumb, index finger or middle finger, like a spoon, fork or pen?
[] 2 No
[] 8 DK
EC12. Is (name) sometimes too sick to play?
[] 2 No
[] 8 DK
EC13. Does (name) follow simple directions on how to do something correctly?
[] 2 No
[] 8 DK
EC14. When given something to do, is (name) able to do it independently?
[] 2 No
[] 8 DK
EC15. Does (name) get along well with other children?
[] 2 No
[] 8 DK
EC16. Does (name) kick, bite, or hit other children or adults?
[] 2 No
[] 8 DK
EC17. Does (name) get distracted easily?
[] 2 No
[] 8 DK
Breastfeeding and dietary intake: BD
[] Child age 3 or 4 (Go to care of illness module.)
BD2. Has (name) ever been breastfed?
[] 2 No (Go to BD4)
[] 8 DK (Go to BD4)
BD3. Is (name) still being breastfed?
[] 2 No
[] 8 DK
BD4. Yesterday, during the day or night, did (name) drink anything from a bottle with a nipple?
[] 2 No
[] 8 DK
BD5. Did (name) drink ORS (oral rehydration solution) yesterday, during the day or night?
[] 2 No
[] 8 DK
BD6. Did (name) drink or eat vitamin or mineral supplements or any medicines yesterday, during the day or night?
[] 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:
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[D] Milk such as tinned, powdered, fresh animal milk or milk diluted with water?
[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank milk
[E] Infant formula, e.g., Milsan, Nana?
[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank infant formula
[] 2 No
[] 8 DK
[] 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'.
[] 2 No
[] 8 DK
_ Number of times drank/ate yogurt
[B] A commercially fortified baby food, e.g., Humana?
[] 2 No
[] 8 DK
[C] Bread, rice, noodles, porridge, or other foods made from grains?
[] 2 No
[] 8 DK
[D] Pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
[] 2 No
[] 8 DK
[E] Potatoes, turnip, wild radish or any other foods made from roots?
[] 2 No
[] 8 DK
[F] Any dark green, leafy vegetables such as broccoli, spinach?
[] 2 No
[] 8 DK
[G] Vitamin A - rich vegetables such as peach, kiwi, or banana?
[] 2 No
[] 8 DK
[H] Any other fruits or vegetables?
[] 2 No
[] 8 DK
[I] Liver, kidney, heart or other organ meats?
[] 2 No
[] 8 DK
[J] Any meat, such as beef, pork, lamb, goat, chicken, or duck?
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[M] Any foods made from beans, peas, lentils, or nuts?
[] 2 No
[] 8 DK
[N] Cheese, milk or other food made from milk?
[] 2 No
[] 8 DK
[O] Any other solid, semi-solid, or soft food that I have not mentioned?
[] 2 No
[] 8 DK
BD9. Check BD8 (Categories "A" through "O").
[] Else (Continue with BD10)
BD10. Check to determine whether a child ate any solid, semi-solid or soft foods yesterday during the day or night.
[] 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'.
[] 8 DK
If an immunization (child health) card or mother and child's health book is available, copy the dates in IM3 for each type of immunization and Vitamin A recorded on the card. IM6-IM17 are for registering vaccinations that rae not recorded on the card. IM6-IM17 will only be asked when a card is not available.
IM1. Does (name) have a vaccination card?
If yes: May I see it please?
[] 2 Yes, mother/caretaker didn't have it (Go to IM2A)
[] 3 No card
IM2. Did name ever have a vaccination card?
[] 2 No (Go to IM6)
IM2A. Has (name) been registered with corresponding community health post?
[] 2 No
IM2B. Does (name) have mother and child's health book?
If yes: May I see it?
[] 2 Yes, mother/caretaker didn't have it (Go to IM6)
[] 3 No card (Go to IM6)
IM3.
(b) Write '4444' in year column if card or book shows that vaccination was given but no date recorded.
IM4. Check IM3. Are all vaccines (BCG to Measles1) recorded on the card or book?
[] No (Continue with IM5)
IM5. In addition to what is recorded on this card or child's health book, did (name) receive any other vaccinations - including vaccinations received in campaigns or immunization days?
[] No/DK (Go to IM18)
IM6. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day?
[] 2 No (Go to IM18)
[] 8 DK (Go to IM18)
IM7. Has (name) ever received a BCG vaccination against tuberculosis - that is, an injection in the arm or shoulder that usually causes a scar?
[] 2 No (Go to IM18)
[] 8 DK (Go to IM18)
IM7A. When did (name) receive the BCG vaccination against tuberculosis after birth?
[A] Within 24 hours after birth?
[] 2 No
[B] After 24 hours but before leaving the health facility?
[] 2 No
[C] Within 2 weeks after birth?
[] 2 No
IM8. Has (name) ever received any vaccination drops in the mouth to protect him/her from polio?
[] 2 No (Go to IM11)
[] 8 DK (Go to IM11)
IM9. When did (name) receive the first polio vaccination after birth?
[A] Within 24 hours after birth?
[] 2 No
[B] After 24 hours but before leaving the health facility?
[] 2 No
[C] Within 2 weeks after birth?
[] 2 No
IM10. How many times was the polio vaccine received?
[] 8 DK
IM11. Has (name) ever received a pentavalent vaccination - that is, an injection in the thigh? Pentavalent is a vaccination against tetanus, whooping cough, diphtheria, hepatitis B, and haemophilus influenzae B?
Probe by indicating that pentavalent vaccinations are sometimes given at the same time as polio vaccination.
[] 2 No (Go to IM13)
[] 8 DK (Go to IM13)
IM12. How many times was a pentavalent vaccine received?
[] 8 DK
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.
[] 2 No (Go to IM16)
[] 8 DK (Go to IM16)
IM14. When did (name) receive the first Hepatitis B vaccine after birth?
[A] Within 24 hours after birth?
[] 2 No
[B] After 24 hours but before leaving the health facility?
[] 2 No
[C] Within 2 weeks after birth?
[] 2 No
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?
[] 2 No (Go to IM18)
[] 8 DK (Go to IM18)
IM16A. How many times was Measles injection recieved?
[] 8 DK
IM18. Did (name) take vitamin A in the last 12 months?
Show common types of ampoule/capsules/syrups
[] 2 No (Go to IM18B)
[] 8 DK (Go to IM18B)
IM18A. How many times was the vitamin A recieved?
[] 8 DK
IM18B. Has (name) ever received Vitamin D?
[] 2 No (Go to IM19)
[] 8 DK (Go to IM19)
IM18C. How many months (name) was when received Vitamin D?
[] 8 DK
IM18D. Has (name) received Vitamin D by tablet or syrup?
[A] Received vitamin D by tablet?
[] 2 No
[] 8 DK
[B] Received vitamin D by syrup?
[] 2 No
[] 8 DK
IM19. Has (name) ever participated in the following national immunization days:
[A] May immunization
[] 2 No
[] 8 DK
[B] October immunization
[] 2 No
[] 8 DK
IM20. Is the vaccination card of the child kept at the health facility?
[] 2 No (Go to next module)
CA1. In the last two weeks, has (name) had diarrhoea?
[] 2 No (Go to CA7)
[] 8 DK (Go to CA7)
CA2. I would like to know how much (name) was given to drink during the diarrhoea (including breastmilk and other liquid).
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?
[] 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?
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Never gave a food
[] 6 Still breastfeeding
[] 8 DK
CA3A. Did you seek any advice or treatment for the diarrhoea from any source?
[] 2 No (Go to CA4)
[] 8 DK (Go to CA4)
CA3B. From where did you seek advice or treatment?
Probe: Anywhere else or someone else? Circle all providers mentioned, but do not prompt with any suggestions. Probe to identify each type of source. If unable to determine whether referred to public or private sector, write the name of the place.
(Name of place) ____
[] B Government health centre
[] C Family clinic
[] D Soum or bag health worker, nurse
[] J Physician
[] K Pharmacy
[] R Traditional practitioner
[] Only one code circled (Go to CA4)
CA3D. Where or whom did you first seek advice?
Probe to identify the type of source. Do not prompt with any suggestions. If unable to determine whether referred to public or private sector, write the name of the place.
(Name of place) ____
[] 12 Government health centre
[] 13 Family clinic
[] 14 Soum or bag health worker, nurse
[] 22 Physician
[] 23 Pharmacy
[] 33 Traditional practitioner
CA4. During the time (name) had diarrhoea, was (name) given to drink:
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
Specify ____
[] Child was not given ORS (all "no" in A-H in CA4) (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) ____
[] 12 Government health centre
[] 13 Family clinic
[] 14 Soum or bag health worker, nurse
[] 22 Physician
[] 23 Pharmacy
[] 33 Traditional practitioner
CA4C. During the time (name) had diarrhoea, was (name) given:
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] Child did not have 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) ____
[] 12 Government health centre
[] 13 Family clinic
[] 14 Soum or bag health worker, nurse
[] 22 Physician
[] 23 Pharmacy
[] 33 Traditional practitioner
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] A homemade ORS fluid for diarrhoea?
[] 2 No
[] 8 DK
[B] Boiled water?
[] 2 No
[] 8 DK
[C] Diluted soup?
[] 2 No
[] 8 DK
[D] Rice juice?
[] 2 No
[] 8 DK
CA5. Was anything (else) given to treat the diarrhoea
[] 2 No (Go to CA7)
[] 8 DK (Go to CA7)
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) ____
[] B Antimotility
[] G Other pill or syrup (Not antibiotic)
[] H Unknown pill or syrup
[] M Non-antibiotic
[] N Unknown injection
[] Q Home remedy/herbal medicine
[] X Other (specify) ____
CA6C. Who recommended such treatment?
[] 2 Pharmaceutics
[] 3 Mother/caretaker
[] 4 Relative/friend
[] 6 Other (specify) ____
[] 8 DK
CA6A. In the last two weeks, has (name) been ill with a fever at any time?
[] 2 No
[] 8 DK
CA7. At any time in the last two weeks, has (name) had an illness with a cough?
[] 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?
[] 2 No (Go to CA9B)
[] 8 DK (Go to CA9B)
CA9. Was the fast or difficult breathing due to a problem in the chest or a blocked nose?
[] 2 Blocked or runny nose only (Go to CA9B)
[] 3 Both (Go to CA9B)
[] 6 Other (specify) ____ (Go to CA9B)
[] 8 DK (Go to CA9B)
[] Child did not have fever (Go to CA14)
CA9B. I would like to know how much (name) was given to drink (including breastmilk) during the illness with a (fever/cough). During the time (name) had (fever/cough), 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?
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Nothing to drink
[] 8 DK
CA9C. During the time (name) had (fever/cough), 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?
[] 2 Somewhat less
[] 3 About the same
[] 4 More
[] 5 Never gave a food
[] 6 Still breastfeeding
[] 8 DK
CA10. Did you seek any advice or treatment for the illness from any source?
[] 2 No (Go to CA12)
[] 8 DK (Go to CA12)
CA11. From where or whom did you seek advice or treatment?
Probe: Anywhere else or someone 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) ____
[] B Government health centre
[] C Family clinic
[] D Soum or bag health worker, nurse
[] J Physician
[] K Pharmacy
[] R Traditional practitioner
[] Only one code circled (Go to CA12)
CA11B. From where or whom did you first seek advice or treatment?
Probe: Anywhere else or someone 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) ____
[] 12 Government health centre
[] 13 Family clinic
[] 14 Soum or bag health worker, nurse
[] 22 Physician
[] 23 Pharmacy
[] 33 Traditional practitioner
CA12. At any time during the illness, was (name) given any medicine/injection for the illness?
[] 2 No (Go to CA14)
[] 8 DK (Go to CA14)
CA13. What medicine/injection was (name) given?
Probe: Any other medicine/injection? Circle all medicines given. Write brand name(s) of all medicines mentioned.
(Names of medicines) ____
[] J Injection
[] Q Aspirin
[] R Ibuprofen
[] Z DK
CA13A. Check CA13 for antibiotic mentioned (codes I or J)?
[] No, (no circled in 'I' or 'J' in CA13) (Go to CA13C)
CA13B. Where did you get the antibiotics?
Probe to identify the type of source. If unable to determine whether referred to public or private, write the name of the place.
(Name of place) ____
[] 12 Government health centre
[] 13 Family clinic
[] 14 Soum or bag health worker, nurse
[] 22 Physician
[] 23 Pharmacy
[] 33 Traditional practitioner
[] 96 Other (specify) ____
[] Child age 3 or 4 (Go to UF13)
CA15. The last time (name) passed stools, what was done to dispose of the stools?
[] 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
UF14. Check List of Household Members, columns HL7B and HL15.
Is the respondent the mother or caretaker of another child under 5 living in this household?
[] 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.)
After questionnaires for all children are complete, the measurer weighs and measures each child under 5.
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 HL of the household questionnaire before recording measurements.
AN1. Measurer's name and number:
AN2. Result of height / length and weight measurement:
[] 2 Child not present (Go to AN6)
[] 3 Child or mother/caretaker refused (Go to AN6)
[] 6 Other (specify) ____ (Go to AN6)
[] 99.9 Weight not measured
AN3A. Was the child undressed to the minimum?
[] No, the child could not be undressed to the minimum.
AN3B. Check AG2 for age of child:
[] Child age 2 or more years (Measure height (standing up))
AN4. Child's length or height:
[] 9999 Length/height not measured (Go to AN5A)
AN4A. How was the child actually measured? Lying down or standing up?
[] 2 Standing up
[] Child age 3 or 4 (Go to AN6)
AN5B. Does (name) have child health book?
[] No (Go to AN6)
[] DK (Go to AN6)
AN5C. Check whether the (name)'s weight has been recorded in his/her health book in the last 4 months and record.
[] No, didn't record
[] DK
AN5D. Check whether the (name)'s length/height has been recorded in his/her health book in the last 4 months and record.
[] No, didn't record
[] DK
AN6. Is there another child in the household who is eligible for measurement?
[] 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 ________
Questionnaire form for vaccination records at health facility
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.
HF5. Mother's/caretaker's name:
HF6. Mother's/caretaker's line number: _ _
HF7. Interviewer's name and number:
HF8. Year/month/day of facility visit
HF9. Year/month/day of birth (from AG1 in questionnaire for children under-5)
UF10. Name of health facility: ____
HF11. Result of health facility visit
[] 02 Vaccination record not seen
[] 96 Other (specify) ____