Identification

Province: _ _

District: _ _

Administrative post: _ _

Urban/rural (urban = 1, rural = 2): _

Name of the communal unit: ____

Name of the place (specify the neighborhood/village): _ _

Name of the listing area: ____

Listing area number (MICS I.D.): _ _ _

Household number: _ _ _

Name of the household head: ____

Name and line number of the mother/person who takes care of the child: ____ _ _

Child's name and line number: ____ _ _

Language used in the interview (Port = 1, Other = 6): _

Visits of the Inquirer

Date

Name of the inquirer: ____

Result: ____

Next visit:

Final visit:

Total number of visits: ____

Children under 5 years old questionnaire results codes:

Supervisor name and date_ _ / _ _ / _ _ _ _

Controller name and date:

Reviewed in the cabinet by name and date:

Typed by: _ _

Written by: _ _

Module on Birth Registration and Learning in Childhood: BR

UF10: On what day, month and year was (name) born?
If the child's mother/caregiver knows the exact date of birth, record the day; if not, draw a circle around "98" concerning the date.
Date of Birth:

UF11: How old is (name)?
Write year completed.
BR1. Does (name) have a birth certificate? Can I see it?

BR1A. Do you have any other document with the date of birth of (name)?

BR1B. Which documents?
Circle all the answers mentioned.
BR1C. Have you seen any of these documents?

BR2. Was the birth of (name) registered in the civil registry office?

BR3. Why was (name) not registered?

BR4. What should you do to register your child?
(1) Have a health card (2) Go to the civil registry office to collect a personal record book in the presence of the parents If indicates one or both options, mark correct (?1?). Otherwise, mark wrong/don?t know (?2?).
BR5. Check the age of the child in UF11: Is the child 3 or 4 years old?
BR6. Does (name) attend any organized learning or infant education, such as, for example, private or state establishments, including crèches?

BR7. In the last seven days, how many hours did (name) spend in this establishment?

BR7A. Check the age of the child in UF11: Is the child less than 1 year old?
BR8. In the past 3 days, did you or any member of the household aged over 15 years, involved in any of the following activities with (name):
If yes, ask: who took part in this activity with the child-- the mother, the father or another adult member of the household (including the person who looks after the child/informant)? Mark with a circle everything that applies.







Child development module: CE

Question CE1 should be asked just once of each tutor.

CE1. How many books are in the house, including school books (do not count books for under-fives)?

CE2. How many books for children or with pictures do you have for (name)?

CE4. Sometimes adults who care for children have to leave the house to go shopping, wash clothes, or for other reasons and have to leave young children with other people. In the last 7 days (day of the week) how many times was (name) left in the care of another child (that is, someone under 10 years old)?

CE5. In the last 7 days, how many times was (name) left alone, that is, without anyone to care for him/her?

Vitamin A Module: VA

VA1. Did (name) receive any dose of vitamin A in the last 6 months?

VA3. Where did (name) take his/her latest dose?

Breastfeeding Module: BF

BF1. Was (name) ever breastfed?

BF1A. How long after birth did (name) begin to breastfeed?
If less than an hour, circle "000" hours. If less than 24 hours, circle the hours, otherwise mark the days.
BF1B. During the first days after the birth, a yellow milk (colostrum) appears. Did (name) take this milk?

BF1C. In the first days after the birth, was anything other than mother?s milk given to (name)?

BF1D. What was given?
Anything other than mother's milk.
BF1E. For how many months did (name) take only breast milk?

BF2. Is (name) still being breastfed?

BF2A. For how many months did (name) take breast milk?

BF3. Since yesterday at this time, did (name) receive any of the following items:
Read each item out loud and register the answer before advancing to the next item









BF4. Check BF3H: Did the child receive solid or semi--sold foods (pap)?
BF5. Since yesterday at this time, how many times did (name) eat solid food, semi--solid food or non-liquid light foods? (if 7 or more times, write 7)
Illness treatment module: CA

CA1. Did (name) have diarrhoea in the last two weeks?
This concerns diarrhoea noted by the mother or person looking after the child, with three or more evacuations per day, or liquid faeces per day, or blood in the faeces.
CA1A. Has/has blood in faeces?

CA1B. On the worst day of the diarrhoea how many times did (name) defecate?

CA1C. How many days did the diarrhoea of (name) last?

CA1D. Does (name) still have diarrhoea?

CA2. When (name) had diarrhoea did you give him any of the following liquids to drink? Read each of the items out loud and record the answer before advancing to the next item.



CA2D. Was he/she given anything else to treat diarrhoea?

CA2E. What was given to treat diarrhoea?
Anything else? Circle all the answers mentioned.
CA3. Did you give (name) the same amount of liquid, more or less than usual?
If she says "less" ask: much less, or less than usual
CA4. Did you give (name) the same amount of food, more or less than usual?
If she says "less" ask: much less, or less than usual
CA5. Has (name) had a cough in the last two weeks?

CA5A. When (name) had a cough was it accompanied by fever?

CA6. When (name) had a cough, did he/she breathe more rapidly than usual, with short and rapid breaths?

CA7. Were the symptoms due to chest problems or to a blocked nose?

CA8. Did you seek advice or treatment for the cause of the cough?

CA9. Where did you seek aid or treatment? Anywhere else?
If a public or private health unit, write the name of the place, and identify the type and whether it is public or private. Circle all the answers, but do not make any suggestion.
CA10. Was (name) given any medicine to treat his/her illness?

CA11. What medicine was given to (name)?
Mark with a circle all the medicines given
CA12. Check UF11: Is the child less than 3 years old?
CA13. The last time that (name) defecated, how did you deal with his/her faeces?

CA14. Sometimes children are seriously ill and should be taken immediately to a health unit.
Ask the following question (CA14) just once to each mother/person taking care of the child.
Continue to ask for more signs or symptoms until the mother/person looking after the child cannot recall any further symptom. Mark with a circle all the symptoms mentioned, But do NOT make any suggestion.
Malaria module ML

ML1. Did (name) have fever in the last two weeks?

ML1A. I would now like to know what you did (in first, second and third place) after discovering that (name) had fever?

ML1A1. What she did in the first place

ML1A2. What she did secondly

ML1A3. What she did third place

ML1B. Check if (name) went to a health unit or a community health workers?
ML2. Did (name) go to any health unit during this illness?

ML3. Did (name) take any medication for fever or malaria which was given or prescribed in a health unit?

ML3A. For each of the following medicines, tell me if he/she took it immediately after the onset of the fever or many days afterwards?
If did not give any of the 3 go to ML3D
ML3B. Where did you obtain (name of antimalaria drug of ML3A)?
Circle all places mentioned
ML3C. How much did you pay for (Name of antimalaria drug of ML3A)?

ML3D. Check ML1A: Did they give medicines at home before taking the child to a health unit or community health worker?
ML5. Was (name) given any medicine for fever or malaria before he/she was taken to the health unit?

ML5A. Check ML1A: Did you give medicines at home or go to the pharmacy to buy them without a prescription?
ML6. Was (name) given any medicine for fever or malaria during this illness?

ML7. What medicine was (name) given at home?
Mark with a circle all the medicines given. Ask to see the medicine of the type is not known. If, even then, the type of medicine cannot be determined, show the person typical antimalarial drugs.

ML8. Check ML7: Anti--malarial drugs mentioned (codes A -- H)?
ML9. How much time after the fever began did (name) take the first (name of antimalarial drug of ML7)?
Register the code for the day on which the first antimalarial was given
ML10. Last night did (name) sleep under a mosquito net?

ML10A. Does (name) use a mosquito net?

ML10B. How did your household obtain the mosquito net?

ML11. How long ago did your household obtain the mosquito net?
If more than a month, circle ?1? and register ?00?. If more than a year and less than 3, circle ?2?and register the number of the corresponding year If the reply is ?12 months? or ?1 year?, ask to determine if it was exactly 12 months, or before or after
ML13. When you obtained this net, was it already treated with insecticide to kill or repel mosquitoes?

ML14. Since you obtained the mosquito net have you ever bathed it in a liquid to repel mosquitoes?

ML15. How long ago was the net bathed in this liquid to repel mosquitoes?

Immunization Module: IM

If a health card is available, copy the dates for IM2?IM8D for each type of vaccine or dose of vitamin A recorded on the card. IM10? IM17 are to record the vaccines that are not noted on the card. Questions IM10?IM17 will only be asked, if the card is not available.

IM1. Do you have a health card for (name)?
If the answer is "yes": Can I please see it?

A. Copy the dates for each vaccine registered on the card.
B. Write '44' in the column if the day of the card shows that the vaccine was given but no date was recorded.
Date of vaccination (DD/MM/YYYY)














IM9. Did (name) receive any vaccine that is not registered on the child's health card

IM9A. Ask for the vaccines that are not registered on the health card (use questions IM11 to IM17 only as an example to obtain replies) and, if the child received one of the vaccines not registered, write ?66? in the column for the day in questions IM2 to IM8D then go to IM19

IM10. Did (name) receive any vaccine to prevent diseases including the vaccines received in the vaccination campaigns?

IM10A. Did (name) receive an injection in the arm which leaves a scar (against tuberculosis)?

IM12. Did (name) receive drops in the mouth (vaccine against polio)?

IM13. Did (Name) receive the first vaccine against polio immediately after birth or later?

IM14. How many times did (name) receive it?

IM15. Did (Name) receive an injection given at the same time as the polio drops (tetravalent vaccine ? DPT/Hep. B)?

IM16. How many times did (name) receive it?

IM17. Did (name) receive an injection in the arm to prevent measles?

IM19. Tell me, please, whether (name) took part in any of the following campaigns:



IM20. Does any other child live in the household who is the son/daughter of, or under the care of, this informant? Check the list of the household, column HL8.
If this is the last child in the household, go to the anthropometry module.

Anthropometry Module: AN
After the questionnaires have been completed for all the children, the measurer weighs and measures each child. Register below the weight and length-height, taking care to register the measurements in the correct questionnaire for each child. Check the name of the child and line number in the household list before recording the measurements.

AN1. Weight of the child:

AN2. Length or height of the child.
Check the age of the child in UF11:
[] Child under 2 years old. [Measure length (child lying down).]
[] Child 2 or more years old. [Measure height (child standing up).]
AN3. Identification code of the measurer

AN4. Result of the measurement

AN5. Is there any other child in the household eligible for measurement?
Put together all the questionnaires of this household and check if all the identification numbers are inserted on each page. Count in the information panel on the household the number of interviews held.