MICS questionnaire for children under five
Nepal Multiple Indicator Cluster Survey 2014
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:
UF8. Day/month/year of interview
Repeat greeting if not already read to this respondent:
We are from Central Bureau of Statistics (a bureau of Nepal Government under the National Planning Commission), in Kathmandu. 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 25 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 25 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)
UF9. Result of interview for children under 5
Codes refer to mother/caretaker.
[] 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 ____ _ _
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 Village Development Committee or Municipality?
[] 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.
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, that is, someone less than 10 years old, for more than an hour?
[] 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?
[] 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.
[] 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
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?
[] 2 No
[] 8 DK
EC8A. Can (name) identify or recognize at least a letter of his/her name?
[] 2 No
[] 8 DK
EC9. Can (name) read at least four simple, popular words?
[] 2 No
[] 8 DK
EC9A. Can (name) identify or recognize four popular logos?
[] 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
EC10A. Can (name) count the number 1 to 10 or walk 10 steps with counting?
[] 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
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
EC18. How many classes would you like (name) to attend?
[] 00 None
[] 98 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, or fresh animal milk?
[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank milk
[E] Infant formula like lactogen?
[] 1 Yes
[] 2 No
[] 8 DK
_ Number of times drank infant formula
[F] Any other liquids like plain tea, coffee?
(Specify) ____
[] 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] Any commercially fortified baby food, e.g., cerelac, nestum, champion?
[] 2 No
[] 8 DK
[C] Bread (roti), 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] White potatoes, white yams, manioc, cassava, or any other foods made from roots?
[] 2 No
[] 8 DK
[F] Any dark green, leafy vegetables like spinach, garden cress, mustard green?
[] 2 No
[] 8 DK
[G] Ripe mangoes, papayas or apricot?
[] 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, buff, yak, lamb, goat, chicken, or duck?
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[L] Fresh or dried fish or shellfish?
[] 2 No
[] 8 DK
[M] Any foods made from beans, peas, lentils, or nuts?
[] 2 No
[] 8 DK
[N] Fresh and dried cheese, paneer or other food made from milk?
[] 2 No
[] 8 DK
[O] Any other solid, semi-solid, or soft food that I have not mentioned? (Specify) ____
[] 2 No
[] 8 DK
BD9. Check BD8 (Categories "A" through "O").
[] At least one "yes" or all "DK" (Go to BD11)
BD10. Probe to determine whether the 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 a child health card (HMIS form no. 3) is availabile, copy the dates in IM3 for each type of immunization and Vitamin A recorded on the card. IM6-IM17 are for registering vaccinations that are not 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?
[] 2 Yes, not seen (Go to IM6)
[] 3 No card
IM2. Did you ever have a vaccination (child health) card for (name)?
[] 2 No (Go to IM6)
IM3.
(b) Write '44' in day column if card shows that vaccination was given but no date recorded.
IM4. Check IM3. Are all vaccines (BCG to Japanese Encephalitis) recorded?
[] 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?
[] 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?
[] 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?
[] 2 No
[] 8 DK
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)
IM10. How many times was the polio vaccine received?
IM11. Has (name) ever received a DPT vaccination / the pentavalent vaccination - that is, an injection in the thigh to prevent him/her from getting tetanus, whooping cough, or diphtheria?
Probe by indicating that DPT/the pentavalent vaccination is sometimes given at the same time as Polio.
[] 2 No (Go to IM16)
[] 8 DK (Go to IM16)
IM12. How many times was a DPT/the pentavalent vaccine received?
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
[] 8 DK
IM16A. Check AG2. Child age is 1 or 2 years?
[] No, child is less than 1 or more than 2 (Continue with IM19)
IM16B. Has (name) ever received a Japanese Encephalitis (JE) injection - that is, a shot in the arm at the age after 12 months or older - to prevent him/her from getting Japanese Encephalitis?
[] 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] National Vitamin A Day, Vitamin A, Kartik 7-8, 2070 BS or Baisakh 6-7, 2071 BS
[] 2 No
[] 8 DK
[B] National Polio Campaign, Against Polio
[] 2 No
[] 8 DK
[C] [Insert date/type of campaign C, antigens]
[] 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.
CA1. In the last two weeks, has (name) had diarrhoea?
[] 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?
[] 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 Stopped food
[] 6 Never gave food
[] 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? 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 Primary health care centre
[] C Health post/sub health post
[] D Village health worker
[] E Mobile/outreach clinic
[] F Female community health volunteer (FCHV)
[] H Other public (specify) ____
[] J Private physician
[] K Private pharmacy
[] L Mobile clinic
[] O Other private medical (specify) ____
[] Q Shop
[] R Traditional practitioner
[] T FPAN
[] H Other NGO (specify) ____
[] Only one code circled (Go to CA4)
CA3D. From where did you first seek advice for diarrhoea?
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 Primary health care centre
[] 13 Health post/sub health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 17 FCHV
[] 16 Other public (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 32 Shop
[] 33 Traditional practitioner
[] 42 Family Planning Association of Nepal (FPAN)
[] 46 Other NGO (specify) ____
CA4. During the time (name) had diarrhoea, was (name) given to drink:
[A] A fluid made from a special packet called Jeevan Jal or Jeevan ball or Nava jeevan?
[] 2 No
[] 8 DK
[B] A pre-packaged ORS fluid for diarrhoea [insert local name for pre-packaged ORS fluid]?
[] 2 No
[] 8 DK
[] Child was not given any 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) ____
[] 12 Primary health care centre
[] 13 Health post/sub health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 17 FCHV
[] 16 Other public (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 32 Shop
[] 33 Traditional practitioner
[] 42 FPAN
[] 46 Other NGO (specify) ____
[] 96 Other (specify) ____
CA4C. During the time (name) had diarrhoea, was (name) given:
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
[] Child was not given any zinc (Go to CA5)
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 Primary health care centre
[] 13 Health post/sub health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 17 FCHV
[] 16 Other public (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 32 Shop
[] 33 Traditional practitioner
[] 42 FPAN
[] 46 Other NGO (specify) ____
[] 96 Other (specify) ____
CA5. Was anything (else) given to treat the diarrhoea
[] 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) ____
[] B Antimotility
[] G Other pill or syrup (Not antibiotic, antimotility or zinc)
[] H Unknown pill or syrup
[] M Non-antibiotic
[] N Unknown injection
[] Q Home remedy/herbal medicine
[] X Other (specify) ____
CA6A. In the last two weeks, has (name) been ill with a fever at any time?
[] 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?
[] 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 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?
[] 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)
[] Child did not have fever (Go to CA14)
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 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) ____
[] B Primary health care centre
[] C Health post/sub health post
[] D Village health worker
[] E Mobile/outreach clinic
[] F FCHV
[] H Other public (specify) ____
[] J Private physician
[] K Private pharmacy
[] L Mobile clinic
[] O Other private medical (specify) ____
[] Q Shop
[] R Traditional practitioner
[] T FPAN
[] U Other NGO (specify) ____
CA12. At any time during the illness, was (name) given any medicine for the illness?
[] 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) ____
[] B Chloroquine
[] C Amodiaquine
[] D Quinine
[] E Combination with Artemisinin
[] H Other anti-malarial (specify) ____
[] J Injection
[] Q Aspirin
[] R Ibuprofen
[] Z DK
CA13A. Check CA13: Antibiotic mentioned (codes I or J)?
[] No (Go to CA13C)
CA13B. Where did you get the antibiotics?
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 Primary health care centre
[] 13 Health post/sub health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 17 FCHV
[] 16 Other public (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 32 Shop
[] 33 Traditional practitioner
[] 42 FPAN
[] 46 Other NGO (specify) ____
[] 96 Other (specify) ____
CA13C. Check CA13: Anti-malarial mentioned (codes A - H)?
[] No (Go to CA14)
CA13D. Where did you get this medicine?
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 Primary health care centre
[] 13 Health post/sub health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 17 FCHV
[] 16 Other public (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 32 Shop
[] 33 Traditional practitioner
[] 42 FPAN
[] 46 Other NGO (specify) ____
[] 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.
[] 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 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 age 0-4 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.
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:
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 age of child in AG2:
[] Child age 2 or more years (Measure height (standing up))
AN4. Child's length or height:
[] 999.9 Length/height not measured (Go to AN6)
AN4A. How was the child actually measured? Lying down or standing up?
[] 2 Standing up
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 ________