[Pakistan (Punjab) 2011]

Under-five child information panel: UF

This questionnaire is to be administered to all mothers or caretakers (see Household Listing Form, column HL9) who care for a child that lives with them and is under the age of 5 years (see Household Listing Form, column HL6).
A separate questionnaire should be used for each eligible child.

UF1. Cluster number (as per survey): _ _ _

UF2. Household number (as per survey): _ _

UF3. Child's name:
Name ____

UF4. Child's line number: _ _

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

UF6. Mother's / caretakers line number: _ _

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

UF8. Day / month / year of interview _ _ / _ _ / 2011

UF9. Result of interview for children under 5
Codes refer to mother/caretaker.
UF10. Field edited by (name and number)

UF11. Data entry clerk (name and number):

UF12. Record the 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/caretaker knows the exact birth date, also enter the day; 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 and correct AG1 and/or AG2 if inconsistent.
Birth registration: BR

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

BR2. Has (name)'s birth been registered with the civil authorities?

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

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 item 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 yesterday, during the day or night?

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

BF6. Did (name) drink milk, such as tinned, powdered or fresh animal milk yesterday, during the day or night?

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

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

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

BF15. Did (name) eat thin 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?

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?
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 made from a packet called ORS Packet?

[B] A pre-packaged ORS fluid?

[C] Home made fluid (boiled water, sugar and salt)?

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

CA6. What (else) was given to treat the diarrhoea?
Probe: Anything else? More than one answers are possible.
(Name) ____

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 any source?

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. More than one answers are possible
(Name of place) ____

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

CA13. What medicine was (name) given?
Probe: Any other medicine?
(Names of medicines) ____

CA14. Check AG2: Child aged under 3?
CA15. The last time (name) passed stools, what was done to dispose of the stools?

Immunization: IM

For children less than 3 years of age. If an immunization card is available, copy the dates in IM3 for each type of immunization recorded on the card. IM6-IM16 are for registering vaccinations that are not recorded on the card. IM6-IM16 will only be asked when a card is not available or the vaccines are not recorded in the card.

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 shows that vaccination was given but no date recorded.

BCG

Polio at birth

Polio 1

Polio 2

Polio 3

DPT+HepB+Hib

DPT+HepB+Hib

DPT+HepB+Hib

Measles (or MMR)

Measles (or MMR)

IM4. Check IM3. Are all vaccines (BCG to Measles) recorded?
IM5. In addition to what is recorded on this card, did (name) receive any other vaccinations - including vaccinations received in campaigns or immunization days?
Record 'Yes' only if respondent mentions vaccines shown in the table above.
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 scar?

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

IM9. Was the first polio vaccine received in the first two weeks after birth or later?

IM10. How many times was the polio vaccine received?

IM11A. Has (name) ever received a Pentavalent vaccination - that is, an injected on the thigh or buttocks - to prevent him/her from getting whooping cough or diphtheria, Pertusis, tetanus, Hepatitis and Influenza?

IM11B. How many times was a Pentavalent vaccine received?

IM16. Has (name) ever received a Measles injection or an MMR injection - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles?

IM18. Has (name) received a vitamin a dose like (this/any of these) within the last 6 months?
Show common types of ampules / capsules / syrups
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] 2-4 May, 2011 National Immunization Day (NID) against Polio

[B] 25-30 April, 2011 Mother child week

UF13. Record the time.
UF14. Is the respondent the mother or caretaker of another child age 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 to be administered to 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 other woman who is mother/care taker of a child under 5 at home.
If yes start in interview: And then start anthropometry measurements of all children under 5 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 child. Check the child's name and line number on the household listing 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 under 2 years old. [Measure length (lying down).]
[] Child age 2 or more years. [Measure height (standing up).]
AN5. Oedema
Observe and record
AN6. Is there another child in the household who is eligible for measurement?

Field editor's observations ________

Team Supervisor's observations ________