Palestine 2010

Under-five child information panel: UF

All information in this questionnaire is for pure statistical purposes only. It is considered confidential in accordance with the Public Statistics Law of 2000.
Now I would talk to you about all the children who live with the family and their ages under 5 years.
This Questionnaire is made to be answered by all mothers or caretaker (check Household members list, question HL9), who provide care to children less than 5 years and live with them ( Household members list HL6).
There must be a separate Questionnaire for every eligible child.

UF2. Household number: _ _ _ _ _

PUF1. Questionnaire's no. in Numeration area: _ _

PUF2. Governorate: _ _

PUF3. Building's Address: ____

PUF4. Locality: _ _ _ _ _ _

PUF5. Name of household head: ____

UF1. Cluster number: _ _ _

UF3. Child's name:
Name ____

UF4. Child's line number (from HL1): _ _

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

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

UF8. Visits' schedule

PUF6. Total number of visits: _ _

UF9. Result of interview for children under 5
Codes refer to mother/caretaker.
UF10. Interviewer number interviewer name ____ _ _ _ _ _

UF11. Supervisor number Supervisor name ____

UF12. Field edited by (name and number)

UF13. Data entry clerk (name and number):

UF14. Date of entry: _ _ / _ _ / 2010

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?
If the mother/caretaker knows the exact birth date, also enter the day; otherwise, circle 98 for day. Month and year must be recorded. Check HL5: Date of birth
AG2. How old is (name)?
Record age in completed years. Compare with HL6. Record '00' if less than 1 year.
Breastfeeding: BF

BF1. Has (name) ever been breastfed?

BF2. Are you still breastfeeding (name)?

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.
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?

BF9. Did (name) drink 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 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?

PBF3. Refer to BF1 and circle the appropriate answer.
PBF4. Why didn?t you breastfeed (name)?
Probe for the main reason.
PBF5. Refer to BF2 Are you still breastfeeding (name)?

PBF6. Why did you stop breastfeeding (name) at this age?
Probe for and record the main reason.
Immunization against childhood illnesses: IM

IM1. Now, I would like to ask you about the health of (name). Do you have an immunization card for (name) where all vaccines given to him/her are recorded?
If yes, ask: Can I see the card?

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

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.

PIM1A.
IM6. For children who do not have a card or has a card but the card was not seen. Was (name) given any vaccine to immunize him/her against illnesses?

Please tell me if (name) has received any of the following vaccinations:.

IM7. 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 month after birth or later?

IM10. How many times was the polio vaccine received?

IM11. Has (name) ever received a DPT vaccination - that is, an injection in the thigh or buttocks - to prevent him/her from getting tetanus, whooping cough, or diphtheria?

IM12. How many times was a DPT vaccine received?

IM13. Has (name) ever been given a Hepatitis B vaccination - that is, an injection in the thigh or buttocks - to prevent him/her from getting Hepatitis B?
Is sometimes given at the same time as Polio and DPT vaccines
IM14. Was the first Hepatitis B vaccine received within 24 hours after birth, or later?

IM15. How many times was a hepatitis B vaccine received?

IM16. Has (name) ever received a Measles injection?

IM18. Has (name) received a vitamin a/d syrup within one year after birth?

PIM1. What is the reason for not receiving vitamin a/d?

PIM2. Has (name) received an iron syrup constantly after 6 months and for 1 year?

PIM3. What is the reason for not receiving iron syrup constantly?
Probe: If there is more than one choice
Care of illness: CA

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

PCA1. For how many days did this diarrhoea last?
If less than 1 day, record 00
PCA2. Was there blood in the stool?

CA2. I would like to know how much fluids (name) was given during the diarrhoea episode. Did he/she take less than usual, the same as usual, or more than usual?
If less, probe: did he/she take very much or a little less than usual?
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:

[A] ORS?

[C] Home made salt and sugar solution

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

CA6. What (else) was given to treat the diarrhoea?
Probe: Anything else?
PCA5A. During diarrhoea, from where did you seek advice or consultation?
Probe: If there more than one choice
PCA5. Why did not you take the advice of or consult anybody regarding the diarrhea?

PCA6. Did (name) have fever at any time during the past two weeks?

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 the advice or consult anybody regarding the fever or cough?

CA11. Where did you go to get the advice or consultation?
Probe: Any other place or person?
CA12. Was (name) given any medicine to treat fever or cough?

CA13. What was (name) given to treat the fever/cough?
Probe: Any prescription or treatment?
PCA7. Why did not you take the advice of or consult anybody regarding the fever or cough?

Birth registration: BR

PBR1. Child?s line number from HL1: _ _

PBR2. Name of child from HL2: ____

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?

Early childhood development: EC

PEC1. Child?s line number from HL1: _ _

PEC2. Name of child from HL2: ____

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?

[B] Toys from a shop?

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

[D] Computer/ Atari?

EC3A. In the past week how many days was (name) left alone for more than an hour?
If 'none' enter '00'. If 'don't know' enter '98'
EC3B. How many days in the past week was (name) left in the care of another child (that is, someone less than 10 years old) for more than an hour?
If 'none' enter '00'. If 'don't know' enter '98'
EC4. Check AG2
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?

EC6. Within the last seven days, about how many hours did (name) attend?

PEC3. Are you satisfied with the care the child received in this organization ?

PEC4. Why are you not satisfied?

Not enough toys in the organization

Carer is not qualified to offer the desired care for the child

Don't think it is important for the child

Not enough control

Other (specify) ____

EC7. In the past 3 days, did you or any household member engage in any of the following activities with (name):

[A] Reading a book

[B] Reading a story

[C] A song

[D] Taking him/her out

[E] Playing with him/her

[F] Spending time with him/her / drawing

EC8. Can (name) identify or name at least ten letters of the alphabet?

EC9. Can (name) read at least four simple, common 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. Does (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?

Anthropometric measurements / height and weight: AN

PAN1. Child?s line number from HL1: _ _

PAN2. Name of child from HL2: ____

AN1. Measurer's name and number:

PAN3. Assistant name and number:

AN2. Result of height / length and weight measurement

AN3. Child's weight in kg

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).]
HB Percentage for children less than 5 years: PCHB

Now I would like to measure the Hemoglobin percentage in the blood (HB) for (name) as part of the survey in order to measure anemia., Anemia is consider as one of the serious problems faced by a child as a result of poor nutrition., We will take some blood from the child?s finger and will get the result within minutes. You can have the examination result as well and we treat it as confidential information.

PHCB1. Result:

PCHB2. Name and number of person taking the HB measurement:

PCHB3. Mother's line number / carer from HL1: _ _

PCHB3. Child's line number from HL1: _ _

PCHB4. Child's name from HL2: ____

PCHB5. Percentage of HB in the blood (G\DL): _ _ _

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________