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Under--five Child information Panel

This questionnaire is to be administered to all mothers or caretakers (see household listing, column HL8) who care for a child that lives with them and is under the age of 5 years (see household listing, column HL5). A separate questionnaire should be used for each eligible child.
Fill in the cluster and household number, and names and line numbers of the child and the mother/caretaker in the space below. Insert your own name and number, and the date.

UF1. Region: _ _ _
Province: _ _ _

UF2. District: _ _ _
Sub-district: _ _ _

UF3. Address No.: _ _ _ _ _
Road: ______
Soi: _____

UF4. Urban area

Rural area

UF5. Primary sampling unit No. ______

UF6. Household number: _ _ _

UF3. Child's name: ____
Copy from HL2 in MICS2 Questionnaire

UF4. Child's line number: _ _
Copy from HL1 in MICS2

UF5. Mother's / caretaker's name: ____
Copy from H2 in MICS2 Questionnaire

UF6. Mother's/ caretaker's line number: _ _
Copy from HL8 in MICS2

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

UF9. Result of Interview for children under 5
See code in no. 7. Record code in UF9

UF8. Editing and Coding: Date _____
Name (Enumerator): ____
Name: (Editor): _____
Name (Supervisor): ______

UF10: Day/month/year of birth
Record day, month, and year of Birth. If don't know the date, Record "98"

UF11: Record age at the last birthday

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Birth Registration and Early Learning Module: BR

BR1. Does (name) have a birth certificate? May I see it?

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

BR3. Why is (name's) birth not registered?

BR4. Do you know how to register your child's birth?
If age 3 or 4 years skip to BR6, otherwise skip to BR8A

BR6. Does (name) attend any organized learning or early childhood education program, such as a private or government facility, including kindergarten or community child care?

BR7. Within the last seven days, about how many hours did (name) attend?

BR8. In the past 3 days, did you or any member of your household over 15 years of age engage in any of the following activities with (name):

If yes, ask: who engaged in each activity.

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Child development: CE

CE1. How many books are there in the household?
If ?none? enter 00

CE2. How many children's books or picture books do you have for (name)?
If 'none' enter 00

CE3. I am interested in learning about the things that (name) plays with when he/she is at home.
What does (name) play with?
Circle all that apply

CE4. 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 with others. Since last (day of the week) how many times was (name) left in the care of another child (that is, someone less than 10 years old)?
If 'none' enter 00

CE5. In the past week, how many times was (name) left alone?
If 'none' enter 00

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Breastfeeding Module: BF

BF1. Has (name) ever been breastfeed?

BF2. Is he/she still being breast--fed?

BF3. Since this time yesterday, did he/she receive any of the following:

For code 1 in BF3H
BF5. Since this time yesterday, how many times did (name) eat solid, semi--solid, or soft foods other than liquids? (if 7 or more times record 7)

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Care of illness module: CA

CA1. Has (name) had diarrhea in the last two weeks, that is, since (day of the week) of the week before last?

CA2. During this last episode of diarrhea, did (name) drink any of the following: (Read each item)

CA3. During (name's) illness did he/she drink much less, about the same, or more than usual?

CA4. During (name's) illness, did he/she eat less, about the same, or more food than usual?

CA5. Has (name) had an illness with a cough at any time in the last two weeks.

CA6. When (name) had an illness with a cough, did he/she breathe faster than usual with short, quick breaths or have difficulty breathing?

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

CA8. Did you seek advice or treatment for the illness outside the home?

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CA9. From where did you seek care? Anywhere else?

Circle all providers mentioned, but do not prompt with any suggestions. If source is hospital, health center, or clinic, write the name of the place

CA10. Was (name) given medicine to treat this illness?

CA11. What medicine was (name) given?
Circle all medicines given

For children age under 3 years (code 0, 1, 2 in UF11)
CA13. The last time (name) passed stools, what was done to dispose of the stools?

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CA14. What types of symptoms would cause you to take your child to a health facility right away?

Circle all symptoms mentioned. Ask CA14 only once for each mother/caretaker. For children age under 5 years.

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Immunization Module: IM

IM1. Is there a vaccination card for (name)?

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.
Date of immunization (DD/MM/YYYY)

IM9. In addition to the vaccinations and vitamin A capsules shown on this card, did (name) receive any other vaccinations?

IM10. Has (name) ever received any vaccinations to prevent him/her from getting diseases?

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IM11. Has (name) ever been given a BCG vaccination against tuberculosis -- that is, an injection in the arm or shoulder that caused a scar?

IM12. Has (name) ever been given any "vaccination drops in the mouth" to protect him/her from getting diseases -- that is, polio?

IM13. How old was he/she when the first dose was given?

IM14. How many times has he/she been given these drops?

IM15. Has (name) ever been given "DPT vaccination injections" - that is, an injection in the thigh or buttocks - to prevent him/her from getting tetanus, whooping cough, diphtheria? (Sometimes given at the same time as polio)

IM16. How many times?

IM17. Has (name) ever been given "Measles vaccination injections" or MMR -- that is, a shot in the arm at the age of 9 months or older?

IM19. Please tell me if (name) has participated in National Immunization Days (Polio)?

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Anthropometry Module: AN
The measurer weighs and measures each child under 5 years after interviewed.

AN1. Child's weight

AN2. Child's length or height

Check age of child in UF11:

[] Child under 2 years old. [Measure length (lying down).]
[] Child age 2 or more years. [Measure height (standing up).]

AN4. Result of measurement