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. Cluster number: _ _ _

UF2. Household number: _ _ _

UF3. Child's name: ____

UF4. Child's line number: _ _

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

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

UF7. Interviewer name and number: ____ _ _

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

UF9. Result of Interview for children under 5
Codes refer to mother/caregiver

Repeat greeting if not already read to this respondent:
We are from NIS. We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will take about (number) minutes. All the information we obtain will remain strictly confidential and your answers will never be identified. Also, you are not obliged to answer any question you do not want to, and you may withdraw from the interview at any time. May I start now?

If permission is given, begin the interview. If the respondent does not agree to continue, thank him/her and go to the next interview. Discuss this result with your supervisor for a future revisit.

UF10: Now I would like to ask you some questions about the health of each child under the age of 5 in your care, who lives with you now. Now I want to ask you about (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.

Date of Birth:

UF11: How old was (name) at his/her last birthday?
Record age in completed years.

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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 Zags?

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

BR4. Do you know how to register your child's birth?

BR5. Check age of child in UF11: Child is under 3 or 4 years old?

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 this activity with the child-- the mother, the child's father or other adult member of the household (including the caretaker/ respondent)?

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Child development: CE

Question CE1 is to be administered only once to each caretaker.

CE1. How many books are there in the household? Please include schoolbooks, but not other books meant for children, such as picture books
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? Does he/she play with

If the respondent says "YES" to any of the prompted categories, then probe to learn specifically what the child plays with to ascertain the response

Code Y if child does not play with any of the items mentioned.

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

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:
Read each item aloud and record response before proceeding to the next item

BF4. Check BF3H: Child received solid or semi--sold (mushy) food?

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?

Diarrhea is determined as perceived by mother or caretaker, or as three or more loose or watery stools per day, or blood in stool.

CA2. During this last episode of diarrhea, did (name) drink any of the following: Read each item aloud and record response before proceeding to the next 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?
If "less", probe: much less or a little less?

Source and cost of supplies for ORS packets

CA4A. Check CA2A: ORS packet used?

CA4B. Where did you get the Rehydron or Apectral?

CA4C. How much did you pay for the Rehydron or Apectral?

CA5. Has (name) had an illness with a cough at any time in the last two weeks, that is, since (day of the week) of the week before last?

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 below. Probe to identify the type of source and circle the appropriate code.

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

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

CA11A. Check CA11: Antibiotic given?

CA11B. Where did you get the antibiotic?

CA11C. How much did you pay for the antibiotic?

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CA14. Sometimes children have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take your child to a health facility right away?

Ask the following question (CA14) only once for each mother/caretaker.

Keep asking for more signs or symptoms until the mother/caretaker cannot recall any additional symptoms. Circle all symptoms mentioned, But do NOT prompt with any suggestions

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Immunization Module: IM

If an immunization card is available, copy the dates in IM2--IM8 for each type of immunization or vitamin A dose recorded on the card. IM10--IM18 are for recording vaccinations that are not recorded on the card. IM10--IM18 will only be asked when a card is not available.

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)

IM10. Has (name) ever received any vaccinations to prevent him/her from getting diseases, including vaccinations received in a campaign or immunization day?

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

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 ? just after birth (within two weeks) or later?

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?

IM16A. Has (name) ever been given "HepB vaccination injections" - that is, an injection in the thigh or buttocks - to prevent him/her from getting Hepatitis B?
(Sometimes given at the same time as DPT and Polio)

IM16B. 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 -- to prevent him/her from getting measles?

IM20A. Obtain all information needed to identify the child's individual card in the healthcare facility. After interview visit the healthcare facility and complete the Immunization Module by healthcare data.

IM20. Does another eligible child reside in the household for whom this respondent is mother/caretaker?

If this is the last eligible child in the household, go on to anthropometry module.

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Anthropometry Module: 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. 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).]

AN2A. Measure of upper arm circumference (MUAC).

AN3. Measurer's identification code

AN4. Result of measurement

AN5. Is there another child in the household who is eligible for measurement?

Gather together all questionnaires for this household and check that all identification numbers are inserted on each page. Tally on the Household Information Panel the number of interviews completed.

Immunization Module By Healthcare Facility Data: IMF

IM1FA. Check IM20A. Information of the immunization record-keeping healthcare facility obtained?

IM1FB. Healthcare facility visited?

IM1FC. Healthcare facility keeps immunization records 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)