Ukraine 2012

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: _ _ _

UF2. Household number: _ _

UF3. Child's name:
Name ____

UF4. Child's line number: _ _

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

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

UF7. Interviewer name and number
Name ____ _ _

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

Repeat greeting if not already read to this respondent:

We are from State Statistics Service. We are working on a project concerned with family health and education. I would like to talk to you about (name)'s health and well-being. The interview will take about 20 minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

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 20 minutes. Again, all the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

May I start now?

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):

UF11. School 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?

Early childhood development: EC

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, cars, or other toys made at home)?

[B] Toys from a shop or manufactured toys?

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

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?

EC4. Check AG2: Age of child

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?

EC7. In the past 3 days, did you or any household member over 15 years of age engage in any of the following activities with (name):

If yes, ask: Who engaged in this activity with (name)? Circle all that apply.

[A] Read books to or looked at picture books with (name)?

[B] Told stories to (name)?

[C] Sang songs to (name) or with (name), including lullabies?

[D] Took (name) outside the home, compound, yard or enclosure?

[E] Played with (name)?

[F] Named, counted, or drew things to or with (name)?

EC8. I would like to ask you some questions about the health and development of your child. 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 your child's development.
Can (name) identify or name at least ten letters of the alphabet?

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

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?

BF9. Did (name) drink borshch/liquid 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?

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?

CA4A. During the time (name) had diarrhoea, was he/she given the oral rehydration solution (Regidron/Gastrolit)?

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

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) ____

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.

(Name of place) ____

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

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) ____

Immunization: IM

If a card listing immunizations is available, copy the dates in IM3 for each type of immunization recorded on the card. IM6-IM15 are for registering vaccinations that are not recorded on the card. IM6-IM15 will only be asked when 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?

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

IM3. Date of Immunization

BCG

Polio 1

Polio 2

Polio 3

Polio 4

DPT1

DPT2

DPT3

DPT4

HepB at birth

HepB1

HepB2

HIB1

HIB2

HIB3

MMR

IM4. Check IM3. Are all vaccines (BCG to MMR) recorded?

IM5. In addition to what is recorded on this card, did (name) receive any other?

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?

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 to protect him/her from getting polio?

IM10. How many times was the polio vaccine received?

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

Probe by indicating that DPT vaccination is sometimes given at the same time as Polio

IM12. How many times was ADPT vaccine received?

IM13. Has (name) ever been given a Hepatitis B vaccination - that is, an injection in the thigh - to prevent him/her from getting Hepatitis B?

Probe by indicating that the Hepatitis B vaccine 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 or an MMR injection - that is, a shot in the arm at the age of 12 months or older - to prevent him/her from getting measles, mumps and rubella?

IM16A. Has (name) ever received a HIB injection or an MMR injection - that is, a shot in the arm at the age of 3 months or older - to prevent him/her from getting haemophiilus influenzae?

IM16B. How many times was a HIB vaccine received?

IM19A. In your opinion, can immunization protect children against certain diseases?

IM19B. In your opinion, is immunization a safe medical practice?

IM19C. Are you going to get your child fully immunized according to the national calendar of compulsory vaccination?

IM19D. Have you ever refused from vaccination (name)?

IM19E. When refusing from vaccinating (name) you did so temporarily (for example, until he is not sick any more) or you did so because you are not going to get him/her vaccinated at all?

IM19F. Has (name) ever had any side reactions to vaccinations?

IM19G. Have you ever had to beg or bribe a health worker to get a fake/false vaccination record for (name)?

UF13. Record the time.

UF14. Is the respondent the mother or caretaker of another child age 0-4 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]

Check to see if there are other woman's, man's or under-5 questionnaires to be administered in this household.

Move to another woman's, man's or under-5 questionnaire.

Under-five child information panel: HF

This questionnaire form is to be used at health facilities to record information on the vaccinations of children age 0-4 years. A separate questionnaire form should be used for each eligible child.
The Questionnaire for Under Five Children must be completed for the child prior to completing this form. This panel should be completed before visiting the health facility.
This questionnaire form must be appended to the Questionnaire for Under Five Children for each child.

HF1. Cluster number: _ _ _

HF2. Household number: _ _

HF3. Child's name:
Name ____

HF4. Child's line number: _ _

HF5. Mother's / caretaker's name:
Name ____

HF6. Mother's / caretakers line number: _ _

HF7. Interviewer name and number
Name ____ _ _

HF8. Day / month / year of facility visit: _ _ / _ _ / _ _ _ _

HF8. Day / month / year of birth (From AG1 in Under-5 Questionnaire): _ _ / _ _ / _ _ _ _

HF3. Name of health facility: ____

HF11. Result of health facility visit

Immunization: HF

HF12. Record day, month and year of birth as written on vaccination: _ _ / _ _ / _ _ _ _

HF13. Date of Immunization

BCG

Polio 1

Polio 2

Polio 3

Polio 4

DPT1

DPT2

DPT3

DPT4

HepB at birth

HepB1

HepB2

HIB1

HIB2

HIB3

MMR

I, ___ (name), the mother/caretaker of the child ___ (name) hereby give my consent to the State Statistics Service of Ukraine to get the data on the vaccinations made to my child kept in the records of the local health facility for the purpose of conducting the Multiple Indicator Cluster Survey.
(date) (signature)