Age of ‘Name’ Record in months. Did ‘Name’ have immunization card? If yes, could Has ‘Name’ ever been given BCG vaccination How many times ‘Name’ has been given these Has ‘Name’ ever been given ‘vaccination injections’
20
SECTION 16: Maternal Child Health
For every married women up to 49 years age in household Woman 1
Woman 2 Woman 3
16.20
How many doses of TT injection have you taken in the arm to prevent your newborn being affected from tetanus?
If none write 0
|__| Doses |__| Doses
|__| Doses 16.21
Did you see anyone for taking advice during this pregnancy i.e. antenatal care other than TT? If yes, whom did you see?
TBA=Traditional Birth Attendant 0 None
1 DoctorNurseMidwife 2 TBA
3 Relative friendother 0 None
1 DoctorNurseMidwife 2 TBA
3 Relative friendother 0 None
1 DoctorNurseMidwife 2 TBA
3 Relative friendother
16.22
After the birth of your last child, did you receive a Vitamin A capsule during NefuzChell period?
Surveyor to show the capsule
0 No 1 Yes
9 Don’t know 0 No
1 Yes 9 Don’t know
0 No 1 Yes
9 Don’t know
16.23
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?
Do not read responses
0 Coughrunning nose 1 Fever
2 DifficultFast Breath 3 Convulsion
4 Unable to drinksuck 5 WateryBloody diarrhoea
6 Other 9
Don’t Knownone 0 Coughrunning nose
1 Fever 2 DifficultFast Breath
3 Convulsion 4 Unable to drinksuck
5 WateryBloody diarrhoea 6 Other
9
Don’t Knownone 0 Coughrunning nose
1 Fever 2 DifficultFast Breath
3 Convulsion 4 Unable to drinksuck
5 WateryBloody diarrhoea 6 Other
9
Don’t Knownone
SECTION 17: Children 0-59 months
C
HILD
N
UMBER
1 2
3 4
5 6
7 8
Child’s Name 17.1
Sex of ‘Name’.
1 Boy 2 Girl
1 Boy 2 Girl
1 Boy 2 Girl
1 Boy 2 Girl
1 Boy 2 Girl
1 Boy 2 Girl
1 Boy 2 Girl
1 Boy 2 Girl