Q301
Module 3:
Children 12-23.9 months |Questionnaire for use with women with children from 12-23.9 months | |
|SY1 |Questionnaire Number which include the | | |
| |Region code, Cluster & Household Number ||_____|_____[____|_____|_____| | |
| |(to be numbered before interview) | | |
| | | | |
| | |Region__________ Zone ___________ Woreda ________ | |
| | | | |
| | | | |
| | |Cluster _______ Household _______ | |
|SY2 |Date of visit | | |
| | |[_____|_____| ______| | |
| | |dd |mm |yyyy | |
|T1 |Time at beginning of interview | | |
| | |____:____ | |
|Background of the Caretaker/Mother |
|SY3 |How old were you on your last birthday? | | |
| | | | |
| | |Age in years………….._________ | |
|SY4 |Are you able to read or write a simple |Yes……….1 | |
| |sentence? |No……….2 | |
|SY5 |Did you ever attend formal school? |Yes……….1 | |
| | | | |
| | |No……….2 |Skip to SY7 |
|SY6 |If yes, what is the highest grade you | Grade _________ | |
| |completed? | | |
|SY7 |What is your current marital status? |Single 1 | |
| | |Married 2 | |
| | |Divorced/Separated 3 | |
| | |Widowed 4 | |
|Background of the Child |
|SY8 |What is the name of your child? | | |
| | | | |
|SY9 |Sex of Child |Boy………..1 | |
| | | | |
| | |Girl………. 2 | |
|SY10 |What is the age of your child? | | |
| | |[____|____] MONTHS | |
| |What is the birth date of [NAME]? | | |
|SY11 | |[______/______/______] | |
| | |DAY / MONTH / YEAR | |
|SY12 |Verify child’s date of birth by asking to|Card seen, date of birth verified……………...1 | |
| |see the Family Health card or vaccination| | |
| |card. |Not possible to verify……………………..3 | |
|SY13 |Look at the age sheet and enter the | | |
| |child’s age in months | | |
| | |[____|____] MONTHS | |
| |Check that the child is 12-23.9 months. | | |
| |If so continue with interview. | | |
|SECTION 1: Immunizations |
|SY101 |Do you have a card where (Name’s) |Yes…………….1 | |
| |vaccinations are written down? |No..…………...2 |Skip to SY103 |
| | | | |
| |If Yes, May I see it? | | |
|SY102 |Did you ever have a vaccination card for |Yes…………….1 | Skip to SY106 |
| |(NAME)? |No..…………...2 |Skip to SY106 |
|WOMAN HAS CHILD’S VACCINATION CARD |
|SY103 |Does the child have a scar from BCG |Yes…………….1 | |
| |vaccination? |No..…………...2 | |
| | | | |
| |CHECK FOR BCG SCAR. | | |
|SY104 |Copy vaccination date for each vaccine | | |
| |from the card | | |
| | | | |
| |Write “44” in “Year” column if card shows| | |
| |that a vaccination was given, but no date| | |
| |is recorded |Day Month Year | |
| | | | |
| |a) BCG |BCG [___|___][___|___][___||___] | |
| |b) Polio 0 |Polio 0 [___|___][___|___][___||___] |If fully vaccinated,|
| |c) Polio 1 |Polio 1 [___|___][___|___][___||___] |then skip to SY116 |
| |d) Polio 2 |Polio 2 [___|___][___|___][___||___] | |
| |e) Polio 3 |Polio 3 [___|___][___|___][___||___] | |
| |f) DPT 1 |DPT 1 [___|___][___|___][___||___] | |
| |g) DPT 2 |DPT 2 [___|___][___|___][___||___] | |
| |h) DPT 3 |DPT 3 [___|___][___|___][___||___] | |
| |i) Measles |Measles [___|___][___|___][___||___] | |
|SY105 |Has (NAME) received any vaccinations that|Yes…………….1 |If yes, then fill |
| |are not recorded on this card, including | |SY104 |
| |vaccinations received in a national | | |
| |immunization day campaign? |No.…………...2 | |
| | | | |
| |PROBE FOR VACCINATIONS AND WRITE “66” IN |IF YES, PROBE FOR VACCINATIONS AND WRITE “66” IN THE CORRESPONDING |If no, then skip to |
| |THE CORRESPONDING DAY COLUMN OF SY104 |DAY COLUMN |SY115 |
| | |ABOVE IN SY104. THEN SKIP TO SY116. | |
|WOMAN HAS NO VACCINATION CARD |
|SY106 |Did (Name) ever receive any |Yes…………….1 | |
| |vaccinations to prevent him/her from|No..…………...2 | |
| |getting diseases, including |Don’t Know…..8 |Skip to SY115 |
| |vaccinations received in a national | |Skip to SY115 |
| |immunization day campaign? | | |
|Please tell me if (Name) received any of the following vaccinations: |
|Read questions SY107 – 114 |
|SY107 |A BCG vaccination against |Yes…………….1 | |
| |tuberculosis, that is, an injection |No..…………...2 | |
| |in the arm or shoulder that usually |Don’t Know…..8 | |
| |causes a scar? | | |
|SY108 |CHECK FOR BCG SCAR. |Yes…………….1 | |
| | |No..…………...2 | |
|SY109 |Polio vaccine, that is, drops in the|Yes…………….1 | |
| |mouth? |No..…………...2 | |
| | |Don’t Know…..8 |Skip to SY112 |
| | | | |
| | | |Skip to SY112 |
|SY110 |When was the first polio vaccine |Just after birth…………….1 | |
| |received, just after birth (within 2|Later than two weeks..…………...2 | |
| |weeks) or later? | | |
|SY111 |How many times was the polio vaccine| | |
| |received? |Number…….._________ | |
| | |Don’t Know…..8 | |
|SY112 |DPT vaccination, that is, an |Yes…………….1 | |
| |injection given in the thigh or |No..…………...2 | |
| |buttocks, sometimes at the same time|Don’t Know…..8 | |
| |as polio drops. | |Skip to SY114 |
| | | |Skip |
| | | |to SY114 |
|SY113 |How many times was the DPT vaccine |Number…….._________ | |
| |received? |Don’t Know…..8 | |
|SY114 |An injection to prevent measles, |Yes…………….1 |If child fully |
| |given around 9 months of age? |No..…………...2 |immunized, skip to |
| | |Don’t Know…..8 |SY116 |
| | | | |
| | | | |
| | | | |
|SY115 |Look back at the information on the |Lack of Information M NM | |
| |child’s immunization card or the |a) Unaware of need for immunization…………1 2 | |
| |information given by the mother |b) Unaware of need to return for 2nd or | |
| | |3rd dose…………………………….…….….1 2 | |
| |If child never immunized or not |c) Place and/or time of immunization | |
| |fully immunized, ask the following |unknown ……………………………………1 2 | |
| |question: |d) Fear of side reactions………………………..1 2 | |
| | |e) Wrong ideas about contra-indications……....1 2 | |
| |Why was the child not fully |f) Postponed until another time………………...1 2 | |
| |immunized? |g) No faith in immunization……………………1 2 | |
| | |Obstacles | |
| |Do Not Read Out List. |h) Place of immunization too far………………..1 2 |All answers skip to |
| | |i) Time of immunization inconvenient…………1 2 |SY201 |
| |MULTIPLE RESPONSES POSSIBLE |j) Vaccinators absent…………………..………..1 2 | |
| | |k) Vaccine not available………………………...1 2 | |
| | |l) Mother too busy……………………………….1 2 | |
| | |m) Child ill-- not brought…………….………….1 2 | |
| | |n) Child ill—brought but not given immunization.1 2 | |
| | |o) Long Waiting time……………………..……..1 2 | |
| | |p) Other…….…………………….………..…….1 2 | |
| | |Specify other ____________________________ | |
|SY116 |Since your child is fully immunized,|Yes…………….1 | |
| |did (NAME) receive the immunization | |Skip to SY201 |
| |diploma? |No..…………...2 | |
| |(Show Immunization Diploma) | | |
|SY117 |If no, did your child complete the |Yes…………….1 | |
| |full series of immunizations before | | |
| |his/her first birthday? |No..…………...2 | |
|Section 2: Child Health, Nutrition During Illness, and Care Seeking |
|SY201 |Has [NAME] been ill at any time in |Yes…………….1 | |
| |the last 2 weeks? |No..…………...2 |Skip to SY210 |
|SY202 |If yes, did [NAME] have….: |(Y = yES, N = NO) | |
| | |y N |If no diarrhea |
| |READ OUT THE LIST |a) Diarrhea….................................……………1 2 |mentioned in SY202 |
| |Circle “1” for yes, and “2” for no.|b) Cough..…………………………………… 1 2 |skip to question |
| | |c) Rapid/Difficulty Breathing…………………1 2 |SY204 |
| | |d) Fever…..................................………………1 2 | |
| | |e)Other….…….............................……………1 2 | |
| | | | |
| | |Other (Specify) _____________________________ | |
|SY203 |If the child had diarrhea: was |(Y = yes, N = no,) |Ask SY203 only if |
| |[NAME] given any of the following |Y N |diarrhea mentioned |
| |to drink: |a) Fluid from an ORS packet…….1 2 |in SY202 |
| | |b) Home made sugar and salt solution...........................…….. 1 | |
| |READ OUT LIST |2 | |
| | |c) Other home made fluid ……….1 2 | |
| |RECORD ALL MENTIONED |d) Other ………………………….1 2 | |
| | | | |
| | |Other (specify)________________________ | |
|SY204 |How much did you breastfeed during |Less……………...…..1 | |
| |the illness? Did you breastfeed |About the same….…..2 | |
| |less than usual, about the same |More than usual……..3 | |
| |amount, or more than usual? |Did not breastfeed..…4 | |
| | |Child weaned…..……5 | |
| | |Don’t Know……..…..8 | |
|SY205 |How much was [NAME] offered to |Less……………...…..1 | |
| |drink during the illness? Was |About the same….…..2 | |
| |[NAME] offered less than usual to |More than usual……..3 | |
| |drink, about the same amount, or |Nothing offered to drink…..…4 | |
| |more than usual to drink? |Child only breastfeeds, so no fluid given……..5 | |
| | |Don’t Know……..…..8 | |
|SY206 |During illness, were the ‘number of|Less……………...…..1 | |
| |meals’ offered to [NAME] less than |About the same….…..2 | |
| |usual, about the same amount, or |More than usual……..3 | |
| |more than usual than before the |Nothing to eat……..…4 | |
| |illness? |Child has not yet started complementary foods……….5 | |
| | |Don’t Know……..…..8 | |
|SY207 |Is [NAME] still ill? |Yes…………….1 | Skip to SY210|
| | |No..…………...2 | |
|SY208 |If NO: How much did you breastfeed |Less……………...…..1 | |
| |after the illness? Did you |About the same….…..2 | |
| |breastfeed less than usual, about |More than usual……..3 | |
| |the same amount, or more than |Child weaned…..……4 | |
| |usual? |Don’t Know……..…..8 | |
|SY209 |After illness, were the ‘number of |Less……………...…..1 | |
| |meals’ offered to [NAME] less than |About the same….…..2 | |
| |usual, about the same amount, or |More than usual……..3 | |
| |more than usual than before the |Child has not yet started complementary foods……….4 | |
| |illness? |Don’t Know……..…..8 | |
|SY210 |Did you own a bed net? |Yes…………….1 | |
| | |No..…………...2 |Skip to |
| | | |SY301 |
|SY211 |Did [NAME] sleep under a bed net |Yes…………….1 | |
| |last night? |No..…………...2 | |
|SY212 |Did you sleep under a bed net last |Yes…………….1 | |
| |night? |No..…………...2 | |
|Section 3: Child Feeding & Preparation Practices: |
|SY301 |Have you ever breastfed [NAME]? |Yes…………….1 | |
| | |No..…………...2 | |
| | | |Skip to |
| | | |SY307 |
|SY302 |Are you still breastfeeding [NAME]? |Yes…………….1 | Skip to SY304 |
| | |No..…………...2 | |
|SY303 |Why did you stop breastfeeding [NAME]? |Mother ill/weak….…………….…01 | |
| | |Child ill/weak….…………………02 |For all responses |
| | |Nipple/breast problem……………03 |skip to SY307 |
| |Skip to Question SY307. |Not enough milk…………………04 | |
| | |Mother working………………….05 | |
| | |Child refused…………….……….06 | |
| | |Weaning age/age to stop…………07 | |
| | |Became pregnant………….……..08 | |
| | |Started using contraception………09 | |
| | |Other……….…………………….10 | |
| | |Specify other_________________________ | |
|SY304 |Up to what age do you intend to |Months _________ | |
| |breastfeed [NAME]? | | |
| | |Don’t Know…………..…98 | |
|SY305 |Since you breastfeed, are the ‘number of |More………….1 | |
| |meals’ you eat more than usual, the same |Same………….2 | |
| |as usual, or less than usual? |Less…………..3 | |
| | |Don’t Know…..8 | |
|SY306 |How many times did you breastfeed [NAME],| | |
| |between sunrise yesterday and sunrise |Number _________ | |
| |today? | | |
| | |Don’t Know…………..…98 | |
| |If response is not numeric, probe for a | | |
| |numeric response | | |
|SY307 |Did [NAME] drink anything from a bottle |Yes……………..1 | |
| |between sunrise yesterday and sunrise |No……………..2 | |
| |today? |Don’t Know……8 | |
|SY308 |At what age did you first introduce | | |
| |liquids or foods (semi-solid or solid) |Months _________ | |
| |other than breast milk to the baby? | | |
| | |Don’t Know…………..…98 | |
| | | |Skip to SY310 |
| | |Not yet started………………97 | |
|SY309 |How many times did you feed [NAME] solid | | |
| |and/or semi-solid food between sunrise |Number of feedings of solids and/or semi-solid foods _________ | |
| |yesterday and sunrise today? | | |
| | |Don’t Know…………..…98 | |
| |If response is not numeric, probe for a | | |
| |numeric response | | |
|SY310 |I would like to ask you about the types | | |
| |of foods [NAME] has been fed over the | | |
| |past 24 hours, from sunrise yesterday to |(M = mentioned, NM= not mentioned) | |
| |sunrise today. Did [NAME] have: |M NM | |
| | | | |
| |READ OUT THE LIST |a) Breastmilk……………..……………...1 2 | |
| |Circle “1” for mentioned and “2” for not|b) Water……………………..………..….1 2 | |
| |mentioned |c) Formula…………………….……...….1 2 | |
| | |d) Animal milk………………..……...….1 2 | |
| | |e) Fruit Juice.………………………...…..1 2 | |
| | |f) Other liquids (sugar water, coffee, | |
| | |tea, broth, soft drinks).…..……..….1 2 | |
| | |g) Any food made from grains (millet | |
| | |(sorghum, maize, rice, wheat, teff) ……...1 2 | |
| | |h) Any other food made from roots or | |
| | |tubers? (white potatoes, cassava, enset, | |
| | |or other local roots or tubers)…..…….1 2 | |
| | |i) Any food made from pumpkins, | |
| | |carrots, red sweet potatoes, mango, | |
| | |papaya………….…...………………..1 2 | |
| | |j.) Green leafy vegetables………………1 2 | |
| | |k) Any other fruits? (e.g., bananas, | |
| | |apples, avocados, tomatoes...................1 2 | |
| | |l.) Any other vegetables? | |
| | |m) Meat , Poultry, Fish …………..……..1 2 | |
| | |n.) Eggs……………………………...…..1 2 | |
| | |o.) Cheese or yoghurt ……………….….1 2 | |
| | |p) Any food made from legumes or nuts | |
| | |(e.g. lentils, beans, soybeans, | |
| | |pulses, or peanuts)?…………..……...1 2 | |
| | |q) Any food made with oil, fat | |
| | |or butter?………………………..……1 2 | |
|SY311 |The last time you prepared food/meal for |Yes…………….1 | |
| |(NAME) did you wash your hands with |No..…………...2 | |
| |soap/ash? | | |
|SY312 |The last time you had to clean (name) |Yes…………….1 | |
| |after he/she defecated, did you wash your|No..…………...2 | |
| |hands with soap/ash immediately | | |
| |afterwards? | | |
|SECTION 4: Vitamin A |
|SY401 |Did [NAME] receive a dose of vitamin A in|Yes…………….1 | |
| |the last 6 months? [Show Vitamin A |No..…………...2 |Skip to SY501 |
| |Capsule] |Do not know…..8 |Skip to SY501 |
|SY402 |If yes, where did your child receive the | | |
| |vitamin A? |Routine Immunizations..…………...1 | |
| | |EOS ..…………...2 | |
| | |Sick child visit……………..3 | |
| | |Well child/growth monitoring……..4 | |
| | |Other..…………...5 | |
| | | | |
| | |Other specify ________________________________ | |
|SECTION 5: Message Recall: TIBF |
|SY501 |How long after birth do you think a baby |Immediately………...…………………00 | |
| |should start breastfeeding? |Hours………………………….________ | |
| | |Days.…………………………. ________ | |
| | |Don’t Know………………………….98 | |
|SY502 |Did you hear a message to put your baby on|Yes……………1 | |
| |the breast immediately after birth? |No……………..2 |Skip to SY506 |
| | | | |
| | |Can’t remember…….8 |Skip to SY506 |
| | | | |
|SY503 |From whom did you hear this message? |(M=Mentioned NM= Not mentioned) | |
| | | | |
| | |M NM | |
| | |a.) Health Worker….…………..….1 2 | |
| | |b.) Health Extension Worker…..…1 2 | |
| | |c.) CBRHA……………………..…1 2 | |
| | |d.) Community Health Promoter.…1 2 | |
| | |e.) Family/friend…….…………….1 2 | |
| | |f.) Radio/TV………….………..….1 2 | |
| | |g.) Community leader….…………1 2 | |
| | |h.) Other……….…….……………1 2 | |
| | | | |
| | |Other (specify) _________________________ | |
|SY504 |When or how did you hear these messages? |(M=Mentioned NM= Not mentioned) | |
| |During: | | |
| | |M NM | |
| | |a.) Pregnancy………………….1 2 | |
| | |b.) Delivery……………………1 2 | |
| | |c.) Post natal/family planning…1 2 | |
| | |d.) Sick child contacts…………1 2 | |
| | |e.) Well child contacts………. .1 2 | |
| | |f.) Immunizations…………..…1 2 | |
| | |g.) EOS contact ………..…… 1 2 | |
| | |h.) Other……….……..…….…1 2 | |
| | | | |
| | |Other (specify) ____________________ | |
| | | | |
|SY505 |Where did you hear these messages? |(M=Mentioned NM= Not mentioned) | |
| | | | |
| | |M NM | |
| | |a.) Health facility……..1 2 | |
| | |b.) Community event…1 2 | |
| | |c.) Home….…………….. 2 | |
| | |d.) Other….…………….. 2 | |
| | |Other (specify) _____________ | |
|MESSAGE RECALL: EBF |
|SY506 |For how long do you think a baby | | |
| |should receive only breastmilk and |Enter age in months:__________ | |
| |nothing else? | | |
| | |Don’t know…….98 | |
|SY507 |Did you hear a message to feed your |Yes……………1 | |
| |baby only breast milk for the first |No……………..2 |Skip to SY511 |
| |six months of life, not even giving | | |
| |water? |Can’t remember…….8 |Skip to SY511 |
| | | | |
|SY508 |From whom did you hear this message? |(M=Mentioned NM= Not mentioned) | |
| | | | |
| | |M NM | |
| | |a.) Health Worker……………..….1 2 | |
| | |b.) Health Extension Worker…..…1 2 | |
| | |c.) CBRHA……………………..…1 2 | |
| | |d.) Community Health Promoter…1 2 | |
| | |e.) Family/friend………………….1 2 | |
| | |f.) Radio/TV…………………..….1 2 | |
| | |g.) Community leader……………1 2 | |
| | |h.) Other……….…………………1 2 | |
| | | | |
| | |Other (specify) _________________________ | |
| | | | |
|SY509 |When or how did you hear these |(M=Mentioned NM= Not mentioned) | |
| |messages? During: | | |
| | |M NM | |
| | |a.) Pregnancy………………….1 2 | |
| | |b.) Delivery……………………1 2 | |
| | |c.) Post natal/family planning…1 2 | |
| | |d.) Sick child contacts…………1 2 | |
| | |e.) Well child contacts………. .1 2 | |
| | |f.) Immunizations…………..…1 2 | |
| | |g.) EOS contact ………..…… 1 2 | |
| | |h.) Other……….……..…….…1 2 | |
| | | | |
| | |Other (specify) ____________________ | |
| | | | |
|SY510 |Where did you hear these messages? |(M=Mentioned NM= Not mentioned) | |
| | | | |
| | |M NM | |
| | |a.) Health facility……..1 2 | |
| | |b.) Community event….1 2 | |
| | |c.) Home….……………1 2 | |
| | |d.) Other….…………….1 2 | |
| | |Other (specify) _____________ | |
|MESSAGE RECALL: TCF |
|SY511 |How long after birth do you think a | | |
| |baby should start to receive |Age in months ____________ | |
| |semi-solid and solid foods? | | |
|SY512 |Did you hear a message on introducing |Yes……………1 | |
| |complementary foods at six months of |No……………..2 |Skip to SY601 |
| |age, such as soft porridge 2-3 times | | |
| |per day? |Can’t remember…….8 |Skip to SY601 |
| | | | |
|SY513 |From whom did you hear this message? |(M=Mentioned NM= Not mentioned) | |
| | | | |
| | |M NM | |
| | |a.) Health Worker……………..….1 2 | |
| | |b.) Health Extension Worker…..…1 2 | |
| | |c.) CBRHA……………………..…1 2 | |
| | |d.) Community Health Promoter…1 2 | |
| | |e.) Family/friend………………….1 2 | |
| | |f.) Radio/TV…………………..….1 2 | |
| | |g.) Community leader……………1 2 | |
| | |h.) Other……….…………………1 2 | |
| | | | |
| | |Other (specify) _________________________ | |
| | | | |
|SY514 |When or how did you hear these |(M=Mentioned NM= Not mentioned) | |
| |messages? During: | | |
| | |M NM | |
| | |a.) Pregnancy………………….1 2 | |
| | |b.) Delivery……………………1 2 | |
| | |c.) Post natal/family planning…1 2 | |
| | |d.) Sick child contacts…………1 2 | |
| | |e.) Well child contacts………. .1 2 | |
| | |f.) Immunizations…………..…1 2 | |
| | |g.) EOS contact ………..…… 1 2 | |
| | |h.) Other……….……..…….…1 2 | |
| | | | |
| | |Other (specify) ____________________ | |
|SY515 |Where did you hear these messages? |(M=Mentioned NM= Not mentioned) | |
| | | | |
| | |M NM | |
| | |a.) Health facility……..1 2 | |
| | |b.) Community event….. 2 | |
| | |c.) Home….…………….. 2 | |
| | |d.) Other….…………….. 2 | |
| | |Other (specify) _____________ | |
|Section 6: Behavioral Change Communication (BCC)/Community Mobilization |
|SY601 |Have you heard about immunization when | | |
| |listening to the radio? |Yes…………….1 | |
| | |No…………..2 |Skip to FY603 |
| | | |Skip to FY603 |
| | |Can’t remember……….8 | |
|SY602 |IF Yes, then what main points do you |(M = mentioned, N = not mentioned) | |
| |remember from the radio message(s)? |M N | |
| | |a) Immunize your child before first birthday.……... 1 2 | |
| |Circle “1” for yes, and “2” for no. |b) Immunization prevents from the 6 killer diseases….……………………...……. 1 | |
| | |2 | |
| | |c) The father should get involved in immunization | |
| | |of his children ……………………….......……. 1 2 | |
| | |d) Bring your child’s immunization card…….……. 1 2 | |
| | |e) Other………………………………….......……. 1 2 | |
| | |Other (Specify) _________________________ | |
|SY603 |In the last 6 months, were you visited by|Yes…………….1 | |
| |a field worker who talked to you about |No..…………...2 | |
| |immunizations? | |Skip to UF605 |
| | |Can’t remember……….8 | |
| | | |Skip to UF605 |
|SY604 |If yes, who did you speak with? |(Y = yes, N = no) | |
| | | | |
| |(Multiple Responses Possible) |Y N | |
| | |a) Health Worker………………….….. 1 2 | |
| | |b) Health Extension Worker. .…. …...... 1 2 | |
| | |c) CBRHA…………………………...... 1 2 | |
| | |d) Community Health Promoter……..…1 2 | |
| | |e) Other………………….…………......1 2 | |
| | |Other (Specify) ____________________________ | |
|SY605 |Have you heard about the FHC? |Yes…………….1 | |
| | |No..…………...2 | |
| | | |Skip to FY608 |
|SY606 |If yes, how did you hear about it? |(Y = yes, N = no) | |
| | | | |
| |(Multiple Responses Possible) |Y N | |
| | |a) Health Worker...………..………….. 1 2 | |
| | |b) Health Extension Worker…. ……..... 1 2 | |
| | |c) CBRHA…………………………...... 1 2 | |
| | |d) Community Health Promoter……..…1 2 | |
| | |e) Neighbor, Friend, Family…..……..…1 2 | |
| | |f) Other………………….…………......1 2 | |
| | |Other (Specify) ____________________________ | |
|SY607 |Does your child [Name] have a FHC? |Yes…………….1 | |
| | |No..…………...2 | |
|SY608 |Have you heard about the Immunization |Yes…………….1 | |
| |Diploma (Show Diploma)? |No..…………...2 | |
| | | |End of Interview |
|SY609 |If yes, how did you hear about it? |(Y = yes, N = no) | |
| | | | |
| |(Multiple Responses Possible) |Y N | |
| | |a) Health Worker...………..………….. 1 2 | |
| | |b) Health Extension Worker…. ……..... 1 2 | |
| | |c) CBRHA…………………………...... 1 2 | |
| | |d) Community Health Promoter……..…1 2 | |
| | |e) Neighbor, Friend, Family…..……..…1 2 | |
| | |f) Other………………….…………......1 2 | |
| | |Other (Specify) ____________________________ | |
| | | | |
| |T2 |Time at end of interview |____:____ |
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