INTEGRATED FAMILY SURVEY
CHILD HEALTH MEASUREMENTS MODULE
TO BE COMPLETED FOR EACH CHILD IN THE HOUSEHOLD AGE 13 OR YOUNGER
WITH THE AID OF AN ADULT IN HOUSEHOLD
INTERVIEWER: COMPLETE BEFORE BEGINNING THE MODULE
1.
Household ID number:
2a.
Child code from board:
2b.
Main adult respondent code from board:
3.
Date of visit:
4.
Interviewer code:
5.
Starting time of module:
Day
Month
Hour
Year
Minute
1
PAGE INTENTIONALLY LEFT BLANK
2
Now we would like to ask you some questions about each of your children, including questions
about their health, education, and immunizations. This form will take about 20 minutes for each
child. We will also give each child a small health checkup. We will share the results of this
health checkup with you.
You can choose not to answer a question at any time. Choosing to do so will not affect your ties
with Seva Mandir or Vidya Bhawan in any way. The information you share with us will be kept
fully confidential. Will you answer our questions?
Yes……………………1
No…………………….2
3
SECTION I: CHILDREN’S MODULE
I1.0
Child’s date of birth or age
Y
Y
M
M
D
D
OR
I1.1
I1.2
I1.3
I1.4
I1.5
YEARS……………………...1
MONTHS…………………...2
DAYS……………………….3
Where was this child born?
CHC/PHC....................................…....1
GOV'T REFERRAL HOSPITAL......2
PRIVATE HOSPITAL.................…...3
ARYUVEDIC HOSPITAL.................4
SUBCENTRE/AIDPOST....................5
NGO CLINIC......................................6
DAIMA'S HOME................................7
HOME............................……….........8
OTHER, SPECIFY..............................996
Who helped with the delivery of GOV'T DOCTOR.................................1
this child?
PRIVATE DOCTOR............................2
ANM.....................................................3
NURSE/COMPOUNDER....................4
DAIMA, UNTRAINED.......................5
CIRCLE ALL THAT APPLY
TBA (SEVA MANDIR OR OTHER
NGO)....................................................6
VHW/CHW (SEVA MANDIR OR
OTHER NGO).....................................7
HRW/BHOPA/TRADITIONAL
HEALER..............................................8
FAMILY MEMBER............................9
OTHER, SPECIFY…………………..996
Do you have an immunization
YES…………………………………..1
card for this child? May I see it? NO CARD………………………..…2
NO YOU MAY NOT/CANNOT SEE
IT……………………………………..3
Has this child received the BCG YES, COMPLETE...............................1
immunization?
NO.............................................……...2
YES, INCOMPLETE…………………3
DO NOT KNOW………–999
Where did this child receive the GOV'T AGENCY, FREE...........................1
BCG immunization?
GOV'T AGENCY WITH CHARGE..........2
PRIVATE AGENCY, FREE......................3
PRIVATE AGENCY WITH CHARGE.....4
4
I1.6
 I1.6
I1.6
Has this child received the DPT
immunization?
I1.7
Where did this child receive the
DPT immunization?
I1.8
Has this child received the OPV
immunization?
I1.9
Where did this child receive the
OPV immunization?
I1.10
Has this child received the
measles vaccine?
I1.11
Where did this child receive the
measles vaccine?
I1.12
Has this child received the pulse
polio immunization?
I1.13
Where did this child receive the
pulse polio immunization?
I1.14
Was this child ever breast-fed?
I1.15
Is this child still being breastfed?
I1.16
For how many months was this
child breast-fed?
I1.17
Does the child take any other
drink or food in addition to
being breast-fed?
YES, COMPLETE...............................1
NO.............................................……...2
YES, INCOMPLETE…………………3
DO NOT KNOW………–999
GOV'T AGENCY, FREE..................…….1
GOV'T AGENCY WITH CHARGE.…….2
PRIVATE AGENCY, FREE..............……3
PRIVATE AGENCY WITH CHARGE….4
YES, COMPLETE...............................1
NO.............................................……...2
YES, INCOMPLETE…………………3
DO NOT KNOW………–999
GOV'T AGENCY, FREE...........................1
GOV'T AGENCY WITH CHARGE..........2
PRIVATE AGENCY, FREE......................3
PRIVATE AGENCY WITH CHARGE.....4
YES, COMPLETE...............................1
NO.............................................……...2
YES, INCOMPLETE…………………3
DO NOT KNOW………–999
GOV'T AGENCY, FREE...........................1
GOV'T AGENCY WITH CHARGE..........2
PRIVATE AGENCY, FREE......................3
PRIVATE AGENCY WITH CHARGE.....4
YES, COMPLETE...............................1
NO.............................................……...2
YES, INCOMPLETE…………………3
DO NOT KNOW………–999
GOV'T AGENCY, FREE...........................1
GOV'T AGENCY WITH CHARGE..........2
PRIVATE AGENCY, FREE......................3
PRIVATE AGENCY WITH CHARGE.....4
YES…………………………..1
NO……………………………2
DONT KNOW..................................-999
YES…………………………..1
NO……………………………2
I1.8
I1.8
I1.10
I1.10
 I1.12
 I1.12
 I1.14
 I1.14
I2.0
I1.17
I1.18
Months
DONT KNOW..................................-999
YES…………………………..1
NO……………………………2
5
I1.18
I2.0
I1.18
I2.0
I2.1
I2.2
For how many months was the
child breast-fed with no other
drink and food?
Is he/she studying this year or
going to an angawadi/balwadi?
Has he/she ever been to school?
Why is he/she not in school this
year?
CIRCLE ALL THAT APPLY
I2.3
I2.4
Which type of school is he/she
attending?
In which class is he/she
studying?
Months
DONT KNOW..................................-999
YES..................................... 1
NO...................................... 2
DO NOT KNOW………–999
YES…………………………….1
NO……………………………..2
DO NOT KNOW………–999
TOO YOUNG................………...1
TOO OLD/FINISHED...…………2
ILL/DISABLED………..………..3
PREGNANT/HAS CHILD.….….4
SCHOOL TOO HARD...………..5
NO MONEY FOR FEES.…….….6
NEEDED TO EARN MONEY….7
NO SCHOOL LOCALLY.….…...8
NO ACCOMMODATION..……..9
LOST INTEREST.………………10
TEACHER BEATS…………..…11
LACK OF TEACHING………....12
HOUSEWORK.................…........13
PARENTS NOT INTERESTED..14
OTHER(specify): ____________996
DO NOT KNOW………–999
GOVERNMENT SCHOOL……....1
RAJEEV GANDHI
SCHOOL.....................….…………2
PRIVATE SCHOOL………………3
NFE................................……….…4
ANGANWADI..............………….5
OTHER PRE-PRIMARY
SCHOOL…………………………..6
OTHER, SPECIFY…………..……996
CLASS 1...................................1
CLASS 2...................................2
CLASS 3...................................3
CLASS 4...................................4
CLASS 5...................................5
CLASS 6...................................6
CLASS 7...................................7
CLASS 8...................................8
CLASS 9...................................9
CLASS 10.................................10
CLASS 11.................................11
CLASS 12.................................12
6
 I2.3
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I2.5
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I3.0
I2.5
What are the activities in the
anganwadi in which this child
participates?
I3.0
Is this child retarded?
I3.1
Is this child handicapped?
NUTRITION…………………………..1
PRE-SCHOOL ACTIVITES…………..2
HEALTH CHECK UP…………………3
IMMUNIZATION…………………….4
OTHER, SPECIFY…………………996
YES………………………….1
NO……………………………2
YES………………………….1
NO……………………………2
7
I4.0
How would you classify your
child's health these days? If the 1….2….3….4….5….6….7….8….9….10
top rung of this ladder represents
very good health and the bottom
rung represents very bad health, DO NOT KNOW………–999
where would you place your
child?
INTERVIEWER
CHECKPOINT: PRESENT
THE PICTURE OF A LADDER
TO THE RESPONDENT AND
CIRCLE THE NUMBER THAT
CORRESPONDS TO THE
RUNG THEY CHOOSE.
10
9
8
7
6
5
4
3
2
8
1
I5.0
Now I would like to ask you
about some health conditions
that children sometimes have.
Has this child experienced
________ in the last 30 days
1. Cold symptoms………….
2 Cough……………………
6. Hot fever…………………….
7 Diarrhea…………………
9.Weakness………….
13. Vomiting…………………
14. Worms in stool…………..
15. Trouble breathing……….
16. Pain in abdomen…………
22. Skin problems……………
996. Other, specify…...………
Was the
condition
serious?
Yes
No
Yes.............No
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
I5.1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
INTERVIEWER
YES..................................... 1
CHECKPOINT:
NO...................................... 2
I6.1
Was there any condition
checked in I5.0?
I5.2
Did you consult anyone about
YES..................................... 1
any of these conditions this
NO...................................... 2
I5.24
child experienced in the last 30
days?
I5.3
How many times did you
consult someone about these
conditions this child
experienced in the last 30 days?
ASK QUESTIONS I5.4 TO I5.22. FOR EACH CONSULTATION THAT RESULTED
FROM THE ONSET OF THE ABOVE MARKED CONDITIONS IN THE LAST 30 DAYS.
9
I5.4
FOR EACH
CONSULTATION: Who did
you consult?
I5.5
Was this facility/health provider
public or private?
I5.6
What is the name of the facility
or health provider?
CHC/PHC..............................………....1
GOVERNMENT REFERRAL
HOSPITAL…………………………...2
PRIVATE HOSPITAL............….…….3
ARYUVEDIC HOSPITAL........…..…4
T.B. HOSPITAL……………………...5
DISPENSARY…………………...…...6
AIDPOST/SUBCENTRE..........….......7
ANGANWADI.............................…....8
HEALTH CAMP............................…..9
NGO CLINIC...............................…...10
PRIVATE QUALIFIED DOCTOR….11
PRIVATE COMPOUNDER/NURSE..12
PRIVATE PHARMACIST…………..13
BENGALI DOCTOR..................…....14
GOVERNMENT DOCTOR, PRIVATE
PRACTICE………………………….15
OTHER GOVERNMENT
PRACTITIONER, PRIVATE……….16
TBA/DAI................................…....…17
VHW/CHW...............................……..18
HRW.......................................…...….19
BHOPA/TRADITIONAL HEALER..20
DON’T KNOW……………………..-999
OTHER (SPECIFY)...................….....996
Private…………………………………1
Public………………………………….2
Don’t know………………………….-999
………………………………………….
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
I5.6
Don't know.........................................-999
I5.7
Where is this facility located, or
where did you consult this
health provider?
VILLAGE/TOWN …………………
TEHSIL ……………………………
DISTRICT ……………………….…
I5.8
I5.9
How may days ago was this
consultation?
INTERVIEWER
CHECKPOINT: Was it more
than 30 days ago?
STATE…………………………….…
[ ][ ] days
Yes……………………………..1
No………………………………2
10
I5.2
(1)
(2)
(3)
(4)
5.4
1 I5.6
2 I5.6
3 I5.6
4 I5.6
5 I5.6
6 I5.6
7 I5.6
8 I5.6
9 I5.6
10 I5.6
11 I5.6
12 I5.6
13 I5.6
14 I5.6
15 I5.6
16 I5.6
17 I5.6
18 I5.6
19 I5.6
20 I5.6
-999
996________________
1 I5.6
2 I5.6
3 I5.6
4 I5.6
5 I5.6
6 I5.6
7 I5.6
8 I5.6
9 I5.6
10 I5.6
11 I5.6
12 I5.6
13 I5.6
14 I5.6
15 I5.6
16 I5.6
17 I5.6
18 I5.6
19 I5.6
20 I5.6
-999
996________________
1 I5.6
2 I5.6
3 I5.6
4 I5.6
5 I5.6
6 I5.6
7 I5.6
8 I5.6
9 I5.6
10 I5.6
11 I5.6
12 I5.6
13 I5.6
14 I5.6
15 I5.6
16 I5.6
17 I5.6
18 I5.6
19 I5.6
20 I5.6
-999
996________________
1 I5.6
2 I5.6
3 I5.6
4 I5.6
5 I5.6
6 I5.6
7 I5.6
8 I5.6
9 I5.6
10 I5.6
11 I5.6
12 I5.6
13 I5.6
14 I5.6
15 I5.6
16 I5.6
17 I5.6
18 I5.6
19 I5.6
20 I5.6
-999
996________________
5.5
1
2
-999
1
2
-999
1
2
-999
1
2
-999
5.6
………………………
………………………
………………………
………………………
5.7
DONT KNOW.....-999 DONT KNOW.....-999 DONT KNOW.....-999 DONT KNOW.....-999
Village/Town……..... Village/Town……..... Village/Town……..... Village/Town…….....
..…………….………
…
Tehsil……..................
.
……………….………
District…….................
..………………………
State…………………
..……………................
..…………….………
…
Tehsil……..................
.
……………….………
District…….................
..………………………
State…………………
..……………................
..…………….………
…
Tehsil……..................
.
……………….………
District…….................
..………………………
State…………………
..……………................
..…………….………
…
Tehsil……..................
.
……………….………
District…….................
..………………………
State…………………
..……………................
1 I5.2
2
1 I5.2
2
1 I5.2
2
1 I5.2
2
5.8
5.9
11
I5.10
I5.11
I5.12
I5.13
FOR EACH
CONSULTATION: Was
anyone from this household
with the child during this
consultation?
Who was it?
INTERVIEWER: RECORD
HOUSEHOLD NUMBER
FROM BOARD FOR EACH
PERSON FROM THE
HOUSEHOLD WHO WAS
PRESENT AT THIS
CONSULTATION
FOR EACH
CONSULTATION: Which
condition(s) was the visit for?
INTERVIEWER: RECORD
THE NUMBER OF EACH
CONDITION FROM L3.3.0 IN
THE GRID
INTERVIEWER
CHECKPOINT:
Was it a consultation to a
bhopa?
Yes……………………………..1
No………………………………2
I5.12
1
2
3
4
5
6
1
7
2
8
3
9
4
10
5
11
6
12
Yes……………………………..1
No………………………………2
12
 I5.15
(1)
(2)
(3)
(4)
5.10
1
2 I5.12
1
2 I5.12
1
2 I5.12
1
2 I5.12
5.11
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
6
1
7
6
1
7
6
1
7
6
1
7
2
8
2
8
2
8
2
8
3
9
3
9
3
9
3
9
4
10
4
10
4
10
4
10
5
11
5
11
5
11
5
11
6
1 I5.15
2
12
6
1 I5.15
2
12
6
1 I5.15
2
12
6
1 I5.15
2
12
5.12
5.13
13
I5.14 At the visit or consultation, did you
get________?
IF YES:
Did you
have to
pay for
______?
YES NO
YES NO
IF YES:
How
much did
you have
to pay for
_____?
(Rs.)
1
Consultation……………………
1
2
1
2
 I5.17
2
Medication given in facility………
1
2
1
2
 I5.17
3
Medication bought outside the
facility………………………….
1
2
1
2
 I5.17
4
Injection………………………
1
2
1
2
 I5.17
5
Drip…………………………
1
2
1
2
 I5.17
6
Operation……………………
1
2
1
2
 I5.17
7
Lab test……………………..
1
2
1
2
 I5.17
8
Other treatment……………..
1
2
1
2
 I5.17
9
Transportation (round trip)……
1
2
1
2
 I5.17
10 Total expense incurred…………
I5.15 Did the child get any jalibuti or any other
treatment?
XXXX
XXXX
 I5.17
Yes.................................................1
No..................................................2
I5.16 How much did this visit to the bhopa cost
you in total (including transportation, fees,
[ ][ ][ ][ ]Rs.
jali buti, offerings and other costs)?
I5.17 FOR EACH CONSULTATION: After
YES ................................... 1
this consultation did the child feel better? NO .................................. 2
I5.18 INTERVIEWER CHECKPOINT: FOR
EACH CONSULTATION: Was any
medication or treatment received or
prescribed at this consultation with a
health provider?
I5.19 Did this child finish the
medicine/treatment?
I5.20 Why did this child interrupt the
medicine/treatment?
YES.................................... 1
NO...................................... 2
Yes………………………………1
No, still going on………………..2
No, interrupted………………….3
........................................................
14
I5.21
 I5.21
 I5.21
(1)
(2)
(3)
(4)
5.14
1
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
2
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
3
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
4
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
5
1
2
1
2
1 2
1 2
1
2
1 2
1 2
1
6
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
7
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
8
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
9
1
2
1
2
1 2
1 2
1 2
1 2
1 2
1 2
10
XX
XX
XX
XX
XX
XX
XX
5.15
XX
2
1
2
1
2
1
2
1
2
1
2
1
1
2
1
1
2
1
1
2
1
2 I5.21
1 I5.21
2 I5.21
2 I5.21
1 I5.21
2 I5.21
2 I5.21
1 I5.21
2 I5.21
2 I5.21
1 I5.21
2 I5.21
3
3
3
3
......................................
......................................
......................................
......................................
5.16
5.17
5.18
5.19
5.20
15
I5.21 INTERVIEWER CHECKPOINT: Did the
child have any other consultation in the
last 30 days regarding any of checked
conditions in I5.0?
I5.22 Facility ID from PRA list
FILL AFTER SURVEY
I5.23 INTERVIEWER CHECKPOINT: Are
there any conditions checked in I5.0 for
which you did not seek consultation from
anyone for this child?
I5.24 Why did you not seek consultation for
those conditions?
YES ................................... 1
NO .................................. 2
I5.25 Did you or anyone else give the child any
treatment by yourself for any of the
conditions checked in I5.0 without
consulting a health provider first?
I5.26 For which conditions checked in I5.0 did
you or anyone else give treatment to your
child without consulting a health provider
first?
YES..................................... 1
NO...................................... 2
YES..................................... 1
NO...................................... 2
I5.27 What kind of treatment did you or anyone
else give to the child without consulting a
health provider first?
(CIRCLE ALL THAT APPLY)
I5.28 Why did you or anyone else decide to
give this treatment without consulting a
health provider first?
I5.29 How much did you pay for this treatment
you undertook without consulting a health
provider first?
I5.25
………………………………….
1
2
3
INTERVIEWER: RECORD THE
NUMBER OF EACH CONDITION
FROM E4.0 IN THE GRID
 I5.4
4
5
6
Tablets/bottled medicine………..1
Home remedy…………………..2
Jali buti…………………………3
Other (specify)………………996
Advised by family member…….1
Advised by neighbor/friend……2
Past experience…………………3
Other (specify)………………996
Rs.
16
I6.1
5.21
5.22
(1)
(2)
(3)
1 I5.4
2
[ ][ ][ ][ ]
1 I5.4
2
[ ][ ][ ][ ]
1 I5.4
2
[ ][ ][ ][ ]
17
(4)
1 I5.4
2
[ ][ ][ ][ ]
I6.1
I6.2
Has this child ever been tested for Tuberculosis
(TB)?
Has this child you ever been diagnosed with
Tuberculosis (TB)?
I6.3
When was the first time that you were told your child
had TB?
I6.4
In the past 12 months, has your child received any
medication or treatment for TB from a doctor, nurse,
clinic or hospital?
INTERVIEWER CHECKPOINT: Has the child
suffered from cough in last 30 days?
Is your child still suffering from cough?
I6.5
I6.6
I6.7
Has the cough been continuing for more than past
two weeks?
18
YES .................................. 1
NO .................................. 2
DO NOT KNOW…–999
YES .................................. 1
NO .................................. 2
DO NOT KNOW…–999
IN PAST 12 MONTHS..... 1
> 12 MONTHS AGO...........2
DO NOT KNOW…–999
YES ................................... 1
NO ................................... 2
DO NOT KNOW…–999
YES .................................. 1
NO .................................. 2
YES .................................. 1
NO .................................. 2
YES .................................. 1
NO .................................. 2
I6.5
I6.5
I6.5
I6.5
J0.1
J0.1
SECTION J: INTERVIEWER EVALUATION
J0.1
ENDING TIME OF MODULE
HOUR:
MINUTE:
J0.2
J0.3
Did you have to go back a second
time?
When did you go back?
Yes……………………1
No…………………….2
Day
J0.6
Month
Year
J0.4
Starting time of module
HOUR:
MINUTE:
J0.5
Ending time of module
HOUR:
MINUTE:
J0.6
COMPREHENSION LEVEL OF
RESPONDENT
J0.7
COOPERATION LEVEL OF
RESPONDENT
J0.8
HOW MUCH DID OTHERS ASSIST
THE RESPONDENT WITH HIS/HER
ANSWERS?
EXCELLENT..................... 1
VERY GOOD..................... 2
GOOD……........................ 3
FAIR................................... 4
POOR………......................5
EXCELLENT................ 1
VERY GOOD...............
2
GOOD…….................... 3
FAIR.............................. 4
POOR……….................. 5
NO ASSISTANCE............. 1
HELP WITH SOME........... 2
HELP WITH MOST........... 3
19
J0.10
J0.9
J0.10
WHO WAS HELPING THE
RESPONDENT WITH HIS OR HER
1
ANSWERS? (IF PERSON IS A
MEMBER OF THE SAME
2
HOUSEHOLD, ENTER THEIR
HOUSEHOLD NUMBER FROM THE 3
BOARD)
4
………………………………...
………………………………...
………………………………...
………………………………...
5
………………………………...
6
………………………………...
ANY ADDITIONAL COMMENTS ABOUT SPECIFIC QUESTIONS OR DATA
QUALITY
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
20
INTEGRATED FAMILY SURVEY
Health measurements
K.0
Date of health measurements :
K.1
Height of the respondent (in cm)
K.2
Weight of the respondent (in kg)
Day[ ][ ]
Month [ ][ ]
Year [ ][ ][ ][ ]
[ ][ ][ ]cm
Refused…………….997
can not do it……….998
[ ][ ][ ].[ ]kg
Refused…………….997
can not do it……….998
K.3
Yes……………………….1
No…………………………2
Is the child wearing any heavy item?
K.4
Which of the following items is the child wearing?
CIRCLE ALL THAT APPLY
Anklets…………………..1
Necklace…………………2
Heavy bracelets………….3
Other heavy item………..4
K.6
Hemo cue reading
[ ][ ].[ ][ ]
K.7
Body Temperature of the respondent (in Celsius)
Refused…………….997
can not do it……….998
[ ][ ].[ ]
Refused…………….997
can not do it……….998
K.8
In how much time does the respondent bow squat
and stand up 5 times?
K.9
[ ][ ][ ]s
Refused…………….997
can not do it……….998
1- [ ][ ][ ]
2- [ ][ ][ ]
3- [ ][ ][ ]
3 Pick flow meter indications
Refused…………….997
can not do it……….998
21
K.6