World Health Survey Template Page 32
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57.
(Questions to be asked in households with children under 5 years only)
CHILD HEALTH: PREVENTIVE CARE
..
..
CHECK HOUSEHOLD ROSTER: Household has children under 5 years -> CONTINUE………. No child under 5 years -> GO TO SECTION 6600
.
Q6500 Can you please tell me the name, the sex, and the date of birth of the
youngest child living in this household?
Name of youngest child _____________________
Q6501 Sex
1. Male
2. Female
Q6502 Date of birth
If child aged over
5 years (born
MM_____________YY__________________
December 1997
Interviewer: USE NAME OF YOUNGEST CHILD IN HOUSEHOLD
or earlier): Go to
FOR THE FOLLOWING QUESTIONS.
Q6600
Q6503 What is your relationship with this child?
1. Parent
2. Grand Parent 3. Brother or
4. Other relative 5. Not related
sister
Q6504 Do you have a card where [NAME]’s vaccinations are written down?
1. Yes, CARD SEEN 2. Yes, BUT CARD
5. No CARD
8. DK
If Card not seen,
NOT SEEN
No Card or DK:
If Yes: May I see it?
Go to Q6513
.
Interviewer: FOR QUESTIONS 6505-6508, COPY VACCINATION DATES FOR EACH OF THE FOLLOWING VACCINES FROM THE CARD. IF
THE CARD INDICATES A VACCINATION WAS GIVEN BUT THE DATE IS NOT RECORDED, CHECK THE BOX WITH “O4/04/0004 “.
.
Q6505 DPT 1
Date not recorded
dd
mm
yy
04/04/0004
Q6506 DPT 2
Date not recorded
dd
mm
yy
04/04/0004
Q6507 DPT 3
Date not recorded
04/04/0004
dd
mm
yy
Q6508 Measles
Date not recorded
dd
mm
yy
04/04/0004
1. Yes
5. No
8. DK
Q6509 Has [NAME] received any additional vaccinations to prevent him/her
If No or DK: Go
to Q6517
from getting diseases that are not recorded on this card?
Q6510 Has [NAME] received additional vaccinations to prevent him/her from
getting diphtheria, tetanus or whooping cough (injection in the thigh or
buttocks)?
1. Yes
5. No
8. DK
WORLD HEALTH SURVEY - COVERAGE
6.8
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