|
a_1 |
Screening Number |
|
|
|
|
a_2 |
Initial of the child |
|
|
a_3 |
Date (according to English
calendar- DDMMYY) |
|
|
a_4 |
Researcher code |
|
|
a_5 |
Date of birth (if known), (English calendar-DDMMYY) |
|
|
a_6 |
Age of child (in months) |
|
|
a_7 |
Sex of child (1=Male, 2=Female) |
|
|
a_8 |
Are there any plans to migrate
within one year? |
|
|
a_9 |
Does the child have any acute
illness? |
|
|
a_10 |
Does the child have any chronic
illness? |
|
|
a_11 |
Does the child taking
multivitamins that include vitamin B12? |
|
|
a_12 |
Does the child have any food
allergy (peanut)? |
|
|
a_13 |
Does parent consenting for
participate in the study? |
|
|
a_14 |
Weight (in kg) |
|
|
a_15 |
Length (in cm) |
|
|
A _16 |
Head Circumference (cm) |
|
|
a_17 |
Length for age <-1 z score |
|
|
a_18 |
Weight for length / HC for age
≤-3 z score |
|
|
a_19 |
Hemoglobin (g/dL) |
|
|
a_20 |
Child enroll number (as on the
packet with medicine) |
|
|
b_1 |
Initials of the child |
|
|
b_2 |
Field Worker code |
|
|
b_3 |
Date of Interview (DDMMYY) |
|
|
b_4 |
Date of
Birth (English
calendar-DDMMYY) |
|
|
b_5 |
Age in months (completed) |
|
|
b_6 |
Sex (1=Male, 2=Female) |
|
|
b_7 |
Birth order of the child |
|
|
b_8 |
Mother's occupation (2=No work,
3=Agriculture, 4=Carpet worker, 5=Daily wage earner, 6=Self employs,
7=Services, 8=Working abroad, 9=Not applicable) |
|
|
b_9 |
Father's occupation (2=No work, 3=Agriculture, 4=Carpet worker, 5=Daily wage
earner, 6=Self employs, 7=Services, 8=Working abroad, 9=Not applicable) |
|
|
b_10 |
Literacy of father (2=Illiterate 3=Primary, 4=Secondary,
5=SLC/Intermediate, 6=Bachelors, 7=Above) |
|
|
b_11 |
Literacy of mother (2=Illiterate 3=Primary, 4=Secondary,
5=SLC/Intermediate, 6=Bachelor, 7=Above) |
|
|
b_12 |
Where was the child born?
(1=Home, 2=Health Facility) |
|
|
b_13 |
Type of delivery (1=Normal,
2=Caesarean section,3=Vacuum/forceps) |
|
|
b_14 |
Gestation week (1=Full-term (40
weeks), |
|
|
2=Preterm (before 37 weeks),
3=Post-term (after 42 weeks) |
|
|
b_14.1 |
Total gestation weeks |
|
|
b_15 |
Birth weight in grams according
to card/Mother’s recall (Not applicable 9999) |
|
|
b_16 |
Was the child hospitalized
during the first month after birth?(2=No, 3=Meningitis, 4=Pneumonia,
5=Preterm, LBW, 6=Sepsis, 7=Others) |
|
|
b_17 |
Is there history of
hospitalization since one months of age (1=Yes, 2=No) |
|
|
b_17i |
Specify, reason for
hospitalization |
|
|
b_18 |
Days with loose watery stool
three or more times in a day? |
|
|
b_19 |
Did the child have cough and
difficulty breathing (1=Common cold, 2=No, 3=Pneumonia, 4=Reactive airway
diseases, 5=Others) |
|
|
b_20 |
Days of fever
(if no, 00) |
|
|
b_21 |
Visit to health
center/traditional healer because child was ill ? (1=Yes, in health facility,
2=No, 3=Yes, traditional healer, 4=Pharmacy) |
|
|
b_22 |
BCG (at 0-45 days) |
|
|
b_23 |
OPV 1st
(at 1
& 1/2 month) |
|
|
b_24 |
OPV 2nd (at 2
& 1/2 month) |
|
|
b_25 |
OPV 3rd
(at 3 & 1/2 month) |
|
|
b_26 |
IPV (3 & ½ months) |
|
|
b_27 |
DPT/Hep B/HIB 1st (at 1 & 1/2 month) |
|
|
b_28 |
DPT/Hep B/HIB 2nd (at 2 & 1/2
month) |
|
|
b_29 |
DPT/Hep B/HIB 3rd (at 3 & 1/2 month) |
|
|
b_30 |
PCV 1st
(at 1 & 1/2 month) |
|
|
b_31 |
PCV 2nd (at 2
& 1/2 month) |
|
|
b_32 |
PCV3rd
(at 12 months) |
|
|
b_33 |
MR (at 9 months) |
|
|
b_34 |
JE (at 12 months) |
|
|
b_35 |
Others (specify) |
|
|
c_1 |
Initials of the child |
|
|
c_2 |
Field Worker code |
|
|
c_3 |
Date of Interview |
|
|
c_4 |
Type of family (1=Nuclear, 2= Joint) |
|
|
c_5 |
No. of family
members |
|
|
c_6 |
No. of children up to the age of 5 years |
|
|
c_7 |
Family Ownership of land (1=yes, 2=no, 3=rented) |
|
|
c_8 |
If yes, how much land (ana)?
(If no, 9999) |
|
|
c_9 |
Is this your own house? (1=Yes, 2= No/Rented) |
|
|
c_10 |
Number of rooms in use by the
household (1 = 1-2 rooms, 2 = 3-5 rooms, 3 =
>5 rooms) |
|
|
c_11 |
Bedroom & Kitchen
(1=separate, 2=not separate) |
|
|
c_12 |
Type of cooking fuel use?
(1=firewood/straw/cow dung, 2=kerosene, 3=Gas, 4= electricity, 5=Others) |
|
|
c_13 |
Indoor tobacco/tamakhu smoking
(1= yes, 2=no) |
|
|
c_14 |
Drinking water supply (1=
mineral water 2= tanker supply 3=tap
water, 4=well, 5=hand pump, 6=stone spout, 7=other) |
|
|
c_15 |
Place of defecation (1= toilet
connected with drainage, 2= toilet with septic tank, 3=field, 4=others) |
|
|
c_16 |
Caste
(1=Bramhin, 2=Chhetri, 3=Newar,
4=Gurung, 5=Rai, 6=Tamang,
7=Lama, 8=Muslim, 9=Others) |
|
|
c_17 |
Ownership of vehicle (2= No, 3=
car/bus/truck, 4= motorbike, 5= Tractor) |
|
|
c_18 |
Do you have tenants in your
house? (1=Yes, 2=No) |
|
|
c_19 |
Remittance from abroad (1=Yes, 2=No) |
|
|
d_1 |
Initials of the child |
|
|
d_2 |
Field Worker code |
|
|
d_3 |
Date of Interview |
|
|
d_4 |
Age of Mother |
|
|
d_5 |
Gravida |
|
|
d_6 |
Paria |
|
|
d_7 |
Regular ANC visit for last
pregnancy? (Yes=1, No=2) |
|
|
d_8ia |
Folate (vitamin/mineral
supplement during last pregnancy start trimester) |
|
|
d_8iia |
Iron (vitamin/mineral
supplement during last pregnancy start trimester) |
|
|
d_8iiia |
Calcium ((vitamin/mineral
supplement during last pregnancy start trimester) |
|
|
d_8iva |
Taken any other medicines? |
|
|
d_8v.txt |
D_8v. Specify: |
|
|
d_8ib |
Folate (vitamin/mineral
supplement during last pregnancy duration ) |
|
|
d_8iib |
Iron (vitamin/mineral
supplement during last pregnancy duration) |
|
|
d_8iiib |
Calcium (vitamin/mineral
supplement during last pregnancy duration) |
|
|
d_8ivb |
Taken any other medicines? |
|
|
d_9 |
Any illness during pregnancy?
(1=Yes, 2=No) |
|
|
d_9_txt |
If yes, Specify? |
|
|
d_10 |
Has the women been hospitalized
during pregnancy? (Yes=1, No=2) |
|
|
d_10_txt |
If yes, specify cause. |
|
|
d_11 |
Any current illness?
(1=Yes, 2=No) |
|
|
d_11_txt |
If yes, specify |
|
|
d_12 |
Does the women/spouse use any
kind of contraception (2 = No, 3 = Condom,4 =Progesterone injection, 5 =
Pills, 6 = IUCD, 7=Norplant, 8 = She or husband has gone through operation, 9
= Not applicable) |
|
|
d_13 |
Measure weight of mother (kgs) |
|
|
d_14 |
Measure height of mother (cms) |
|
|
d_15_s |
Measure Blood pressure systolic |
|
|
d_15_d |
Measure Blood pressure diastolic |
|
|
e_1 |
Initials of the child |
|
|
e_2 |
Field Worker code |
|
|
e_3 |
Date of Interview |
|
|
e_4 |
Is child on breastfeeding
(1=Yes, 2=No) |
|
|
e_5 |
If not, when breastfeeding
stopped |
|
|
e_6 |
When was breastfeeding
initiated after birth? (1=within 1 hour, 2=2-4 hours, 3= 5-24 hours, 4=after 24 hours) |
|
|
e_7 |
Which food was given first just
after birth (1= Breast milk of mother, 2=Donner milk, 3= glucose water,
4=Formula milk, 5=Animal milk, 6=others, specify) |
|
|
e_8 |
Reason for giving other
food/drink just after birth.(1= Ceasarian section, 2=Preterm/LBW 3=Illness of
Baby, 4=Illness of mother, 5=No milk secretion, 6= Others, specify) |
|
|
e_8i |
Did you continue to give the
other food/drink after starting breastfeeding ? (1= Yes, 2= No, 9= NA) |
|
|
e_8ii |
If no, how long other food/drink
was given? (1= less than1 day, 2=1-2
days, 3=3 to 7days, 4= more than 7 days, 9=NA
) |
|
|
e_9 |
Which complementary food was
given first? (1=Lito, 2=Cerelac,
3=Animal/dairy milk, 4= Formula milk, 5= Rice, 6=Others |
|
|
e_10 |
When (month) start to feed
water or water based drink? |
|
|
e_11 |
When (month) start to feed with
animal or formula milk? |
|
|
e_12 |
When (month)
start to feed solid. Semisolid foods |
|
|
e_13 |
Reason for introducing other
food before 6 months of age (1=crying/hungry, 2=mother illness, 3=no enough
breast milk, 4=working mother, 5= others, 9=not applicable) |
|
|
e_14 |
Did you give janma ghuti?
(Yes=1, No=2) |
|
|
e_14i |
If yes, when started to give?
(months) |
|
|
e_14ii |
Up to which age (in month) it
was given ( if still giving write 99) |
|
|
e_14iii |
Reason for giving janmaghuti.
(1= to make vomiting, 2= to make abdomen comfort, 3= advice from other 4= do
not know, 5=other, specify) |
|
|
e_15 |
How long child was feed on
exclusively breastfeeding (months)? Write 00 if < 2 weeks and 99 if still
practicing exclusive breastfeeding. |
|
|
f_1 |
Day |
|
|
f_2 |
Is child available? |
|
|
f_3 |
Did he/she eat all paste of a
sachet? |
|
|
f_4 |
Vomiting after supplementation? |
|
|
f_5 |
Why paste not given? |
|
|
f_6 |
Fever? |
|
|
f_7 |
Diarrhea /vomiting? |
|
|
f_8 |
Blood in stool? |
|
|
f_9 |
Cough/ Shortness of breath? |
|
|
f_10 |
Visit to health center? |
|
|
f_11 |
Antibiotic use? |
|
|
f_12 |
Group of Antibiotic? |
|
|
f_13 |
Hospitalization? |
|
|
f_14 |
Other illness |
|
|
F14_txt |
If yes, specify |
|
|
f_15 |
Breast milk |
|
|
f_16 |
# times during night |
|
|
f_17 |
# times during day |
|
|
f_18 |
Infant formula |
|
|
f_19 |
Animal,Tinned or powdered milk |
|
|
f_20 |
Tea, coffee |
|
|
f_21 |
Fruit juices |
|
|
f_22 |
Other liquids |
|
|
f_23 |
Lito, cerelac? |
|
|
f_24 |
Rice or other cereals? |
|
|
f_25 |
Dal or other lentils/pulses |
|
|
f_26 |
White potatoes, white yams,
manioc, other roots? |
|
|
f_27 |
Meat/fish/ egg? |
|
|
f_28 |
Green and other vegetable |
|
|
f_29 |
Fruits like Bananas, Apples? |
|
|
f_30 |
Curd? |
|
|
f_31 |
Other foods |
|
|
g_1 |
Initials of the child |
|
|
g_2 |
Researcher Code |
|
|
|
|
g_3 |
Date of blood collection |
|
|
g_4 |
Time of blood collection |
|
|
g_5 |
Time of last meal
(khana) / snack (khaja) (If not today
enter 8888) |
|
|
|
|
g_6 |
Time of last breast
feed (If not today enter 8888) |
|
|
|
|
g_7 |
Amount of whole blood
(ml) |
|
|
|
|
g_8 |
Time of Plasma separation |
|
|
g_9 |
Hemoglobin level |
|
|
|
|
g_10 |
Blood group |
|
|
|
|
g_11 |
Number of Plasma Aliquots |
|
|
g_12 |
Time of transfer plasma aliquots
from field |
|
|
hit_1 |
Date |
|
|
hit_2 |
Field Worker's Code |
|
|
hit_3 |
Identity of primary caregiver (person being
interviewed)Mother=01, Father=02, Grandmother=03, Grandfather=04, Aunt=05,
Uncle=06, Other relative=07, Other non-relative=08 |
|
|
hit_4 |
Identity of those present in addition to the child and primary
caregiver (Mother=01, Father=02, Brother=03, Sister=04, Grandmother=05,
Grandfather=06, Aunt=07, Uncle=08,
Cousin=09, Other relative=10,
Other non-relative=11 |
|
|
hit_5 |
Caregiver spontaneously
vocalizes to the child at least twice during the visit (exclude scolding). (Observation) |
|
|
hit_6 |
Caregiver responds to child’s vocalizations with a verbal
response.(Observation) |
|
|
hit_7 |
Caregiver reports no instances of physical punishment during
the past week. (Interview) |
|
|
hit_8 |
Caregiver does not scold or criticize the child during the
visit. (Observation) |
|
|
hit_9 |
Caregiver tends to keep
the child within visual range and looks at the child quite often. (Observation) |
|
|
hit_10 |
Caregiver consciously encourages developmental advances. (Either) |
|
|
hit_11 |
Caregiver structures the child’s day. (Interview) |
|
|
hit_12 |
Caregiver believes the
child’s behavior can be changed or modified and is influenced by the parent’s
behavior. (Interview) |
|
|
hit_13 |
When the primary
caregiver is away, care is provided by one of three regular substitutes. (Interview) |
|
|
hit_14 |
Child is not cared for by another child (under 12 years of
age). (Interview) |
|
|
hit_15 |
There are some toys,
tins, balls, dolls, slates, or material in the house that are appropriate
play materials for the child. (Either) |
|
|
hit_16 |
The child has a riding toy or some toy that provides gross
motor stimulation. (Either) |
|
|
hit_17 |
The caregiver provides toys or interesting activities for the
child during the visit. (Observation) |
|
|
hit_18 |
There are some magazines, newspapers, or books visible in the
house.(Observation) |
|
|
hit_19 |
The caregiver tells the child stories or nursery rhymes at
least once a week. (Interview) |
|
|
hit_20 |
The caregiver sings to the child everyday. (Interview) |
|
|
hit_21 |
Where is taken the
observation/interview? 1= Own home, 2=Mother's home, 3=Relative's home,
4=Tent/temporary home, 5=Rent |
|
J _1 |
Initials of the child |
|
|
J _2 |
Field worker code |
|
|
J _3 |
Date |
|
|
J _4 |
Age of the Child (Months) |
|
|
J _5 |
Weight (kg) |
|
|
J _6 |
Length (cm) |
|
|
J _7 |
Head Circumference (cm) |
|
|
J _8 |
Vaccination in the last
month? |
|
|
J _8_txt |
If yes, specify |
|
|
J _9 |
Deworming on the last one
month? (Yes=1, No=2) |
|
|
J _10 |
Vitamin A on the last one
month? (Yes=1, No=2) |
|
|
J _11 |
Overall feeding status
(appetite) of the child on the last month? 1=Poor, 2=Satisfaction, 3=Good.
4=Excellence1=Poor, 2=Satisfaction, 3=Good. 4=Excellence |
|
|
J _12 |
Overall growth of the child
according to caregiver on the last month? (1=Poor, 2=Satisfaction, 3=Good.
4=Excellence) |
|
|
J _13 |
Overall developmental of the
child according to a caregiver on the last month? (1=Poor, 2=Satisfaction,
3=Good. 4=Excellence1=Poor, 2=Satisfaction, 3=Good. 4=Excellence) |
|
|
J _14 |
Complains of the caregiver on
the B12 supplementation on the last month (1=Poor, 2=Satisfaction, 3=Good.
4=Excellence) |
|
|
k_1 |
Day |
|
|
k_2 |
Does the FW visit the child? |
|
|
k_3 |
Did he/she eat B12 supplement? |
|
|
k_4 |
Vomiting
after supplementation? |
|
|
k_5 |
Why paste not given? |
|
|
k_6 |
Fever? |
|
|
k_7 |
Diarrhea /vomiting? |
|
|
k_8 |
Blood in stool? |
|
|
k_9 |
Cough/ Shortness of breath? |
|
|
k_10 |
Visit to health center? |
|
|
k_11 |
Antibiotic use? |
|
|
k_12 |
Group of Antibiotic? |
|
|
k_13 |
Hospitalization? |
|
|
k_14 |
Other problem |
|
|
k_14txt |
If yes, specify |
|
|
k_15 |
Breast milk |
|
|
k_16 |
# times during night |
|
|
k_17 |
# times during day |
|
|
k_18 |
Infant formula |
|
|
k_19 |
Animal,Tinned or powdered milk |
|
|
k_20 |
Tea, coffee |
|
|
k_21 |
Fruit juices |
|
|
k_22 |
Other liquids |
|
|
k_23 |
Lito, cerelac? |
|
|
k_24 |
Rice or other cereals? |
|
|
k_25 |
Dal or other lentils/pulses |
|
|
f_26 |
White potatoes, white yams,
manioc, other roots? |
|
|
k_27 |
Meat/fish/ egg? |
|
|
k_28 |
Green and other vegetable |
|
|
k_29 |
Fruits like Bananas, Apples? |
|
|
k_30 |
Curd? |
|
|
k_31 |
Other foods |
|
|
l_1 |
Study Researcher /Supervisor ID |
|
|
l_2 |
Today’s date |
|
|
l_3 |
Weight (kg) |
|
|
l_4 |
Length (cm) |
|
|
l_5 |
Head circumference (cm) |
|
|
m_1 |
Initials of the child |
|
|
m_2 |
Researcher code |
|
|
m_3 |
Date of Interview |
|
|
m_4 |
Why did the caregiver seek
health care for the child (1=Diarrhoea/vomiting, 2=Cough /cold/sore throat,
3= Fever, 4= ENT problem, 5= Feeding problems, 6= Skin problem, 7=Eye, 8=
Other, specify) |
|
|
m_4txt |
If other, specify |
|
|
m_5 |
Did the child seek out medical
care as a result of the illness before? (1= Yes, 2=No) |
|
|
m_6 |
Was any medicine given the
child for the illness? (2=No, 3=
Symptomatic, 4= Antibiotic, 5=vitamins/minerals, 6= Others |
|
|
m_6txt |
If other, specify |
|
|
m_7 |
Clinical Diagnosis 1 (1=AGE, 2=
AGE with dehydration, 3=Bacterial dysentery,4=URTI, 5= ALRI, 6= RAD, 7=Otitis
Media, 8= Anemia, 9= Malnutrition, 10=Skin allergic rash, 11=Pyoderma, 12=
Fever 13= Eye infection, 14=Others |
|
|
m_7txt |
If other, specify |
|
|
m_8 |
Hospitalization?( 2 = No, 3=
Severe pneumonia, 4=AGE with dehydration, 5=High grade fever under
investigations, 6=Fever with convulsion, 7=Severe PEM, 8=UTI, 9= Meningitis,
10=Other)( 2 = No, 3= Severe pneumonia, 4=AGE with dehydration, 5=High grade
fever under investigations, 6=Fever with convulsion, 7=Severe PEM, 8=UTI, 9=
Meningitis, 10=Other) |
|
|
m_8txt |
If other, specify |
|
|
m_9 |
Referred to other Health
Facility? |
|
|
m_9txt |
If Yes, reason? |
|
|
m_10 |
Medication given (2=No, 3=
Symptomatic, 4= Antibiotics, 5= Anti-convulsant, 6= Local medicine,7=Other) |
|
|
m_10txt |
If Antibiotic, which group? |
|
|
NCF_1 |
Initials of the child |
|
|
ncf_2 |
Study researcher ID |
|
|
ncf_3 |
Date of Interview |
|
|
ncf_4 |
What is the reason for leaving
the study? |
|
|
ncf_4i |
If refused, reason for refusal |
|
|
ncf_5 |
Date of last contact |
|
|
o_1 |
Initial of the child |
|
|
o_2 |
Field Worker code |
|
|
o_3 |
Date of Interview (DD/MM/YY) |
|
|
o_4 |
Age of Father |
|
|
o_5 |
Any chronic illness? (1=Yes,
2=No) |
|
|
o_5_txt |
If yes, Specify? |
|
|
o_6 |
Cigarette smoking? (1=Yes,
regularly, 2=No, 3=Yes, occasionally, 4=Previous smoker) |
|
|
o_7 |
Alcohol drinking? (1=Yes, 2=No) |
|
|
o_7.1 |
If yes, how often? (1= Daily,
2= Once a week, 3=2-4 times a week, 4=Once a month or less) |
|
|
o_8 |
How much time per day spending
with the child? hours |
|
|
o_9 |
Is father taking care of the
child eg, feeding, bathing? (Yes=1, No= 2) |
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o_9_txt |
If yes, specify (feeding, bathing, playing, napping/sleeping, toilet/diaper
changes, or others) |
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o_10 |
Measure weight of father (kgs) |
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o_11 |
Measure height of father (cms) |
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o_12 |
Measure blood pressure systolic |
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o_13 |
Measure blood pressure diastolic |
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p_1 |
Child enroll number |
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p_2 |
Researcher code |
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p_3 |
Date (according to English
calendar- DDMMYY) |
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p_4_a |
Age |
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p_4_b |
Sex (1=Male, 2=Female) |
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p_5 |
Is there any problem to feed
the paste? 1=Yes, 2=No |
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p_6 |
If yes, what is the main
problem? 1=Difficult to feed any food, 2= difficult to feed only paste, 3=
Frequent illness, 4= No time to feed, 5= other, 9=NA |
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p_6txt |
If other, specify |
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p_7 |
Usually, how did you give the
paste? 1= direct only paste, 2= with water, 3=with breast feeding, 4=with
liquid or food, 5= other |
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p_7txt |
If other, specify |
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p_8 |
Usually, how frequently you
give the paste? 1= once a day, 2= twice a day, 3= three or more times a day. |
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p_9 |
Does the child finished whole
packet of the paste most of the time? 1= yes, 2 = only 3/4 paste, 3=only1/2
paste, 4= only ¼ paste |
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p_10 |
1=once a week (4 days a month), 2=two to
three days a month, 3=once a month, 4= less than once a months, 5=frequently(
> 4 days a month), 6= never |
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|
p_10txt |
If frequently did not take,
Specify reason |
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p_11 |
What is your impression of the
paste on growth and development of your child? 1= Very good, 2= Good, 3=
satisfactory, 4= bad |
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p_12 |
Weight (in kg) |
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p_13 |
Length (in cm) |
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p_14 |
Head Circumference (cm) |
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p_15 |
Length for age in z score:1= <-1, 2=<-2, 3=< -3, 4= >-1 |
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p_16 |
Weight for length z score:1=
<-1, 2=<-2, 3=< -3, 4= >-1 |
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p_17 |
Hemoglobin (g/dL) |
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bsd_1 |
Initials of the child |
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bsd_2 |
Researcher's code |
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bsd_3 |
Date |
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bsd_4 |
Identity of primary caregiver
(person being interviewed) (Mother=01, Father=02, Grandmother=03,
Grandfather=04, Aunt=05, Uncle=06, Other relative=07, Other non-relative=08) |
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bsd_5 |
Cognitive |
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bsd_6 |
Receptive Communication |
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bsd_7 |
Expressive Communication |
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bsd_8 |
Total Score (sum of Receptive
and Expressive Communication Scores) |
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bsd_9 |
Fine Motor |
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bsd_10 |
Gross Motor |
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bsd_11 |
Total Score (sum of Fine and
Gross Motor Scores) |
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bsd_12 |
Social-Emotional |
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