Jigawa State
Facility ID
Q2. Ages (Months )
Q5. Gender
Q10. Type of Household
Q11. Marital Status
Q11_OTH. Other Specify
Q12. Type of marriage
Q13. Mother's order of marriage
Q13. Specify Others
Q15. Mother' number of children
Q15a How many children under 5 does the mother have in total
Q16. Number of Children under 5
Q17. Birth Order
Q17a Birth Type
Q18. Place of Delivery
Q18 Others Specify
Q19. Mother's Age
Q20. Father's Age
Q21. Highest Education attained by mother
Q21a Others Specify
Q22. Highest Education attained by father
Q22a Others Specify
Q23. Mother's Occupation
Q23. Other Specify
Q24. Father's Occupation
Q24. Other Specify
Q25. Mother's Monthly Income
Q26. Father's Monthly Income
Q27. Living with Parents
Q28. Living with ...
Q29 Specify Others
Q30. Ever Breastfeed Child?
Q31a If No, What did you give
Q31ai Specify Others
Q35. How soon after delivery was breast feeding started?
Q35a What was given to the baby in the first 3 days after delivery
Breast Milk
Infant formula
Animal milk
Date(Debino)
Glucose water
Religious substances
Don't know
Other specify
Q35b Others specify
Q35c Did you discard the first yellow breast milk (colostrum)
Q32b. Did you do exclusively breast feeeding?
Q32c. How long did you exclusively breastfeed? (Months)
Q32d. What else was added to breast feeding
Formular
Religious Substances
None of the above
Q32d_OTH. Other Specify
Q34. How long was the child breastfed? (Total duration of breast feeding)
Q37. Have you stopped breastfeeding the child?
Q37a.At what age (months ) did you stop breast feeding?
Q38. At what age did you introduce semi solid/solid food to the child? (Months)
Q39. Any education on infant feeding
Q39a Source of Information
Religious centre
Role model mother
Q39_OTH. Other Specify
Q40. Who decided child should come to CMAM facilty?
Q40a Others Specify
Q41A. Carbohydrate - 3 days recall.
Sweet potatoes
Cassava/Garri
Maize/Millet/Sorghum/Wheat
Q41A_OTH. Other Specify
Q41B. Protein - 3 days recall.
Fresh Fish
Dry Fish
Cray fish/Fish/Sea food
Beans/Moimoi/Akara
Milk/Yoghourt/Awara
Q41B_OTH. Other Specify
Q41C. Oil &amp; Fats - 3 days recall.
Vegetable Oil
Red Oil
Soya Bean Oil
Animal Oil
Coconut Oil
Q41C_OTH. Other Specify
Q41D. Fruits &amp; Vegetables - 3 days recall.
Garden Egg
Water melon
Green leafy vegetable
Q41D_OTH. Other Specify
Q41E. Snacks - 3 days recall.
Buns/PuffPuff/ChinChin
Sweetended Drinks/Soda
Date (Debino)
Q41E_OTH. Other Specify
Q42. Immmunization Status
Q43. Child ill in the last month?
Increase in MUAC
Q44. For how many days was the child ill?
Q45. Symptoms of ill child
Fast Breathing
Watery stool
Bloody Stool
Refusl to Eat
Body Swelling
Cough and Cattarh
Q45_OTH Other Specify
Q46. Oedema
Q47A. Weight 1
Q48A. Height/Length 1
Q49A. MUAC 1
Q50A. Head Circumference (cm)
D1. Duration spent in CMAM in (Weeks)?
D2. How many clinic sessions have you missed?
D3. Criteria for discharge
Increase in weight
Lost of Oedema
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