Jigawa State
Facility ID
S4. Relationship to Child
S5. Contact Number of Primary Caregiver
S5a. Does the child have a Secondary Caregiver?
Q2. Ages (Months )
Q5. Gender
Q8. Duration spent in CMAM clinic (weeks)
Q6. State of Origin
Q7. Ethnicity
Q7a. Ethnicity - Other Specify
Q8. Religion
Q8a. Religion -Other Specify
Q3. Was the child discharged as
Q4. Was the child ever treated at the stabilization centre?
Q5. Has the child been admitted into any other hospital/clinic since discharge?
Q6. Has the child been readmitted into CMAM Clinic since discharge?
Q7. If yes, how many weeks after discharge?
Q8. Is the child alive?
Q16. . If alive, present state of health
Q17. Has the child been ill at any time in the last month?
Q18. For how many days was the child ill?
Q9.Family size/No of people living in the household (Immediate family members)
Q10. Type of Household
Q11.Marital status of parents or caregiver:
Q11_OTH. Other Specify
Q12. Type of marriage
Q13. Mother's position among wives
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
Q20. Since discharge has any of the following occurred
Insurgence
Communal clashes
Job losses
Geographical Weaning
Relocation/New Delivery
Demise of a child in the family
Separation of the Parents
Loss of Job
Maternal demise/Illness
Change of Care giver
Ill Sibling
Any additional immunization
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. Has any other child in the household been admitted to CMAM clinic?
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
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.Have you ever received any information on infant and young child feeding?
Q39a Source of Information
Media
PHc
Relations
Friends
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.
bread
Rice
Indomie
Sweet Potatoes
Yam
cassava/ Garri
Plantain
cocoyam
Maize/Millet/Sorghum/Wheat
Potato
Refused
don't know
Q41A_OTH. Other Specify
Q41B. Protein - 3 days recall.
beef
Pork
Goat
Poultry
Fresh Fish
dry Fish
cray fish/Fish/Sea food
beans/Moimoi/akara
Soyabeans
eggs
Milk/Yoghourt/awara
Q41B_OTH. Other Specify
Q41C. Oil & Fats - 3 days recall.
Vegetable Oil
butter
Red Oil
Soya bean Oil
animal Oil
coconut Oil
Q41C_OTH. Other Specify
Q41D. Fruits & Vegetables - 3 days recall.
Mango
Pawpaw
banana
Orange
apple
Garden egg
Water melon
Pineapple
carrot
Green leafy vegetable
Okro
Q41D_OTH. Other Specify
Q41E. Snacks - 3 days recall.
chocolate
Sweet
Pasteries
biscuits
buns/PuffPuff/chinchin
Masa
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
Fever
Cough
Fast Breathing
Vomitting
Watery stool
Bloody Stool
Refusl to Eat
Convulsion
Weakness
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
P3. When did the child die? (In months after discharge)
P1. How many months old was the child at death?
P4. Where did the child die?
P4_OTH Others specify
P2. Was the child ill before death?
P5. If yes, What where the symptoms noticed prior to death?
P5_OTH Others