Vaccination HISTORY Survey (children 6 - 59 Months / 12-23 MONTHS) - Questionnaire

Please adapt according to the context of the study

Date ¦__¦__¦ / MM / 20XXVillage name: ______

Team N° ¦__¦Cluster N° ¦__¦__¦Household N° ¦__¦__¦

Circle relevant answers below

Eligible for Coverage Survey:1=yes0=no

If no, stop the interview and go to next household. Retain this incomplete form.

Verbal consent given by caretaker: 1=yes0=no

If no, stop the interview and go to next household. Retain this incomplete form.

Relationship of caretaker to child:

1=mother2=father3=grandmother4=grandfather5=aunt

6=uncle7=brother8=sister9=other (specify: ______)

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Questionnaire / Vaccination Coverage Survey / 20XX, Version 1.1: May 2017

No. / Question / Codes for answers / ANSWER / Comments
SECTION A – INITIAL QUESTIONS
A1 / Name of child
[ONLY IF NEEDED FOR CHECKING AGAINST HEALTH CENTRE REGISTERS] / If collected, do not enter this information into electronic database
A2 / Date of birth of child
[ONLY IF NEEDED FOR CHECKING AGAINST HEALTH CENTRE REGISTERS] / Format: dd/mm/yyyy
(For instance, 21 August 2013 = 21 / 08 / 2013)
A3 / Age of child / In years and months.If less than 1 year old write ‘0’ for years. Use Calendar of events if respondent uncertain. / Years: ______
Months: ______
A4 / Has the child ever received a vaccination –drops (oral vaccine) or injection? / 1 = Yes
0 = No / If yes, continue.
If no, go to Section D.
A5 / Vaccination card available? / 1 = Yes
0 = No / If yes, go to Section C.
If no, go to Question B1.
A6 / Health Facility records available?
[ONLY IF CHECKING HEALTH CENTRE REGISTERS OTHERWISE DELETE QUESTION] / 1 = Yes
0 = No / Health Facility: ______
Date Checked: ______/ Use a red pen to note changes to this record based on health facility information
SECTION B - VACCINATION HISTORY WITHOUT A VACCINATION CARD
[THESE QUESTIONS NEED AMENDING ACCORDING TO THE NATIONAL VACCINATION SCHEDULE]
B1 / Has the child ever received an injection in the left/rightupper arm or shoulder that usually causes a scar - that is, BCG vaccination against tuberculosis? / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B3.
B2 / If the child is present, check for evidence of a scar / 1 = Scar Present
2 = No Scar Present
3 = Child not available to check
B3 / Has the child ever received any “vaccination drops in the mouth” – that is, polio vaccine? / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B6.
B4 / How many times has the child received a polio drops vaccine at a health facility? / Write the number. If never, write ‘0’
If don’t know/can’t remember, write ‘999’
B5 / How many times has the child received a polio drops vaccine during a large campaign, usually involving a large group of children in the area and perhaps vaccinating at your house? / Write the number. If never, write ‘0’
If don’t know/can’t remember, write ‘999’
B6 / Has the child ever received an injection vaccination that you were told is polio? This is usually given in the first two years of life along with other regular childhood vaccinations / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B8.
B7 / How many polio injections has the child received? / Write the number.
If don’t know/can’t remember, write ‘999’
B8 / Has the child ever received an injection on the upper outer thigh in the first two years of life – that is a quad or penta vaccination to prevent him/her from getting diseases like tetanus, whooping cough, diphtheria, influenza or hepatitis / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B10.
B9 / How many times? / Write the number.
If don’t know/can’t remember, write ‘999’
B10 / Has the child ever received a Pneumococcal Conjugate Vaccine (PCV) – that is an injection to prevent lung disease, pneumonia? This is usually given in the first two years of life along with other regular childhood vaccinations / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B12.
B11 / How many times? / Write the number.
If don’t know/can’t remember, write ‘999’
B12 / Has the child ever received a measles injection? In routine vaccination in clinics this is givenaround the age of 9 months and then 2 years, in the left upper arm. It was also given in a mass campaign in this area in [month/year] / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B14.
B13 / How many times?
[FUTHER QUESTIONS ON WHETHER THESE WERE RECECEIVED AT A HEALTH FACILITY OR IN A MASS CAMPAIGN CAN BE ADDED (AS FOR POLIO) IF THIS WOULD BE CONSIDERED USEFUL IN THE CONTEXT] / Write the number.
If don’t know/can’t remember, write ‘999’
B14 / Has the child ever received Yellow Fever vaccine?
[FUTHER QUESTIONS ON WHETHER THESE WERE RECECEIVED AT A HEALTH FACILITY OR IN A MASS CAMPAIGN CAN BE ADDED (AS FOR POLIO) IF THIS WOULD BE CONSIDERED USEFUL IN THE CONTEXT]
[DELETE YELLOW FEVER QUESTIONS IF NOT RELEVANT FOR THE CONTEXT] / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B16.
B15 / How many times? / Write the number.
If don’t know/can’t remember, write ‘999’
B16 / Has the child ever received Rotavirus vaccine – that is a vaccine to prevent diarrhoea? This is usually given in the first two years of life along with other regular childhood vaccinations
[DELETE ROTAVIRUS QUESTIONS IF NOT RELEVANT FOR THE CONTEXT] / 1 = Yes
0 = No
999 = Don’t know/Can’t remember / If yes, continue.
If no, go to Question B18.
B17 / How many times? / Write the number.
If don’t know/can’t remember, write ‘999’
B18 / In what type of facility does/did the child usually receive vaccinations? / 1= Local GovernmentHealth Clinic
2= Local PrivateDoctor's Office
3 = Local Other
4 = Government HealthClinic in another area
5 = PrivateDoctor's Office in another area
6 = Other type of facility in another area / If ‘other’ (option 3 or 6), specify:
______
______
B19 / Write the name of the clinic or facility.
[ONLY IF NEEDED FOR CHECKING AGAINST HEALTH CENTRE REGISTERS] / Write ‘Don’t know’ or ‘Can’t remember’ if this is the case
B20 / [Ask the caretaker:] Do you think your child has received all the vaccines that are recommended? / 1 = Yes
0 = No
999 = Don’t know / If yes or don’t know, continue to Question B21.
If no, go to Section D.
B21 / [Interviewer to look back at responses given in this section. Do the answers indicate that all recommended injections have been received?] / 1 = Yes
0 = No / If yes, END THE QUESTIONNAIRE HERE– THANK THE CARETAKER FOR TAKING PART AND ASK IF THEY HAVE ANY QUESTIONS.
If no, continue to Question B22.
B22 / [Interviewer to explain to the caretaker that, from the answers given, it seems the child has not received all the vaccines that are recommended. Ask the caretaker what they think, and ask if there are any injections they might have forgotten] / If the caretaker has forgotten any vaccines, go back and alter the relevant answers then RETURN TO QUESTION B20.
If the caretaker agrees that not all recommended vaccines have been received by the child, go to Section D.
If the caretaker (still) believes that all recommended vaccines have been received by the child, END THE QUESTIONNAIRE HERE– THANK THE CARETAKER FOR TAKING PART AND ASK IF THEY HAVE ANY QUESTIONS.
SECTION C - VACCINATION HISTORY WITH A VACCINATION CARD
[THE VACCINES LISTED IN THIS SECTION NEED AMENDING ACCORDING TO THE NATIONAL VACCINATION SCHEDULE]
  • If the caretaker agrees, take a photo of the vaccination card
[AMEND THIS INSTRUCTION ACCORDING TO THE CONTEXT AND NEEDS OF THE SURVEY]
  • For each injection listed below, look at the vaccination card and EITHERwrite the date it was given ORput a tick in the box if no date is written and only a mark was made on the card (a tick, cross or signature).
  • If the injection was NOT received, leave the date and box BLANK

Vaccine / Date given OR Mark on card / Vaccine / Date given OR Mark on card
BCG / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / Yellow Fever / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
DTP-Hib 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / IPV 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
DTP-Hib 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / IPV 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
DTP-Hib 3 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / IPV 3 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Hepatitis B 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / OPV 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Hepatitis B 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / OPV 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Hepatitis B 3 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / OPV 3 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Measles/MMR 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / Pneumococcal/PCV 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Measles/MMR 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / Pneumococcal/PCV 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Vaccine / Date given OR Mark on card / Vaccine / Date given OR Mark on card
Rotavirus 1 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / Pneumococcal/PCV 3 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Rotavirus 2 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / [Blank] / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
Rotavirus 3 / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card / [Blank] / ¦__¦__¦ / ¦__¦__¦ / ¦__¦__¦__¦__¦
 No date but mark on card
[add in relevant vaccines if routine in EPI in the context and considered important for planning response. For example, pneumococcal, meningococcal A conjugate.
Interviewer to look back at responses given in this section. Do the answers indicate that all recommended injections have been received?
If yes, END THE QUESTIONNAIRE HERE– THANK THE CARETAKER FOR TAKING PART AND ASK IF THEY HAVE ANY QUESTIONS.
If no,GO TO SECTION D.

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Questionnaire / Vaccination Coverage Survey / 20XX, Version 1.1: May 2017

SECTION D – REASONS FOR NON-VACCINATION
Question / Codes for answers / ANSWER
Why hasn't the child received all recommended vaccines? / DO NOT READ THE FOLLOWING LIST TO THE CARETAKER. JUST RECORD THE EACH OF THE REASONS THAT THE CARETAKER MENTIONS IN THEIR ANSWER:
1 = Vaccines dangerous for the child
2 = Previous bad experience with a vaccination
3 = Vaccines are not beneficial
4 = Vaccination is painful for the child
5 = Father did not allow mother to vaccinate the child
6 = Religious beliefs
7 = Did not know that s/he could vaccinate the child
8 = Vaccination place too far away/too expensive
9 = Caretaker/family working or too busy to take child for routine vaccination or to a vaccine campaign
10 = Family was away when a routine vaccine was due or during a vaccination campaign
11 = Child was sick when a routine vaccination was due or during a vaccination campaign so missed an opportunity
12 = Vaccinator refused to/decided not to vaccinate the child
13 = Not enough vaccine at the vaccination place
14 = Vaccination place was closed or there was a long wait
15 = Other
999 = Don’t know / If ‘other’ (option 15), specify:
______
______
______
THIS IS THE END OF THE QUESTIONNAIRE – THANK THE CARETAKER FOR TAKING PART AND ASK IF THEY HAVE ANY QUESTIONS.

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Questionnaire / Vaccination Coverage Survey / 20XX, Version 1.1: May 2017