7 2018 MCH Survey Juris Module_Palau_English_Formatted

Palau

[ONLY ASK THIS QUESTION IF CHILD IS 0-5 YEARS OLD]

1. Has your child ever completed the Ages and Stages Questionnaire (ASQ) from their doctor or another professional?

   1. ☐ Yes

   2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

The next 2 questions ask about bullying. Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way.

2. Has your child ever been bullied on school property?

   1. ☐ Yes

   2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

3. [ONLY ASK THIS QUESTION IF CHILD IS 12-17 YEARS OLD]

Has your child ever been electronically bullied? (Count being bullied through texting, Instagram, Facebook, or other social media.)

1. ☐ Yes

2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

4. Have you or any other adult in your child's life discussed avoidance of violence or prevention of injury with your child?

   1. ☐ Yes

   2. ☐ No

77. ☐ Don’t Know

99. ☐ Prefer not to answer

[ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

The next few questions are about your health during and post pregnancy.

5. During your most recent pregnancy, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each one, check No if no one talked with you about it or Yes if someone did.

   	YES	NO	Don’t Know	Prefer Not to Answer
   PA5a. Foods that are good to eat during pregnancy	1 ☐	2 ☐	77 ☐	99 ☐
   PA5b. Exercise during pregnancy	1 ☐	2 ☐	77 ☐	99 ☐
   PA5c. Programs or resources to help me gain the right amount of weight during pregnancy	1 ☐	2 ☐	77 ☐	99 ☐
   PA5d. Programs or resources to help me lose weight after pregnancy	1 ☐	2 ☐	77 ☐	99 ☐

6. [ONLY ASK THIS QUESTION IF CHILD IS 0-1 YEAR OLD AND IF BIOLOGICAL MOTHER]

How much weight did you gain during your most recent pregnancy?

lbs OR kilos

1. ☐ I didn’t gain any weight during my pregnancy

77. ☐ Don’t Know

99. ☐ Prefer not to answer