Caregiver Questionnaire

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Parent Questionnaire
Participant ID	_______________________
Name of Assessor	__________________(free type)
Name of Data Clerk	__________________(free type)
Date of assessment	______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)
Section A: General Health
In general, how would you describe your child’s health? If fair or poor, explain:		 Excellent  Very good  Good  Fair  Poor _______________ (free type)
Since your child was born, has he/she had any of the following? Seizures Hearing problems Vision problems Eating or swallowing problems Problems digesting food, including stomach/intestinal problems, constipation, or diarrhea Other condition If yes, describe: Hospitalization If yes, describe:		 No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes _______________ (free type)  No  Yes _______________ (free type)
Has your child received all the recommended vaccines for their age on schedule? What was the primary reason for not receiving the recommended vaccines? What was the specific reason for the suggestion or decision for your child to not receive all the recommended vaccines on schedule?		 No  Yes If YES, go to Section B: Breastfeeding  A healthcare provider told us not to  I decided to delay some or all of the vaccines  I decided my child would not receive any of the vaccines  Other, specify _______________ (free type) _______________ (free type)
Section B: Breastfeeding
Was this child EVER breastfed or fed breast milk? If yes, how old was this child when he or she COMPLETELY stopped breastfeeding or being fed breast milk? How old was this child when he or she was FIRST fed formula? Did any of the below reasons affect your decision to not breastfeed or to stop breastfeeding your baby? My baby had trouble sucking or latching on My baby had trouble swallowing Breastfeeding was too painful My baby became sick and could not be breastfed My baby was not gaining enough weight My baby was too irritable and fussy My baby lost interest and began to wean him or herself I was worried about passing Zika virus to my baby Other How old was this child when he or she was FIRST fed anything other than breast milk or formula? Include juice, cow’s milk, sugar water, baby food, or anything else that your child might have been given, even water.			 No  Yes _____ days (1 digit) OR _____ weeks (1 digit) OR _____ months (2 digits) OR  check this box if still breastfeeding _____ days (1 digit) OR _____ weeks (1 digit) OR _____ months (2 digits) OR  check this box if child has never been fed formula  check this box if still breastfeeding and go to the next question  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes, specify: _______________ (free type) _____ days (1 digit) OR _____ weeks (1 digit) OR _____ months (2 digits)
Section C. Sleep
Does your child have any problems falling asleep? Does your child wake up a lot at night? Does your child snore a lot or have difficulty breathing at night? Does your child have restless sleep, or often change position during the night? Do you think that your child has sleeping difficulties?				 Often  Sometimes  Never  Often  Sometimes  Never  Often  Sometimes  Never  Often  Sometimes  Never  Often  Sometimes  Never
Section D. Family Functioning
Since your child was born, did your family have problems paying for any of this child’s medical or health care bills? Since your child was born, have you or other family members: Stopped working because of this child’s health status? Cut down on the hours you work because of this child’s health or health conditions? IN AN AVERAGE WEEK, how many hours do you or other family members spend providing health care at home for this child? Care might include changing bandages, or giving medication and therapies when needed. DURING THE PAST 12 MONTHS, was there someone that you could turn to for day-to-day emotional support with parenting or raising children? Does this child receive care for at least 10 hours per week from someone other than his or her parent or guardian? This could be a day care center, preschool, family child care home, nanny, au pair, babysitter or relative. Have you or anyone in the family have to quit a job, not take a job, or greatly change your job because of problems with child care for this child? SINCE THIS CHILD WAS BORN, how often has it been very hard to get by on your family’s income – hard to cover the basics like food or housing? At any time DURING THE PAST 12 MONTHS, even for one month, did anyone in your family receive: Cash assistance from a government welfare program? Food Stamps or Supplemental Nutrition Assistance Program benefits? Government assistance with childcare? DURING THE PAST 6 MONTHS, how much income did your family make in a month? Please include income from all members in your household.					 No  Yes  No  Yes  No  Yes  Less than 1 hour per week  1-4 hours per week  5-10 hours per week  11 or more hours per week  No  Yes  No  Yes  No  Yes  Never  Rarely  Somewhat often  Very often  No  Yes  No  Yes  No  Yes  < R$500  R$500-R$1,499  R$1,500-R$2,999  R$3,000-R$6,999  > R$7,000  Do not know