Date of interview: ___ /_____/______ House ID :_____________________

Interviewers: [] 1 [] 2 [] 3 Children : [] 0 active TB [] 1 without TB

A. Parents/guardian sociodemographic
No Questions Code
A1 Gender 1[ ] female 2[ ] male
A2 Date of birth (dd / mm / yyyy) (_____/________/________)
A3 Marital status 1[] single 2[] married 3[] widowed 4[] divorced
A4 Ethnicity ? 1[] Minangkabau 2[] Javanese 3[] batak 4[] other, specify ___________
A5 What is your highest education ? 1[] don’t have education 2[] primary school
3[] junior high school 4[] senior high school 5[] bachelor 6[] above bachelor
A6 what is your current occupation ? (multiple choice) 1[] housewife / house keeper
2[] entrepreneur / self employed 3[] agriculture /farmer 4[] fisherman 5[] lecturer 6[]
civil servant 7[] private employees 8[] retired 9[] other , specify___________
A7 How many hours of work per day________ hour
A8 Average monthly household income (IDR) ? 1[] < 1,000,000 2[] 1,000,000 – 3,000,000
3[] 4,000,000 – 5,000,000 4[] > 5,000,000
A9 Spending on food per month 1[] ≤ 600,000 2[] 600,000 – 1,000,000 3[] ≥ 1,000,000
A10 How many people living in your house including yourself ? ______ (specify)
A11 How many children <15 yo living there ? ______ (specify)
A12 What is your relationship with the child ?
1[] mother 2[] father 3[] grandparents 4[] relatives 5[] other, __________
A15 Have you ever received nutritional counselling? 1[] yes 2[] no 3[] not sure
B. Family eating characteristics
No Questions Code
B1 Who determines your main child daily menu ? 1[] mother 2[] caregiver 3[] father
4[] parents /in-laws 5[] helper 6[] Others, specify ________________
B2 How do you get your child daily menu ? 1[] cook at home 2[] buy ready made
3[] instant food 4[] Others, specify______________
B3 What are the considerations in choosing a menu for your child ? (multiple choices)
1[] nutrition 2[] finance 3[] ease of obtaining/food availability
4[] children’s tastes/likes 5[] Others, specify___________________
B4 How often does your family eat meals together at home?
a) Almost always; everyday b) Fairly often, not everyday
c) Occasionally, only when there an event d) Rarely, once a week
B5 How much time does your child typically spend on screens (e.g., TV, computer, tablet, smartp
hone) each day? 1[] <1 hour 2[] 1-2 hours 3[] 2-4 hours 4[] >4 hours
C. Feeding style
No Questions Code
C1 How you feed your child?
1[] I am authoritative, I set clear rules and support my child's needs
2[] I am indulgent, I let my child eat whatever they want.
3[] I am authoritarian, I enforce strict rules without much warmth.
C2 How do you react when your child expresses a preference for unhealthy snacks or treats?
1[] I allow my child to eat whatever they want, even if it's not nutritious.
2[] I try to balance treats with healthier options and encourage moderation.
3[] I ignore their preferences and insist they eat what I provide
D. Child eating behavior
No Questions Code
D1 How child's enjoy of eating food? 1[] They consistently excited and happy while eating.
2[] They rarely show enjoyment while eating and may seem disinterested.
3[] Their enjoyment depending on the meal or snack.
D2 Is your child a picky eater? 1[] They are not picky eaters. 2[] They are somewhat picky, sho
wing reluctance to try new foods 3[] They are very picky, often refusing certain foods

E. Household Smoking situation

No Questions Code
B1 Does anyone in your house smoke (past/current), including yourself? 0[] Yes 1[] No
(if No, skip smoking questions)
B2.1 If yes, what is their/ your smoking status? 1[] current 2[] former 3[] No
B2.1.1 If former, how long year since the last smoking ? ________ years
B2.1.2 If current, how many people smoke in the last 6 months, include yourself ? ______ specify
B2.1.3 If current, how many pack perdays ? ________ cigarettes/packs per day
B2.1.4 How long they/you have been smoking? ________ years
For researcher : Pack years 1) 0.1 - 10 2) 11 - 20 3) 20 - 40 4) >40
B2.2 Where do you / other usually smoke ? 1[] inside house 2[] outside house 3[] both
Warning ! Questions below (C3) is for ONLY parents of adolescent (11-15 years old)
B3 Have your child ever smoked? 1[] Yes 2[] No 3[] Current smoker 88[] don’t know
Note : Lower than 2 cigarettes per week not consider as a smoker
For researcher : if parents answer no/don’t know, need to ask the child for age >10 yo
B3.1 If yes, how many pack per day ?_______ cigarettes/pack per day
B3.2 How long have s/he been smoking?________ years

F. Parents / guardians Medical History

No Questions Code
C1 Do you have any underlying diseases (diagnosed by doctor) ? Multiple choices
1[] Hypertension 2[] Diabetes 3[] COPD 4[] Asthma 5[] Cancer
6[] Psychiatric problem 7[] HIV 8[] Other, specify____________9[] don’t have
C2 Body weight ___ ___ . ____ kg Body height ___ ____ ____ cm
C3 Have you ever been diagnosed, now or on the past that you had tuberculosis ?
0[] Yes 1[] No (if no, jump into index case part)
C3.1 If yes, do you complete your treatment ? 1[] Yes 2[] No 3[]current on-going

G. Index case medical record (if this section completed already by hospital based data, than skip)
No Questions Code
D1 Index case gender? [] 1 female [] 2 male
D2 His/her date of birth (dd / mm / yyyy) (_____/________/________)
D3 What is his/her relationship with the child ? 1[] mother 2[] father
3[] grandparents 4[] siblings 5[] relatives 6[] other, specify _______________
D4 Her/his treatment status? 1[] cure 2[] completion 3[] treatment interruption
4[] lost to follow up 5[] death 6[] not evaluated 88[] don’t know
D5 Do she/he have any following disease ? multiple choices
1[] Hypertension 2[] Diabetes 3[] COPD 4[]Asthma 5[] Cancer
6[] Psychiatric problem 7[] HIV 8[] Other (specify)_________ 9[] don’t have

H. Children Medical Record (if this section completed already by hospital based data, than skip)
No Questions Code
E1 Child gender 1[] female 2[] male
E2 Has your child previously received the BCG vaccine? 0 [] yes 1 [] no
Has your child ever been diagnosed with tuberculosis? 1[] yes 2 [] no
E3
E4 When was she/he diagnosed with tuberculosis? _______ month ________ year

E5 What is following symptoms s/he have ? (multiple answer)

1 [] Cough 2 [] Fever 3 [] Night sweats 4 [] Loss of appetite
5 [] Less playful (not energetic) 6 [] Weight loss 7 [] Other, specify__________
E6 TPT history? 1[] completed 2[] on going 3[] not received
Your child treatment status?
E7
1[] cure 2[] completion 3[] treatment interruption
4[] lost to follow up 5[] death 6[] not evaluated 88[] don’t know
Since how many months has your child been receiving tuberculosis treatment?
E8
1 [] 1-2 2 [] 3-4 3 [] 5-6 4 [] >6 88 [] don’t know

E9 Where do you think your kids got tuberculosis ?

1[] household 2[] school 3[] neighbor 4[] other, specify _________
E10 Is s/he has any underlying disease ? 1[] Hypertension 2[] Diabetes 3[] COPD
4[]Asthma 5[] Cancer 6[] Psychiatric problem 7[] HIV
8[] Other (specify)________________ 9[] don’t have
PRACTICE
A. Breastfeeding or History of breastfeeding
Warning ! current practice breastfeeding ONLY being ask for parents of infants (0-23 months).
For parents of children and adolescent, use term “history of breastfeeding”
No Questions Code
1 Was the child ever breastfed ? [] 0 yes [] 1 no
(if NO, END questions about BF)
3 was the child received colostrum ? [] 0 yes [] 1 no
4 Exclusive breast feeding (only) for the first 6 months ? [] 0 yes [] 1 no, mixed

4.1 If no, what type of milk/liquid you give to your child ? Multiple choices
[] 1 formula milk [] 2 evaporated milk [] 3 animal milk [] 4 plants / soy milk [] 5 plain
water [] 6 tea /coffee [] 7 fruit juice [] 8 honey [] 9 other ______
5 Are you continuing / will breastfeeding to your child until 12 – 23 months ?
[] 0 yes [] 1 no
6 What is your difficulties to give exclusive breastfeeding ? Multiple choices
[] 1 painful breast by anycause
[] 2 insufficient breastmilk production
[] 3 lack of support
[] 4 short maternity leave periods
[] 5 emotional stress
[] 6 lack of knowledge
[] 7 cultural influence
[] 8 mother unable to breastfeeding [] 9 other, specify________________
B. Complementary Food
NO Questions Code
1 At what time you give complementary food ? 1[] < 6 months 2[] > 6 months
2 How many times did (name of the baby) eat foods, that is meals and snacks other than liquids
yesterday? _______ number of times [] 88 don’t know
C Minimum Dietary Diversity (24 hr-recall)
Group Food lists code
Group 1 : Breast Milk Breast Milk (direct to mother breast or bottle feeding)
(only for infant parent) [] 0 yes [] 1 no
Group Food lists code
Group 2 : Grains, Porridge, bread, rice, lontong, noodles or other foods made from grains
roots and tubers [] 0 yes [] 1 no
White potatoes, white y ams, cassava or any other foods made from roots
[] 0 yes [] 1 no
Group 3: Legumes Any foods made from beans, peas, lentils, nuts or seeds (beans, long
and nuts beans, gadang beans, soybeans, peanuts) [] 0 yes [] 1 no
Group 4: Dairy Infant formula, such as ®bebelac, ®dancow [] 0 yes [] 1 no
products How many times ? ____
Milk, such as tinned, powdered or fresh animal milk [] 0 yes [] 1 no
How many times ? ____
Cheese or other dairy products [] 0 yes [] 1 no
Group 5: Flesh foods Liver, kidney, heart or other organ meats [] 0 yes [] 1 no
Any meat, such as beef, lamb, goat, chicken or duck [] 0 yes [] 1 no
Fresh or dried fish (bandeng, nil/mujair, lele), seafood [] 0 yes [] 1 no
Snails [] 0 yes [] 1 no
Group 6: Eggs Eggs [] 0 yes [] 1 no
Group 7: Vitamin A Pumpkin, carrots, squash or sweet potatoes that are yellow or orange
fruits and vegetables inside [] 0 yes [] 1 no
Any dark green vegetables (kang kong, spinach, cassava leaves, broccoli,
mustard, cabbage, ) [] 0 yes [] 1 no
Ripe mangoes, papaya, banana, star fruit, langsat, watermelon (rich vit A
fruits) [] 0 yes [] 1 no
Group 8: Other fruits Any other fruits or vegetables [] 0 yes [] 1 no
and vegetable
Others (not counted in Any oil, fats, or butter or foods made with any of these (rempeyek,
the dietary diversity gorengan, karupuak) [] 0 yes [] 1 no
score)
Any sugary foods, such as chocolates, sweets, candies, pastries, cakes or
biscuits (martabak, donat, brownis, bolu) [] 0 yes [] 1 no
Condiments for flavour, such as chillies, spices, herbs or fish powder
[] 0 yes [] 1 no
Instant drinks (®popice, ®marimas, ®nutrisari) and Soft drinks
(®cocacola, ®sprite, ®fanta) [] 0 yes [] 1 no
No Questions code
4 What is your difficulties to give divers food ? Multiple choices
[] 1 financial difficulties
[] 2 child is picky eater
[] 3 lack of knowledge
[] 4 have no time / busy
[] 5 lack of child appetite
[] 6 unhealthy food preference
[] 7 other ________
D Food Frequency Questionnaire (FFQ) (within 1 year)

Times/month Times/week Times/day

Group 1: Breast milk Never
1-3 times 1-3 times >3 times 1-3 times >3 times
1 Breast milk (only for infant parent)
Never Times/month Times/week Times/day
Group 2 : Grains, roots and tubers
1-3 times 1-3 times >3 times 1-3 times >3 times
1 White rice
2 bread
3 Porridge
4 lontong
5 Instant noodles (mie or bihun)
6 Boiled corn
7 Cassava
8 Potatoes
9 Sweet potatoes
10 Biscuit
Never Times/month Times/week Times/day
Group 3 : Legumes and nuts
1-3 times 1-3 times >3 times 1-3 times >3 times
1 beans
2 long beans
3 gadang beans
4 soybeans
5 peanuts
Group 4: Dairy products Never Times/month Times/week Times/day
1-3 times 1-3 times >3 times 1-3 times >3 times
1 Infant formula, such as
®bebelac, ®dancow, ®SGM,
®Frisian flag
2 Soy milk
3 Animal milk
4 Yogurt or drinking yogurt
5 cheese
Group 5: Flesh food Never Times/month Times/week Times/day
1-3 times 1-3 times >3 times 1-3 times >3 times
1 Liver, kidney, heart or other organ
meats
2 beef
3 goat
4 chicken
5 duck
6 Milk fish
7 Tilapia fish
8 Parrot fish
9 Seafood (shrimp, squid)
10 snails

Group 6: Eggs Never Times/month Times/week Times/day

1-3 times 1-3 times >3 times 1-3 times >3 times
1 Eggs
Group 7: Vitamin A fruits and Never Times/month Times/week Times/day
vegetables 1-3 times 1-3 times >3 times 1-3 times >3 times
1 Pumpkin
2 carrots
3 squash
4 Kangkong
5 Spinach
6 Cassava leaves
7 Broccoli
8 mustard
9 cabbage
10 Ripe mangoes,
11 Papaya
12 Banana
13 starfruit
14 langsat
15 Watermelon
Group 8: Other fruits and vegetables Never Times/month Times/week Times/day
1-3 times 1-3 times >3 times 1-3 times >3 times
1 Snakefruit
2 Orange
3 Duku
4 Guava
5 jicama
6 Dates
7 avocado
8 Melon
9 Longan
10 Cucumber
Other foods and drinks Never Times/month Times/week Times/day
1-3 times 1-3 times >3 times 1-3 times >3 times
1 Any oil, fats, or butter or foods
(rempeyek, bakwan, risol,
karupuak)
2 Any sugary foods, (permen,
martabak, donat, brownis, bolu)
3 Condiments for flavour, such as
chillies, spices, herbs or fish powder
(seblak, bakso bakar, telur gulung)
4 Instant drinks (®popice, ®marimas,
®nutrisari) and Soft drinks
(®cocacola, ®sprite, ®fanta)

E. Home Food availability

Group subgroup Availability in home code
1[] always 2[] often 3[] rarely
Group 2 : Rice, bread, rice, noodles or other foo
Grains, roots and ds made from grains
tubers
Group 3: Legumes beans, peas, lentils, nuts or seeds (bun
and nuts cis, kacang panjang, kacang gadang)

Group 4: Dairy Milk

products
Group 5: Flesh Any meat, such as beef, lamb, goat, ch
foods icken or duck, Fresh or dried fish, shel
lfish or seafood

Group 6: Eggs eggs

Group 7: fruits Any fruits
Group 8: vegetables Any vegetables
Others (not counted Oil, fat, butter foods
in the dietary candies
diversity score) beverages

KNOWLEDGE
A. Breastfeeding
No Questions Code
1 Have you ever heard about exclusive breast feeding? [] 0 yes [] 1 no
2 Colostrum is important for baby [] 0 yes [] 1 no [] 88 don’t know
3 A neonate should start breastfeeding within 1 h of birth [] 0 yes [] 1 no [] 88 don’t know
4 An infant should exclusively breastfeed for the first 6 months
[] 0 yes [] 1 no [] 88 don’t know
5 Benefit of breastfeeding for baby
[] 1 baby will grow healthy [] 2 protects from diseases [] 3 other [] 88 don’t know
6 Benefit of breastfeeding for mother
[] 1 Delays fertility [] 2 Helps her lose the weight [] 3 Lowers risk of breast cancer
[] 4 Improves mother and baby relationship [] 5 Other [] 88 Don’t know
7 How long is it recommended that a woman breastfeeds her child?
1[] Six months or less 2[] 6–11 months 3[] 12–23 months
4[] 24 months and more 5[] Other 88[] Don’t know

B. Complementary Food
NO Questions Code
1 An infants should start complementary food at 6 months [] 0 yes [] 1 no [] 88 don’t know
2 Reason for giving complementary foods
[] 1 Breastmilk alone is not sufficient (enough)/cannot supply all the nutrients needed for
growth
[] 2 baby needs to know different flavour of foods [] 88 Don’t know
3 Which foods or types of food can be added to rice porridge make it more nutritious?
multiple choices
[] 1 protein-rich foods (meat, poultry, fish, liver/organ meat, eggs, etc.)
[] 2 Pulses and nuts: flours of groundnut and other legumes (peas, beans, lentils, etc.),
[] 3 Vitamin-A-rich fruits and vegetables (carrot, orange- yellow pumpkin, mango, etc.)
[] 4 Green leafy vegetables (e.g. kangkung, bayam, etc)
[] 5 rich sugary and strong flavor food
[] 6 Other, specify_________ [] 88 Don’t know
4 Why is it bad to eat too many sweets and candies?
[]1 Because they can cause tooth decay []2 Because they are not nutritious
[]3 Because they interfere with appetite []4 Other [] 88 Don’t know
C. Knowledge about malnutrition
No Questions Code
1 How can you recognize that your child is not having enough food/nutrition ?
Multiple choices
[] 1 Lack of energy/weakness: cannot work, study or play as normal (disability)
[] 2 Weakness of the immune system (becomes ill easily or becomes seriously ill)
[] 3 Loss of weight/thinness
[] 4 Children do not grow as they should (growth faltering)
[] 5 Other [] 88 Don’t know
2 What are the reasons why children are undernourished? Multiple choices
[] 1 Not getting enough food [] 2 Food is watery, not enough nutrients
[] 3 Disease/ill and not eating food [] 4 Other, [] 88 Don’t know
3 How can you (caregiver) find out if the baby is growing well or not?
̈ [] 1 Go to the health centre/ask a doctor or nurse (health professional)(seeking health-care
services for growth monitoring)
[] 2 measure yourself [] 3 never find out [] 4 Other [] 88 Don’t know
4 If the baby is not gaining weight, What could be the causes?
[] 1 The baby is not eating well/the baby does not want to eat
[] 2 The baby may be sick often [] 3 genetic [] 4 Other [] 88 Don’t know
5 What should you do to prevent your child from malnutrition?
[] 1 Breastfeed exclusively/give only breastmilk under 6 month
[] 2 Go to the health centre and check that the child is growing (growth monitoring services)
[] 3 give a lot of food [] 4 Other [] 88 don’t know