Child ID : _________________________ Children No : O 1 O2 O3

O4 O5 O6

Birthdate : (_____/________/___________) Sex : O 1. male O 2. female

Age : _________

A. Child TB risk factors

No Questions Code

1 Type of index case contact

O 1. Household contact O 2. close contact O 3. unknown

2 Is your child sleep in the same room with TB index case ?

O 0. yes O 1. No
In the last 1 year, has your child ever been diagnosed with tuberculosis?
3
O 0. Yes O 1. No
If No, jump to number 4
When was she/he diagnosed with tuberculosis? _______ month ________ year
3.1
3.2 What is following symptoms s/he have ? (choose all that aply)
[] 1. Cough [] 2. Fever [] 3. Night sweats
[] 2. Loss of appetite [] 5. Less playful (not energetic) [] 6. Weight loss
[] 7. Other, specify__________

3.3 How is your child treatment status?

O 1. Cure O 2. Completion O 3. Treatment interruption
O 4. Lost to follow up O 5. Death O 6. Not evaluated O 88. don’t know

3.4 Since how many months has your child been receiving tuberculosis treatment?
O 1. 1-2 O 2. 3-4 O 3. 5-6 O 4. >6 O 88. Don’t know
Is your child ever have TPT?
4
O 1. Yes, completed O 2. not completed O 3. on going O 4. not received

5 In the last 1 month is your child ever have symptoms of ….. (choose all that apply)
[] 1. COPD (fever, cough < 2 weeks, sore throat, flu)
[] 2. Diarrhea
[] 3. pneumonia (fever, cough, hard breathing)
[] 4. TB (cough > 3 weeks, fever > 2 weeks, weight not increasing)
[] 5. measles ( high fever, cough, flu, red eye and watery, rush)
[] 6. helminthiasis (child feel itchy on anus area, scratching that area)

6 Observed BCG scars? O 0. No O 1. Yes

B. Posyandu program participation
No Questions Code
1 How much this child attend posyandu in the last 6 months ?
O 1. > 4 times O 2. < 4 times O 3. never attend posyandu
2 What is your reason to not go posyandu regularly?
O 1. mother/caregiver is busy on work O 2. my kids was ill/sick
O 3. the posyandu too far O 4. I don’t get benefit
O 5. I don’t feel my kids have growth problem O 6. my kids are too young <4 months
O 7. other, specify_____________________________________________
3 Are you receive health education about child nutrition in posyandu in the las 6 months ?
O 0. No O 1. Yes O 88. Not sure
What types of services have your children received at the posyandu in the last 6 months?
4
growth monitoring O 0. yes O 1. No
4.1
Immunizations O 0. yes O 1. No
4.2
Vitamin A distribution O 0. yes O 1. No
4.3
supplementary food O 0. yes O 1. No
4.4
health care O 0. yes O 1. No
4.5
worm medicine O 0. yes O 1. No
4.6
other, specify_______________________________________
4.7
5 Do this kids have child mother health (CMH) book?
O 1. yes, can show it O 2. yes, couldn’t show it
O 3. the health volunteer keeps it O 4. ever have but lost
O 5. never have
Are your kids getting completed immunization until his/her current age ?
6
O 0. completed O 1. not completed
Noted. This should be validated by records from MCH book
O 1. yes, by MCH book O 2. no, by respondent statement
If not completed, go to 6.1
Reason why not completed the immunization?
6.1
O 1. do not know posyandu schedule O 2. there is no posyandu
O 3. health facility/posyandu is far O 4. no transportation/ expensive
O 5. the kids were ill/often ill O 6. the vaccine is not available
O 7. my family didn’t allow O 8. iam afraid my kids will get sick
O 9. afraid of covid-19 O 10. religion belief
O 11. Other, specify_________________________________
C. Breastfeeding practice
No Questions Code
1 Was the child ever breastfed ?
O 1. Never breastfed O 2. Yes, ever O 3. currently breastfeed
If No, go to question 1.1
1.1 What is the reason ?
O 1. breast cant produce milk O 2. baby couldn’t do breastfed
O 3. split care O 4. mother medical reason
O 5. child medical reason O 6. mother died
O 7. norm/culture
O 8. other, specify______________________
2 (For child >6 months) Exclusive breast feeding (only) for the first 6 months ?
O 0. No O 1. Yes
If No, go to question 2.1
2.1 If no, what type of milk/liquid you give to your child age 0-6 months?
O 1. Breastmilk only
O 2. breastmilk + formula
O 3. formula only
O 4. breastmilk + complementary food
O 5. complementary food + formula
O 6. breastmilk + complementary food + formula
3 Do you continuing / will breastfeeding to your child until 1 year ?
O 0. No O 1. Yes
D. Complementary Food (MP-ASI)
No Questions Code
1 At what age you start give complementary food ?
O 1. < 6 months O 2. 6 months – 8 months O 3. more than 8 months
2 Reason start for giving complementary foods at that age ?
O 1. breast cant produce milk
O 2. baby couldn’t do breastfed
O 3. split care
O 4. mother medical reason
O 5. child medical reason
O 6. mother died
O 7. norm/culture
O 8. other, specify______________________
3 Frequency of giving complementary food in a day?
O 1. 2-3 times perday O 2. 3-4 times perday
4 Which texture you usually make for your kids ? O 1. moist food O 2. condensed food

E. Dietary diversity (24 hour recall)

Code : O 0. No O 1. Yes
Frequency : O 1. 1 x O 2. 2-3 x O 3. 3-4 x
Portion : O 1 ctg O 1 small bowl O 1 pieces O 1 slices O 1 tbs O 1 teaspoon O 1 plate , etc
Group Food lists Code Frequency portion
Group 1 : Porridge, bread, rice, noodles or other foods made from
Grains, roots grains
White potatoes, white yams, cassava or any other foods
and tubers
made from roots
Group 2: Any foods made from beans, peas, lentils, nuts or seeds
Legumes and (beans, long beans, gadang beans, soybeans, peanuts)
nuts
Group 3: Dairy Infant formula, such as ®bebelac, ®dancow
products Milk, such as tinned, powdered or fresh animal milk
Yogurt
Cheese or other dairy products
Group 4: Flesh Liver, kidney, heart or other organ meats
foods Any meat, such as beef, lamb, goat, chicken or duck
Fresh or dried fish (bandeng, nil/mujair, lele), seafood
Group 5: Eggs Eggs
Group 6: Pumpkin, carrots, squash or sweet potatoes that are yellow
Vitamin A or orange inside
fruits and Any dark green vegetables (kang kong, spinach, cassava
vegetables leaves, broccoli, mustard, cabbage, )
Ripe mangoes, papaya, banana, star fruit, langsat,
watermelon, jackfruitt (rich vit A fruits)
Group 7: Other Any other fruits or vegetables,
fruits and specify ___________
vegetable
Others (not Any oil, fats, or butter or foods made with any of these
counted in the Any sugary foods, such as chocolates, sweets, candies,
dietary pastries, cakes or biscuits
diversity score) Condiments for flavour, such as chillies, spices, herbs or
fish powder
No Questions code
13 What is your difficulties to give divers food ? (choose all that apply)
[] 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, specify___________________

E. Children Anthropometry Assessment

Child
Child ID Items
Number
Age ______ months/years

Sex [] 1. male [] 2. female

Weight: __ __. __ kg
Height: __ __. __ cm
Length: __ __. __ cm