English Version Questionnaire

Questionnaire to assess the prevalence of anemia and associated factors among under five
children attending Guguftu health center ,South Wollo, Northeast Ethiopia.

Questionnaires ID.No______________ Address______________

Name of health facility____________________ Date of interview____________

Time started_________________ Time finished______________

Participant code _________________

Part I: Questions on socio-demographic, economic characteristics and anthropometric

measurement of the child

101. Age of child (months) ______________

102. Age of mother (in years) _______________

103. Sex
1. Male 2. Female

104. Residence
1. Urban 2. Rural

105. Mother’s education

1. Illiterate 2. Non formal education
3. Primary 4. Secondary
5. College and above

106. Mother’s occupation

1. Housewife 2. Small scale business

3. Employed 4. Farmer

107. Monthly income of the household (in Ethiopian Birr) ________________

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108. Introduction of complementary foods at the Age of:

1. ≤ 6 month 2. > 6 months

109. Number of children <5 years ________________

110. Birth order of the child _____________________

111. Birth interval of the child (in month/year) ______________

112. Current weight of the child (in kilogram) ________________

113. Current height of the child (in centimeter [cm]) ______________

114. Mid upper arm circumference (MUAC) (in cm)____________________

Name of the interviewer _____________________________________

Signature _________________ Date ______________

Part II: Laboratory result

201. Stool examination for intestinal parasite

1. No O/P seen 2. Positive (list name of parasite )

1. ______________
2. _______________
3. ________________

202. Blood film examination for malaria

1. No Hemoparasite seen 2. P. f
3. P. v 4. Mixed

203. Hemoglobin level _________________ g/dl or g/l

Name of the Laboratory professional_______________________

Signature _________________ Date ______________

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Amharic version questionnaire

የመጠይቁ መ.ቁ…………….. አድራሻ…….......... የጤናተቋሙስም .................. ቃለመጠይቅ

የተደረገበት ቀን ………………….. የተጀመረበት ሰዓት…………… ያለቀበት ሰዓት……………
የተሳታፊ ኮድ ……….

ክፍል አንድ፡ሥነ-ሕዝብ፣ኢኮኖሚ እና የህጻኑ አንትሮፖሜትሪ የተመለከቱ ጥያቄዎች

101. የህጻኑ ዕድሜ (በ ወር)………………………….

102. የእናት እድሜ (በ ዓመት): ………………

103. የህጻኑ ጾታ
1. ወንድ 2. ሴት

104. የመኖርያ ቦታ
1. ከተማ 2. ገጠር

105. የእናትየዉ የትምህርት ደረጃ

1. ያልተማረች 4. 2 ኛደረጃ(9-12 ኛ)

2. የመሰረተ ትምህርት 5. ኮለጅ እና ከዛ በላይ

3. 1 ኛደረጃ (1-8 ኛ)

106. የእናትየዉ ሰራ
1. የቤት እመቤት 2. ነጋዴ
3. መንግስት ሰራተኛ 4. ገበሬ

107. የቤተሰብ ወርሃዊ ገቢ ስንት ነው?: …………… ብር

108. ህጻኑ ተጨማሪ ምግብ የጀመረበት ግዜ መቼ ነዉ?

1. ከ 6 ወር በፊት 2. ከ 6 ወር በኃላ

109. ከ 5 ዓመት በታች ህጻናት ብዛት ………………

110. ህጻኑ ስንተኛ ልጅ ነዉ?.....................

111. ህጻኑ ከታላቁ የስንት ወር/ዓመት ልዩነት አላቸዉ?.......................

112. የህጻኑ የአሁን ክብደት በ ኪ.ግ……………..

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 113. የህጻኑ የአሁን ቁመት በ ሴ.ሜ………………

114. የክንድ ዙርያ ልኬታ (MUAC) (በ ሴ.ሜ)……………..

የጠያቂዉ ሰም……………………

ፌርማ………………………………………. ቀን፡……………………

ክፍል ሁለት፡ የላቦራቶሪ ዉጤት

201. የሰገራ ምርመራ ለ አንጀት ጥገኛ ተሀዋስያን ዉጤት

1. ምንም ኦቫ/ፓራሳይት አልተገኘም 2. ፖዘቲቭ (የተገኘዉ/ኙ ፓራሳይት ግለጽ)

1. ______________
2. _______________
3. ________________

202. የዎባ ምርመራ ዉጤት

1. ምንም ሄሞፓራሳይት አልተገኘም 3. ፕ.ቫይቫክስ

2. ፕ.ፋልሲፐረም 4. ሚክሰድ

203. የሄሞግሎቢን ዉጤት _________________ ግ/ዴሊ or ግ/ሊ

የላቦራቶሪ ባለሞያዉ ስም………………………………………

ፌርማ………………………….. ቀን……………………