/6/0 Ministry of Health & Ministry of Planning/ Central Statistics Organization In Iraq In collaboration With WHO/Iraq Office Detection of Congenital Birth Defects Survey 0 Questionnaire for Newborn with CBD
Questionnaire for Newborn with CBD Newborn Information Panel CH:Household No. CH4: Name and no.of local supervisor ا. No Name CH:Cluster(Majal) No.: CH:Name and no. of field surveyor No. :Name CH5: Name and line no. of respondent in household roster(name of newborn's mother) Line No. Pregnancy Sequence No. CH8:Location Governorate. CH6:Name of newborn CH7: Environment... Urban... Rural District. sub-district Nahya. Name and No. of Mahala (locality).4 Name and No. of Mukatta (province).5 Name and No. of Village.6 Block No..7 Census building No..8
(MATERNAL& NEWBORN HEALTH MODULE) MN NEWBORN BACKGROUNG) NB Name of newborn. Alive...Dead What is the kind of CBD?* NB NB 5 4 5 4 5 Doctor... Nurse/birth attendant.. Mother /Father Relative/friends. Others. Yes No.. Yes.. No. NVD -------------------- C/S ------------------- Induced vaginal delivery------ - Home -------------------- Public Hospital ---------- Private Hospital ------------ PHCC ---- Others(specify). Who diagnosed or detected the case? Is there any document or medical report to support diagnosis? Was the report seen? What was the type of delivery for (name)? Where was (name) born? NB NB NB 4 NB 5 NB6 Code of Q. NB*.: CBD of heart &circulatory system= 0,Down syndrome= 0,other chromosomal anomalies=0,cleft lip=04,cleft palate=05,spina Bifida= 06,congenital hydrocephaly=07,microcephaly=08,other congenital birth defects of brain and spinal cord=09 ambiguous genitalia=0,congenital hydrocele=, undescending testis =,hypospadia or epispadia=,other congenital anomalies of genitalia = 4,congenital anomalies of skin = 5,imperforate anus=6,other congenital anomalies of GIT system = 7,eye congenital anomalies=8,extra auricle = 9,upper limb congenital anomalies=0, lower limb congenital anomalies =,cleft lip and palate =,polydactyl =,fused fingers = 4,congenital blindness, 5= congenital cataract =, 6vertebral column congenital anomalies=, 7congenital deafness =, 8congenital esophageal atrasia= 9 congenital hip dislocation = 0,others=96,DK = 98 :
Yes ------------------------ No -------------------------- DK ------------------- During your pregnancy by (name),did you receive health care? MN MN4 & Yes... No -------------------------- DK ------------------- Regularly(daily) Irregularly.. DK.. During the first trimester of your pregnancy in (name), did you take folic acid tablets? How did you take those tablets? MN MN A B C D E F G H Rubella. Toxoplasmosis Chicken pox Syphilis Diabetic Mellitus Hypothyroidism. Others(specify) Didn't suffer During your pregnancy (name) did you suffer from any of the following health problems? Probe and circle the answers MN4 MN 0 Yes... No... Don't remember... During your pregnancy (name),did you take any medicine(s)? MN 5 A B C D E F Epanutin... Anti carcinogenic drugs... Steroid... Chloramphenicol... Others(specify) DK the drug... What was/were the type of medicine(s) Probe and circle the answers MN 6 A B C D 4 Yes ------------------------ No -------------------------- st trimester - nd trimester rd trimester. Whole pregnancy period. Days. Weeks. Months DK Same area. Other area. Mention: Governorate District Is it possible to see the medicine(s) packet?(if available) In which period of your pregnancy did you take that/those medicine(s)? For how long did you take that/those medicine(s) during your pregnancy? Where were you living during the st trimester of your pregnancy in (name)? MN 7 MN 8 MN 9 MN 0 RE Yes No Beside your work at home, were you working outside home when you were pregnancy with (name)? What was your occupation? MN MN 4
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RE (RADIATION EXPOSURE MODULE) FB Diagnostic radiation Therapeutic radiation.. Not exposed. During your pregnancy in (name), were you exposed to any kind of radiation? RE Month. DK 98 In which month of pregnancy did you expose to the radiation? RE Yes No DK.. Were suitable protective measures taken by the care provider? RE FB ( FATHER BACKGROUND) MODULE 98 9998 month Don't know the month --------------------- year Don't know the year -------------------- On what month and year was the (name's) father born? FB FB4 9998 Yes No.. Age in years year Don't know the year -------------------- Is the father still alive? How old is the father? On what year did the father die? FB FB FB4 FB 9, A B C D E F G Age in years Occupation Yes No DK.. The father himself His father /mother. Brothers/sisters. Children of brothers/sisters.. Uncles/aunts... Cousins.. Others (specify). How old was the father when he died? Before your pregnancy in (name),what was his father's occupation? Did (name's) father or any member of his family have congenital birth defects? Specify the relationship to the father Circle the choices FB5 FB6 FB7 FB8 Cousins Other relation Is/was there any relationship between you FB9 6
No relation and (name's) father? Yes No DK. Before your pregnancy in (name), was his father exposed to any therapeutic radiation? FB0 7
Field surveyor.:name / /..:Date- Local supervisor...: Name / /..:Date Central Supervisor..:Name / /..:Date Central Editor :.Name / /..:Date Data Entry..:Name / /..:Date 8