Caregiver

1. Name and code

What is your name?

Insert respondent code

_ _ _ _

2. Sex

Insert the sex of the caregiver

Male 

Female 

3. Relationship

What is your relationship with the child you take care of?

Mother 

Father 

Grandmother/Grandfather Other 

4. Caregiver’s age

When is your birthday?

Probe if necessary:

On what day and in which month and year were you born?

_ _/_ _ /_ _ _ _

day month year

How old are you?

Probe if necessary:

What was your age at your last birthday?

If the information conflicts with the previous question, determine which one is more accurate

Age in completed years

_ _

5. Parity (only for women)

How many children do you have?

For pregnant women: ask if this is her first pregnancy

Number of children_ _ _ _

First pregnancy