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Microsoft Word - AMICS-29Jan2013 - Childinfo.org

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Name _________________________ ___ ___ Name ___________________________ ___ ___<br />

UF12. Record the time.<br />

Hour and minutes ..................... __ __ : __ __<br />

AGE<br />

AG1. NOW I WOULD LIKE TO ASK YOU SOME<br />

QUESTIONS ABOUT THE HEALTH OF (name).<br />

IN WHAT MONTH AND YEAR WAS (name) BORN?<br />

Probe:<br />

WHAT IS HIS / HER BIRTHDAY?<br />

If the mother/caretaker knows the exact<br />

birth date, also enter the day; otherwise,<br />

circle 98 for day<br />

Month and year must be recorded.<br />

AG2. HOW OLD IS (name)?<br />

Probe: HOW OLD WAS (name) AT HIS / HER<br />

LAST BIRTHDAY?<br />

Record age in completed years.<br />

Record 0 if less than 1 year.<br />

Compare and correct AG1 and/or AG2 if<br />

inconsistent.<br />

Date of birth<br />

Day .................................................. __ __<br />

DK day ...................................................98<br />

Month ............................................... __ __<br />

Year ....................................... __ __ __ __<br />

Age (in completed years) .......................... __<br />

AG<br />

215

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