survey Name of household head * Name Address * City/Town * State/Province * --Select-- Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara Phone Number * Marital Status * --Select-- Single Married Divorced widowed Do you have children? * No Yes How many children do you have? * 1-5 5-7 7-10 How many children do you have that are 6 months – 10 years * --Select-- 1-3 3-5 Do you know what a balanced diet it? * No Yes In the last 7 days did your child/children who are 6 months-10 years eat the following? * Rice Beans Yam Cassava Fruits Fish Beef Chicken Egg Milk Soy Beans Maize Millet Goat Meat Mutton Pork Vegitables How many times did your child/children who are 6 months-10 years eat yesterday? * 1 2 Others In the last 6 months was your child sick? * No Yes Which of the facilities did you take him/ her to? * If yes, how much did it cost you for their treatment? * How many minutes did it take you to get to the facility? * How is the appetite of your child? * Good Average Bad Do you give your child alternative meals? * No Yes If yes, what do you give them? * Do you give your children supplements? * If yes, what type of supplements do you give them? * Send survey Created with Perfect Survey
