Organisation name:    Survey title:    Date:    SID: 
Modules reported:  Nutrition  Mortality  Vaccination

Pre-survey preparation and planning
Objective of the survey: 1) Nutrition: N
2) Mortality: N
3) Vaccination: N
4) Type of population stated: N
5) Total population in universe stated: N
6) Geographical scope of the survey stated: N
7) Area excluded from sampling frame listed: NA
Time period: 8) Survey dates are clearly stated ((dd)-mm-yyyy): N
Translation: 9) Language of the questionnaire is stated: N
10) Language of the interview is stated: N
Questionnaire/tool: 11) Pre-testing of questionnaire stated: N
12) Use of local event calendar stated: N
Training: 13) Training arrangement stated: N
Informed consent: 14) Informed consent to participate in the survey mentioned: N
Sampling design: 15) Type of sampling design stated:N   Cluster sampling
17-19 only if cluster sampling,
19 for other sampling designs
16) Rationale for sampling design explained:N
17) State if PPS was used:N
18) Number of clusters: (cluster x children) for malnutrition x 
                                            (cluster x hh) for mortality x 
Final stage: 19) State final stage sampling method:N
20 only if mortality module
include, otherwise 21
20) State if HH without U5 were included:N
21) Stated whether sample size was increased to
account for non response:
Household: 22) State definition of HH:N
23 only if nutrition/vaccination
module include, otherwise 24
23) State selection of U5 in the HH for nut/vacc:N
24) HH selection in a compound is explained:NA
25) Procedure for choosing respondent stated:N
26) Procedure for re-visiting absent HH stated:N
Sample size precision: 27) Expected GAM: Stated why? NA
27-29 only if nutrition module
included, 30; 30-32 only if
28) Expected Deff for GAM: Stated why? NA
mortality module included
otherwise 33
29) Desired precision for GAM: Stated why? NA
30) Expected CMR: Stated why? NA
31) Expected Deff for CMR: Stated why? NA
32) Desired precision for CMR: Stated why? NA
Nutrition survey: 33) GAM includes bilateral oedema:N
33-37 only if nutrition module
included, otherwise 38
34) Inclusion criteria in terms of age or
height described?
35) Weight and height smallest rounding
unit described?
36) Cut-off for measuring children lying or
standing stated?
37) Questionnaire is provided in Appendix:N
Mortality survey: 38) Recall period stated:N
38-41 only if mortality module
included, otherwise 42
39) Denominator calculation indicated:N
40) Census method indicated:N
41) Questionnaire provided in Appendix:N
Analysis: 42) Name, version of the software
and statistical procedure stated:
Nutritional indicators: Definition:43) Prevalence of GAM based on
Weight for Height Z-scores
43-50 only if nutrition module
included, otherwise 51
44) Type of growth ref. used
(WHO or NCHS) stated:
Precision:45) Confidence interval:[]
46) Design effect:
47) Plausibility checks mentioned:NA
48) Definition of flags stated:N
49) Flags exclusion from analysis
50) Sample size of 6-59 months:
Mortality indicators: Definition:51) CMR expressed as deaths per
       10,000/day, 1,000/month or
51-60 only if mortality modules
included, otherwise 61
Precision:52) Confidence interval:[]
53) Design effect:
Demographic indicators: 54) Births:              55) Deaths:   
56) Persons joined:57) Pers. left:
58) Population at the time of the survey:
59) nº of households:
60) nº of U5 (0-59 months):
Vaccination indicators: 61) Measles-Containing Vaccine (MCV)
coverage by card and history:
61-64 only if vaccionation module
included, otherwise 65
62) Confidence interval:[]
63) Age range for inclusion in analysis
64) Number of children in the analysis:
Limitation and bias:65) % non response:
66-68 only if cluster sampling,
68 only if replacement was made
65) % inaccesible clusters:
otherwise 6967) Final number of clusters
68) Replacement method stated? NA
69) Potential bias described? N
Comparison of results:70) Results are compared to a reference:N
Interpretation of results:71) Recommendations are given:N