UNICEFWG MODULE ON CHILD FUNCTIONING Domains Children aged

UNICEF/WG MODULE ON CHILD FUNCTIONING

Domains Children aged 2 to 4 Children aged 5 to 17 Seeing Hearing Mobility Self care Fine motor Communication/Comprehension Learning Remembering Focusing attention and concentrating Relationships Copying with change Controlling behaviour Emotions : anxiety and depression Playing

Seeing Children aged 2 -17 years Does (name) wear glasses or contact lenses*? Yes No When wearing his/her glasses or *contact lenses, does (name) have difficulty seeing? Does (name) have difficulty seeing? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all *Only in 5 -17 questionnaire

Hearing Children aged 2 -17 years Does (name) use a hearing aid? Yes No When using his/her hearing aid, does (name) have difficulty hearing sounds like peoples’ voices or music? Does (name) have difficulty hearing sounds like peoples’ voices or music? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Mobility (a) 2 -4 years Does (name) use any equipment or receive assistance for walking? Yes Without his/her equipment or assistance, does (name) have difficulty walking? Would you say… Some difficulty A lot of difficulty Cannot do at all With his/her equipment or assistance, does (name) have difficulty walking? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all No Compared with children of the same age, does (name) have difficulty walking? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Mobility (b) 5 -17 years Does (name) use any equipment or receive assistance for walking? YES Without his/her equipment or assistance, does (name) have difficulty walking 100 yards/meters on level ground? That would be about the length of 1 football field. [Or insert country specific example]. Without his/her equipment or assistance, does (name) have difficulty walking 500 yards/meters on level ground? That would be about the length of 5 football fields. [Or insert country specific example]. Would you say… Some difficulty A lot of difficulty Cannot do at all

Mobility (c) 5 -17 years Does (name) use any equipment or receive assistance for walking? NO Compared with children of the same age, does (name) have difficulty walking 100 yards/meters on level ground? That would be about the length of 1 football field. [Or insert country specific example]. Compared with children of the same age, does (name) have difficulty walking 500 yards/meters on level ground? That would be about the length of 5 football fields. [Or insert country specific example]. Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Fine Motor 2 -4 years Compared with children of the same age, does (name) have difficulty picking up small objects with his/her hand? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Self-Care 5 -17 years Does (name) have difficulty with self-care such as feeding or dressing him/herself? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Communication/ Comprehension 2 -4 years 5 -17 years Does (name) have difficulty understanding you? When (name) speaks, does he/she have difficulty being understood by people inside of this household? When (name) speaks, do you have difficulty understanding him/her? When (name) speaks, does he/she have difficulty being understood by people outside of this household? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Learning 2 -17 years Compared with children of the same age, does (name) have difficulty learning things? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Remembering 5 -17 years Compared with children of the same age, does (name) have difficulty remembering things? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Focusing attention and concentrating 5 -17 years Does (name) have difficulty concentrating on an activity that he/she enjoys doing? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Coping with change 5 -17 years Does (name) have difficulty accepting changes in his/her routine? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Playing 2 -4 years Compared to children of the same age, does (name) have difficulty playing? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Relationships 5 -17 years Does (name) have difficulty making friends? Would you say… No difficulty Some difficulty A lot of difficulty Cannot do at all

Controlling behaviour 2 -4 years 5 -17 years Compared with children of the same age, how much does (name) kick, bite or hit other children or adults? Compared with children of the same age, does (name) have difficulty controlling his/her behaviour? Would you say… Not at all The same or less More A lot more No difficulty Some difficulty A lot of difficulty Cannot do at all

Emotions 5 -17 years How often does (name) seem very anxious, nervous or worried? How often does (name) seem very sad or depressed? Would you say… Daily Weekly Monthly A few times a year Never