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BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2011
HOUSEHOLD QUESTIONNAIRE

NIPORT, MOHFW, and Mitra and Associates

IDENTIFICATION

DIVISION_____

DISTRICT_____

UPAZILA_____

UNION/WARD_____

VILLAGE/MOHALLA/BLOCK_____

CLUSTER NUMBER____

HOUSEHOLD NUMBER____

RURAL, CITY CORPORATION, OR OTHER URBAN:

RURAL 1
CITY CORPORATION 2
OTHER URBAN 3

HOUSEHOLD SELECTED FOR MEN’S SURVEY:

YES 1
NO 2

ALTITUDE (METER) ____

INTERVIEWER VISITS

FIRST VISIT:
DATE____
INTERVIEWER’S NAME____
RESULT:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9

NEXT VISIT:
DATE____
TIME____

SECOND VISIT:
DATE____
INTERVIEWER’S NAME____
RESULT:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9

NEXT VISIT:
DATE____
TIME____

THIRD VISIT:
DATE____
INTERVIEWER’S NAME____
RESULT:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9

FINAL VISIT:
DAY____
MONTH____
YEAR____
INT. NUMBER____
RESULT:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _____ 9

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD__
TOTAL WOMEN 12 TO 49 YR.
TOTAL MEN 15 TO 54 YR.
TOTAL ADULTS 35 OR MORE YEARS__
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE__

SUPERVISOR
NAME___

FIELD EDITOR
NAME___

HEALTH TECHNICIAN___

OFFICE EDITOR___

KEYED BY___

INTRODUCTION AND CONSENT

Hello. My name is__________________________. I am working with NIPORT, the Ministry of Health and Family Welfare, and Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all over Bangladesh. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than the members of our survey team. You don’t have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don’t want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: _________________________ DATE: ________________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

1) LINE NO_______

2) USUAL RESIDENTS AND VISITORS
Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX OF EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-22 FOR EACH PERSON.

NAME__________

2A) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE))
NO

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES (ADD TO TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

3) RELATIONSHIP TO HEAD OF THE HOUSEHOLD
What is the relationship of (NAME) to the head of the household?

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON’T KNOW 98

4) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE
5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE
How old is (NAME)?
IF 95 OR MORE, RECORD ‘95’

AGE IN YEARS___

IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL
MARITAL STATUS IF AGE 12 OR OLDER
8) What is (NAME)’s current marital status?

CURRENTLY MARRIED 1
DIVORCED/SEPARATED/DESERTED/WIDOWED 2
NEVER MARRIED 3

IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL
9) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 13)

10) What is the highest level of school (NAME) has attended?

LEVEL
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON’T KNOW 8
CLASS
LESS THAN 1 YEAR COMPLETED 00
DON’T KNOW 98

IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE
11) Did (NAME) attend school at any time during the (2010-2011) school year?

YES 1
NO 2 (GO TO 13)

12) During this/that school year, what level and class [is/was] (NAME) attending?
SEE CODES BELOW.

LEVEL
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON’T KNOW 8
CLASS
LESS THAN 1 YEAR COMPLETED 00
DON’T KNOW 98

IF AGE 8 OR OLDER
CURRENT WORK STATUS
13) Is (NAME) currently working?

YES 1
NO 2

IF AGE 0 TO 4 YEARS
BIRTH REGISTRATION
14) Does (NAME) have a birth certificate?
IF NO, PROBE: Has the (NAME)’s birth ever been registered with the civil authority?

HAS CERTIFICATE 1
REGISTERED 2
NEITHER 3
DON’T KNOW 4

15) CIRCLE LINE NUMBER OF ALL EVER-MARRIED WOMEN AGE 12-49

16) CIRCLE LINE NUMBER OF ALL EVER-MARRIED MEN AGE 15-54 IF HOUSEHOLD SELECTED FOR MALE SURVEY

17) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0 TO 5

18)
HEIGHT____
WEIGHT____
ANEMIA____

CIRCLE LINE NUMBER EVER-MARRIED WOMEN AGE 12 TO 49 IF COLUMN 4 IS 2 AND IF COLUMN 7 IS 35 TO 49 AND IF COLUMN 8 IS 1 OR 2.

19)
BLOOD PRESSURE____
BLOOD GLUCOSE____

CIRCLE LINE NUMBER EVER-MARRIED WOMEN AGE 35-49 IF COL. 4 IS 2 AND IF COL. 7 IS 35-49 AND IF COL. 8 IS 1 OR 2.

20)
HEIGHT____
WEIGHT____
BLOOD PRESSURE____
BLOOD GLUCOSE____

CIRCLE LINE NUMBER EVER-MARRIED WOMEN AGE 50 AND UP IF COL. 4 IS 2 AND IF COL. 7 IS 50 AND UP AND IF COL. 8 IS 1 or 2. NEVER-MARRIED WOMEN AGE 35 AND UP IF COL. 4 ARE 2 AND IF COL. 7 ARE 35 AND UP AND IF COL. 8 IS 3.

21)
HEIGHT____
WEIGHT____

CIRCLE LINE NUMBER OF ALL EVER-MARRIED MEN AGE 15-34 IF COL. 4 IS 1 AND IF COL. 7 IS 15-34 AND IF COL. 8 IS 1 OR 2.

22)
HEIGHT____
WEIGHT____
BLOOD PRESSURE____
BLOOD GLUCOSE____

CIRCLE LINE NUMBER IF ALL MEN AGE 35 AND UP
IF COL. 4 IS 1 AND IF COL. 7 IS 35 OR OLDER.

HOUSEHOLD CHARACTERISTICS

102) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) _________________ 96

103) Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE (GO TO 3)

104) How long does it take to go there, get water, and come back?

MINUTES_____________
DON’T KNOW 998

104A) Do you share this source with other households?

YES 1
NO 2 (GO TO 105)

104B) How many households use this source of water?

NO. OF HOUSEHOLDS IF LESS THAN 10 ___________
10 OR MORE HOUSEHOLDS 95
DON’T KNOW 98

105) Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 107)
DON’T KNOW 8 (GO TO 107)

106) What do you usually do to make the water safer to drink?
Anything else?

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ___________ X
DON’T KNOW Z

107) What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON’T KNOW WHERE 15
PIT LATRINE
VENTILATION IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER (SPECIFY)___________ 96

108) Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 110)

109) How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 ______
10 OR MORE HOUSEHOLDS 95
DON’T KNOW 98

110) Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A mobile telephone?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
An almirah/wardrobe?
YES 1
NO 2
A table?
YES 1
NO 2
A chair?
YES 1
NO 2
An electric fan?
YES 1
NO 2
A DVD/VCD player?
YES 1
NO 2
A water pump?
YES 1
NO 2

111) What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 113A)
OTHER (SPECIFY) ___________ 96

112) Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 113A)
OUTDOORS 3 (GO TO 113A)
OTHER (SPECIFY) _________ 6 (GO TO 113A)

113) Do you have a separate room which is used as a kitchen?

YES 1
NO 2

113A) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

114)
MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY)_________ 96

115)
MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
TIN 31
WOOD 32
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY)__________ 96

116)
MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
PLYWOOD 24
CARDBOARD 25
FINISHED WALLS
TIN 31
CEMENT 32
STONE WITH LIME/CEMENT 33
BRICKS 34
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY)_________ 96

117) How many rooms in this household are used for sleeping?

ROOMS___

118) Does any member of this household own:

An autobike?
YES 1
NO 2
A rickshaw/van?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor schooder/tempo/CNG?
YES 1
NO 2

121) Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 122A)

122) How many of the following animals does this household own?
IF NONE, ENTER ‘00’.
IF 95 OR MORE, ENTER ‘95.’
IF UNKNOWN, ENTER ‘98’.

Buffaloes?
BULLS/BUFFALOES____
Cows?
MILK COWS/BULLS____
Goats or sheep?
GOAT/SHEEP____
Chickens or ducks?
CHICKENS/DUCKS____

122A) Does your household own any homestead?
IF ‘NO’ PROBE:
Does your household own homestead in any other places?

YES 1
NO 2

122B) Does your household own any land (other than the homestead land)?

YES 1
NO 2 (GO TO 123)

122C) How much land does your household own (other than the homestead land)?

AMOUNT _________
SPECIFY UNIT ________
IF 95 OR MORE CIRCLE ‘9995’

AREA

ACRES_____ .DECIMALS _______
95 OR MORE ACRES 9995
DON’T KNOW 9998

123) Does any member of this household have a bank account?

YES 1
NO 2

137) Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

138) OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

139) OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP DETERGENT OR OTHER CLEANSING AGENT.

SOAP (BAR, LIQUID, PASTE) A
DETERGENT (BAR, LIQUID, POWDER) B
ASH, MUD, SAND C
NONE D

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE PRESENT 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) __________ 6

WEIGHT, HEIGHT, AND HAEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5.

201) CHECK COLUMN 17 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 17
NAME FROM COLUMN 2

LINE NUMBER _______
NAME_________

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)’s birth date?

DAY________
MONTH_______
YEAR_______

204) CHECK 203:
CHILD BORN IN JANUARY 2006 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)

205) WEIGHT IN KILOGRAMS

KG_____.______
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CM. _______._____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

207A) CHECK THE COVER PAGE: HOUSEHOLD SELECTED FOR MEN’S SURVEY

YES 1 (GO ON)
NO 2 (GO TO 213)

208) CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E. WAS THE CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

0 TO 5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)
OLDER 2

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD ‘00’ IF NOT LISTED.

LINE NUMBER_______

210) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2006 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ___________________
REFUSED 2

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA

G/DL ________.______
NOT PRESENT 994
REFUSED 995
OTHER 996

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

WEIGHT, HEIGHT, HAEMOGLOBIN MEASUREMENT FOR EVER-MARRIED WOMEN AGE 12-49

CLUSTER NUMBER________
HOUSEHOLD NUMBER_______

214) CHECK COLUMN 18 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGIBLE EVER-MARRIED WOMEN IN 215. IF THERE ARE MORE THAN THREE EVER MARRIED WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215)
LINE NUMBER FROM COLUMN 18
NAME FROM COLUMN 2

LINE NUMBER__________
NAME____________

216) WEIGHT IN KILOGRAMS

KG___________.______
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217) HEIGHT IN CENTIMETERS

CM. __________.______
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

218) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN’S SURVEY

YES 1 (CONTINUE)
NO 2 (GO TO 223)

219) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?

220) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ____________________
RESPONDENT REFUSED 2 (SIGN) _____________ (GO TO 223)

221) PREGNANCY STATUS: CHECK 226 IN WOMAN’S QUESTIONNAIRE TO ASK:
Are you pregnant?

YES 1
NO 2
DON’T KNOW 8

222) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL _______.______
NOT PRESENT 994
REFUSED 995
OTHER 996

223) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE: IF NO MORE EVER-MARRIED WOMEN AGE 12-49, BUT HOUSEHOLD IS SELECTED FOR MEN’S SURVEY, GO TO 224; OTHERWISE END MEASUREMENT.

WEIGHT AND HEIGHT MEASUREMENT FOR EVER-MARRIED MEN AGE 15-34

CLUSTER NUMBER __________
HOUSEHOLD NUMBER__________

HOUSEHOLD SELECTED FOR MEN’S SURVEY

YES (CONTINUE)
NO (END MEASUREMENT)

224) CHECK COLUMN 21 IN HOUSEHOLD SCHEDULE, RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE EVER-MARRIED MEN AGE 15-34 IN 225. IF THERE ARE MORE THAN THREE EVER-MARRIED MEN AGE 15-34, USE ADDITIONAL QUESTIONNAIRE(S).

225)LINE NUMBER FROM COLUMN 18
NAME FROM COLUMN 2

LINE NUMBER__________
NAME____________

226) WEIGHT IN KILOGRAMS

KG___________.______
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

227) HEIGHT IN CENTIMETERS

CM. __________.______
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

228) GO BACK TO 225 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE: IF NO MORE EVER-MARRIED MEN AGE 15-34, GO TO 229.
BIOMARKER DATA FORM (FOR ADULTS 35 OR OLDER)

CLUSTER NUMBER ___________
HOUSEHOLD NUMBER __________

USE THIS BIOMARKER DATA FORM ONLY IF HOUSEHOLD IS SELECTED FOR MEN’S SURVEY AND RESPONDENT IS 35 OR OLDER

229) CHECK COLUMNS 19, 20, AND 22 IN HOUSEHOLD SCHEDULE, RECORD THE LINE NUMBER AND NAME OF ALL ELIGIBLE WOMEN AND MEN AGE 35 AND ABOVE FOR BIOMARKER MEASUREMENTS IN 230. IF THERE ARE MORE THAN THREE ADULTS, USE ADDITIONAL QUESTIONNAIRE(S).

230) LINE NUMBER FROM COLUMNS 19, 20, AND 22
NAME FROM COLUMN 2

LINE NUMBER _________
NAME __________

231) SEX FROM COLUMN 4 OF THE HOUSEHOLD SCHEDULE

MALE 1 (GO TO 233)
FEMALE 2

232) PREGNANCY STATUS: CHECK 226 IN WOMAN’S QUESTIONNAIRE OR ASK:
Are you pregnant?

YES 1
NO 2
DON’T KNOW 3

233) CHECK HOUSEHOLD SCHEDULE: COLUMN 19 CIRCLED

NO (CONTINUE)
YES (GO TO 240)

233A) PROVIDE INFORMATION ABOUT BIOMARKER TESTING

Now I am going to ask you to participate in several physical measurements or tests. I will explain each measurement or test before starting the procedure. You will be free to say yes or no to each one. Before taking the measurements, I am going to ask a few questions about yourself.

234) AGE
How old were you at your last birthday?

YEARS__________

235) MARITAL STATUS
What is your current marital status?

NEVER MARRIED 1
MARRIED, DIVORCE, SEPARATED, DESERTED, OR WIDOWED 2

236) EDUCATION
Have you ever attended school or madrasha?

YES 1
NO 2 (GO TO 238)

237) What is the highest level of school you attended, primary, secondary, college or higher?

PRIMARY 1
SECONDARY 2
COLLEGE OR HIGHER 3

238) WORK
Are you currently working?

YES 1
NO 2 (GO TO 240)

239) What is your occupation, that is the kind of work do mainly do?

OCCUPATION______________

240) ASK CONSENT FOR BLOOD PRESSURE MEASUREMENT

I would like to measure your blood pressure. this will be done three times during the interview, with an interval of about five to ten minute period. This is a harmless procedure. It is used to find out if a person has high blood pressure.

If it is not treated, high blood pressure may eventually cause serious damage to the heart.

The results of this blood pressure measurement will be given to you after the measurement process is completed. I will explain the meaning of your blood pressure numbers. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey.

Do you have any questions about the blood pressure measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having the blood pressure measurement now. You can also decide at any time not to participate in the blood pressure measures.

241) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

(MARK CODE 3 ONLY IF YOU HAVE MADE AT LEAST 3 CALL BACKS TO FIND THE RESPONDENT)

GRANTED 1 (SIGN)
RESPONDENT REFUSED 2 (SIGN) (GO TO 248)
RESPONDENT NOT PRESENT (SIGN) (GO TO 248)
(SIGN)________________

242) Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements.
Have you done any of the following within the past 30 minutes:
Eaten anything?
Had coffee, tea, cola, or other drink that has caffeine
Smoked any tobacco product?

EATEN
YES 1
NO 2
HAD CAFFEINATED DRINK
YES 1
NO 2
SMOKED
YES 1
NO 2

243) May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment.

BEFORE TAKING THE FIRST BLOOD PRESSURE READING, MEASURE THE CIRCUMFERENCE OF THE RESPONDENT’S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER.
RECORD THE MEASUREMENT IN CENTIMETRES.

ARM CIRCUMFERENCE (IN CENTIMETRES)_________

244) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE.
CIRCLE THE CODE FOR THE CUFF SIZE.

SMALL: 16 CM - 23 CM 1
MEDIUM: 24 CM - 35 CM 2
LARGE: 36 CM - 45 CM 3

245) RECORD TIME

HOURS_________
MINUTES __________

246) TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
THEN PROCEED TO Q.248. IF YOU ARE UNABLE TO MEASURE THE RESPONDENT’S BLOOD PRESSURE, RECORD THE REASON IN Q.247.
BLOOD PRESSURE MEASURED

SYSTOLIC__________
DIASTOLIC__________

247) RECORD REASON BLOOD PRESSURE IS NOT MEASURED
REASON BLOOD PRESSURE NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

248) Before this survey, has your blood pressure ever been checked?

YES 1
NO 2

249) Have you ever been told by a doctor or a nurse that you have high blood pressure?

YES 1
NO 2

250) To lower your blood pressure, are you now taking a prescribed medicine?

YES 1
NO 2

252) HEALTH TECHNICIAN: CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

253) RECORD TIME

HOURS _______
MINUTES ________

254) May I take your blood pressure this time?

YES 1
NO 2 (GO TO 256)

255) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
THEN PROCEED TO Q. 257. IF YOU ARE UNABLE TO MEASURE THE RESPONDENT’S BLOOD PRESSURE, RECORD THE REASON IN Q. 256.
BLOOD PRESSURE MEASURED

SYSTOLIC_________
DIASTOLIC_________

256) RECORD REASON BLOOD PRESSURE IS NOT MEASURED
REASON BLOOD PRESSURE NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

257) Have you ever heard of an illness called diabetes (local name)?

YES 1
NO 2 (GO TO 261)

258) Have you ever been told by a doctor or nurse that you have diabetes?

YES 1
NO 2

259) Are you taking medication for diabetes prescribed by a doctor or nurse?

YES 1
NO 2 (GO TO 261)

260) How do you take the medication?

INJECTED 1
ORALLY 2
INJECTED AND ORALLY 3

261) HEALTH TECHNICIAN: CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.

262) RECORD TIME

HOURS _________
MINUTES _________

263) May I take your blood pressure this time?

YES 1
NO 2 (GO TO 265)

264) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.
THEN PROCEED TO Q. 266. IF YOU ARE UNABLE TO MEASURE THE RESPONDENT’S BLOOD PRESSURE, RECORD THE REASON IN Q. 265.
BLOOD PRESSURE MEASURED

SYSTOLIC ________
DIASTOLIC ________

265) RECORD REASON BLOOD PRESSURE IS NOT MEASURED
REASON BLOOD PRESSURE NOT MEASURED

REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996

266) CHECK HOUSEHOLD SCHEDULE: COLUMN 19 CIRCLED

NO (CONTINUE)
YES (GO TO 275)

271) RECORD THE WEIGHT IN KILOGRAMS
THEN PROCEED TO Q273. IF YOU ARE UNABLE TO MEASURE THE RESPONDENT’S WEIGHT RECORD THE REASON IN Q272.

KG. ________._______

272) RECORD REASON WEIGHT IS NOT MEASURED
REASON WEIGHT NOT MEASURED

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

273) RECORD THE HEIGHT IN CENTIMETERS
THEN PROCEED TO Q275. IF YOU’RE UNABLE TO MEASURE THE RESPONDENT’S HEIGHT RECORD THE REASON IN Q274.

CM. _________.______

274) RECORD REASON HEIGHT IS NOT MEASURED
REASON HEIGHT NOT MEASURED:

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

275) ASK CONSENT FOR FASTING BLOOD SUGAR TESTING

As part of this survey, we are also measuring the level of sugar in blood. If it is not treated, high level of blood sugar may increase the risk for heart disease stroke.

For the blood glucose testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for glucose immediately, and the results will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

The results of this blood glucose test will be given to you with an explanation of the meaning of your blood glucose number. If your blood glucose is high, we will suggest that you consult a health facility or doctor since we cannot provide any counseling, further testing or treatment during the survey.

Do you have any questions about the blood glucose measurement so far? If you have any questions about the procedure at any time, please ask me.

To obtain correct measurement, we would ask that you do not eat or drink anything except plain water from about the time of call of the evening prayer until my visit tomorrow morning.

Would you allow me to return in the morning to take your blood glucose measurement before you break your fast?

276) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
RESPONDENT REFUSED 2 (SIGN) (IF REFUSED, GO TO 286)
(SIGN)____________

277) FIRST APPOINTMENT FOR BLOOD GLUCOSE TESTING

DATE ____________
HOURS ___________
MINUTES __________

277A) SECOND APPOINTMENT FOR BLOOD GLUCOSE TESTING (IF THE RESPONDENT WAS NOT FASTING AT THE DATE AND TIME IN Q277, TAKE ANOTHER APPOINTMENT)

DATE ____________
HOURS ___________
MINUTES __________

277B) THIRD APPOINTMENT FOR BLOOD GLUCOSE TESTING (IF THE RESPONDENT WAS NOT FASTING AT THE DATE AND TIME IN Q277A, TAKE ANOTHER APPOINTMENT)
(IF RESPONDENT IS NOT AVAILABLE FOR THE MEASUREMENT, SKIP TO 285)

DATE ____________
HOURS ___________
MINUTES __________

278) ASK CONSENT FOR FASTING BLOOD SUGAR TESTING

As I mentioned yesterday, we are going to measure the level of sugar in blood. If it is not treated, high level of blood sugar nay increase the risk for heart disease and stroke.

For the blood glucose testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for glucose immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

The results of this blood glucose test will be given to you with an explanation of the meaning of your blood glucose number. If your blood glucose is high, we will suggest that you consult a health facility of doctors since we cannot provide any counseling, further testing or treatment during the survey.

Do you have any questions about the blood glucose measurement so far? If you have any questions about the procedure at any time, please ask me.

You can say yes or no to having the blood glucose measurement now.

Would you allow me to proceed to take your measurement?

279) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
RESPONDENT REFUSED 2 (SIGN) (IF REFUSED, GO TO 286)
(SIGN) ______________

280) When was the last time you had something to eat?

HOURS _______
MINUTES ________

281) When was the last time you had something to drink other than plain water?

HOURS _______
MINUTES ________

282) PREPARE EQUIPMENT AND SUPPLIES FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST.

283) RECORD TIME FOR BLOOD GLUCOSE TESTING

DAY __________
MONTH _________
YEAR_________
HOURS _________
MINUTES _________

284) RECORD FASTING BLOOD SUGAR IN MG/DL THEN PROCEED TO Q286

IF YOU’RE UNABLE TO MEASURE THE RESPONDENTS BLOOD GLUCOSE RECORD THE REASON IN Q285

MG/DL __________

285) RECORD REASON BLOOD GLUCOSE IS NOT MEASURED\
REASON BLOOD GLUCOSE IS NOT MEASURED:

NOT PRESENT 994
REFUSED 995
OTHER 996

286) GO BACK TO 230 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE ADULTS ELIGIBLE FOR BIOMARKER, END MEASUREMENT.