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HEALTH AND DEMOGRAPHIC SURVEY AND MULTIPLE INDICATORS IN BURKINA FASO (EDS-MICS B) - 2010 HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME_____
CLUSTER NUMBER_____
PLOT NUMBER_____
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD_____
HOUSEHOLD NUMBER_____
REGION ____

URBAN/RURAL:

URBAN 1
RURAL 2

MILIEU:

OUAGADOUGOU 1
OTHER CITIES 2
RURAL 3

HOUSEHOLD SELECTED FOR MEN'S SURVEY/ HIV TEST/ANEMIA TEST?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_____
INTERVIEWER'S NAME_____
RESULT_____

RESULT CODES:

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

NEXT VISIT
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR 2010
NAME_____
RESULT_____

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONS_____

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____
KEYED BY_____

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Institute of Statistics and Demography (INSD). We are conducting a survey about health all over Burkina Faso. 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 members of our survey team. You don't have to agree to participate 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?

SIGNATURE OF INTERVIEWER _____
DATE _____

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 01.
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

HOUSEHOLD SCHEDULE

01. LINE NUMBER:

LINE NO. _____

02. 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.

NAME _____

03. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

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

04. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

[AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.]

Just to make sure that I have a complete listing:

2A) Are there any other persons such as small children or infants that we have not listed?

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN 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 (ENTER EACH IN TABLE)
NO

05. RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

06. RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

07. AGE: How old is (NAME)?
IF 95 OR OLDER RECORD '95'.

IN YEARS_____

MARITAL STATUS, IF AGE 15 OR OLDER:

08. What is (NAME)'s current marital status?

1 MARRIED OR LIVING TOGETHER
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED TOGETHER

ELIGIBILITY:
09. CIRCLE LINE NUMBER OF ALL WOMEN 15-49.

ELIGIBILITY:
10. CIRCLE LINE NUMBER OF ALL MEN 15-59.

ELIGIBILITY:
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS, IF AGE 0-17 YEARS:

12. Is (NAME)'s natural mother alive?

YES 1
NO 2 (GO TO 14)
DOESN'T KNOW 8 (GO TO 14)

13. Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name? RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.

MOTHER'S LINE NO. _____

14. Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 16)
DOESN'T KNOW 8 (GO TO 16)

15. Does (NAME)'s natural father live in this household or was he a guest last night?
IF YES: What is his name? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

FATHER'S LINE NO. ______

EVER ATTENDED SCHOOL, IF AGE 5 YEARS OR OLDER:

16. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

17. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

LEVEL _____
PRIMARY 1
SECONDARY (1ST CYCLE)
SECONDARY (2ND CYCLE)
SUPERIOR 4
DOESN'T KNOW 8
GRADE _____
PRIMARY
0 LESS THAN ONE YEAR COMPLETED
1 CP1
2 CP2
3 CE1
4 CE2
5 CM1
6 CM2
8 DOESN'T KNOW
SECONDARY (1ST CYCLE)
0 LESS THAN ONE YEAR COMPLETED
1 6TH
2 5TH
3 4TH
4 3RD
5 FPP
8 DOESN'T KNOW
SECONDARY (2ND CYCLE)
0 LESS THAN ONE YEAR COMPLETED
1 2ND
2 1ST
3 FINAL
4 FPB
8 DOESN'T KNOW
SUPERIOR
0 LESS THAN ONE YEAR COMPLETED
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

CURRENT/RECENT SCHOOL ATTENDANCE, IF AGE 5-24 YEARS:

18. Did (NAME) attend school at any time during the (2009-2010) school year?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

19. During this/that school year, what level and grade (is/was) (NAME) attending?

LEVEL _____
PRIMARY 1
SECONDARY (1ST CYCLE)
SECONDARY (2ND CYCLE)
SUPERIOR 4
DOESN'T KNOW 8
GRADE _____
PRIMARY
1 CP1
2 CP2
3 CE1
4 CE2
5 CM1
6 CM2
8 DOESN'T KNOW
SECONDARY (1ST CYCLE)
1 6TH
2 5TH
3 4TH
4 3RD
5 FPP
8 DOESN'T KNOW
SECONDARY (2ND CYCLE)
1 2ND
2 1ST
3 FINAL
4 FPB
8 DOESN'T KNOW
SUPERIOR
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

BIRTH REGISTRATION, IF AGE 0-4 YEARS:

20. Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

1 HAS CERTIFICATE
2 REGISTERED
3 NEITHER
8 DOESN'T KNOW

WORK OF CHILDREN AGE 5-14 YEARS

20A. CHECK COLUMN 7:
RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

NUMBER OF CHILDREN 5-14 YEARS _____

20B. CHECK QUESTION 20A:

AT LEAST ONE CHILD (GO TO 20C)
NO CHILDREN (GO TO 101)

20C. LIST OF CHILDREN AGE 5-14 YEARS:
CHECK COLUMN 7 OF HOUSEHOLD TABLE. RECORD THE NAMES AND LINE NUMBERS OF ALL THE CHILDREN AGE 5-14 YEARS IN THE ORDER OF THE HOUSEHOLD TABLE.

NAME _____
LINE NO. _____

Now I would like to ask you some questions on the type of work that children in your household did last week.

IF AGE 5-14 YEARS:

20D. In the last week, did (NAME) do any work for anyone who is not a member of this household? IF YES: Was he/she paid in cash or in kind?

YES, PAID 1
YES, UNPAID 2
NO 3 (GO TO 20F)

20E. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

NUMBER OF HOURS WORKED _____

20F. In the past week, did (NAME) go get water or wood for the household?

YES 1
NO 2 (GO TO 20H)

20G. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend getting water or wood for the household?
IF MORE THAN ONE TIME, ADD UP ALL THE HOURS.

NUMBER OF HOURS _____

20H. In the past week, did (NAME) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?
INCLUDE WORK DONE FOR A BUSINESS DONE BY THE CHILD ALONE OR DONE WITH ONE OR SEVERAL PARTNERS.

YES 1
NO 2 (GO TO 20J)

20I. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing work for his/her family or him/herself?
IF MORE THAN ONCE, ADD UP ALL THE HOURS.

NUMBER OF HOURS _____

20J. In the last week, did (NAME) do any household chores, such as shopping, cleaning, washing clothes, cooking, or taking care of children, old people, or sick people?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

20K. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?
IF MORE THAN ONCE, ADD UP ALL THE HOURS.

NUMBER OF HOURS ______

HOUSEHOLD CHARACTERISTICS

101. 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
LES THAN MONTHLY 4
NEVER 5

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED INTO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
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 the water source located?

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

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

MINUTES_____
DOESN'T KNOW 998

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

YES 1
NO 2 (GO TO 107)
DOESN'T KNOW 8 (GO TO 107)

106. What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE A WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) _____ X
DOESN'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, DOESN'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
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?

NUMBER OF HOUSEHOLDS IF LESS THAN 10_____

10 OR MORE HOUSEHOLDS 95
DOESN'T KNOW 98

110. Does your household have (REGARDING WORK EQUIPMENT):

Electricity?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
A TV5 antenna?
A subscription to Canal?
A washing machine?
A portable stove or gas/electric stove?
An improved fireplace?
A CD/DVD player?
An air conditioner?
A computer?
Internet at home?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
TV 5 ANTENNA
YES 1
NO 2
SUBSCRIPTION TO CANAL
YES 1
NO 2
WASHING MACHINE
YES 1
NO 2
PORTABLE STOVE/GAS OR ELECTRIC STOVE
YES 1
NO 2
IMPROVED FIREPLACE
YES 1
NO 2
CD/DVD PLAYER
YES 1
NO 2
AIR CONDITIONER
YES 1
NO 2
COMPUTER
YES 1
NO 2
INTERNET AT HOME
YES 1
NO 2

111A. What is the main method of evacuation for the household waste?

GARBAGE TRUCK 01
HORSE-DRAWN CARRIAGE/CART 02
AUTHORIZED DEPOT 03
UNAUTHORIZED DEPOT 04
BURIAL 05
INCINERATION 06
IN THE YARD 07
IN THE STREET 08
OTHER (SPECIFY) _____ 96

111B.What is the main method of evacuation for the used water in your household?

IN THE SEWER 01
CLOSED CANAL 02
OPEN CANAL 03
STREET GRATE 04
POND/RIVER 05
HOLE 06
OUTDOORS 07
IN THE YARD 08
IN THE STREET 09
OTHER (SPECIFY) _____ 96

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 114)
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 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFY) _____ 6 (GO TO 114)

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

YES 1
NO 2

114. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOODEN BOARDS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED 31
VINYL/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) _____ 96

115. MAIN MATERIAL OF THE ROOF:
RECORD OBSERVATION.

NATURAL MATERIAL
NO ROOF 11
CANE/PALMS/LEAVES 12
EARTH/CLAY MOUND 13
RUDIMENTARY MATERIAL
MATS 21
PALM/BAMBOO 22
WOODEN BOARDS 23
CARDBOARD 24
FINISHED ROOFING
SHEET METAL 31
WOOD 32
ZINC/FIBER CEMENT 33
TILES 34
CEMENT 35
SHINGLES 36
OTHER (SPECIFY) _____ 96

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

NATURAL WALLS
NO WALLS 11
BAMBOO/CANE/PALMS/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONES WITH MUD 22
ADOBE, NOT COVERED/COATED 23
PLYWOOD 24
CARDBOARD 25
RECYCLED WOOD 26
FINISHED WALLS
CEMENT 31
LIME STONES/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOODEN PLANKS/SHINGLES 36
OTHER (SPECIFY) _____ 96

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

NUMBER OF ROOMS_____

118. Does any member of your household own:

A watch?
Plows?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A canoe or fishing nets?
A car or truck?
A boat with a motor?

WATCH
YES 1
NO 2
PLOWS
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CANOE/FISHING NETS
YES 1
NO 2
CAR OR TRUCK
YES 1
NO 2
BOAT WITH A MOTOR
YES 1
NO 2

119. Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.

NUMBER OF HECTARES ____

95 OR MORE HECTARES 950
DOESN'T KNOW 998

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

YES 1
NO 2 (GO TO 123)

122. How many of the following animals does this household own?
IF NONE, RECORD '00'. IF 95 OR MORE RECORD '95'. IF DOESN'T KNOW RECORD '98'.

Cattle?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens?

NUMBER OF CATTLE _____
NUMBER OF MILK COWS OR BULLS _____
NUMBER OF HORSES, DONKEYS, OR MULES _____
NUMBER OF GOATS _____
NUMBER OF SHEEP _____
NUMBER OF CHICKENS _____

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

YES 1
NO 2

124. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES 1
NO 2 (GO TO 126)
DOESN'T KNOW 8 (GO TO 126)

125. Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) _____ X
DOESN'T KNOW Y

126. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 137)

127. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS _____

128. ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

129. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO _____

MORE THAN 36 MONTHS AGO 95
NOT SURE 98

130. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET:

IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
OLISET 12 (GO TO 134)
DURANET 13 (GO TO 134)
NETPROTECT 14 (GO TO 134)
INTERCEPTOR 15 (GO TO 134)
OTHER/DOESN'T KNOW BRAND 16 (GO TO 134)
'PRETREATED' NET
PERMETHRINE 21 (GO TO 132)
DELTA METHRINE 22 (GO TO 132)
CYFULTRINE 23 (GO TO 132)
OTHER/DOESN'T KNOW BRAND 26 (GO TO 132)
OTHER BRAND 96
DOESN'T KNOW BRAND 98

131. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
NOT SURE 8

132. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO _____

MORE THAN 24 MONTHS AGO 95
NOT SURE 98

134. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 136)
DOESN'T KNOW 8 (GO TO 136)

135. Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LIST UP TO FOUR PEOPLE PER NET.

NAME_____
LINE NUMBER_____

136. GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

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 HAND WASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

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

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

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

141. SELECTION TABLE FOR WOMEN FOR "HOUSEHOLD RELATIONSHIPS":

THIS SECTION APPLIES TO ALL THE SAMPLING HOUSEHOLDS. ONE WOMAN WILL BE INTERVIEWED PER HOUSEHOLD FOR THIS SECTION: THE SCHEDULE BELOW WILL ALLOW YOU TO RANDOMLY SELECT THIS WOMAN IN THE HOUSEHOLD.

1. THERE IS ONLY ONE ELIGIBLE WOMAN IN THE HOUSEHOLD:

IN THE FIRST LINE OF THE FOLLOWING TABLE, RECORD THE NAME, AGE, LINE NUMBER OF THE WOMAN (SEE COLUMN 8) FROM THE HOUSEHOLD SCHEDULE: THIS WOMAN WILL BE INTERVIEWED ON "HOUSEHOLD RELATIONSHIPS"

2. THERE ARE SEVERAL ELIGIBLE WOMEN IN THE HOUSEHOLD:

1) IN THE TABLE, RECORD THE NAME, AGE, AND LINE NUMBER OF ALL THE ELIGIBLE WOMEN (SEE COLUMN 9 IN THE HOUSEHOLD SCHEDULE), STARTING WITH THE OLDEST AND ENDING WITH THE YOUNGEST.

2) TAKE THE LAST DIGIT OF THE CONCESSION NUMBER RECORDED ON THE COVER PAGE OF THE QUESTIONNAIRE AND CIRCLE THE CORRESPONDING NUMBER IN THE HEADING LINE OF THE FOLLOWING TABLE. GO DOWN THE COLUMN IDENTIFIED BY THE DIGIT UNTIL THE LINE CORRESPONDING TO THE LAST WOMAN REGISTERED ON THE TABLE. CIRCLE THE CORRESPONDING DIGIT AT THE INTERSECTION OF THIS COLUMN AND THE NEXT LINE.

3) THIS DIGIT WILL GIVE YOU THE ORDER NUMBER OF WOMEN SELECTED WOMAN FOR SECTION 13 OF THE WOMEN'S QUESTIONNAIRE (THE 1ST, 2ND, 3RD, ETCÂ…WOMAN LISTED). THEN CIRCLE IN THE TABLE THE LINE NUMBER OF THE SELECTED WOMAN.

ORDER NUMBER (1ST, 2ND, 3RD, ETC.):

ORDER NUMBER _____

NAME OF WOMAN:

NAME _____

AGE OF WOMAN:

AGE _____

LINE NUMBER FROM HOUSEHOLD QUESTIONNAIRE:

LINE NO. _____

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

200. CHECK COVER PAGE:

HOUSEHOLD SELECTION CODE IS '1' (GO TO 201)
HOUSEHOLD SELECTION CODE IS '2' (END HOUSEHOLD QUESTIONNAIRE)

201. CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202. LINE NUMBER FROM COLUMN 11:
NAME FROM COLUMN 2:

LINE NO. _____
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 day?

DAY_____
MONTH_____
YEAR_____

204. CHECK 203:
CHILD BORN IN JANUARY 2005 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

208. CHECK 203:
WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

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

OLDER 2

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

LINE NO. OF PARENT/RESPONSIBLE ADULT _____

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 2005 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 (SIGN) _____

212. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET:

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, HEMOGLOBIN MEASUREMENT AND HIV TEST FOR WOMEN AGE 15-49

214. CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215. LINE NUMBER FROM COLUMN 9:
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. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 223)

219. MARITAL STATUS:
CHECK COLUMN 8.

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 223)

220. RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NO. OF PARENT/RESPONSIBLE ADULT _____

221. ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17:

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 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 and (NAME OF ADOLESCENT) 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 for (NAME OF ADOLESCENT), or you can say 'no'. It is up to you to decide.

Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?

222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 228)

223. 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 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 in the anemia test?

224. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

RESPONDENT GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 226)

225. PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DOESN'T KNOW 8

226. AGE:
CHECK COLUMN 218.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 230)

227. MARITAL STATUS:
CHECK COLUMN 219.

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 230)

228. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (COUNTRY).

For the HIV test, we 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.

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 ADOLESCENT) to take the HIV test?

229. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 239)

230. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (COUNTRY).

For the HIV test, we 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know your HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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 HIV test?

231. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:
ENTER YOUR INTERVIEWER NUMBER:

RESPONDENT GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 239)
INTERVIEWER NUMBER _____

232. QUESTIONS 232 TO 238 ARE FOR PROCEDURES FOR ADDITIONAL TESTS IF THERE ARE ANY FOR THE WOMEN. IF THERE ARE NO ADDITIONAL TESTS, CONTINUE TO 239.

239. PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) THAT YOU GOT CONSENT FOR AND CONTINUE WITH THE TESTS.

240. RECORD THE HEMOGLOBIN LEVEL HERE ON THE ANEMIA PAMPHLET.

G/DL _____

NOT PRESENT 994
REFUSED 995
OTHER 996

241. BAR CODE LABEL:
PUT THE FIRST BAR CODE LABEL HERE. PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

242. GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 243.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

243. CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

244. LINE NUMBER FROM COLUMN 10:
NAME FROM COLUMN 2:

LINE NUMBER_____
NAME _____

245. QUESTIONS 245 TO 246 ARE ONLY TO MEASURE THE WEIGHT AND THE HEIGHT OF MEN IN COUNTRIES WHERE MEN'S WEIGHT AND HEIGHT ARE SERIOUS PUBLIC HEALTH PROBLEMS. IF NOT MEASURED, CONTINUE TO 247.

247. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 252)

248. MARITAL STATUS:
CHECK COLUMN 8.

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 252)

249. RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NO. OF PARENT/ OTHER RESPONSIBLE ADULT_____

250. ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

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 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 and (NAME OF ADOLESCENT) 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 for (NAME OF ADOLESCENT), or you can say 'no'. It is up to you to decide.

Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?

251. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 256)

252. 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 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 in the anemia test?

253. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

RESPONDENT GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____

254. AGE:
CHECK COLUMN 247.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 258)

255. MARITAL STATUS:
CHECK COLUMN 248.

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 258)

256. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (COUNTRY).

For the HIV test, we 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know his HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say 'yes' to the test for (NAME OF ADOLESCENT), or you can say 'no'. It is up to you to decide.

Will you allow (NAME OF ADOLESCENT) to take the HIV test?

257. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 267)

258. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (COUNTRY).

For the HIV test, we 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know your HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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 HIV test?

259. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:
ENTER YOUR INTERVIEWER NUMBER:

RESPONDENT GRANTED 1(SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 267)
INTERVIEWER NUMBER _____

260. QUESTIONS 260 TO 266 ARE FOR PROCEDURES FOR ADDITIONAL TESTS IF THERE ARE ANY FOR THE MEN. IF THERE ARE NO ADDITIONAL TESTS, CONTINUE TO 267.

267. PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) THAT YOU GOT CONSENT FOR AND CONTINUE WITH THE TESTS.

268. RECORD THE HEMOGLOBIN LEVEL HERE ON THE ANEMIA PAMPHLET:

G/DL _____

NOT PRESENT 994
REFUSED 995
OTHER 996

269. BAR CODE LABEL:
PUT THE FIRST BAR CODE LABEL HERE. PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

270. GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END THE INTERVIEW.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT _____

COMMENTS ON SPECIFIC QUESTIONS _____

ANY OTHER COMMENTS _____

SUPERVISOR'S OBSERVATIONS _____
NAME _____
DATE_____

EDITOR'S OBSERVATIONS_____
NAME _____
DATE_____