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DEMOGRAPHIC AND HEALTH SURVEY (EDSB-IV, 2011) REPUBLIC OF BENIN
NATIONAL OFFICE OF STATISTICS AND ECONOMIC ANALYSIS - MINISTRY OF DEVELOPMENT, ECONOMIC ANALYSIS, AND FORECASTING

IDENTIFICATION

DEPARTMENT_________
COMMUNE __________
DISTRICT_______

URBAN/RURAL

URBAN 1
RURAL 2

VILLAGE/NEIGHBORHOOD___________
CLUSTER NUMBER_________
STRUCTURE NUMBER ____________
NAME OF HEAD OF HOUSEHOLD____________
HOUSEHOLD NUMBER _________

HOUSEHOLD SELECTED FOR MAN'S QUESTIONNAIRE, HIV, ANEMIA, MALARIA AND BLOOD PRESSURE TEST?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_______
INTERVIEWER'S NAME________
RESULT ____

NEXT VISIT
DATE ________
TIME________

FINAL VISIT
DAY_____
MONTH_______
YEAR 2011
INTERVIEWER CODE_________
RESULT ____

RESULT CODES:

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 NO. OF VISITS__________

TOTAL PERSONS IN HOUSEHOLD________

TOTAL ELIGIBLE WOMEN________

TOTAL ELIGIBLE MEN___________

TOTAL PEOPLE AGE 6 OR OLDER_________

TOTAL PEOPLE AGE 18 OR OLDER_______

TOTAL PEOPLE UNDER AGE 6__________

NAME AND NUMBER OF RESPONDENT_________

QUESTIONNAIRE USED: FRENCH

LANGUAGE OF INTERVIEW

FRENCH 1
ADJA 2
BARIBA 3
FON 4
DENDI 5
DITAMARI 6
YORUBA 7
OTHER 8

INTERPRETER

YES 1
NO 2

RESPONDENT NUMBER_____

SUPERVISOR
NAME_______
DATE________

FIELD EDITOR
NAME_______
DATE_________

OFFICE EDITOR________

KEYED BY__________

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Office of Statistics and Economic Analysis (INSAE). We are conducting a survey about health all over Benin. 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 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 (IT'S A BADGE).

GIVE CARD WITH CONTACT INFORMATION FOR THESE PEOPLE.

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

SIGNATURE OF INTERVIEWER____________
DATE______

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

HOUSEHOLD SCHEDULE

1) LINE NO.

LINE NUMBER___

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 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.

NAME_______

3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (name) to the head of the household?
SEE CODES BELOW.

HEAD 1
WIFE OR HUSBAND 2
SON OR DAUGHTER 3
SON-IN-LAW OR DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
BROTHER OR SISTER 8
OTHER RELATIVE 9
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'.

IN YEARS_______

8) MARITAL STATUS IF AGE 10 OR OLDER
What is (NAME)'s current marital status?

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

EDSB ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-64

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

EMICOV ELIGIBILITY
11A) CIRCLE LINE NUMBER OF ALL PEOPLE AGE 6 OR OLDER

11B) CIRCLE LINE NUMBER OF ALL PEOPLE AGE 18 OR OLDER

11C) CIRCLE LINE NUMBER OF ALL LAND OWNERS (INCLUDING THROUGH INHERITANCE) OR RENTERS (INCLUDING SHARECROPPERS) OF A PLOT IN THE LAST 12 MONTHS.

SOCIOCULTURAL CHARACTERISTICS:

11D) ETHNICITY
What is (NAME)'s ethnicity?
SEE CODES BELOW

ADJA AND SIMILAR 11
BARIBA AND SIMILAR 21
DENDI AND SIMILAR 31
FON AND SIMILAR 41
YONG AND LOKPA AND SIMILAR 51
BETAMARIBE AND SIMILAR 61
PEULH AND SIMILAR 71
YORUBA AND SIMILAR 81
ADJACENT COUNTRIES 91
OTHER COUNTRY 92
OTHER ETHNICITY 96

11E) RELIGION
What is (NAME)'s religion?
SEE CODES BELOW

VODOUN 11
OTHER TRADITIONAL 12
ISLAM 21
CATHOLIC 31
PROTESTANT/METHODIST 41
OTHER PROTESTANT 42
CELESTE 51
OTHER CHRISTIAN RELIGION 52
OTHER RELIGION 61
NO RELIGION 71

MIGRATION DURING LIFE FOR RESIDENTS:

11F) BIRTHPLACE
In what municipality was (NAME) born?
RECORD MUNICIPALITY OR COUNTRY FOR FOREIGNERS.

MUNICPALITY______

11G) FORMER RESIDENCE
In what residential municipality did (NAME) live before moving here?
RECORD MUNICIPALITY OR COUNTRY FOR FOREIGNERS

MUNICPALITY______

11H) LENGTH OF CURRENT RESIDENCE
How long did (NAME) stay in that municipality?

RECORD: 1 AND THE NUMBER OF MONTHS FOR STAYS SHORTER THAN 1 YEAR OR 2 AND NUMBER OF YEARS FOR STAYS LONGER THAN 1 YEAR AND 998 IF SINCE BIRTH.

________

11I) RETURNED MIGRATION
Is (NAME) back in this municipality after having stayed there for less than 6 months?

YES 1
NO 2

11J) MIGRATION STATUS
CONCLUDE MIGRATION STATUS

RECORD:
1 NON MIGRANT IF QUESTION 11H=9 98
2 RETURNED MIGRANT IF QUESTION 11H DOES NOT EQUAL 9 98 AND Q11H =1
3 OTHER MIGRANT IF QUESTION 11H DOES NOT EQUAL 9 98 AND Q11H=2

11K) REASON FOR SETTLING
What is the main reason for which (NAME) settled in this municipality?

ADVENTURE 11
MARRIAGE 12
DIVORCE/WIDOW/SEPARATION 13
CEREMONIES 14
FAMILY AUTHORITY 15
FAMILY CONFLICTS 16
STUDY/APPRENTICE 17
WORK 18
RETIREMENT/PERMANENT RETURN 19
OTHER REASONS 20
SINCE BIRTH 98
DON'T KNOW 96

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)
DON'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.

LINE NUMBER______

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

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

15) Does (NAME)'s natural father usually 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.

LINE NUMBER_______

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

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 1 2
SECONDARY 2 3
HIGHER 4
PRE-PRIMARY/NURSERY SCHOOL 5
INFORMAL PROGRAM 6
DON'T KNOW 8
GRADE ____
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

18) Did (NAME) attend school at any time during the (2010-2011) school year?

YES 1
NO 2 (GO TO NEXT LINE)

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

LEVEL ____
PRIMARY 1
SECONDARY 1 2
SECONDARY 3 3
HIGHER 4
PRE-PRIMARY/NURSERY SCHOOL 5
INFORMAL PROGRAM 6
DON'T KNOW 8
GRADE ____
DON'T KNOW 98

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?

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

ASSISTANCE FOR ORPHANS IF AGE 0-17 YEARS AND IF CODE 2 CIRCLED IN COLUMN 12 OR 14

20A) AT LEAST ONE PARENT DEAD:
Did (NAME) receive at least one form of outside assistance in the last 12 months?
IF YES, which ones? IF NO, CIRCLE CODE 'F' (NONE)

MEDICAL A
EDUCATIONAL B
ECONOMIC C
PSYCHO-SOCIAL D
OTHER E
NONE F

LITERACY IF AGE 6 OR OLDER

20B) Does (name) know how to read, write and understand at least one language?
IF YES, which ones?

AF (LITERATE IN FRENCH) 1
ALN (LITERATE IN NATIONAL LANGUAGES) 2
AFLN (LITERATE IN FRENCH AND NATIONAL LANGUAGES) 3
NLE (NOT LITERATE AT ALL) 4
DON'T KNOW 8

TICK HERE IF CONTINUATION SHEET USED________

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 EACH IN TABLE)
NO

2B) 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 (ADD 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 (ADD EACH IN TABLE)
NO

WORK OF CHILDREN AGE 5-14 YEARS

21) CHECK COLUMN 7:
RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

NUMBER OF CHILDREN______

21A) CHECK Q.21

IF AT LEAST ONE CHILD (GO TO 21B)
IF NO CHILDREN (GO TO 101)

21B) LINE NUMBER

LINE NUMBER____

21C) 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_______

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

21D) 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?

1: PAID WORK
2: UNPAID WORK
3: NO WORK

YES PAID 1
YES UNPAID 2
NO 2 (GO TO 21F)

21E) 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________

21F) In the last week, did (NAME) go get water or wood for the household?

YES 1
NO 2- (GO TO 21H)

21G) 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________

21H) In the last 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 21J)

21I) 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_______

21J) In the last week, did (NAME) do any household chores, such as shopping, cleaning, clothes washing, cooking, or taking care of children, old people, or sick people?

YES 1
NO 2 (GO TO NEXT LINE)

21K) 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
LESS 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/BARREL 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_______
DON'T KNOW 998

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?
RECORD ALL MENTIONED

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 MANUAL FLUSH TOILET
CONNECTED FLUSH
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
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?

NO. OF HOUSEHOLDS IF LESS THAN 10________

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110) Does your household have:

Electricity?
A generator?
A radio?
A stove?
Hi-fi system?
A CD/DVD player?
A video recorder?
A washing machine?
A television?
A mobile telephone?
A non-mobile telephone?
A computer?
Internet connection?
A refrigerator?

ELECTRICITY?
YES 1
NO 2
GENERATOR?

YES 1
NO 2
RADIO?
YES 1
NO 2
STOVE?
YES 1
NO 2
HI-FI SYSTEM?
YES 1
NO 2
CD/DVD PLAYER?
YES 1
NO 2
VIDEO RECORDER?
YES 1
NO 2
WASHING MACHINE?
YES 1
NO 2
TELEVISION?
YES 1
NO 2
MOBILE TELEPHONE?
YES 1
NO 2
NON-MOBILE TELEPHONE?
YES 1
NO 2
COMPUTER?
YES 1
NO 2
INTERNET?
YES 1
NO 2
REFRIGERATOR?
YES 1
NO 2

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

ELECTRICITY 01
LIQUIFIED PROPANE GAS (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
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED MATERIAL
PARQUET OR WAXED WOOD 31
VINYL/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER______ (SPECIFY) 96

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS/LEAVES 12
SOD 13
RUDIMENTARY FLOOR
MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED MATERIAL
SHEET METAL 31
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
SHINGLES 36
OTHER_______ (SPECIFY) 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED MATERIAL
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER_______ (SPECIFY) 96

116A) Where do you usually throw away your household waste?

PUBLIC REFUSE COLLECTION 11
PRIVATE REFUSE COLLECTION/NGO 12
BURIED 13
BURNED 14
IN THE YARD 15
IN NATURE/OUTDOORS 16
OTHER_______ (SPECIFY) 96

116B) Where do you usually throw away your used water?

CLOSED GUTTER 11
OPEN GUTTER 12
SEPTIC TANK 13
ISOLATED WELL 14
SEWER 15
IN THE YARD 16
OUTDOORS 17
OTHER (SPECIFY) 96

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

ROOMS________

118) Does any member of your household own:

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

WATCH
YES 1
NO 2
BICYCLE
YES 1
NO 2
A MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CANOE
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'

HECTARES_______

95 OF MORE HECTARES 950
DON'T KNOW 998

121) Does this household own any livestock, herds of 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, ENTER '00'
IF 95 OR MORE, ENTER '95'
IF UNKNOWN, ENTER '98'

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

CATTLE________
MILK COWS OR BULLS_________
HORSES, DONKEYS, OR MULES________
GOATS_______
SHEEP________
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)
DON'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
DON'T KNOW Z

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 ALL 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 97

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)
PERMENET 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/DON'T KNOW BRAND 16 (GO TO 134)
'PRETEATED' NET
PERMETHRINE 21 (GO TO 132)
DELTA METHRINE 22 (GO TO 132)
CYFULTRINE 23 (GO TO 132)
OTHER/DON'T KNIW BRAND 26 (GO TO 132)
OTHER BRAND 96
DON'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
NO SURE 98

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

YES 1
NO 2 (GO TO 136)
NOT SURE 8 (GO TO 136)

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

NAME_______
LINE NUMBER_____

136A) Where was this mosquito net obtained?

HEALTH FACILITY 1
PRIVATE PHARMACY 2
BUSINESS/MARKET 3
COMMERCIAL ASSOCIATION 4
OTHER NON-COMMERCIAL 5
DISTRIBUTION CAMPAIGN 6
OTHER______ (SPECIFY) 7
DON'T KNOW 8

136B) How did you acquire this mosquito net?

PURCHASED WITHOUT COUPON 1
PURCHASED WITH COUPON 2
FREE 3
OTHER_______ (SPECIFY) 6
DON'T KNOW 8

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 WHERE MEMBERS OF THE HOUSEHOLD WASH THEIR HANDS

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

SECTION 6. WEIGHT, HEIGHT, MALARIA, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

600) CHECK COVER PAGE:

IF HOUSEHOLD = 1 (GO TO 601)
IF HOUSEHOLD = 2 (END HOUSEHOLD QUESTIONNAIRE)

601) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS (UNDER 6 YEARS) IN QUESTION 602. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). THE FINAL RESULT OF THE WEIGHT AND HEIGHT MEASUREMENTS MUST BE RECORDED IN Q605 AND Q 606, THE ANEMIA TEST IN Q613 AND THE MALARIA TEST IN Q 613A.

602) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER________
NAME_________

603) What is (NAME)'s date of birth?
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___

604) CHECK 603:
CHILD BORN IN JANUARY 2006 OR LATER?

YES 1
NO 2 (GO TO 603 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 700)

605) WEIGHT IN KILOGRAMS

KG____

ABSENT 9994
REFUSED 9995
OTHER 9996

606) HEIGHT IN CENTIMETERS

CM______

ABSENT 9994
REFUSED 9995
OTHER 9996

607) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

607A) PRESENCE OF BILATERAL EDEMA ON FEET?

YES 1
NO 2

609) CHECK 603:
IF CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 603 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 700)
OLDER 2

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

LINE NUMBER_____

611) READ THE CONSENT STATEMENT FOR ANEMIA AND MALARIA TEST TO PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
REQUEST FOR CONSENT FOR THE ANEMIA AND MALARIA TEST.

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. The results of this survey will allow the government to develop and put in place programs to prevent and treat anemia and malaria.

We ask that all children born in 2006 or later take part in anemia and malaria testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood for this test 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 and malaria 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 member 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.

611A) ASK FOR CONSENT FOR THE ANEMIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
ASK FOR CONSENT FOR THE ANEMIA TEST
Will you allow (NAME OF CHILD(REN)) to participate in the anemia test?

611B) CIRCLE THE APPROPRIATE CODE FOR THE ANEMIA TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN________)
REFUSED 2 (SIGN________)

611C) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
ASK FOR CONSENT FOR THE MALARIA TEST
Will you allow (NAME OF CHILD(REN)) to participate in the anemia test?

611D) CIRCLE THE APPROPRIATE CODE FOR THE MALARIA TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN________)
REFUSED 2 (SIGN________)

611E) CHECK 611B AND 611D:

ACCEPTED AT LEAST ONE OF THE TWO TESTS, CODE 1 CIRCLED IN AT LEAST ONE SPACE (IN 611B, 611D) (GO TO 612)
REFUSED BOTH TESTS, CODE 2 CIRCLED IN BOTH SPACES (IN 611B AND 611D) (GO TO 613)

612) CONSENT WAS OBTAINED FOR THE CHILD, CONTINUE WITH THE TEST. PREPARE THE THICK DROPS OF BLOOD ON THE TWO MICROSCOPE SLIDES IF THE CONSENT WAS OBTAINED FOR THE MALARIA TEST AND CONTINUE TO 613.

613) RESULT CODE FOR MALARIA TEST

IF TEST WAS ACCEPTED, STICK BAR CODES:
PUT FIRST BAR CODE HERE
PUT A STICKER ON EACH OF THE TWO SLIDES
PUT ONE ON THE RAPID DIAGNOSTIC TEST (TDR)
PUT THE FIFTH ON THE SAMPLE TRANSMISSION SHEET

PUT FIRST STICKER HERE__________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

614) RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

G/DL_________

NOT PRESENT 994
REFUSED 995
OTHER 996

615) CHECK 613:

MALARIA TEST ACCEPTED (GO TO 616)
MALARIA TEST REFUSED (GO TO 621)

616) RECORD TDR RESULT ON MALARIA PAMPHLET

POSITIVE 1
NEGATIVE 2 (GO TO 621)

617) ASK IF THE CHILD IS CURRENTLY RECEIVING TREATMENT FOR MALARIA PRESCRIBED BY A DOCTOR OR ANOTHER HEALTH PROFESSIONAL.
Is the child currently receiving treatment prescribed by a doctor or another health professional?
CIRCLE A CODE AND CONTINUE.

YES, ALREADY RECEIVED MEDICAL TREATMENT 1 (GO TO 621)
NO 2

618) CONSENT AND TREATMENT FOR CHILDREN WITH A POSITIVE RESULT ON THE RAPID DIAGNOSTIC TEST (TDR)
READ THE INFORMATION FOR MALARIA TREATMENT AND THE CONSENT TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. CIRCLE A CODE AND SIGN.

The diagnostic test for malaria shows that your child has malaria. We can offer you free drugs. These drugs are called CTA. CTA are very effective and in a few days, should eliminate the fever and other symptoms. CTA is also very safe. However, like with all drugs, there are side effects, and this drug can have some. The most common side effects are dizziness, fatigue, loss of appetite, and palpitations. CTA should never be taken by people with serious heart problems or with severe malaria (for example, cerebral malaria) or problems regulating salt in the body.

ASK IF THE MOTHER IS AWARE THAT THE CHILD HAS ANY OF THESE PROBLEMS. IF YES, DO NOT OFFER THE CTA. EXPLAIN THE RISKS OF MALARIA, AND REFER THE CHILD TO THE CLOSEST HEALTH ESTABLISHMENT.

You do not have to give your child this drug. It is for you to decide.
Please tell me if you accept the drugs or not.

619) CIRCLE THE APPROPRIATE CODE AND SIGN

GRANTED 1 (SIGN________)
REFUSED 2 (SIGN_______)

620) RECORD THE RESULT OF MALARIA TREATMENT.

TREATED 1
NOT TREATED, BUT REFERRED 2
NOT TREATED AND NOT REFERRED 3

621) GO BACK TO 603 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE FOR CHILD 4-6; IF NO MORE CHILDREN, GO TO 701.

TREATMENT OF BASIC MALARIA WITH CTA ACCORDING TO THE NATIONAL TREATMENT PROTOCOL FOR THE BENIN, 2011 IN CASES RANGING FROM SIMPLE MALARIA TO PLASMODIUM FALCIPARUM

ACCORDING TO AVAILABILITY IN THE TERRAIN, DOSE TO ADMINISTER WILL BE AS FOLLOWS, ON THE 1ST DAY, 2ND DAY, AND 3RD DAY.

APPROXIMATE AGE: 6 TO 35 MONTHS (6 MONTHS TO 3 YEARS)
DOSAGE: ARTEMETHER-LUMEFANTRINE (20/120MG)
DAY 1: 1 TABLET MORNING, 1 TABLET EVENING
DAY 2: 1 TABLET MORNING, 1 TABLET EVENING
DAY 3 1 TABLET MORNING, 1 TABLET EVENING
APPROXIMATE AGE: 36 TO 59 MONTHS (3 TO 5 YEARS)
DOSAGE: ARTEMETHER-LUMEFANTRINE (20/120MG)
DAY 1: 2 TABLET MORNING, 2 TABLET EVENING
DAY 2: 2 TABLET MORNING, 2 TABLET EVENING
DAY 3: 2 TABLET MORNING, 2 TABLET EVENING
APPROXIMATE AGE: 6 TO 11 MONTHS
PACKET OF 3 CP DOSED AT 25/67.5 MG
DOSAGE: ARTESUNATE-AMODIAQUINE FIXED COMBINATION
DAY 1: 1 TABLET (MORNING OR NIGHT)
DAY 2: 1 TABLET (MORNING OR NIGHT)
DAY 3: 1 TABLET (MORNING OR NIGHT)
APPROXIMATE AGE: 12 TO 59 MONTHS (1 TO 5 YEARS)
PACKET OF 3 CP DOSED AT 50/135 MG
DOSAGE: ARTESUNATE-AMODIAQUINE FIXED COMBINATION
DAY 1: 1 TABLET (MORNING OR NIGHT)
DAY 2: 1 TABLET (MORNING OR NIGHT)
DAY 3: 1 TABLET (MORNING OR NIGHT)

YOU MUST ALSO TELL THE PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD:
If (NAME) has any of the following symptoms, you must take him/her to a health professional immediately to received care:
High fever
Convulsions, coma
Rapid breathing or difficulty breathing
Not able to drink or breastfeed
Gets sick or doesn't get better in 2 days

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TEST FOR WOMEN 15-49

700) CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL WOMEN AGE 15-49 IN 701. IF THERE ARE MORE THAN SIX WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

THE FINAL MEASUREMENTS RESULTS OF WEIGHT AND HEIGHT MUST BE RECORDED IN Q. 702 AND Q. 703, IN Q712 FOR THE ANEMIA TEST, AND IN Q712B FOR THE HIV TEST.

701) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER_______
NAME_______

702) WEIGHT IN KILOGRAMS

KG_______

ABSENT 99994
REFUSED 99995
OTHER 99996

703) HEIGHT IN CENTIMETERS

CM______

ABSENT 99994
REFUSED 99995
OTHER 99996

705) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 709)

706) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 709)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT________

708) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 707 AS RESPONSIBLE FOR ADOLESCENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST FROM THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT

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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and AIDS.

For the anemia and 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.

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 member of our survey team.

For the HIV 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 the results of (NAME OF THE ADOLESCENT) either.

If you want to know (NAME OF ADOLESCENT)'s HIV status, I can provide a list of [nearby] facilities to (NAME OF ADOLESCENT) that offer counseling and testing for HIV. I will also give you a voucher for free services for (NAME OF ADOLESCENT) to 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.

708A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE ANEMIA TEST
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

708B) CIRCLE THE APPROPRIATE CODE FOR THE CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN________)
REFUSED 2 (SIGN_________)

708C) ASK FOR CONSENT FOR THE HIV TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE HIV TEST
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

708D) CIRCLE THE APPROPRIATE CODE FOR THE HIV TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN__________)
REFUSED 2 (SIGN___________)

708E) CHECK 708B AND 708D:

CODE 1 CIRCLED AT LEAST ONCE (IN 708B, 708D) (GO TO 708F)
CODE 2 CIRCLED BOTH TIMES (IN 708B AND 708D) (GO TO 712)

708F) CHECK 708B AND 708D:

CODE 1 CIRCLED ONCE (IN 708B, 708D) (GO TO 708G)
CODE 1 CIRCLED BOTH TIMES (IN 708B AND 708D) (GO TO 709)

708G) CHECK 708B AND 708D:

CODE 1 CIRCLED ONLY IN 708B (ANEMIA TEST) (GO TO 708H)
CODE 2 CIRCLED ONLY IN 708D (HIV TEST) (GO TO 708J)

708H) READ THE DECLARATION OF CONSENT FOR MALARIA TEST TO THE RESPONDENT
DECLARATION OF CONSENT FOR MALARIA TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE ANEMIA TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 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.

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 member 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.

708I) NEXT GO TO 709A

708J) CONSENT FOR HIV TEST FOR RESPONDENT

READ THE DECLARATION OF CONSENT FOR HIV TEST TO THE RESPONDENT
DECLARATION OF CONSENT FOR HIV TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE HIV TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 the Benin.

This survey will assist the government to develop programs to prevent and treat HIV.

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 that offer 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.

708K) THEN GO TO 709C

709) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO BE READ TO 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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and HIV.

For the anemia and 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.

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 member of our survey team.

For the HIV 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.

709A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE ANEMIA TEST
Will you take the anemia test?

709B) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN___________)
REFUSED 2 (SIGN____________)

709C) CONSENT FOR THE HIV TEST FROM THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE HIV TEST
Will you take the HIV test?

709D) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE HIV TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN____________)
REFUSED 2 (SIGN__________)

710) CHECK 709B AND 709D:

RESPONDENT ACCEPTED AT LEAST ONE OF THE TWO TESTS; CODE 1 CIRCLED IN AT LEAST ONE SPACE (IN 709B, 709D) (GO TO 711)
RESPONDENT REFUSED BOTH TESTS; CODE 2 CIRCLED IN BOTH SPACES (IN 709B AND 709D) (GO TO 712)

711) CHECK ONCE AGAIN 709B AND 709D AND PREPARE THE INSTRUMENTS NECESSARY FOR THE TESTS FOR WHICH CONSENT WAS OBTAINED. THEN, PERFORM THE TEST. FOR EACH ELIGIBLE WOMAN, THE RESULT CODE FOR THE HIV TEST MUST BE RECORDED IN 712 AND FOR THE ANEMIA TEST IN 713, EVEN IF SHE WASN'T PRESENT, REFUSED, OR COULD NOT BE TESTED FOR OTHER REASONS.

712) RESULT CODE FOR HIV TEST:
IF HIV TEST WAS ACCEPTED, STICK BAR CODES

PUT FIRST BAR CODE HERE________

NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND ON THE RESPONDENT'S FILTER PAPER, AND THE 3RD ON THE HIV SAMPLE TRANSMISSION SHEET

713) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA BROCHURE

G/DL_______

NOT PRESENT 994
REFUSED 995
OTHER 996

714) GO BACK TO Q 702 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT WOMAN. IF THERE ARE MORE THAN 3 WOMEN, USE THE ADDITIONAL QUESTIONNAIRE. IF THERE ARE NO MORE WOMEN, GO TO 800.

700) IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE

HEMOGLOBIN AND HIV TEST FOR MEN AGE 15-64

800) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME OF ALL MEN AGES 15-59 IN QUESTION 801. IF THERE ARE MORE THAN 6 MEN, USE THE ADDITIONAL QUESTIONNAIRE.

THE FINAL RESULTS OF THE MEASUREMENTS FOR THE ANEMIA TEST MUST BE RECORDED IN Q 812 AND IN 812 BE FOR THE HIV TEST [##translator note: the original document does not indicate which test, the text is cut off. I indicated the HIV test because of the section heading, referring to the HIV test]

LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

LINE NUMBER_________
NAME_____________

805) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-59 YEARS 2 (GO TO 809)

806) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 809)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT________

808) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 807 AS RESPONSIBLE FOR ADOLESCENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST FROM THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT

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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and HIV.

For the anemia and 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.

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 member of our survey team.

For the HIV 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 the results of (NAME OF THE ADOLESCENT) either.

If you want to know (NAME OF ADOLESCENT)'s 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 (NAME OF ADOLESCENT) to 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.

808A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE ANEMIA TEST
Will you allow (name of adolescent) to take the anemia test?

808B) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

GRANTED 1 (SIGN________)
REFUSED 2 (SIGN________)

808C) ASK FOR CONSENT FOR THE HIV TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE HIV TEST
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

808D) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE HIV TEST AND SIGN YOUR NAME.

GRANTED 1-SIGN_______
REFUSED 2-SIGN_________

808E) CHECK 808B AND 808D:

CODE 1 CIRCLED AT LEAST ONCE (IN 808B, 808D)
CODE 2 CIRCLED BOTH TIMES (IN 808B AND 808D)- (GO TO 812)

808F) CHECK 808B AND 808D:

CODE 1 CIRCLED ONCE (IN 808B, 808D)
CODE 1 CIRCLED BOTH TIMES (IN 808B AND 808D) (GO TO 809)

808G) CHECK 808B AND 808D:

CODE 1 CIRCLED ONLY IN 808B (ANEMIA TEST)
CODE 2 CIRCLED ONLY IN 808D (HIV TEST)- (GO TO 808J)

808H) READ THE DECLARATION OF CONSENT FOR THE ANEMIA TEST TO THE RESPONDENT
DECLARATION OF CONSENT FOR MALARIA TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE ANEMIA TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 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.

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 member 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.

808I) NEXT GO TO 809A

808J) READ CONSENT FOR HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR HIV TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE HIV TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 the Benin.

This survey will assist the government to develop programs to prevent and treat AIDS.

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 that offer 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.

808K) THEN GO TO 809C

809) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO BE READ TO 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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and HIV.

For the anemia and 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.

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 member of our survey team.

For the HIV 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 that offer 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.

809A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE ANEMIA TEST
Will you take the anemia test?

809B) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME. [##translator note: the original document asks for consent for the "anemiele" test, which is not a word that I was able to find. I believe it is a typographical error, and thus have translated the test to "anemia," based on the other information in the text]

GRANTED 1 (SIGN___________)
REFUSED 2 (SIGN__________)

809C) REQUEST CONSENT FOR THE HIV TEST FROM THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE HIV TEST
Will you take the HIV test?

809D) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE HIV TEST AND SIGN YOUR NAME.

GRANTED 1-SIGN__________
REFUSED 2-SIGN____________

810) CHECK 809B AND 809D:

RESPONDENT ACCEPTED AT LEAST ONE OF THE TWO TESTS; CODE 1 CIRCLED IN AT LEAST ONE SPACE (IN 809B, 909D) (GO TO 811)
RESPONDENT REFUSED BOTH TESTS; CODE 2 CIRCLED IN BOTH SPACES (IN 809B AND 809D) (GO TO 812)

811) CHECK ONCE AGAIN 809B AND 809D AND PREPARE THE INSTRUMENTS NECESSARY FOR THE TESTS FOR WHICH CONSENT WAS OBTAINED. THEN, PERFORM THE TEST. FOR EACH ELIGIBLE MAN, THE RESULT CODE FOR THE HIV TEST MUST BE RECORDED IN 812 AND FOR THE ANEMIA TEST IN 813, EVEN IF HE WASN'T PRESENT, REFUSED, OR COULD NOT BE TESTED FOR OTHER REASONS.

812) PUT FIRST BAR CODE HERE____

NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND ON THE RESPONDENT'S FILTER PAPER, AND THE 3RD ON THE HIV SAMPLE TRANSMISSION SHEET

813) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA BROCHURE

G/DL______

NOT PRESENT 994
REFUSED 995
OTHER 996

814) GO BACK TO Q 802 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT MAN. IF THERE ARE MORE THAN 3 MEN, USE THE ADDITIONAL QUESTIONNAIRE

800) IF THERE ARE MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE

814) GO BACK TO Q 802 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT MAN. IF THERE ARE MORE THAN 3 MEN, END OF QUESTIONNAIRE