Data Cart

Your data extract

0 variables
0 samples
View Cart

DEMOCRATIC REPUBLIC OF CONGO
MINISTRY OF PLANNING AND MODERNIZATION
MINISTRY OF PUBLIC HEALTH

DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE

CONFIDENTIAL

IDENTIFICATION

RESPONDENT POOL

POOL ____

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) ____

NAME OF HEAD OF HOUSEHOLD ____

CLUSTER NUMBER ____

HOUSEHOLD NUMBER

HOUSEHOLD ____

FORMER PROVINCE

FORMER PROVINCE ____

NEW PROVINCE

NEW PROVINCE ____

URBAN/RURAL

URBAN 1
RURAL 2

KINSHASA - MAIN CITY OF PROVINCE - OTHER CITY - CITY - STATE - RURAL

RESIDENCE ____
KINSHASA 1
MAIN CITY OF PROVINCE 2
OTHER CITY 3
CITY - STATE 4
RURAL 5

HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANEMIA, MALARIA, HIV TEST, VACCINATIONS, AND ANTHROPOMETRIC MEASUREMENTS (YES 1, NO 2)

Household selected ____

INTERVIEWER VISITS

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
INTERVIEWER'S NAME ____
RESULT*

THIRD VISIT DATE ____
INTERVIEWER'S NAME ____
RESULT*

FINAL VISIT
DAY ____
MONTH ____
YEAR 201_
INTERVIEWER CODE ____
RESULT

TOTAL NUMBER OF VISITS ____

*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)

TOTAL PERSONS IN HOUSEHOLD ____

TOTAL ELIGIBLE WOMEN ____

TOTAL ELIGIBLE MEN ____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

LANGUAGE OF QUESTIONNAIRE: FRENCH

SUPERVISOR ____
NAME ____
DATE ____

FIELD EDITOR ____
NAME ____
DATE ____

OFFICE EDITOR ____

KEYED BY ____

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the Ministry of Planning and the Ministry of Health. We are conducting a survey about health all over the Democratic Republic of Congo. 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.
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 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

1) 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 CODE BELOW.

CODES FOR QUESTION 3: RELATIONSHIP TO HEAD OF 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 NEPHEW/NIECE
10 NEPHEW/NIECE BY MARRIAGE
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NOT RELATED
98 DON'T KNOW

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 ____

IF AGE 15 OR OLDER:
8) MARITAL STATUS
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
9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-59

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

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

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

YES 1
NO 2 (GO TO 21)

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

LEVEL ____
GRADE ____
LEVEL
1 PRIMARY
GRADE
00 LESS THAN 1 YEAR COMPLETED
01 1ST YEAR PRIMARY
02 2ND YEAR PRIMARY
03 3RD YEAR PRIMARY
04 4TH YEAR PRIMARY
05 5TH YEAR PRIMARY
06 6TH YEAR PRIMARY
98 DON'T KNOW
LEVEL
2 SECONDARY
GRADE
00 LESS THAN 1 YEAR COMPLETED
01 1ST YEAR SECONDARY
02 2ND YEAR SECONDARY
03 3RD YEAR SECONDARY
04 4TH YEAR SECONDARY
05 5TH YEAR SECONDARY
06 6TH YEAR SECONDARY
98 DON'T KNOW
LEVEL
3 HIGHER
GRADE
00 LESS THAN 1 YEAR COMPLETED
01 PREPARATORY YEAR
02 1ST YEAR GRADUATE
03 2ND YEAR GRADUATE
04 3RD YEAR GRADUATE
05 1ST YEAR LICENSE
06 2ND YEAR LICENSE OR HIGHER
98 DON'T KNOW
8 DON'T KNOW

IF AGE 5-24 YEARS:
CURRENT/RECENT SCHOOL ATTENDANCE:
18) Did (NAME) attend school at any time during the (2012-2013) 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 ____
GRADE ____
LEVEL
1 PRIMARY
GRADE
00 LESS THAN 1 YEAR COMPLETED
01 1ST YEAR PRIMARY
02 2ND YEAR PRIMARY
03 3RD YEAR PRIMARY
04 4TH YEAR PRIMARY
05 5TH YEAR PRIMARY
06 6TH YEAR PRIMARY
98 DON'T KNOW
LEVEL
2 SECONDARY
GRADE
00 LESS THAN 1 YEAR COMPLETED
01 1ST YEAR SECONDARY
02 2ND YEAR SECONDARY
03 3RD YEAR SECONDARY
04 4TH YEAR SECONDARY
05 5TH YEAR SECONDARY
06 6TH YEAR SECONDARY
98 DON'T KNOW
LEVEL
3 HIGHER
GRADE
00 LESS THAN 1 YEAR COMPLETED
01 PREPARATORY YEAR
02 1ST YEAR GRADUATE
03 2ND YEAR GRADUATE
04 3RD YEAR GRADUATE
05 1ST YEAR LICENSE
06 2ND YEAR LICENSE OR HIGHER
98 DON'T KNOW
8 DON'T KNOW

IF AGE 0-4 YEARS:
BIRTH REGISTRATION:
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 DON'T KNOW

IF HOUSEHOLD NOT SELECTED FOR MEN'S SURVEY:
HOSPITALIZATION:
21) During the last six months, was (NAME) hospitalized in a health care facility?

YES 1
NO 2 (GO TO 23)
DON'T KNOW 8 (GO TO 23)

22) CIRCLE THE LINE NUMBER OF THE ELIGIBLE PERSON FROM THE HOUSEHOLD FOR THE MODULE ON HOSPITAL CARE.
CHECK COLUMN 21 CODE 1 CIRCLED

OUTPATIENT CARE:
23) During the last four weeks, did (NAME) receive care from a health care worker, a pharmacist, or a traditional practitioner without being hospitalized, including visits for family planning, antenatal/postnatal care, infant follow-up care?

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

24) CIRCLE THE LINE NUMBER OF THE ELIGIBLE PERSON FROM THE HOUSEHOLD FOR THE MODULE ON OUTPATIENT CARE.
CHECK COLUMN 23 CODE 1 CIRCLED

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) 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 (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

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
PIPED TO NEIGHBOR 14
TUBE WELL OR BOREHOLD 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 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
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
DON'T KNOW 98

110) Does your household have:
Electricity?
A radio?
A television?
A non-mobile telephone?
A refrigerator/freezer?
A generator?
A portable stove/gas or electric stove?
A chair/chairs?
A bed/beds?
A lamp/lamps?
A stove?
A hoe?
A sewing machine?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
GENERATOR
YES 1
NO 2
PORTABLE STOVE
YES 1
NO 2
CHAIR
YES 1
NO 2
BED
YES 1
NO 2
LAMP
YES 1
NO 2
STOVE
YES 1
NO 2
SEWING MACHINE
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
SAW/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 FLOOR
PARQUET OR WAXED WOOD 31
VINYL/ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION.

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS LEAF 12
SOD 13
RUDIMENTARY MATERIAL
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED FLOOR
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
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
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
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 mobile phone?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?
A whaleboat/motorized canoe?
A computer?
A rental house?

WATCH
YES 1
NO 2
MOBILE PHONE
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/MOTOR SCOOTER
YES 1
NO 2
CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BOAT
YES 1
NO 2
WHALEBOAT/MOTORIZED CANOE
YES 1
NO 2
COMPUTER
YES 1
NO 2
RENTAL HOUSE
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, 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

Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Ducks?
Hens/roosters/other poultry?

COWS/BULLS ____
HORSES/DONKEYS/MULES ____
GOATS ____
SHEEP ____
PIGS ____
DUCKS ____
HENS/ROOSTERS ____

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 136A)

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 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)
PERMANET 2.0 11 (GO TO 134)
OLYSET 12 (GO TO 134)
DURANET 13 (GO TO 134)
INTERCEPTOR BRAND 14 (GO TO 134)
YORKOOL LN BRAND 15 (GO TO 134)
LIFENET 16 (GO TO 134)
MAGNET 17 (GO TO 134)
NETPROTECT 19 (GO TO 134)
OTHER/DON'T KNOW BRAND 21 (GO TO 134)
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)
DON'T KNOW 8 (GO TO 136)

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

NAME ____
LINE NUMBER ____

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

136A) How do you get malaria?
PROBE: Anything else?
RECORD ALL MENTIONED.

MOSQUITO BIT A
BIT FROM OTHER INSECT B
BLOOD TRANSFUSION C
TRANSMISSION FROM MOTHER TO BABY D
DRINKING WATER E
WITCHCRAFT F
OTHER (SPECIFY) X
DON'T KNOW Z

136B) What are the symptoms of malaria?
PROBE: Any other symptoms?
RECORD ALL MENTIONED.

FEVER A
HEADACHE B
GENERAL PAIN C
DIARRHEA D
COMA E
CHILLS F
CONVULSIONS G
OTHER (SPECIFY) X
DON'T KNOW Z

136C) What are you doing to protect yourself from mosquitoes?
PROBE: Anything else?
RECORD ALL MENTIONED.

NOTHING A
USES INSECTICIDE B
USES SMOKE STICK C
SMOKE WITH HELP OF PLANT ESSENCE D
USE INSECTICIDE SOAKED MOSQUITO NET E
USE PLAIN MOSQUITO NET F
SANITATION OF SPACE G
OTHER (SPECIFY) X

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

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.

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

HEALTH CARE EXPENSES "HOSPITALIZATION CARE"

200) CHECK COVER PAGE:

HOUSEHOLD NOT SELECTED FOR MEN'S SURVEY
HOUSEHOLD SELECTED FOR MEN'S SURVEY (GO TO 300)

201) CHECK COLUMN 22 OF HOUSEHOLD SCHEDULE:

AT LEAST ONE HOSPITALIZATION
NO HOSPITALIZATIONS (GO TO 221)

202) CHECK COLUMN 22 OF HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER AND NAME OF EACH MEMBER OF THE HOUSEHOLD WHO HAS BEEN HOSPITALIZED. Now I would like to ask you some questions about the people in your household who stayed an entire night in a health care facility in the last six months. (IF MORE THAN 2 PATIENTS HOSPITALIZED, USE ADDITIONAL QUESTIONNAIRE (S).)

203) CHECK COLUMN 22 OF HOUSEHOLD SCHEDULE

HOSPITALIZED MEMBER 1
LINE NUMBER ____
HOSPITALIZED MEMBER 2
LINE NUMBER ____
HOSPITALIZED MEMBER 3
LINE NUMBER ____

204) NAME FROM COLUMN 2 OF HOUSEHOLD SCHEDULE

NAME ____

205) Where was (NAME) hospitalized last time?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH POST 13
MATERNITY 14
OTHER PUBLIC (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
DOCTOR'S OFFICE 23
TRAVELING NURSE 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 26
OTHER (SPECIFY) 96

206) What was the main reason for (NAME)'s hospitalization?

ANTENATAL/POSTNATAL CARE 01
DELIVERY 02
FEVER/MALARIA 03
ILLNESS OTHER THAN FEVER/MALARIA 04
ACCIDENT/INJURY 05
OTHER (SPECIFY) 06

207) How much did the treatment and services from (NAME)'s recent hospitalization cost? We would like to know the total of all the expenses for this last hospitalization, including fees for lab tests, drugs, consultations, transportation, etc.

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS

COST ____
FREE 00000 (GO TO 208)
IN KIND 99995 (GO TO 208)
LESS THAN ONE $ 99996
DON'T KNOW 99998

207A) How much did the following treatment and services from (NAME)'s recent hospitalization cost?

Hospital fees alone without drugs, exams, etc ____
Drugs and other prescription products ____
Lab test not included in hospitalization bill ____
Medical imaging not included in hospitalization bill ____
Transportation ____
Other ____

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS
FOR EACH ITEM, USE THE CODES CORRESPONDING TO "FREE," "IN KIND," "LESS THAN ONE $," "DON'T KNOW" FROM 207 BASED ON THE SITUATION. IF "NO OBJECT" RECORD 99992 FOR THE ITEM.

CODES FROM 207

FREE 00000
IN KIND 99995
LESS THAN ONE $ 99996
DON'T KNOW 99998

208) Was (NAME) hospitalized in a health care establishment at another time in the last six months?

YES 1
NO 2 (GO TO 218)

209) Where was (NAME) hospitalized the time before?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH POST 13
MATERNITY 14
OTHER PUBLIC (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
DOCTOR'S OFFICE 23
TRAVELING NURSE 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 26
OTHER (SPECIFY) 96

210) What was the main reason for (NAME)'s second-to-last hospitalization?

ANTENATAL/POSTNATAL CARE 01
DELIVERY 02
FEVER/MALARIA 03
ILLNESS OTHER THAN FEVER/MALARIA 04
ACCIDENT/INJURY 05
OTHER (SPECIFY) 06

211) How much did the treatment and services from (NAME)'s second-to-last hospitalization cost? We would like to know the total of all the expenses for this last hospitalization, including fees for lab tests, drugs, consultations, transportation, etc.

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS

COST ____
FREE 00000 (GO TO 212)
IN KIND 99995 (GO TO 212)
LESS THAN ONE $ 99996
DON'T KNOW 99998

211A) How much did the following treatment and services from (NAME)'s second-to-last hospitalization cost?

Hospital fees alone without drugs, exams, etc ____
Drugs and other prescription products ____
Lab test not included in hospitalization bill ____
Medical imaging not included in hospitalization bill ____
Transportation ____
Other ____

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS
FOR EACH ITEM, USE THE CODES CORRESPONDING TO "FREE," "IN KIND," "LESS THAN ONE $," "DON'T KNOW" FROM 211 BASED ON THE SITUATION. IF "NO OBJECT" RECORD 99992 FOR THE ITEM.

CODES FROM 211

FREE 00000
IN KIND 99995
LESS THAN ONE $ 99996
DON'T KNOW 99998

212) Other than the two hospitalizations that you just told me about, was (NAME) hospitalized in a health care facility at any other time in the last six months?

YES 1
NO 2 (GO TO 218)

213) Where was (NAME) hospitalized this third-to-last time?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH POST 13
MATERNITY 14
OTHER PUBLIC (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
DOCTOR'S OFFICE 23
TRAVELING NURSE 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 26
OTHER (SPECIFY) 96

214) What was the main reason for (NAME)'s third-to-last hospitalization?

ANTENATAL/POSTNATAL CARE 01
DELIVERY 02
FEVER/MALARIA 03
ILLNESS OTHER THAN FEVER/MALARIA 04
ACCIDENT/INJURY 05
OTHER (SPECIFY) 06

215) How much did the treatment and services from (NAME)'s third-to-last hospitalization cost? We would like to know the total of all the expenses for this last hospitalization, including fees for lab tests, drugs, consultations, transportation, etc.

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS

COST ____
FREE 00000 (GO TO 216)
IN KIND 99995 (GO TO 216)
LESS THAN ONE $ 99996
DON'T KNOW 99998

215A) How much did the following treatment and services from (NAME)'s third-to-last hospitalization cost?

Hospital fees alone without drugs, exams, etc ____
Drugs and other prescription products ____
Lab test not included in hospitalization bill ____
Medical imaging not included in hospitalization bill ____
Transportation ____
Other ____

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS
FOR EACH ITEM, USE THE CODES CORRESPONDING TO "FREE," "IN KIND," "LESS THAN ONE $," "DON'T KNOW" FROM 215 BASED ON THE SITUATION. IF "NO OBJECT" RECORD 99992 FOR THE ITEM.

CODES FROM 215

FREE 00000
IN KIND 99995
LESS THAN ONE $ 99996
DON'T KNOW 99998

216) Other than the three hospitalizations that you just told me about, was (NAME) hospitalized in a health care facility at any other time in the last six months?

YES 1
NO 2 (GO TO 218)

217) In total, how many times was (NAME) hospitalized in a health care facility in the last six months?

NUMBER OF HOSPITALIZATIONS ____

218) Is (NAME) covered by health insurance?

YES 1
NO 2 (GO TO 220)
DON'T KNOW 8 (GO TO 220)

219) What is the main type of health insurance that (NAME) is covered by?

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY) X

220) GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE HOSPITALIZED PATIENTS, GO TO 221.

HEALTH EXPENSES "OUTPATIENT CARE"

221) CHECK COLUMN 24 OF HOUSEHOLD SCHEDULE:

AT LEAST ONE TIME OUTPATIENT CARE
NOT A SINGLE TIME OUTPATIENT CARE (GO TO 242)

222) CHECK COLUMN 24 OF HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER (Q223) AND THE NAME OF EACH MEMBER OF THE HOUSEHOLD (Q.224) HAVING RECEIVED OUTPATIENT CARE. Now I would like to ask some questions about the people in your household who received care from a health care worker, a pharmacist, or a traditional practitioner without being hospitalized, including family planning, antenatal/postnatal care, follow-up on infant care, in the last four weeks. (IF MORE THAN 3 PEOPLE HAVE RECEIVED OUTPATIENT CARE, USE ADDITIONAL QUESTIONNAIRE (S).)

223) LINE NUMBER FROM COLUMN 24 IN HOUSEHOLD SCHEDULE

OUTPATIENT MEMBER 1
LINE NUMBER ____
OUTPATIENT MEMBER 2
LINE NUMBER ____
OUTPATIENT MEMBER 3
LINE NUMBER ____

224) NAME FROM COLUMN 2 OF HOUSEHOLD SCHEDULE

NAME ____

225) Now I would like to ask you some questions about the health care that (NAME) received in the last 4 weeks, without being hospitalized. Where or from whom did (NAME) receive care the last time (without being hospitalized)?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH POST 13
MATERNITY 14
MOBILE CLINIC 15
TRAVELING NURSE 16
OTHER PUBLIC (SPECIFY) 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
PRIVATE DOCTOR'S OFFICE 25
TRAVELING NURSE 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 27
OTHER SOURCE
SHOP 31
TRADITIONAL PRACTITIONER 32
TRAVELLING PEDDLER 33
OTHER (SPECIFY) 96

226) What is the main reason for which (NAME) received health care the last time?

FAMILY PLANNING 01
ANTENATAL/POSTNATAL CARE 02
INFANT HEALTH FOLLOW-UP 03
MALARIA 04
FEVER 05
DIARRHEA 06
HIV/AIDS/STI 07
OTHER ILLNESS 08
PREVENTATIVE CARE 09
ACCIDENT/INJURY 10
OTHER (SPECIFY) 96
DON'T KNOW 98

227) How much did the treatment and care from (Name Of Place From Q.225) cost? Please include consultation fees as well as drugs, exams, and transportation.
TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS

COST ____
FREE 00000 (GO TO 228)
IN KIND 99995 (GO TO 228)
LESS THAN ONE $ 99996
DON'T KNOW 99998

227A) How much was spent on the following treatments and services that (NAME) received from (NAME OF PLACE IN Q. 225) the last time?

CONSULTATION AND CARE FEES ____
DRUGS AND OTHER PRESCRIPTION PRODUCTS ____
LABORATORY TESTS ____
MEDICAL IMAGING ____
MEDICAL SUPPLIES (GLASSES, PROSTHETICS) ____
TRANSPORTATION ____
OTHER ____

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS
FOR EACH ITEM, USE THE CODES CORRESPONDING TO "FREE," "IN KIND," "LESS THAN ONE $," "DON'T KNOW" FROM 227 BASED ON THE SITUATION. IF "NO OBJECT" RECORD 99992 FOR THE ITEM.

CODES FROM 227

FREE 00000
IN KIND 99995
LESS THAN ONE $ 99996
DON'T KNOW 99998

228) Did (NAME) receive care at another time in the last four weeks from a health care worker, a pharmacist, or a traditional healer, without being hospitalized?

YES 1
NO 2 (GO TO 239)

229) Where or from whom did (NAME) receive care the second-to-last time (without being hospitalized)?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH POST 13
MATERNITY 14
MOBILE CLINIC 15
TRAVELING NURSE 16
OTHER PUBLIC (SPECIFY) 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
PRIVATE DOCTOR'S OFFICE 25
TRAVELING NURSE 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 27
OTHER SOURCE
SHOP 31
TRADITIONAL PRACTITIONER 32
TRAVELLING PEDDLER 33
OTHER (SPECIFY) 96

230) What is the main reason for which (NAME) received health care the second-to-last time?

FAMILY PLANNING 01
ANTENATAL/POSTNATAL CARE 02
INFANT HEALTH FOLLOW-UP 03
MALARIA 04
FEVER 05
DIARRHEA 06
HIV/AIDS/STI 07
OTHER ILLNESS 08
PREVENTATIVE CARE 09
ACCIDENT/INJURY 10
OTHER (SPECIFY) 96
DON'T KNOW 98

231) How much did the treatment and care from (Name Of Place From Q.229) cost? Please include consultation fees as well as drugs, exams, and transportation.
TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS

COST ____
FREE 00000 (GO TO 232)
IN KIND 99995 (GO TO 232)
LESS THAN ONE $ 99996
DON'T KNOW 99998

231A) How much was spent on the following treatments and services that (NAME) received from (NAME OF PLACE IN Q. 229) the second-to-last time?

CONSULTATION AND CARE FEES ____
DRUGS AND OTHER PRESCRIPTION PRODUCTS ____
LABORATORY TESTS ____
MEDICAL IMAGING ____
MEDICAL SUPPLIES (GLASSES, PROSTHETICS) ____
TRANSPORTATION ____
OTHER ____

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS 900 CONGOLESE FRANCS
FOR EACH ITEM, USE THE CODES CORRESPONDING TO "FREE," "IN KIND," "LESS THAN ONE $," "DON'T KNOW" FROM 231 BASED ON THE SITUATION. IF "NO OBJECT" RECORD 99992 FOR THE ITEM.

CODES FROM 231

FREE 00000
IN KIND 99995
LESS THAN ONE $ 99996
DON'T KNOW 99998

232) Other than the last two times you just told me about, Did (NAME) receive care at another time in the last four weeks from a health care worker, a pharmacist, or a traditional healer?

YES 1
NO 2 (GO TO 239)

233) Where or from whom did (NAME) receive care the third-to-last time without being hospitalized?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH POST 13
MATERNITY 14
MOBILE CLINIC 15
TRAVELING NURSE 16
OTHER PUBLIC (SPECIFY) 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
PRIVATE DOCTOR'S OFFICE 25
TRAVELING NURSE 26
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 27
OTHER SOURCE
SHOP 31
TRADITIONAL PRACTITIONER 32
TRAVELLING PEDDLER 33
OTHER (SPECIFY) 96

234) What is the main reason for which (NAME) received health care the third-to-last time?

FAMILY PLANNING 01
ANTENATAL/POSTNATAL CARE 02
INFANT HEALTH FOLLOW-UP 03
MALARIA 04
FEVER 05
DIARRHEA 06
HIV/AIDS/STI 07
OTHER ILLNESS 08
PREVENTATIVE CARE 09
ACCIDENT/INJURY 10
OTHER (SPECIFY) 96
DON'T KNOW 98

235) How much did the treatment and care from (NAME OF PLACE FROM Q.233) cost? Please include consultation fees as well as drugs, exams, and transportation.
TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS900 CONGOLESE FRANCS

COST ____
FREE 00000 (GO TO 236)
IN KIND 99995 (GO TO 236)
LESS THAN ONE $ 99996
DON'T KNOW 99998

235A) How much was spent on the following treatments and services that (NAME) received from (NAME OF PLACE IN Q. 233) the third-to-last time?

CONSULTATION AND CARE FEES _____
DRUGS AND OTHER PRESCRIPTION PRODUCTS ____
LABORATORY TESTS ____
MEDICAL IMAGING ____
MEDICAL SUPPLIES (GLASSES, PROSTHETICS) ____
TRANSPORTATION _____
OTHER ____

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS900 CONGOLESE FRANCS
FOR EACH ITEM, USE THE CODES CORRESPONDING TO "FREE," "IN KIND," "LESS THAN ONE $," "DON'T KNOW" FROM 227 BASED ON THE SITUATION. IF "NO OBJECT" RECORD 99992 FOR THE ITEM.

CODES FROM 227

FREE 00000
IN KIND 99995
LESS THAN ONE $ 99996
DON'T KNOW 99998

236) Other than the last three times you just told me about, was health care sought out for (NAME) in the last four weeks?

YES 1
NO 2 (GO TO 239)

237) How many times did (NAME) receive outpatient care in the last four weeks?

NUMBER OF TIMES RECEIVING OUTPATIENT CARE ____

238) How many times was money spent?

NUMBER OF TIMES PAYMENT MADE ____

239) Is (NAME) covered by health insurance?

YES 1
NO 2 (GO TO 241)
DON'T KNOW 8 (GO TO 241)

240) What is the main type of health insurance that (NAME) is covered by?

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY) X

241) GO BACK TO 225 IN NEXT COLUMN; OR, IF NO MORE HOSPITALIZED PATIENTS, GO TO 242.

242) Sometimes people buy vitamins, drugs, and medicinal plants without consulting a health care worker, a pharmacist, or a traditional practitioner. They can also purchase health care accessories like Band-Aids, thermometers and other devices without medical advice. In the last four week, how much have you spent for these types of purchases for members of your household?

TOTAL IN $USD. CONVERT TOTAL TO CONGOLESE FRANC AT THE RATE OF $1US EQUALS900 CONGOLESE FRANCS

COST ____
NOTHING 00000
IN KIND ONLY 99995
DON'T KNOW 99998

SELECTION TABLE FOR CHILDREN'S WORK AND FOR DISCIPLINE OF CHILD

244) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 1 AND 17 YEARS OLD LIVING IN THIS HOUSEHOLD:

TWO OR MORE
ONLY ONE (GO TO 252)
NONE (GO TO 292)

TABLE 1: ELIGIBLE CHILDREN AGE 1-17 FOR QUESTIONS ON "WORK"/CHILDREN'S "DISCIPLINE"
RECORD EACH CHILD AGE 1-17 FROM THE HOUSEHOLD TABLE IN THE TABLE BELOW, IN THE SAME ORDER AS ON THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS WHO ARE NOT AGE 1-17. RECORD THE LINE NUMBER, NAME, SEX AND AGE OF EACH CHILD, THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 1-17 IN THE RESERVED SPACE. (Q.250)

245) RANK NUMBER

246) LINE NUMBER FROM Q. 1 ____

247) NAME FROM Q. 2 ____

248) SEX FROM Q. 4

MALE 1
FEMALE 2

249) AGE FROM Q. 7 ____

250) TOTAL NUMBER OF CHILDREN AGE 1-17 ____

TABLE 2: RANDOM SELECTION FOR QUESTIONS ON "WORK"/CHILDREN'S "DISCIPLINE"
USE THIS TABLE TO SELECT ONE CHILDREN AGE 1-17.

A) TAKE THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE OF THE QUESTIONNAIRE.
B) THIS IS THE NUMBER OF THE LINE TO SELECT.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN IN Q.250.
D) THIS IS THE NUMBER OF THE COLUMN TO SELECT
E) FIND THE SPACE WHERE THE SELECTED LINE AND COLUMN MEET AND CIRCLE THAT NUMBER.
F) THIS IS THE RANK NUMBER OF THE CHILD WHO WILL BE SELECTED FOR "WORK"/CHILDREN'S "DISCIPLINE"
(1ST, 2ND, 3RD, ETC).

EXAMPLE:
THE HOUSEHOLD NUMBER IS 36, SO PICK LINE 6.
THERE ARE 3 ELIGIBLE CHILDREN IN THIS HOUSEHOLD, SELECT COLUMN 3.
THE SPACE AT THE INTERSECTION OF LINE 6 AND COLUMN 3 CONTAINS THE NUMBER 2: THE 2ND ELIGIBLE CHILD LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED. IF THE LINE NUMBER OF 3 ELIGIBLE CHILDREN IS 07, 11, AND 16, THE CHILD SELECTED IS THE 2ND CHILD LISTED, MEANING THE ONE WITH LINE NUMBER 11.

251) LAST DIGIT IN HOUSEHOLD NUMBER
0-9
TOTAL NUMBER OF ELIGIBLE CHILDREN IN HOUSEHOLD 1-8 OR MORE

252) (Q. 246), NAME (Q. 247) AND AGE (Q. 249) OF THE CHILD SELECTED

RANK OF CHILD ____
LINE NUMBER OF CHILD ____
NAME OF CHILD ____
AGE OF CHILD ____

CHILDREN'S WORK

255) CHECK 252:

AGE 5-17
AGE 1-4 (GO TO 270)

256) Now I would like to ask you some questions on the type of work that children in your household can do.
Since last (DAY OF WEEK), did (NAME) do any of the following activities, even if only for one hour?

A) Did (NAME) work on his/her own land/farm/garden or help on one of a household member, or take care of animals. For example: help grow farm produce, harvest, feed animal, take them to pasture or bring them back?

YES 1
NO 2

B) Did (NAME) help in a relative's family business, without with payment or worked in his or her own business?

YES 1
NO 2

C) Did (NAME) produce or sell items, artisanal products, clothes, food, or agricultural products?

YES 1
NO 2

D) Did (NAME) do any kind of activity in exchange for payment in cash or in kind, even for only one hour?

YES 1
NO 2

IF NO, PROBE:
Please include any type of activity that (NAME) might have done like regular or temporary employment, for his own business or for an employer, or as an unpaid family worker in the household or farm.
ALL OTHER ACTIVITY

YES 1
NO 2

257) CHECK 256 A-D:

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 262)

258) Since last (Day Of Week), approximately how many hours total did (NAME) work on this activity/these activities?

NUMBER OF HOURS ____

259) Does this activity/do these activities require carrying heavy loads?

YES 1 (GO TO 262)

260) Does this activity/do these activities require working with dangerous tools (knives, etc.) or big machines?

YES 1 (GO TO 262)
NO 2

261) How would you describe (NAME)'s work environment?

A) Is (NAME) exposed to dust/smoke or gas?

YES 1 (GO TO 262)
NO 2

B) Is (NAME) exposed to cold, heat, or excessive humidity?

YES 1 (GO TO 262)
NO 2

C) Is (NAME) exposed to loud noises or vibrations?

YES 1 (GO TO 262)
NO 2

D) Is (NAME) exposed to working at high heights?

YES 1 (GO TO 262)
NO 2

E) Is (NAME) exposed to chemical products (pesticides, glues, etc) or to explosives?

YES 1 (GO TO 262)
NO 2

F) Is (NAME) exposed to other things, behaviors, or conditions that are bad for his/her behavior or security?

YES 1
NO 2

262) Since last (day of week), did name fetch water or firewood for the household?

YES 1
NO 2

263) In total, since last (day of week), how many hours did (NAME) spend fetching water or firewood for the household?
IF LESS THAN ONE HOUR, RECORD 00

NUMBER OF HOURS ____

264) Since last (DAY OF WEEK), did (NAME) do any of the following tasks for the household?

A) Make purchases for the household?

YES 1
NO 2

B) Fix any type of equipment for the household?

YES 1
NO 2

C) Cook or clean utensils for the household?

YES 1
NO 2

D) Wash clothing?

YES 1
NO 2

E) Take care of children?

YES 1
NO 2

F) Take care of elderly or sick people?

YES 1
NO 2

G) Other tasks for the household?

YES 1
NO 2

265) CHECK 264 A-G:

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 270)

266) Since last (DAY OF WEEK OF INTERVIEW), about how many hours in total did (NAME) spend doing these activities?

NUMBER OF HOURS ____

DISCIPLINE OF CHILDREN

270) CHECK 252: AGE OF SELECTED CHILD

AGE 1-14
AGE 15-17 (GO TO 275)

271) RECORD THE CHILD'S LINE NUMBER AND NAME FROM 252

LINE NUMBER ____
NAME ____

272) Adults use certain methods to teach child how to behave well or to correct behavioral problems. I will read you a list of methods that are used and I'd like you to tell me if you or someone else in your household has used one of these methods with (NAME) in the last month.

A) Revoke privileges, not allow (NAME) to do something that he/she likes or now allow him/her to leave the house
B) Explain to (NAME) why his/her behavior is not acceptable
C) Shake him/her?
D) Yell or scream?
E) Give him/her something else to do?
F) Hit or spank him/her on his/her buttocks with bare hands?
G) Hit him/her on his/her buttocks or elsewhere on his/her body with something like a belt, a whip, a stick, or another hard object?
H) Call him/her an idiot, lazy, or a similar word?
I) Slap or hit him/her on the face, head, or ears?
J) Slap or hit him/her on the hands, arms or legs?
K) Beat him/her, that is, hitting as hard as possible without stopping?

A) REVOKE PRIVILEGES
YES 1
NO 2
B) EXPLAIN BEHAVIOR IS UNACCEPTABLE
YES 1
NO 2
C) SHAKE
YES 1
NO 2
D) YELL OR SCREAM
YES 1
NO 2
E) GIVE SOMETHING ELSE TO DO
YES 1
NO 2
F) SPANK WITH BARE HANDS
YES 1
NO 2
G) HIT WITH BELT, WHIP, STICK, OTHER HARD OBJECT
YES 1
NO 2
H) CALL AN IDIOT, LAZY, OR SIMILAR WORD
YES 1
NO 2
I) SLAP FACE, HEAD, OR EARS
YES 1
NO 2
J) SLAP HANDS ARMS OR LEGS
YES 1
NO 2
K) BEAT
YES 1
NO 2

273) Do you think that to properly raise and educate (NAME), you must punish him/her physically?

YES 1
NO 2
DON'T KNOW/NO OPINION 8

HANDICAP

275) CHECK COLUMNS 5 AND 7 OF THE HOUSEHOLD SCHEDULE: NUMBER OF CHILDREN BETWEEN AGE 2 AND 9 WHO USUALLY LIVE IN THE HOUSEHOLD

ONE OR MORE
NONE (GO TO 292)

275A) CHECK COLUMN 1, 4, AND 7 FROM HOUSEHOLD SCHEDULE. RECORD IN Q. 276 THE LINE NUMBER AND NAME, IN Q. 277 THE SEX AND IN Q. 278 THE AGE OF ALL ELIGIBLE CHILDREN BETWEEN AGE 2 AND 9. IF THERE ARE MORE THAN 6 CHILDREN, USE A SUPPLEMENTARY QUESTIONNAIRE.

276) LINE NUMBER FROM COLUMN 1
NAME FROM COLUMN 2

LINE NUMBER ____
NAME ____

277) SEX FROM CHILD IN COLUMN 4

MALE 1
FEMALE 2

278) AGE OF CHILD FROM COLUMN 7

AGE ____

279) Compared to other children, does/did (NAME) have a serious delay in sitting, standing up, or walking?

YES 1
NO 2

280) Compared to other children, does/did (NAME) have difficulty seeing, either during the day or night?

YES 1
NO 2

281) Does (NAME) seem to have trouble hearing (use an hearing aid, hear with difficulty, or is completely deaf)?

YES 1
NO 2

282) When you tell (NAME) to do something, do you believe that he/she understands what you are saying?

YES 1
NO 2

283) Does (NAME) seem to have difficulty walking or moving his/her arms or is there a weakness or a rigidness in his/her arms or legs?

YES 1
NO 2

284) Does (NAME) sometimes have fits, becoming rigid or losing consciousness?

YES 1
NO 2

285) Does (NAME) learn how to do things like other children his/her age?

YES 1
NO 2

286) Does (NAME) speak (can he/she make him/herself understood through words, can he/she speak recognizable words)?

YES 1
NO 2

287) CHECK 278:
AGE OF CHILDREN

3-9 YEARS
2 YEARS (GO TO 289)

288) Does (NAME) seem to have difficulty speaking or does (NAME) speak differently from others (not clear enough to be understood by people other than immediate family members)?

YES 1 (GO TO 290)
NO 2 (GO TO 290)

289) Can (NAME) name at least one object (for example, an animal, a toy, a cup, a spoon)?

YES 1
NO 2

290) compared to other child of the same age, does (NAME) seem mentally delayed, passive, or slow?

YES 1
NO 2

291) GO BACK TO 279 IN NEXT COLUMN OR IF NO MORE CHILDREN, GO TO 292.

SELECTION TABLE FOR WOMEN FOR "DOMESTIC VIOLENCE"

292) CHECK COLUMN 9 FROM HOUSEHOLD SCHEDULE: NUMBER OF ELIGIBLE WOMEN

TWO OR MORE ELIGIBLE WOMEN
ONE ELIGIBLE WOMAN (GO TO 293A)
NO ELIGIBLE WOMEN (GO TO 294)

TABLE 1: WOMEN BETWEEN 15 AND 49 ELIGIBLE FOR QUESTIONS ON DOMESTIC VIOLENCE
RECORD EACH WOMAN AGED 15-49 YEARS FROM HOUSEHOLD SCHEDULE ONTO TABLE BELOW IN ORDER BASED ON HER LINE NUMBER (Q1) FROM HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER MEMBERS OF THE HOUSEHOLD WHO ARE NOT WOMEN AGE 15-49. RECORD THE NAME, AGE AND LINE NUMBER OF EACH WOMAN. THEN RECORD THE TOTAL NUMBER OF WOMEN AGE 15-49 IN THE BLANK SPACE (Q. 293).

RANK NUMBER ____
NAME OF WOMAN FROM Q. 2 ____
AGE FROM Q 7 ____
LINE NUMBER ____

293) TOTAL WOMEN AGE 15-49 IN HOUSEHOLD ____

TABLE 2: RANDOM SELECTION FOR QUESTIONS ON DOMESTIC VIOLENCE
USE THIS TABLE TO SELECT ONE WOMAN AGE 15-49, IF THERE IS MORE THAN ONE IN THE HOUSEHOLD.

A) CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE.
B) USE THIS FIGURE AS THE LINE NUMBER TO PICK FROM.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN FROM Q. 293
D) USE THIS FIGURE AS THE COLUMN NUMBER TO PICK FROM.
E) FIND THE SPACE THAT CORRESPONDS TO THE INTERSECTION OF THAT LINE AND COLUMN AND CIRCLE THE NUMBER.
F) THIS NUMBER CORRESPONDS TO THE WOMAN WHO WILL BE SELECTED FOR "DOMESTIC VIOLENCE": THE 1ST, 2ND, 3RD WOMAN, ETC.

EXAMPLE:
THE HOUSEHOLD STRUCTURE NUMBER IS 36: SELECT LINE 6
THERE ARE 3 ELIGIBLE WOMEN IN THIS HOUSEHOLD, SELECT COLUMN 3.
THE INTERSECTING SPACE OF LINE 6 AND COLUMN 3 IS 2: THE 2ND ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED.
IF THE LINE NUMBER OF THE 3 ELIGIBLE WOMEN ARE 3,, 06, AND 10, THE WOMAN SELECTED IS THE 2ND WOMAN LISTED, MEANING THE ONE WITH LINE NUMBER 06.

[LINE]
LAST DIGIT OF STRUCTURE NUMBER
[COLUMN]
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD

293A) NAME OF WOMAN SELECTED ____
LINE NUMBER OF WOMAN SELECTED FORM HOUSEHOLD SCHEDULE ____

294) END OF HOUSEHOLD QUESTIONNAIRE

WEIGHT, HEIGHT, ANEMIA, AND MALARIA TEST FOR CHILDREN AGE 0-5

300) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN Q. 301 IN THE ORDER OF THEIR LINE NUMBERS. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE (S).
BE SURE TO FILL OUT Q. 311, 312, AND 313

301) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER ____
NAME ____

302) What is (NAME)'s date of birth?
COPY MONTH AND YEAR OF CHILD'S BIRTH FROM 215 IN THE MOTHER'S BIRTH HISTORY AND ASK THE DAY. FOR CHILDREN NOT INCLUDED IN ANY HISTORY, ASK THE DAY, MONTH, AND YEAR.

DAY ____
MONTH ____
YEAR ____

303) CHECK 302:
CHILD BORN IN 2008 OR LATER?

YES 1
NO 2 (GO TO 301 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 330)

304) WEIGHT IN KILOGRAMS

KILOGRAMS ____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

305) HEIGHT IN CENTIMETERS
IF 2 YEARS OR UNDER, MEASURE THE CHILD LYING DOWN, OTHERWISE STANDING UP.

CENTIMETERS ____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

306) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

307) CHECK 302:
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 301 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 330)
OLDER 2

308) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD. RECORD 00 IF NOT LISTED.

LINE NUMBER ____

309) READ INFORMED CONSENT FOR ANEMIA TEST TO PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD.
CIRCLE CODE AND SIGN

GRANTED 1 SIGN ____
REFUSED 2 SIGN ____

310) READ INFORMED CONSENT FOR MALARIA TEST TO PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD.
CIRCLE CODE AND SIGN

GRANTED 1 SIGN ____
REFUSED 2 SIGN ____

310A) READ INFORMED CONSENT FOR VACCINATION TEST TO PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD.
CIRCLE CODE AND SIGN

GRANTED 1 SIGN ____
REFUSED 2 SIGN ____

PERFORM ONLY THE TESTS FOR WHICH CONSENT WAS OBTAINED ON THE CHILDREN

311) ORANGE BARCODE STICKER FOR MALARIA TEST
1) PUT 1ST BARCODE ON APPROPRIATE COLUMN
2) PUT 2ND BARCODE ON RDT
3) PUT 3RD BARCODE STICKER ON CORRESPONDING SLIDE
4) PUT 4TH BARCODE STICKER ON TRANSMISSION SHEET: THICK DROPS OF BLOOD
5) PUT 5TH BARCODE STICKER ON FILTER PAPER
6) PUT 6TH BARCODE STICKER ON TRANSMISSION SHEET: FILTER PAPER

GRANTED
PUT 1ST STICKER HERE
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

312) ORANGE BARCODE STICKER FOR VACCINES TEST
1) PUT 7TH BARCODE ON APPROPRIATE COLUMN
IF THERE ISN'T ALREADY A BARCODE STICKER ON THE FILTER PAPER AND A STICKER ON THE TRANSMISSION SHEET OF THE FILTER PAPER
2) PUT 5TH BARCODE STICKER ON THE FILTER PAPER
3) PUT THE 6TH BARCODE STICKER ON THE TRANSMISSION SHEET: VACCINES

GRANTED
PUT 7TH STICKER HERE
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

313) RECORD THE HEMOGLOBIN LEVEL HERE

G/DL ____
NOT PRESENT 992
REFUSED 993
OTHER 996

314) RECORD THE RESULT CODE FROM THE MALARIA TDR TEST [RAPID DIAGNOSTIC TEST] HERE

TESTED 1
ABSENT 2 (GO TO 319)
REFUSED 3 (GO TO 319)
OTHER 6 (GO TO 319)

315) RECORD THE RESULT CODE FROM THE MALARIA TDR [TEST RAPID DIAGNOSTIC TEST] HERE.

POSITIVE FALCIPARUM 1 (GO TO 318)
NEGATIVE 2

316) CHECK Q. 313
HEMOGLOBIN LEVEL

BELOW 7.0 G/DL SEVERE ANEMIA 1
7.0 G/DL OR HIGHER 2 (GO TO 328)
NOT TESTED 3 (GO TO 328)

317) REFERENCE DECLARATION FOR SEVERE ANEMIA
The anemia diagnostic test shows that (NAME OF CHILD) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.
(GO TO 328)

318) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms"

Prostration, that is, extreme weakness?
Loss of consciousness?
Difficulty breathing with whistling?
Has or has had convulsions?
Abnormal bleeding?
Icterus/jaundice (with coloration of eyes)?
Black or brown urine?
Vomit everything he/she consumes?

RECORD ALL MENTIONED

PROSTRATION, THAT IS, EXTREME WEAKNESS A
LOSS OF CONSCIOUSNESS B
DIFFICULTY BREATHING WITH WHISTLING C
HAS OR HAS HAD CONVULSIONS D
ABNORMAL BLEEDING E
ICTERUS/JAUNDICE (WITH COLORATION OF EYES) F
BLACK OR BROWN URINE G
VOMIT EVERYTHING HE/SHE CONSUMES H
NONE OF ABOVE SYMPTOMS Y

319) CHECK 318:
IS A CODE A-H CIRCLED

ONE CODE A-H CIRCLED 1 (GO TO 321)
ONLY CODE Y CIRCLED 2

320) CHECK 313:
HEMOGLOBIN LEVEL

UNDER 6.0 G/DL 1
6.0 D/DL OR HIGHER 2 (GO TO 322)
NOT PRESENT 4 (GO TO 322)
REFUSED 5 (GO TO 322)
OTHER 6 (GO TO 322)

321) REFERENCE DECLARATION FOR SERIOUS MALARIA
The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. You child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. You child is seriously ill and must be taken to a health care establishment immediately.
(GO TO 327)

322) In the last two weeks, has (NAME) taken or is (NAME) taking an antimalarial drug?
IF YES, ASK: What treatment (drug) did he/she take (is he/she taking)?
CHECK BY ASKING TO SEE THE TREATMENT

YES, authorized CTA (Artesunate/Amodiaquine, Artemether/Lumefantrine 1
YES, other CTA (Coartem, Arsucam, Co-arinate, etc) 2
YES, OTHER (SPECIFY) 3
NO 4 (GO TO 324)

323) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.
You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment for further testing.
(GO TO 327)

324) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.
The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

325) CIRCLE THE APPROPRIATE CODE AND SIGN.

DRUG ACCEPTED 1 SIGNATURE ____
REFUSED 2 (GO TO 327)
OTHER 6 (GO TO 327)

326) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST
CHILD LESS THAN ONE YEAR OLD OR LESS THAN 8 KGS.
25 MG TABLET OF ARTESUNATE AND 67.5 MG OF AMODIAQUINE (ROSE STRIPED BROCHURE)

DAY 1 (1 TABLET)
DAY 2 (1 TABLET)
DAY 3 (1 TABLET)

CHILD AGE 1-5 YEARS OR 8-17 KGS.
50 MG TABLET OF ARTESUNATE AND 135 MG OF AMODIAQUINE (PURPLE STRIPED BROCHURE)

DAY 1 (1 TABLET)
DAY 2 (1 TABLET)
DAY 3 (1 TABLET)

TELL THE PARENTS/ADULT RESPONSIBLE FOR CHILD: If (NAME) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you must take him/her to a health professional for treatment immediately.

327) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET

DRUG GIVEN 1
DRUG REFUSED 2
REFERRED FOR SEVERE MALARIA 3
REFERRED BECAUSE CHILD ALREADY TOOK CTA 4
OTHER 6

328) GO BACK TO 301 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE (S); IF THERE ARE NO MORE CHILDREN, GO TO 330

INFORMED CONSENT FOR ANEMIA TEST

As part of this survey, we are asking children 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 2008 or later take part in anemia testing in this survey and give 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 will be destroyed. The result will be told to you right away. The result will be kept strictly confidential. If the test shows that (NAME OF CHILD) has severe anemia, we will refer him/her to the closest health center for follow up.
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 take the anemia test?

DECLARATION OF CONSENT FOR MALARIA TEST

We are asking all of the children in this country to participate in a malaria test. Malaria is a serious health problem caused by a parasite transmitted from a mosquito bite. This survey will assist the government to develop programs to prevent and treat anemia.
We ask that all children born in 2008 or later take part in anemia testing in this survey and give 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. (We use the blood from the same needle prick as for the anemia test)
The blood will be tested for malaria immediately, and the result will be told to you right away. Some drops will be saved on one or more slides and sent to a laboratory to be tested. You will not find out the results of the lab test. The result will be kept strictly confidential. If the test shows that (NAME OF CHILD) has malaria, we will suggest a treatment.
We hope that you will consent to test (NAME OF CHILD) immediately for malaria and to use the extra drops of blood for additional malaria tests at the central laboratory.
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 take the anemia test?

DECLARATION OF CONSENT FOR VACCINATIONS TEST

As part of this survey we are asking children all over the country to participate in a vaccination test. This test will allow us to know if children are completely vaccinated and if they are protected against certain childhood illnesses. This survey will help the government develop programs to improve young children's health. We ask that all children born in 2008 or later to take the vaccinations test included in this survey by giving a few drops of blood. 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. (We use the blood from the same needle prick as for the anemia test)
You will not find out of (NAME OF CHILD)'s test results; they are strictly confidential. We hope that you will contest to using (NAME OF CHILD)'s drops of blood for the vaccinations test at the laboratory.
Do you have any questions about the vaccinations test? 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 take the vaccinations test?

Weight, height, hemoglobin measurement, and HIV test for women age 15-49

330) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 331. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

331) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER ____
NAME ____

332) WEIGHT IN KILOGRAMS

KILOGRAMS ____
ABSENT 99994
REFUSED 99995
OTHER 99996

333) HEIGHT IN CENTIMETERS

CENTIMETERS ____
ABSENT 99994
REFUSED 99995
OTHER 99996

334) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 339)

335) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 339)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ____

337) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 336 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 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 and to (NAME OF ADOLESCENT) 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 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 anemia test?

338) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
REFUSED BY PARENT/OTHER RESPONSIBLE ADULT 2 SIGNATURE ____ (GO TO 344)

339) 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 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, or you can say no to the test. It is up to you to decide.
Will you take the anemia test?

340) CIRCLE APPROPRIATE CODE AND SIGN

GRANTED 1 SIGNATURE ____
RESPONDENT REFUSED 2 SIGNATURE ____(GO TO 342)

341) PREGNANCY: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

342) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 346)

343) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 346)

344) ASK CONSENT FOR GGS (DBS) COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 336 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 the Democratic Republic of Congo.
For the HIV test, we need a few (more) 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 the results of (NAME OF ADOLESCENT'S) test either.

Location covered by fixed Voluntary Testing Center: 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.
Location not covered by fixed Voluntary Testing Center: In the next few days, the Ministry of Health will send a mobile team to offer HIV testing and counseling services. If (NAME OF ADOLESCENT) wants to know her HIV status, I will also give her a voucher for free services that can be used for this mobile 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 ADOLESCENT) to take the HIV test?

345) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
REFUSED BY PARENT/OTHER RESPONSIBLE ADULT 2 SIGNATURE ____ (GO TO 355)

346) 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 the Democratic Republic of Congo.
For the HIV test, we need a few (more) 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.

Location covered by fixed Voluntary Testing Center: If you want to know you 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.
Location not covered by fixed Voluntary Testing Center: In the next few days, the Ministry of Health will send a mobile team to offer HIV testing and counseling services. If you want to know you HIV status, I will also give you a voucher for free services for you (and for your partner if you want) that you can use for this mobile team.

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

347) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.

GRANTED 1 SIGNATURE ____
RESPONDENT REFUSED 2 SIGNATURE ____ (GO TO 355)

348) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 352)

349) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 352)

350) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 336 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.

We ask you to allow the Ministry of Planning and the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

351) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 SIGNATURE ____ (GO TO 354)

352) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow the Ministry of Planning and the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

353) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
RESPONDENT REFUSED 2 SIGNATURE ____ (GO TO 355)

354) ADDITIONAL TESTS
CHECK 351 AND 353: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

355) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST (S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST (S).

356) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ____
NOT PRESENT 994
REFUSED 995
OTHER 996

357) BAR CODE LABEL FOR HIV (WHITE COLOR)
(PUT THE 1ST BAR CODE HERE)

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE WHITE TRANSMITTAL FORM.

358) GO BACK TO 332 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 360.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

360) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN Q. 361. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE (S).

361) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

LINE NUMBER ____
NAME ____

362) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-59 YEARS 2 (GO TO 367)

363) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 367)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ____

365) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 364 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 member 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?

366) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 SIGNATURE ____ (GO TO 371)

367) 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 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.
Will you take in the anemia test?

368) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
RESPONDENT REFUSED 2 SIGNATURE ____

369) AGE: CHECK COLUMN 7

15-17 YEARS 1 373
18-49 YEARS 2 (GO TO 373)

370) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 373)

371) ASK CONSENT FOR GSS (DBS) COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 364 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 the Democratic Republic of Congo.
For the HIV test, we need a few (more) 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 the results of (name of adolescent's) test either.

Location covered by fixed Voluntary Testing Center: 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.
Location not covered by fixed Voluntary Testing Center: In the next few days, the Ministry of Health will send a mobile team to offer HIV testing and counseling services. If (NAME OF ADOLESCENT) wants to know his HIV status, I will also give him a voucher for free services that can be used for this mobile 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 ADOLESCENT) to take the HIV test?

372) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 SIGNATURE ____ (GO TO 382)

373) 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 the Democratic Republic of Congo.
For the HIV test, we need a few (more) 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.

Location covered by fixed Voluntary Testing Center: If you want to know you 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 that for you (and for your partner if you want) that you can use at any of these facilities.
Location not covered by fixed Voluntary Testing Center: In the next few days, the Ministry of Health will send a mobile team to offer HIV testing and counseling services. If you want to know you HIV status, I will also give you a voucher for free services for you (and for your partner if you want) that you can use for this mobile team.

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

374) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 SIGNATURE ____
RESPONDENT REFUSED 2 SIGNATURE ____ (GO TO 382)

375) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-59 YEARS 2 (GO TO 379)

376) MARITAL STATUS: CHECK QUESTION 363

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 37)

377) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 364 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
We ask you to allow the Ministry of Planning and the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

378) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 SIGNATURE (GO TO 381)

379) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow the Ministry of Planning and the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

380) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGNATURE ____
RESPONDENT REFUSED 2 SIGNATURE ____ (GO TO 382)

381) ADDITIONAL TESTS
CHECK 387 AND 380: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

382) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST (S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST (S).

383) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ____
NOT PRESENT 994
REFUSED 995
OTHER 996

384) BAR CODE LABEL FOR HIV (WHITE COLOR)
(PUT THE 1ST BAR CODE HERE)

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE WHITE TRANSMITTAL FORM.

385) GO BACK TO 362 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.