IDENTIFICATION

DEPARTMENT NAME _____
LOCATION NAME _____
NAME OF HEAD OF HOUSEHOLD _____
CLUSTER NUMBER _____
STRUCTURE NUMBERS _____
HOUSEHOLD NUMBER _____
ORDER OF HOUSEHOLD SELECTION IN CLUSTER ____

BRAZZAVILLE, POINTE NOIRE, OTHER CITIES, RURAL:

HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE?

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:

TOTAL NO. OF VISITS_______

TOTAL PERSONS IN HOUSEHOLD_______

TOTAL ELIGIBLE WOMEN_______

TOTAL ELIGIBLE MEN_______

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______

SUPERVISOR
NAME_______
DATE_______

FIELD EDITOR
NAME_______
DATE________

OFFICE EDITOR_______

KEYED BY_______

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working for the Demographic and Health Survey, supported by the government and its partners. We are conducting a survey about health. 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 20 to 25 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_______

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.

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

4) SEX: Is (NAME) male or female?

RESIDENCE:

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?
IF LESS THAN ONE YEAR, RECORD 00.
IF 95 OR MORE, RECORD 95.

IF AGE 15 OR OLDER:

8) MARITAL STATUS: What is (NAME)'s current marital status?

ELIGIBILITY:
9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CHECK COVER PAGE: HH SELECTED FOR MEN'S SURVEY: YES 1
CIRCLE LINE NUMBER OF ALL MEN 15-49.

11) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY: NO 2
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

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?

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?

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

IF AGE 0-17 YEARS:

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:

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

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'.

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

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'.

IF AGE 5 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

16) Has (NAME) ever attended school?

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

IF AGE 5-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school at any time during the current (2011-2012) school year?

19) During this/that school year (2011-2012), what level and grade (is/was) (NAME) attending?

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?

HOUSEHOLD CHARACTERISTICS

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

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

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

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

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

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

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

109) How many households use this toilet facility?

109a) Where are the stools disposed of most often?

110) Does your household have:

Electricity?
A radio/tape player?
A television?
A mobile telephone?
A non-mobile telephone?
A computer (portable or not)?
A refrigerator/an electric, gas, or petroleum freezer?
A portable gas stove/a stove?
A portable petroleum stove?
A petroleum lamp?
A gas lamp?

110A) What is your household's main mode of lighting?

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

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

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

114) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

115) MAIN MATERIAL OF ROOF.
RECORD OBSERVATION.

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

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

118) Does any member of your household own:

A watch?
A bicycle?
A motorcycle or motor scooter?
A car or truck?
A boat without a motor?
A boat with a motor/speedboat?

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

119a) Does any member of this household any farmed land?

120) How many hectares of agricultural land do members of this household own?
If 95 or more, circle 950

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

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 or bulls?
Pigs?
Goats/kids?
Sheep?
Chickens, ducks, pigeons, turkeys, guinea fowl?

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

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

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

128) Ask the respondent to show you the nets in the household.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

129) How many months ago did your household get the mosquito net?
IF LESS THAN 4 YEARS, RECORD IN MONTHS.
IF LESS THAN ONE MONTH, RECORD 00.

130) Did you get this mosquito net during a visit to a health care establishment or during a distribution campaign in a health care establishment?

131) Did you get this mosquito net during the Ministry of Health's distribution campaign or the distribution campaign of an organization related to the Ministry of Health?

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

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

135) WHO SLEPT UNDER THE MOSQUITO NET LAST NIGHT?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

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

137) How do members of your household usually wash their hands?

138) What do members of your household generally use to wash their hands:

Soap or detergent (in a piece, powder, or liquid)?
Ash, mud, sand?

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

WORK OF CHILDREN AGE 5-14 YEARS

141) CHECK COLUMN (5) AND (7) NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

142) RECORD THE LINE NUMBER FOR EACH CHILD LIVING IN THE HOUSEHOLD IN THE ORDER OF COLUMN 1 OF THE HOUSEHOLD SCHEDULE.

143) RECORD THE NAME OF EACH CHILD

ASK THE FOLLOWING QUESTIONS TO THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE MORE THAN 8 CHILDREN, USE THE ADDITIONAL QUESTIONNAIRE):

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

144) Since the last (DAY OF THE WEEK OF THE INTERVIEW), 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?

145) Since the last (DAY OF THE WEEK OF THE INTERVIEW), 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.

146) In the last 12 months, 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?

147) Since the last (DAY OF THE WEEK OF THE INTERVIEW), did (NAME) do any household chores? For example, doing the dishes, shopping, cleaning, clothes washing, getting water, or taking care of children?

148) Since the last (DAY OF THE WEEK OF THE INTERVIEW), approximately how many hours did he/she spend doing these household chores?

149) Since the last (DAY OF THE WEEK OF THE INTERVIEW), did (NAME) do work in family fields or in a family business (farm, business, or selling merchandise in the street)?

150) Since the last (day of the week of the interview), approximately how many hours did he/she spend doing this work in family fields or in a family business?

DISCIPLINE OF CHILD

151) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 2 AND 14 YEARS OLD USUALLY LIVING IN THIS HOUSEHOLD:

TABLE 1: CHILDREN AGE 2-14 YEARS ELIGIBLE FOR QUESTIONS REGARDING DISCIPLINE

RECORD EACH CHILD AGE 2-14 YEARS FROM THE HOUSEHOLD SCHEDULE IN THE TABLE BELOW IN THE ORDER FROM THE LINE NUMBER (Q 1) FROM THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE MEMBERS OF THE HOUSEHOLD WHOSE AGE IS OUTSIDE OF 2-14 YEARS. RECORD THE LINE NUMBER, NAME, SEX AND AGE FOR EACH CHILD. THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS IN THE SPACE PROVIDED (Q.157)

152) RANK NUMBER:

153) LINE NUMBER:

154) NAME FROM Q. 1:

155) SEX FROM Q. 4:

156) AGE FROM Q. 7:

157) TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS:

TABLE 2: RANDOM SELECTION OF THE CHILD FOR QUESTIONS ON DISCIPLINE:

USE TABLE 2 TO SELECT A CHILD BETWEEN 2 AND 14 YEARS IF, IN THE HOUSEHOLD, THERE ARE MORE THAN ONE CHILD IN THIS AGE GROUP.

A) TAKE THE LAST DIGIT FROM THE STRUCTURE NUMBER RECORDED ON THE COVER PAGE OF THE QUESTIONNAIRE.

B) THIS DIGIT CORRESPONDS TO THE LINE TO SELECT FROM

C) CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN IN Q. 157

D) THIS DIGIT CORRESPONDS TO THE COLUMN TO SELECT FROM.

E) FIND THE SPACE THAT CORRESPONDS TO THE INTERSECTION OF THE LINE AND THE COLUMN IDENTIFIED AND CIRCLE THIS DIGIT.

F) THIS DIGIT CORRESPONDS TO THE CHILD WHO WILL BE SELECTED FOR CHILD DISCIPLINE (THE 1ST, 2ND, 3RD, ETC).

EXAMPLE:
THE HOUSEHOLD STRUCTURE NUMBER IS 136, SELECT LINE 6.
THERE ARE 3 ELIGIBLE CHILDREN IN THE HOUSEHOLD, SELECT COLUMN 3.
THE SPACE THAT INTERSECT BETWEEN LINE 6 AND COLUMN 3 IS 2: THE 2ND ELIGIBLE CHILD LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED.

IF THE LINE NUMBER OF 3 ELIGIBLE CHILDREN IS 02, 04, 07, THE CHILD SELECTED IS THE 2ND CHILD LISTED, THUS THE ONE WITH LINE NUMBER 4

158) TABLE:

159) RECORD THE NAME AND LINE NUMBER OF THE CHILD SELECTED FROM COLUMN 1 OF THE HOUSEHOLD SCHEDULE

160) Adults use certain methods to teach child how to behave well. 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 OF CHILD FROM Q. 159) in the last month.

In the last month, did you or someone else in your household withhold privileges from (NAME OF CHILD FROM Q. 159), or forbid something from him/her, or not allow him/her to leave the house?

161) Did you explain to him/her why the behavior was bad?

162) In the last month, did you or someone else in your household shake (NAME OF CHILD FROM Q. 159)?

163) In the last month, did you or someone else in your household scream at (NAME OF CHILD FROM Q. 159)?

164) In the last month, did you or someone else in your household give (NAME OF CHILD FROM Q. 159) something else to do?

165) In the last month, did you or someone else in your household take away a meal from (NAME OF CHILD FROM Q. 159) to punish him/her?

166) In the last month, did you or someone else in your household pull/box (NAME OF CHILD FROM Q. 159)'s ears?

167) In the last month, did you or someone else in your household hit or slap (NAME OF CHILD FROM Q. 159)?

168) In the last month, did you or someone else in your household hit (NAME OF CHILD FROM Q. 159) on his/her bottom or elsewhere on his/her body with something like a belt, a hairbrush, a stick, or another hard object?

169) In the last month, did you or someone else in your household call (NAME OF CHILD FROM Q. 159) an idiot, lazy, or something similar?

170) In the last month, did you or someone else in your household slap or hit (NAME OF CHILD FROM Q. 159) on the face, head, or ears?

171) In the last month, did you or someone else in your household hit (NAME OF CHILD FROM Q. 159) on his/her hands, arms, or legs?

172) In the last month, did you or someone else in your household beat (NAME OF CHILD FROM Q. 159), meaning did you hit him/her repeatedly, as hard as possible?

173) Do you think you could raise and educate a child correctly without physically punishing the child?

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

200) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY?

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

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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

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

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

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

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

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

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

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

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than 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 allow (NAME OF CHILD) to take the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA BROCHURE.

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(s); IF THERE ARE NO MORE CHILDREN, GO TO 214.

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

214) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN FROM QUESTION 215. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

215) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

216) WEIGHT IN KILOGRAMS

217) HEIGHT IN CENTIMETERS

218) AGE: CHECK COLUMN 7

219) MARITAL STATUS: CHECK COLUMN 8

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

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

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

For the anemia 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?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

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

For the anemia 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?

224) CIRCLE APPROPRIATE CODE AND SIGN

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

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

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