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DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE - CAMEROON 2004

MINISTRY OF ECONOMIC AFFAIRS, OF PROGRAMMING, AND OF TERRITORIAL DEVELOPMENT.
NATIONAL STATISTICS INSTITUTE.
REPUBLIC OF CAMEROON.
PEACE-WORK-COUNTRY.

IDENTIFICATION

PROVINCE ___
PROVINCE ___
DEPARTMENT ___
DEPARTMENT LAYER ___
DISTRICT___

CITY/CANTON/GROUP

YAOUNDE/DOUALA 1
GAROUA/MAROUA/BAFOUSSAM/BAMENDA 2
OTHER CITIES 3
RURAL 4

VILLAGE ___
CLUSTER ___
NEIGHBORHOOD/PLACE ___
STRUCTURE ___
HOUSEHOLD ___
NAME OF HOUSEHOLD HEAD ___

HOUSEHOLD SELECTED FOR INQUIRY:

MALE/FEMALE GENITAL CUTTING (SECTION 10F) AND ANEMIA TESTS/ANTHROPOMETRY INQUIRY 1
RELATIONSHIP TO HOUSEHOLD (SECTION 11F), NOT MALE INQUIRY 2

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___

RESULTS___

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

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__

TOTAL NUMBER OF VISITS____
TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___
LINE NUMBER OF SURVEYED HOUSEHOLD ___

SUPERVISOR
NAME: ___
DATE: ___

FIELD EDITOR
NAME: ___
DATE: ___

OFFICE EDITOR ___
KEYED BY ___

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

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 household.

______

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

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDSON OR GRANDDAUGHTER 05
MOTHER OR FATHER 06
MOTHER-IN-LAW OR FATHER-IN-LAW 07
BROTHER OR SISTER 08
CO-SPOUSE 09
OTHER RELATIVE 10
STEP-CHILD 11
ADOPTED/FOSTER CHILD 12
NOT RELATED 13
DK 98

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

M 1
F 2

5. RESIDENCE: 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 LESS THAN ONE YEAR, MARK '00'. IF 95 YEARS OR MORE, MARK '95'.

IN YEARS: ___

IF AGED 15-59 YEARS:
7A) CHRONIC ILLNESS: Was (NAME) very sick for at least 3 months of the last 12 months? By very sick, I mean that (NAME) was too sick to work or do to normal activities at home.

YES 1
NO 2

8) ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN AGE 15-49.

9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.

9A) ELIGIBILITY: CHECK IF THE HOUSEHOLD IS SELECTED FOR THE MALE INQUIRY. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

NOTE: FOR QUESTION 10 THROUGH 13: THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN QUESTION 11 AND 13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD:

10) Is (NAME)'s biological mother alive?

YES 1
NO 2
DK 8

11) IF ALIVE: Does (NAME)'s biological mother live in this household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER.

____

12) Is (NAME)'s biological father alive?

YES 1
NO 2
DK 8

13) IF ALIVE: Does (NAME)'s biological father live in this household?

IF YES: What is his name?

RECORD FATHER'S LINE NUMBER.

______

EDUCATION

IF AGE 3 YEARS OR OLDER:

14) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT HOUSEHOLD MEMBER)

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

LEVEL:

NURSERY SCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DK 8

GRADE:

NURSERY SCHOOL
IN ALL CASES 1
PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

IF AGE 3-24 YEARS:
16) Is (NAME) currently attending school?

YES 1 (GO TO 18)
NO 2

17) During the current school year (2003-2004), did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 19)

18) During the current school year (2003-2004) what level and grade is/was (NAME) attending?

LEVEL:

NURSERY SCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DK 8

GRADE:

NURSERY SCHOOL
IN ALL CASES 1
PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

19) During the previous school year (2002-2003), did (NAME) attend school at any time?

YES 1
NO 2 (GO TO NEXT HOUSEHOLD MEMBER)

20. During that school year (2002-2003), what level and grade did (NAME) attend?

LEVEL:

NURSERY SCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DK 8

GRADE:

NURSERY SCHOOL
IN ALL CASES 1
PRIMARY
LESS THAN ONE YEAR 0
INFANT/CLASS ONE/SIL 1
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
DK 8
SECONDARY
LESS THAN ONE YEAR 0
FORM 1/SIXTH/1ST YEAR 1
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
DK 8
HIGHER
LESS THAN ONE YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH+ YEAR 4
DK 8

TICK HERE IF CONTINUATION SHEET USED:

________

Just to make sure that I have a complete listing:

1. Are there any other persons such as small children or infants that we have not listed?

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

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

YES: ___ (ENTER EACH IN TABLE)
NO: __

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

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

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 23)
PIPED INTO YARD 12 (GO TO 23)
PIPED INTO NEIGHBOR'S YARD 13
PUBLIC TAP 14
WELL WATER
WELL WITH PUMP 21
WELL WITHOUT PUMP 22
UNPROTECTED WELL 23
SURFACE WATER
RIVER/BACKWATER/MARSHLAND/UNPROTECTED SPRING 31
PROTECTED SPRING 32
RAINWATER 41 (GO TO 23)
OTHER (SPECIFY): ___ 96

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

MINUTES: ___
ON PREMISES 996

23) What kind of toilet facilities does your household have?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31 (GO TO 25)
OTHER (SPECIFY): ___ 96

24) Do you share these facilities with other households?

YES 1
NO 2

25) Does your household have:

Electricity?
A radio?
A television?
A landline telephone?
A refrigerator?
A hotplate/gas or electric stove?

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
HOT PLATE/STOVE
YES 1
NO 2

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

BOTTLED GAS/NATURAL GAS/BIOGAS 01
PETROLEUM 02
WOOD CHARCOAL 03
BURNING WOOD/STRAW/SAWDUST 04
OTHER (SPECIFY): ___ 96

26A) In your household, how many rooms do you use to sleep?

ROOMS: ___

27) MAIN MATERIAL OF THE FLOOR.

RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
JETFLEX OR ASPHALT 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY): ___ 96

28) Does any member of your household own:

A bicycle?
A motorcycle or motorized scooter?
A car or truck?
A mobile phone?

BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
CAR OR TRUCK
YES 1
NO 2
MOBILE PHONE
YES 1
NO 2

29) Does your household have any bednets that can be used while sleeping?

YES 1
NO 2 (GO TO 35)

29A) How many bednets do you have in your household?

NO. OF BEDNETS: ___

30) ASK THE RESPONDENT TO SHOW YOU THE BEDNETS. ASK THE FOLLOWING QUESTION FOR EACH BEDNET.

IF THERE ARE MORE THAN 3 BEDNETS, USE A SUPPLEMENTARY QUESTIONNAIRE.

BEDNET 1
OBSERVED 1
NOT OBSERVED 2
BEDNET 2
OBSERVED 1
NOT OBSERVED 2
BEDNET 3
OBSERVED 1
NOT OBSERVED 2

31) How long ago did your household obtain the bednet?

MONTHS: ___
3 YEARS AGO OR MORE 96

31A) How did you get the bednet?

PURCHASE 1
DONATION FROM MINISTRY OF HEALTH 2
DONATION FROM NGO 3
GIFT FROM FAMILY MEMBER/FRIEND 4
OTHER (SPECIFY): ___ 5
DK/NOT SURE 8

31B) How much did you pay for the bednet?

PRICE: ___
FREE 99995
DK 99998

32) OBSERVE OR ASK THE BRAND OF BEDNET.

PERMANENT OLYSET NET 1
OTHER (SPECIFY): ___ 2
DK/NOT SURE 8

32A) Since you got the bednet, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?

YES 1
NO 2 (GO TO 32C)
DK/NOT SURE 8 (GO TO 32C)

32B) How long ago was the net last soaked or dipped?

IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS: ___
3 YEARS AGO OR MORE 96
DK/NOT SURE 98

32C) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 32E)
DK/NOT SURE 8 (GO TO 32E)

32D) Who slept under this mosquito net last night?

RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME: ___
LINE NUMBER: ___
NAME: ___
LINE NUMBER: ___
NAME: ___
LINE NUMBER: ___
NAME: ___
LINE NUMBER: ___
NAME: ___
LINE NUMBER: ___

32E) GO BACK TO 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 35.

35) ASK THE RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION). IF THE SALT IS NOT TESTED, GIVE THE REASON.

0 PPM (NO IODINE) 1
7 PPM 2
15 PPM 3
30 PPM 4
NO SALT IN HH 5
SALT NOT TESTED (SPECIFY REASON): ___ 6

35A) TABLE SELECTION OF WOMEN FOR "RELATIONSHIPS IN THE HOUSEHOLD"

USE ONLY IF SECTION 11 OF THE "RELATIONSHIP IN THE HOUSEHOLD"
IS PROVIDED IN THE INDIVIDUAL SURVEY (CHECK THE COVER)

1 - IF THERE IS ONLY ONE WOMAN ELIGIBLE IN HOUSEHOLD:

IN THE FIRST LINE OF THE TABLE BELOW, ENTER THE LINE NUMBER OF ELIGIBLE WOMEN (SEE COLUMN (8) IN THE HOUSEHOLD SURVEY): THIS WOMAN WILL BE SURVEYED ON "RELATIONS IN THE HOUSEHOLD."

2 - IF THERE ARE MANY ELIGIBLE WOMEN IN HOUSEHOLD:

1. IN THE TABLE, ENTER THE NAME, AGE AND THE LINE NUMBER OF ALL ELIGIBLE WOMEN (SEE COLUMN (8) OF THE HOUSEHOLD SURVEY), STARTING WITH THE OLDEST AND ENDING WITH THE YOUNGEST.

2. TAKE THE LAST DIGIT OF THE STRUCTURE NUMBER MARKED ON THE COVER PAGE OF THE QUESTIONNAIRE AND CIRCLE THE DIGIT CORRESPONDING TO THE FIRST LINE OF THE FOLLOWING SCHEDULE. DESCEND THE COLUMN IDENTIFIED BY THE DIGIT UNTIL THE LINE CORRESPONDING TO THE LAST WOMAN REGISTERED ON THE SCHEDULE. CIRCLE THE DIGIT CORRESPONDING TO THE CROSSING OF THIS LAST COLUMN AND THIS LINE.

3. THIS DIGIT GIVES YOU THE ORDER NUMBER OF THE WOMAN SELECTED FOR SECTION 11 OF THE FEMALE QUESTIONNAIRE (THE 1ST, 2ND, 3RD, ETCÂ…LISTED WOMAN). CIRCLE IN THE SCHEDULE THE LINE NUMBER OF THIS SELECTED WOMAN.

ORDER NUMBER: ___
NAME OF WOMAN: ___
AGE OF WOMAN: ___
LINE NO. OF HOUSEHOLD: ___

MEASUREMENTS OF WEIGHT, HEIGHT AND HEMOGLOBIN LEVEL

CHECK COLUMNS 8 AND 9; RECORD THE LINE NUMBER, NAME, AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

36) WOMEN 15-49: LINE NUMBER FROM COLUMN 8

_____

37) WOMEN 15-49: NAME FROM COLUMN 2

________

38) WOMEN 15-49: AGE FROM COLUMN 7

YEARS: ___

39) WOMEN 15-49: What is (NAME)'s date of birth?

______

40) WEIGHT AND HEIGHT MEASUREMENTS OF WOMEN 15-49: WEIGHT (KILOGRAMS)

________

41) WEIGHT AND HEIGHT MEASUREMENTS OF WOMEN 15-49: HEIGHT (CENTIMETERS)

________

42) WEIGHT AND HEIGHT MEASUREMENTS OF WOMEN 15-49: MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

43) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER

36) CHILDREN UNDER AGE 6: LINE NUMBER FROM COLUMN 9

_______

37) CHILDREN UNDER AGE 6: NAME FROM COLUMN 2

_______

38) CHILDREN UNDER AGE 6: AGE FROM COLUMN 7

_______

39) CHILDREN UNDER AGE 6: What is (NAME)'s date of birth?

FOR THE CHILDREN NOT INCLUDED IN ANY OF THE 2 SECTIONS OF REPRODUCTION (ORPHANS, ADOPTED CHILDREN, ETC) ASK THE DAY, THE MONTH, AND THE YEAR OF BIRTH.

FOR ALL OTHER CHILDREN, COPY THE MONTH AND THE YEAR OF QUESTION 215 IN SECTION 2 OF THEIR MOTHERS AND ASK THE DATE OF BIRTH.

DAY: ___
MONTH: ___
YEAR: ___

40) WEIGHT AND HEIGHT MEASUREMENTS OF CHILDREN BORN IN 1999 OR LATER: WEIGHT (KILOGRAMS)

______

41) WEIGHT AND HEIGHT MEASUREMENTS OF CHILDREN BORN IN 1999 OR LATER: HEIGHT (CENTIMETERS)

______

42) WEIGHT AND HEIGHT MEASUREMENTS OF CHILDREN BORN IN 1999 OR LATER: MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

43) WEIGHT AND HEIGHT MEASUREMENTS OF CHILDREN BORN IN 1999 OR LATER: RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER

TICK HERE IF CONTINUATION SHEET USED:

______

44) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: CHECK COLUMN 38

AGE 15-17 1
AGE 18-40 2 (GO TO 46)

45) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

_____

46) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE AND SIGN.

CONSENT STATEMENT

As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in 1999 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. To take these drops we use disposable sterile instruments. They were never used before you, and they will not be used again after. The blood is taken with new materials and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

May I now ask that you and (NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

GO TO COLUMN 46 AND CIRCLE THE APPROPRIATE CODE.

GRANTED 1 (SIGN): __________
REFUSED 2 (GO TO 49)

47) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: HEMOGLOBIN LEVEL (G/DL)

____

48) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: CURRENTLY PREGNANT?

YES 1
NO/DK 2

49) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
5 OTHER

45) HEMOGLOBIN LEVEL (G/DL) OF CHILDREN BORN IN 1999 OR LATER: LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

_____

46) HEMOGLOBIN LEVEL (G/DL) OF CHILDREN BORN IN 1999 OR LATER: READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT. CIRCLE CODE AND SIGN.

CONSENT STATEMENT

As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in 1999 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. To take these drops we use disposable sterile instruments. They were never used before you, and they will not be used again after. The blood is taken with new materials and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

May I now ask that you and (NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

GO TO COLUMN 46 AND CIRCLE THE APPROPRIATE CODE.

GRANTED 1 (SIGN): _____
REFUSED 2 (GO TO 49)

47) HEMOGLOBIN LEVEL (G/DL) OF CHILDREN BORN IN 1999 OR LATER: HEMOGLOBIN LEVEL (G/DL)

_____

49) HEMOGLOBIN LEVEL (G/DL) OF CHILDREN BORN IN 1999 OR LATER: RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER

MEASUREMENT OF HEMOGLOBIN LEVEL OF MEN AGED 15-59

CHECK COLUMNS 9A, 2, AND 7; RECORD THE LINE NUMBER, NAME, AND AGE OF ALL MEN AGE 15-59.

50) LINE NUMBER FROM COLUMN 9A

______

51) NAME FROM COLUMN 2

_______

52) AGE FROM COLUMN 7

YEARS: ___

53) CHECK COLUMN 52

AGE 15-17 1
AGE 18-59 2 (GO TO 55)

54) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.

RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

______

55) READ CONSENT STATEMENT TO MAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE AND SIGN.

CONSENT STATEMENT

As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in 1999 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. To take these drops we use disposable sterile instruments. They were never used before you, and they will not be used again after. The blood is taken with new materials and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

GO TO COLUMN 46 AND CIRCLE THE APPROPRIATE CODE

GRANTED 1 (SIGN): ___
REFUSED 2 (GO TO 57)

56) HEMOGLOBIN LEVEL (G/DL)

____

57) RESULT

1 MEASURED
2 NO PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER

TICK HERE IF CONTINUATION SHEET USED: ___

58) CHECK 47, 48 (FOR WOMEN) AND 58 (FOR MEN):

NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW CUTOFF POINT: LESS THAN 7G/DL FOR CHILDREN, FOR MEN, AND FOR WOMEN WHO ARE NOT PREGNANT (OR WHO DON'T KNOW IF THEY ARE PREGNANT), LESS THAN 9G/DL FOR PREGNANT WOMEN.

ONE OR MORE: ___
GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND READ THE DECLARATION FROM QUESTION 59 TO THE PERSON WITH LOW HEMOGLOBIN.
NONE: ___
GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND (GO TO QUESTION 60).

59) We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILDREN). This indicates that (you/NAME OF CHILDREN) have developed severe anemia, which is a serious health problem. We recommend that you go to a health center as soon as possible to be examined and to get treatment.

GIVE THEM THE REFERENCE SHEET ON ANEMIA AND GO TO QUESTION 60.

INFORMED CONSENT (HIV TEST)

INFORMED CONSENT FOR ADULT 18 YEARS OR OLDER

In the survey, we are doing a study of HIV/AIDS among women aged 15-49 and men aged 15-49. You are aware, perhaps, that HIV is the virus that causes AIDS. AIDS is a serious illness, usually deadly. We are in the process of doing an HIV test to measure the severity of the AIDS problem in Cameroon.

For the HIV test, we ask all the eligible women and men in the country to give a few drops of blood from a finger. To obtain the drops we use a sterile instrument made of new materials for one-time use. They have never been used before you, and they will not be used after.

The blood is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, I will give you a reference sheet for you to go to the Prevention and Voluntary screening center for a free test.

Do you have any questions?

Now, will you participate in the study?

(GO TO COLUMN 67 AND CIRCLE THE APPROPRIATE CODE.)

INFORMED CONSENT FOR YOUNG PEOPLE AGE 15-17.

1ST STAGE: ASK FOR INFORMED CONSENT OF PARENT/RESPONSIBLE ADULT.

The HIV/AIDS study includes young women and men starting at 15 years. For the HIV test of these young people aged 15-17, we ask their parents or a responsible adult to give their consent, and we also get the consent of the young person.

We ask that the young person (NAME), participates in the HIV test by giving us a few drops of blood from a finger. To obtain these drops of blood we use sterile, non-reusable instruments made of new materials. They have never been used before you, and they will not be used after.
The blood is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results t of the test. No one else will then know the results of your blood test. Meanwhile, I will give (NAME OF YOUNG PERSON) a reference sheet for you to go to the Prevention and Voluntary screening center for a free test.

Now, do you agree that (NAME) may participate in the HIV test?

GO TO COLUMN 66 AND CIRCLE THE APPROPRIATE CODE

2ND STAGE: INFORMED CONSENT OF YOUNG PERSON

IF THE PARENT/RESPONSIBLE ADULT OF THE YOUNG PERSON ACCEPTS THAT HE/SHE CAN PARTICIPATE IN A TEST, READ THE INFORMED CONSENT TO THE YOUNG PERSON.

In the survey, we are doing a study of HIV/AIDS among women aged 15-49 and men aged 15-59. You are aware, perhaps, that HIV is the virus that causes AIDS. AIDS is a serious illness, usually deadly. We are in the process of doing an HIV test to measure the severity of the AIDS problem in Cameroon.

For the HIV test, we ask all the eligible women and men in the country to give a few drops of blood from a finger. To obtain the drops we use a sterile instrument made of new materials for one-time use. They have never been used before you, and they will not be used after.

The blood is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, I will give you a reference sheet for you to go to the Prevention and Voluntary screening center for a free test.

Do you have any questions?

Now, will you participate in the study?

GO TO COLUMN 67 AND CIRCLE THE APPROPRIATE CODE.

DO NOT FORGET TO GIVE EACH ELIGIBLE PERSON A REFERENCE SHEET FOR THE VOLUNTARY FREE TEST.

HIV TEST - WOMEN AND MEN

TOTAL NUMBER OF SAMPLES: ___

CHECK COLUMNS 8 AND 9A IN THE HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER, THE SEX, AND THE AGE OF ALL WOMEN 15-49 AND MEN 15-59.

THIS SHEET SHOULD BE DESTROYED AT THE OFFICE BEFORE THE RESULTS OF THE TEST ARE SENT, BASED ON THE DATA OF THE EDSC III (HEALTH AND DEMOGRAPHIC SURVEY OF CAMEROON).

60) LINE NO. FROM COLUMN 8 OR COLUMN 9A

______

61) NAME FROM COLUMN 2

NAME: ___

62) SEX FROM COLUMN 4

M 1
F 2

63) AGE FROM COLUMN 7

YEARS: ___

64) CHECK THE AGE IN COLUMN 63

15-17 1
AGE 18+ 2 (GO TO 67)

65) LINE NUMBER OF PARENT/RESPONSIBLE ADULT

______

66) READ THE CONSENT TO THE PARENT OR RESPONSIBLE ADULT. CIRCLE THE CODE AND SIGN.

AGREED 1 SIGN: ____
REFUSED 2
NOT READ 3

67) READ THE CONSENT TO THE WOMAN/MAN OR THE YOUNG PERSON. CIRCLE THE CODE AND SIGN.

AGREED 1 SIGN: ____
REFUSED 2
NOT READ 3

68) RESULT

1 SAMPLING DONE
2 REFUSED
3 ABSENT
4 TECHNICAL PROBLEMS
6 OTHER (SPECIFY): ___

69) BARCODE LABELS. PUT THE 1ST STICKER HERE AND STICK THE SECOND STICKER ON THE FILTER PAPER OF THE SURVEYED PERSON AND THE 3RD ON THE SHEET THAT TRANSMITS THE SAMPLING.

TICK HERE IF CONTINUATION SHEET USED:

_____