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

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

HOUSEHOLD SELECTED FOR INQUIRY:

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

RESULTS___

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?

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

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

6. Did (NAME) stay here last night?

7. AGE: How old is (NAME)?

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

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.

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?

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?

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?

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

LEVEL:

GRADE:

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

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

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

LEVEL:

GRADE:

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

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

LEVEL:

GRADE:

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?

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?

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

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

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

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

24) Do you share these facilities with other households?

25) Does your household have:

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

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

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

27) MAIN MATERIAL OF THE FLOOR.

RECORD OBSERVATION.

28) Does any member of your household own:

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

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

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

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.

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

31A) How did you get the bednet?

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

32) OBSERVE OR ASK THE BRAND OF BEDNET.

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

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

IF LESS THAN 1 MONTH, RECORD '00'.

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

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

RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

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.

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, ETC?LISTED WOMAN). CIRCLE IN THE SCHEDULE THE LINE NUMBER OF THIS SELECTED WOMAN.

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

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

43) RESULT

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.

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

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

TICK HERE IF CONTINUATION SHEET USED:

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

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.

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

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

49) HEMOGLOBIN MEASUREMENT OF WOMEN 15-49: RESULT

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.

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

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

53) CHECK COLUMN 52

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

56) HEMOGLOBIN LEVEL (G/DL)

57) RESULT

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.

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

62) SEX FROM COLUMN 4

63) AGE FROM COLUMN 7

64) CHECK THE AGE IN COLUMN 63

65) LINE NUMBER OF PARENT/RESPONSIBLE ADULT

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

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

68) RESULT

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: