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EGYPT DEMOGRAPHIC AND HEALTH SURVEY 2005
HOUSEHOLD QUESTIONNAIRE


IDENTIFICATION

GOVERNORATE
PSU/SEGMENT NO.
KISM/MARKAZ
BUILDING NO.
SHIAKHA/VILLAGE
HOUSING UNIT NO.
HOUSEHOLD NUMBER

URBAN/RURAL

URBAN 1
RURAL 2

LOCALITY

LARGE CITY 1
SMALL CITY 2
TOWN 3
VILLAGE 4

ANEMIA SUBSAMPLE:

YES 1
NO 2

NAME OF HOUSEHOLD HEAD
ADDRESS IN DETAIL


INTERVIEWER VISITS

FIRST VISIT

DATE
TEAM
INTERVIEWER
SUPERVISOR
RESULT

NEXT VISIT:
DATE
TIME

SECOND VISIT

DATE
TEAM
INTERVIEWER
SUPERVISOR
RESULT

NEXT VISIT:
DATE
TIME

THIRD VISIT

DATE
TEAM
INTERVIEWER
SUPERVISOR
RESULT

FINAL VISIT

DAY __ __
MONTH __ __
YEAR __ __ __ __

TEAM __ __
INT. NUMBER __ __
SUP. NUMBER __ __
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 __ __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __

ADDRESSED CHECKED BY: ________________

YES 1
NO 2

REINTERVIEW:

YES 1
NO 2

FIELD EDITOR

NAME
DATE
SIGNATURE

OFFICE EDITOR

NAME
DATE
SIGNATURE

CODER

NAME
DATE
SIGNATURE

KEYER

NAME
DATE
SIGNATURE


HOUSEHOLD SCHEDULE

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

001) LINE NO.

__

002) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who slept here last night, starting with the head of the household.

AFTER LISTING NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT THE LISTING IS COMPLETE.
THEN GO ON TO QUESTION 006.

006) RELATIONSHIP: What is the relationship of (NAME) to the head of the household?
(SEE CODES BELOW)

CODES FOR Q006
RELATIONSHIP TO HEAD OF HOUSEHOLD:

01 = HEAD
02 = WIFE/HUSBAND
03 = SON/DAUGHTER
04 = SON-IN-LAW/DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER/SISTER
09 = BROTHER-IN-LAW/ SISTER-IN-LAW
10 = OTHER RELATIVE
11 = ADOPTED/FOSTER CHILD
12 = STEPCHILD
13 = NOT RELATED
98 = DON'T KNOW

007) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

008) RESIDENCE: Did (NAME) sleep here last night?

YES 1
NO 2

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

MALE 1
FEMALE 2

010) AGE: How old was (NAME)? at his/her last birthday?
RECORD IN COMPLETED YEARS

IN YEARS __ __

MARITAL STATUS

011) IF AGE 15 OR OLDER: What is (NAME'S) current marital status?

1 MARRIED
2 WIDOWED
3 DIVORCED
4 SEPARATED
5 SIGNED CONTRACT
6 NEVER MARRIED

Just to make sure that I have a complete household listing:

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

YES __ (ADD TO 002)
NO __

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

YES __ (ADD TO 002)
NO __

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

YES __ (ADD TO 002)
NO __

CODES FOR Q006
RELATIONSHIP TO HEAD OF HOUSEHOLD:

01 = HEAD
02 = WIFE/HUSBAND
03 = SON/DAUGHTER
04 = SON-IN-LAW/DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER/SISTER
09 = BROTHER-IN-LAW/ SISTER-IN-LAW
10 = OTHER RELATIVE
11 = ADOPTED/FOSTER CHILD
12 = STEPCHILD
13 = NOT RELATED
98 = DON'T KNOW

ELIGIBILITY

012) WOMEN: CIRCLE LINE NUMBER OF ELIGIBLE WOMEN

(I.E., EVER-MARRIED WOMEN AGE 15-49 WHO ARE USUAL RESIDENTS OR SLEPT THERE ON THE NIGHT BEFORE THE INTERVIEW).

013) CHILDREN: CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

014) ADOLESCENTS: CIRCLE LINE NUMBER OF ALL MALE ADOLESCENTS AGE 10-19 AND NEVER-MARRIED FEMALE ADOLESCENTS AGE 10-19 WHOSE MARITAL STATUS IS NEVER MARRIED OR SIGNED CONTRACT.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

015) IF AGE 0-17 YEARS: Is (NAME)'s natural mother alive?

QUESTION REFERS TO CHILD'S BIOLOGICAL MOTHER.

YES 1
NO 2 (GO TO 017)
DON'T KNOW 8 (GO TO 017)

016) IF AGE 0-17 YEARS: Does (NAME)'s natural mother live in this household?

IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.

IF NO: RECORD 00.

__ __

017) IF AGE 0-17 YEARS: Is (NAME)'s natural father alive?

QUESTION REFERS TO CHILD'S BIOLOGICAL FATHER.

YES 1
NO 2 (GO TO 019)
DON'T KNOW 8 (GO TO 019)

018) IF AGE 0-17 YEARS: Does (NAME)'s natural father live in this household?

IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.

IF NO: RECORD 00.

__ __

EDUCATION

019) IF AGE 6 YEARS OR OLDER: Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 026)

020) IF AGE 6 YEARS OR OLDER: What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
(SEE CODES BELOW)

LEVEL __
GRADE __

021) IF AGE 6-24 YEARS: Did (NAME) attend school at any time during the 2004-2005 school year?

YES 1
NO 2 (GO TO 023)

022) IF AGE 6-24 YEARS: During this/that school year, what level and grade [is/was] (NAME) attending?
(SEE CODES BELOW)

LEVEL __
GRADE __

023) IF AGE 6-24 YEARS: Did (NAME) attend school at any time during the previous school year, that is, in the 2003-2004 school year?

YES 1
NO 2 (GO TO 026)

024) IF AGE 6-24 YEARS: During that school year, what level and grade did (NAME) attend?
(SEE CODES BELOW)

LEVEL __
GRADE __

025) IF AGE 3-5 YEARS: Has (NAME) ever attended kindergarten, private nursery or other program to prepare (him/her) for primary school?
(SEE CODES BELOW)

__

CODES FOR Qs. 020, 022, AND 024 CODES

EDUCATION LEVEL:
0 = NURSERY SCHOOL
1 = PRIMARY
2 = PREPARATORY
3 = SECONDARY
4 = UPPER INTERMEDIATE
5 = UNIVERSITY
6 = MORE THAN UNIVERSITY
EDUCATION GRADE:
0 = LESS THAN 1 YEAR COMPLETED (FOR Q.020 ONLY. THIS CODE IS NOT ALLOWED FOR Qs 022 AND 024.)
8 = DON'T KNOW

CODES FOR Q025

1 = KINDERGARTEN AT PUBLIC SCHOOL
2 = KINDERGARTEN AT PRIVATE SCHOOL
3 = PRIVATE NURSERY
4 = OTHER
5 = DIDN'T ATTEND PRESCHOOL PROGRAM
8 = DON'T KNOW

CHILD LABOR

Now I would like to ask you about any work that children in this household may do.

026) IF AGE 5-14 YEARS: During the past week, did (NAME) do any kind of work for someone who is not a member of this household even if it was only for a short period of time?

IF YES: Was (NAME) paid in cash or in kind for his/her work?

YES PAID 1
YES UNPAID 2
NO 3 (GO TO 028)

027) IF AGE 5-14 YEARS: Since last (DAY OF THE WEEK), about how many hours did (NAME) do this work for someone who is not a member of this household?

IF MORE THAN ONE JOB, INCLUDE ALL HOURS AT ALL JOBS.

IF 95 HOURS OF MORE, RECORD 95.

HOURS __ __ (GO TO 029)

028) IF AGE 5-14 YEARS: During the past year, did (NAME) do any kind of work for someone who is not a member of this household even if it was only for a short period of time?

IF YES: Was (NAME) paid for his/her work during the past 12 months?

YES PAID 1
YES UNPAID 2
NO 3

029) IF AGE 5-14 YEARS: During the past week, did (NAME) help with household chores, such as house cleaning, shopping, collecting firewood, fetching water, or caring for children even if it is for a short period of time?

YES 1
NO 2 (GO TO 031)

030) IF AGE 5-14 YEARS: Since last (DAY OF THE WEEK), about how many hours did (NAME) spend doing these chores?

IF 95 HOURS OR MORE, RECORD 95.

HOURS __ __

031) IF AGE 5-14 YEARS: During the past week, did (NAME) do any (other) family work, such as helping on the farm or in a family business or selling goods (in a shop, on the street, ...) even if it is for a short period of time?

YES 1
NO 2 (GO TO NEXT LINE)

032) IF AGE 5-14 YEARS: Since last (DAY OF THE WEEK) about how many hours did (NAME) spend doing this work?

IF 95 HOURS OR MORE, RECORD 95.

HOURS __ __ (GO TO NEXT LINE OR 033)

033) CHECK 012 AND ENTER THE TOTAL NUMBER OF ELIGIBLE WOMEN __ __

034) CHECK 013 AND ENTER THE TOTAL NUMBER OF ELIGIBLE CHILDREN __ __

035) CHECK 014 AND ENTER THE TOTAL NUMBER OF ELIGIBLE ADOLESCENTS __ __

036) TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED __

CHECK IF HOUSEHOLD IS IN THE ANEMIA SUBSAMPLE ON THE IDENTIFICATION SHEET

IN THE SUBSAMPLE __
NOT IN THE SUBSAMPLE __ (GO TO 101)

TABLE FOR SELECTION OF THE ELIGIBLE WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS

IF THERE IS NO ELIGIBLE WOMAN, RECORD '00' IN BOXES ASSIGNED FOR RECORDING LINE NUMBER OF ELIGIBLE WOMAN. THEN GO TO QUESTION 101.

037) LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE.
PUT BOX AROUND THAT NUMBER ON THE LEFT IN THE TABLE BELOW TO IDENTIFY THE ROW YOU WILL USE IN SELECTING THE ELIGIBLE RESPONDENT.

CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON Q033/THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. PUT A BOX AROUND THAT NUMBER AT THE TOP OF THE TABLE TO IDENTIFY THE COLUMN YOU WILL USE IN SELECTING THE ELIGIBLE RESPONDENT.

FIND POINT WHERE THE ROW AND THE COLUMN YOU HAVE MARKED MEET. CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS NUMBER IS USED TO IDENTIFY WHETHER THE FIRST ('1'), SECOND ('2'), THIRD ('3'), ETC. ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.

EXAMPLE;
IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.

FIND THE BOX WHERE ROW '6' AND COLUMN '3' MEET. THE NUMBER IN THAT BOX ('2') INDICATES THAT THE SECOND ELIGIBLE WOMAN IN THE HOUSEHOLD LISTING SHOULD BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.

IF THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07', THEN THE SECOND ELIGIBLE WOMAN IS THE WOMEN WHOSE LINE NUMBER IS '03'. THIS WOMAN WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS (SECTION 9 IN THE WOMAN QUESTIONNAIRE).

LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE SECTION __ __

ADD A BOX ON THE LINE NUMBER FOR THIS WOMAN IN 012.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW).
Numbers 0 through 9 follow.

TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)
Rows of numbers 1 through 8, 1 number in each column, follows.

101) What type of dwelling does your household live in?

APARTMENT 1
FREE STANDING HOUSE 2
OTHER (SPECIFY) ___________________ 6

102) Is your dwelling owned or rented by your household?

IF OWNED: Is it owned solely by your household or jointly with someone else?

OWNED 1
OWNED JOINTLY 2
RENTED 3
OTHER (SPECIFY) __________________ 6

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 108)
PIPED TO YARD/PLOT 12 (GO TO 108)
PUBLIC TAP/STANDPIPE 13 (GO TO 105)
TUBE WELL 21 (GO TO 105)
DUG WELL
PROTECTED WELL 31 (GO TO 105)
UNPROTECTED WELL 32 (GO TO 105)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 105)
UNPROTECTED SPRING 42 (GO TO 105)
TANKER TRUCK 61 (GO TO 105)

CART WITH SMALL TANK 71 (GO TO 105)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 105)
BOTTLED WATER 91
OTHER (SPECIFY) _______________ 96 (GO TO 108)

104) What is the main source of water used by your household for other purposes such as cooking and handwashing?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 108)
PIPED TO YARD/PLOT 12 (GO TO 108)
PUBLIC TAP/STANDPIPE 13
TUBE WELL 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER (SPECIFY) _______________ 96

105) Where is (SOURCE IN 103 OR 104) located?

IN OWN DWELLING 1 (GO TO 108)
IN OWN YARD/PLOT 2 (GO TO 108)
ELSEWHERE 3

106 How long does it take to go there, get water, and come back?

MINUTES __ __ __
ON/NEXT TO PREMISES 996 (GO TO 108)
DON'T KNOW 998

107) Who usually goes to this source to fetch the water for your household?

ADULT WOMAN 15+ 1
ADULT MAN 15+ 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) _________________ 6

108) During the last two weeks, was there any time when water was not available from (SOURCE IN 103 OR 104)?

YES 1
NO 2 (GO TO 110)
DON'T KNOW 8 (GO TO 110)

109) Did this happen on a daily or almost daily basis, only a few times per week, or less frequently?

DAILY/ALMOST DAILY 1
FEW TIMES PER WEEK 2
LESS FREQUENTLY 3
DON'T KNOW 8

110) Do you treat your water in any way to make it safer to drink?

YES 1
NO 2 (GO TO 112)
DON'T KNOW 8 (GO TO 112)

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

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH/COTTON 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

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

MODERN FLUSH TOILET 11
TRADITIONAL TANK FLUSH 12
TRADITIONAL BUCKET FLUSH 13
PIT TOILET/LATRINE TOILET 21
BUCKET TOILET 41
NO FACILITY/FIELD 61 (GO TO 117)
OTHER (SPECIFY) ________________ 96

113) Into where does this toilet flush drain?

PIPED SEWER SYSTEM 01
VAULT (BAYARA) 02
SEPTIC SYSTEM 03
PIPED CONNECTED TO CANAL 04
PIPED CONNECTED TO GROUND WATER 05
EMPTIED (NO CONNECTION) 06
OTHER (SPECIFY) _______________ 96
DON'T KNOW WHERE 98

114) Are you or your neighbors currently experiencing any problems with this drainage system?

YES 1
NO 2 (GO TO 116)

115 What problems are you experiencing?

POOLING AROUND OWN DWELLING A
POOLING AROUND NEIGHBOR'S DWELLING B
COST OF EVACUATION C
MOSQUITOES/INSECTS D
OTHER (SPECIFY) ________________ X

116) Including your own household, how many households use this toilet?

NO. OF HOUSEHOLDS IF LESS THAN 10 __ __
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

117) Does your household have:

Electricity?
YES 1
NO 2
A radio with cassette recorder?
YES 1
NO 2
A color television?
YES 1
NO 2
A black and white television?
YES 1
NO 2
A video or DVD player?
YES 1
NO 2
A mobile?
YES 1
NO 2
A telephone?
YES 1
NO 2
A satellite dish?
YES 1
NO 2
A personal home computer?
YES 1
NO 2
A sewing machine?
YES 1
NO 2
An electric fan?
YES 1
NO 2
An air conditioner?
YES 1
NO 2

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

ELECTRICITY 01 (GO TO 120)
LPG 02 (GO TO 120)
NATURAL GAS 03 (GO TO 120)
BIOGAS 04 (GO TO 120)
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
OTHER (SPECIFY) _______________ 96

119) In your household, is food cooked on a stove or an open fire?
PROBE FOR TYPE.

OPEN FIRE OR STOVE WITHOUT CHIMNEY/HOOD 1
OPEN FIRE OR STOVE WITH CHIMNEY/HOOD 2
CLOSED STOVE WITH CHIMNEY 3
OTHER (SPECIFY) ________________ 6

120) 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 122)
OUTDOORS 3 (GO TO 122)
OTHER (SPECIFY) ________________ 6 (GO TO 122)

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

YES 1
NO 2

122) How does your household mainly dispose of kitchen waste
and trash?

RECORD MAIN METHOD OF DISPOSAL ONLY.
IF TWO OR MORE METHODS ARE USED EQUALLY, RECORD THE METHOD HIGHEST ON THE LIST.

COLLECTED
FROM HOME 11
FROM CONTAINER IN STREET 12
DUMPED
INTO STREET/EMPTY PLOT 21
INTO CANNAL/DRAINAGE 22
BURNED 31
FED TO ANIMALS 41
OTHER (SPECIFY) ______________ 96

123) Does your household have:

A refrigerator?
YES 1
NO 2
A freezer?
YES 1
NO 2
A water heater?
YES 1
NO 2
A dishwasher?
YES 1
NO 2
An automatic washing machine?
YES 1
NO 2
Any other washing machine?
YES 1
NO 2
A bed?
YES 1
NO 2
A sofa?
YES 1
NO 2
A hanging lamp (yellow with no cover)?
YES 1
NO 2
A table?
YES 1
NO 2
A "Tablia" (very low round table)?
YES 1
NO 2
A chair?
YES 1
NO 2
Kolla/Zeer (a container for reserving water)?
YES 1
NO 2

124) How many rooms does your household use for living (excluding the bathrooms, kitchens and stairway areas)?

ROOMS __ __

125) MAIN MATERIAL OF THE FLOOR.

RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC/MARBLE TILES 32
CEMENT TILES 33
CEMENT 34
WALL-TO-WALL CARPET 35
VINYL 36
OTHER (SPECIFY) _____________ 96

126) TYPE OF WINDOWS.

RECORD OBSERVATION.

ALL WINDOWS WITH GLASS 1
SOME WINDOWS WITH GLASS AND SOME WITHOUT GLASS 2
ALL WINDOWS WITHOUT GLASS 3
NO WINDOW OPENINGS 4

127) Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2

128) Does any member of this household own any land that can be used for agriculture?

YES 1
NO 2 (GO TO 130)

129) How many feddans or kirates of agricultural land do members of this household own?

IF MORE THAN 95 FEDDAN, ENTER '9995'.

LAND AREA
FEDAN __ __
KIRATE __ __
DON'T KNOW 9998

130) Does your household own any livestock, herds, or farm animals or any poultry or birds?

YES 1
NO 2 (GO TO 132)

131) How many of the following does your household own?

IF NONE, ENTER '00'.
IF MORE THAN 95, ENTER '95'.
IF UNKNOWN, ENTER '98'.

Cattle (buffalo, calf)?
__ __
Milk cows or bulls?
__ __
Horses, donkeys, or mules?
__ __
Goats?
__ __
Sheep?
__ __
Birds (Chickens, geese, ducks, and pigeons)?
__ __

132) Does any member of your household have an account in a bank or any saving institution?

YES 1
NO 2

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

RECORD PPM (PARTS PER MILLION)

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


WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT

CHECK COLUMNS 012-014: RECORD THE LINE NUMBER, NAME AND AGE OF ALL EVER-MARRIED WOMEN AGE 15-49, ALL CHILDREN UNDER AGE 6, AND MALE AND NEVER-MARRIED FEMALE ADOLESCENTS AGE10-19.

EVER-MARRIED WOMEN 15-49

201) LINE NO. FROM 012

__ __

202) NAME FROM 002)

_____________

203) AGE FROM 010

YEARS __ __

WEIGHT AND HEIGHT MEASUREMENT OF EVER-MARRIED WOMEN 15-49

205) WEIGHT (KILOGRAMS)

__ __ __ . __

206) HEIGHT (CENTIMETERS)

__ __ __. __

208) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

CHILDREN AGE 0-5

201) LINE NO. FROM 013

__ __

202) NAME FROM 002

_____________________

203) AGE FROM 010

__ __

204) What is (NAME)'s date of birth?

IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY.
IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH, AND YEAR.

DAY __ __
MONTH __ __
YEAR __ __ __ __

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN AGE 0-5

205) WEIGHT (KILOGRAMS)

__ __ __ . __

206) HEIGHT (CENTIMETERS)

__ __ __ . __

207) MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

208) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

MALE AND NEVER-MARRIED FEMALE ADOLESCENTS AGE 10-19

201) LINE NO. FROM 014

__ __

202) NAME FROM 002

______________________

203) AGE FROM 010

YEARS __ __

204) What is (NAME)'s date of birth?

IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY.
IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH, AND YEAR.

DAY __ __
MONTH __ __
YEAR __ __ __ __

WEIGHT AND HEIGHT MEASUREMENT OF ELIGIBLE ADOLESCENTS AGE 10-19

205) WEIGHT (KILOGRAMS)

__ __ __ . __

206) HEIGHT (CENTIMETERS)

__ __ __ . __

208) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

CHECK IN THE IDENTIFICATION SECTION ON THE COVER PAGE IF THE HOUSEHOLD ISINCLUDED IN THE ANEMIA SUBSAMPLE

IN THE SUBSAMPLE ___
NOT IN SUBSAMPLE ___ (GO TO 301)

HEMOGLOBIN MEASUREMENT OF EVER-MARRIED WOMEN 15-49

LINE NO. FROM 201 __ __

209) NAME
CHECK COLUMN (202):

______________________________

211) READ CONSENT STATEMENT TO WOMAN*
CIRCLE CODE (AND SIGN)

GRANTED 1
SIGN ______________
REFUSED 2 (GO TO NEXT LINE)

212) HEMOGLOBIN LEVEL (G/DL)

__ __. __

213) CURRENTLY PREGNANT

YES 1
NO/DON'T KNOW 2

214) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

HEMOGLOBIN MEASUREMENT OF CHILDREN AGE 0- 5 YEARS

LINE NO. FROM 201 __ __

209) NAME
CHECK COLUMN (202):

_________________________

210a) CHECK COLUMN (204)
CHILD AGE 0-5 MONTHS, I.E., BORN IN MONTH OF INTERVIEW OR PREVIOUS 5 MONTH?

AGE 0-5 MONTHS 1 (GO TO NEXT CHILD)
OTHER 2

210) LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

__ __

211) READ CONSENT STATEMENT TO PARENT/ PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

GRANTED 1
SIGN _______________
REFUSED 2 (GO TO NEXT LINE)

212) HEMOGLOBIN LEVEL (G/DL)

__ __ . __

214) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

HEMOGLOBIN MEASUREMENT OF MALE AND NEVER-MARRIED FEMALE ADOLESCENTS AGE 10-19

LINE NO. FROM 201 __ __

209) NAME
CHECK COLUMN (202):

_________________________

210a) CHECK COLUMN (203)
Yes

AGE 10-17 1
AGE 18-19 2 (GO TO 211)

210) LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

__ __

211) READ CONSENT STATEMENT TO ADOLEXCENT/PARENT/ PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

GRANTED 1
SIGN _______________
PARTENT/RESP ADULT REFUSED 2 (GO TO NEXT LINE)
ADOLESCENT REFUSED 3 (GO TO NEXT LINE)

212) HEMOGLOBIN LEVEL (G/DL)

__ __ . __

214) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

TICK HERE IF CONTINUATION SHEET USED ___

215) NAME OF MEASURER/TESTER __ __
NAME OF ASSISTANT __ __

* CONSENT STATEMENT
As part of this survey, we are studying anemia among women, children and adolescents. 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 request that you (and all children under age 6, and all male and never married female adolescents aged 10-19) to participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment 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 CHILD[REN]/ADOLESCENT) 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.


OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

301) INTERVIEWER'S OBSERVATIONS

COMMENTS ABOUT RESPONDENT:
____________________________________

COMMENTS ON SPECIFIC QUESTIONS:
____________________________________

ANY OTHER COMMENTS:
______________________________________

302) SUPERVISOR'S OBSERVATIONS
______________________________________

NAME OF SUPERVISOR: _________________________
DATE: __________

303) EDITOR'S OBSERVATIONS
______________________________________

NAME OF EDITOR: ________________________
DATE: _________