IDENTIFICATION

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

URBAN/RURAL

LOCALITY

ANEMIA SUBSAMPLE:

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:

TOTAL PERSONS IN HOUSEHOLD __ __

TOTAL ELIGIBLE WOMEN __ __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __

ADDRESSED CHECKED BY: ________________

REINTERVIEW:

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:

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

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

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

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

MARITAL STATUS

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

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?

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?

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

CODES FOR Q006
RELATIONSHIP TO HEAD OF HOUSEHOLD:

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.

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.

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?

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)

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

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

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?

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

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

CODES FOR Q025

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?

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.

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?

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?

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.

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?

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.

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

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).

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?

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

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

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

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

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

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

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

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

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

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

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

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

113) Into where does this toilet flush drain?

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

115 What problems are you experiencing?

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

117) Does your household have:

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

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

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

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

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.

123) Does your household have:

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

125) MAIN MATERIAL OF THE FLOOR.

RECORD OBSERVATION.

126) TYPE OF WINDOWS.

RECORD OBSERVATION.

127) Does any member of this household own:

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

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

IF MORE THAN 95 FEDDAN, ENTER '9995'.

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

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

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

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

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

RECORD PPM (PARTS PER MILLION)

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

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

205) WEIGHT (KILOGRAMS)

206) HEIGHT (CENTIMETERS)

208) RESULT

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.

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN AGE 0-5

205) WEIGHT (KILOGRAMS)

206) HEIGHT (CENTIMETERS)

207) MEASURED LYING DOWN OR STANDING UP

208) RESULT

MALE AND NEVER-MARRIED FEMALE ADOLESCENTS AGE 10-19

201) LINE NO. FROM 014

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.

WEIGHT AND HEIGHT MEASUREMENT OF ELIGIBLE ADOLESCENTS AGE 10-19

205) WEIGHT (KILOGRAMS)

206) HEIGHT (CENTIMETERS)

208) RESULT

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

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)

212) HEMOGLOBIN LEVEL (G/DL)

213) CURRENTLY PREGNANT

214) RESULT

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?

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)

212) HEMOGLOBIN LEVEL (G/DL)

214) RESULT

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

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)

212) HEMOGLOBIN LEVEL (G/DL)

214) RESULT

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: _________