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EGYPT DEMOGRAPHIC AND HEALTH SURVEY 2014 HOUSEHOLD QUESTIONNAIRE

DATA COLLECTED FROM THIS STUDY ARE CONFIDENTIAL AND WILL BE USED FOR SCIENTIFIC PURPOSES ONLY.

IDENTIFICATION

GOVERNORATE____________
PSU/SEGMENT NO. ____________
KISM/MARKAZ_______________
BUILDING NO.________________
SHIAKHA/VILLAGE_____________
HOUSING UNIT NO.______________

URBAN/RURAL

URBAN 1
RURAL 2

HOUSEHOLD NO. ___________

ANEMIA TESTING SUBSAMPLE:

YES 1
NO 2

NAME OF HOUSEHOLD HEAD______________
ADDRESS IN DETAIL____________________

TELEPHONE:

CELLULAR______________
LANDLINE______________

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS):
DATE___________
TEAM__________
INTERVIEWER_______________
SUPERVISOR______________
RESULT________________

RESULT

1 COMPLETED
2 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

NEXT VISIT:
DATE_____________
TIME_________________

FINAL VISIT:
DAY______
MONTH_______
YEAR_________
TEAM_____
INT.NUMBER__________
SUP.NUMBER__________
RESULT______________

TOTAL NUMBER OF VISITS____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

FOR ALL HOUSEHOLDS:

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN AGE 15-49____
TOTAL ELIGIBLE FOR HEIGHT AND WEIGHT MEASUREMENT____

FOR HOUSEHOLDS IN ANEMIA TESTING SUBSAMPLE:

TOTAL ELIGIBLE FOR ANEMIA TESTING____

ADDRESS CHECKED BY: _____________________

YES 1
NO 2

RE-INTERVIEW:____________________

YES 1
NO 2

FIELD EDITOR
NAME______
DATE______
SIGNATURE_______

OFFICE EDITOR
NAME______
DATE_________
SIGNATURE________

CODER
NAME______
DATE________
SIGNATURE________

KEYER
NAME________
DATE___________
SIGNATURE_______

INTRODUCTION AND CONSENT

Hello. My name is______________

I am working with the Ministry of Health and Population.

We are conducting a survey about health all over Egypt. The information we collect will help the government 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 15 to 20 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 questions 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.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER:__________________ DATE:____________________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 001)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

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.

LINE NUMBER___

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 stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, GO TO QUESTIONS 005-009 TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 010-039 FOR EACH PERSON.

NAME___

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

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

004. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

005. Just to make sure that I have a complete household listing: Are there any other persons such as small children or infants that we have not listed?

YES (ADD TO 002)
NO

006. 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

007. 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

008. TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED

____

009. RECORD TOTAL PERSONS

__________

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

YES 1
NO 2

011. Did (NAME) sleep here last night?

YES 1
NO 2

012. AGE: How old was (NAME) at his/her last birthday?
RECORD IN COMPLETED YEARS. IF 95 OR MORE, RECORD '95.'

IN YEARS_____

013. MARITAL STATUS (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

014. ELIGIBILITY: CIRCLE LINE NUMBER OF EVER-MARRIED FEMALES

015. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MALES AGE 0-19

015A. ELIGIBILITY: CIRCLE LINE NUMBER OF NEVER-MARRIED FEMALES AGE 15-19

016. ELIGIBILITY: CIRCLE LINE NUMBER OF NEVER-MARRIED PERSONS AGE 1-17.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS

017. Is (NAME)'s natural mother alive?
QUESTION REFERS TO CHILD'S BIOLOGICAL MOTHER.

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

018. 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.'

LINE NUMBER________

019. Is (NAME)'s natural father alive?
QUESTION REFERS TO CHILD'S BIOLOGICAL FATHER.

YES 1
NO 2 (GO TO 025)
DON'T KNOW 8 (GO TO 025)

020. 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.'

LINE NUMBER________

021. CHECK 014 AND RECORD NUMBER ELIGIBLE FOR EVER-MARRIED WOMAN INTERVIEW.

NUMBER_____

022. CHECK 014, 015, AND 015A AND RECORD NUMBER ELIGIBLE FOR HEIGHT AND WEIGHT MEASUREMENT.

NUMBER_____

023. CHECK 014, 015, AND 015A AND RECORD NUMBER ELIGIBLE FOR ANEMIA TESTING.

NUMBER_____

024. CHECK 016 AND RECORD NUMBER ELIGIBLE FOR CHILD LABOR AND/OR DISCIPLINE MODULE.

NUMBER______

EDUCATION:

025. (IF AGE 6 YEARS OR OLDER) EVER ATTENDED SCHOOL: Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 037)

026. (IF AGE 6 YEARS OR OLDER) EVER ATTENDED SCHOOL:
What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

LEVEL_____
0 NURSERY SCHOOL
1 PRIMARY
2 PREPARATORY
3 SECONDARY
4 UPPER INTERMEDIATE
5 UNIVERSITY
6 MORE THAN UNIVERSITY
GRADE_____
0 LESS THAN 1 YEAR COMPLETED
8 DON'T' KNOW

027. CURRENT/RECENT SCHOOL ATTENDANCE (IF AGE 6-24 YEARS)
Did (NAME) attend school at any time during the current school year, that is, the 2013/2014 school year?

YES 1
NO 2

028. CURRENT/RECENT SCHOOL ATTENDANCE (IF AGE 6-24 YEARS)
During this school year, what level and grade (is/was) (NAME) attending?

LEVEL_____
0 NURSERY SCHOOL
1 PRIMARY
2 PREPARATORY
3 SECONDARY
4 UPPER INTERMEDIATE
5 UNIVERSITY
6 MORE THAN UNIVERSITY
GRADE_______
8 DON'T' KNOW

029. EARLY CHILDHOOD EDUCATION PROGRAM ATTENDANCE (IF AGE 3-5 YEARS)
Is (NAME) currently attending kindergarten, a private nursery school, or other program to prepare him/her for primary school?

IF NO: Has (NAME) ever attended any type of program to prepare him/her for school?

1 YES, CURRENTLY
2 YES, IN PAST, NOT CURRENTLY
3 NO

030. EARLY CHILDHOOD EDUCATION PROGRAM ATTENDANCE (IF AGE 3-5 YEARS)
Within the last seven days, how many hours did (NAME) attend kindergarten, a private nursery school, or any other program.

IF DID NOT ATTEND IN LAST SEVEN DAYS, RECORD '00'

HOURS____

031. BIRTH REGISTRATION (IF AGE 0-4 YEARS): Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

1 HAS CERTIFICATE
2 REGISTERED
3 NEITHER
8 DON'T KNOW

032. CHILDCARE (IF AGE 0-4 YEARS): Sometimes adults taking care of children have to leave the house to go shopping, wash clothes, or for other reasons and have to leave young children. On how many days in the past week, was (NAME) left alone for more than one hour?

IF NEVER LEFT ALONE, RECORD '0.'

DAYS________

033. On how many days in the past week, was (NAME) left in the care of another child, that is, someone less than 10 years old, for more than one hour?

IF NEVER LEFT IN THE CARE OF ANOTHER CHILD, RECORD '0.'

DAYS________

034. HOME INJURY AND ACCIDENTS (IF AGE 0-4 YEARS): Has (NAME) ever been injured or involved in an accident at home?

YES 1
NO 2 (GO TO 037)

035. HOME INJURY AND ACCIDENTS (IF AGE 0-4 YEARS): What type of injury(ies) or accident(s) did (NAME) have?
CIRCLE CODE FOR EACH TYPE OF INJURY OR ACCIDENT MENTIONED

A BURN
B FRACTURE
C OPEN WOUND
D ELECTRIC SHOCK
X OTHER

036. HOME INJURY AND ACCIDENTS (IF AGE 0-4 YEARS)
Did the injury or accident (NAME) had at home require medical?

YES 1
NO 2

037. DISABILITY (IF AGE 0-9 YEARS): Does (NAME) have any physical, mental or other condition(s) or disability(ies) that make(s) it difficult for (him/her) to carry out daily activities in the same manner as other people (his/her)age?

YES 1
NO 2 (GO TO NEXT PERSON/101)

038. DISABILITY (IF AGE 0-9 YEARS): What type of disability(ies) does (NAME) have?
CIRCLE CODE FOR EACH TYPE OF DISABILITY MENTIONED

A AUTISM/OTHER MENTAL
B VISUAL
C MOTOR
D AUDITORY
E SPEECH
X OTHER

039. DISABILITY (IF AGE 0-9 YEARS): How old was (NAME) when he first showed signs of a disability?
RECORD AGE WHEN DISABILITY STARTED. IF CHILD WAS BORN WITH A DISABILITY RECORD '94.' IF CHILD WAS LESS THAN ONE YEAR OLD WHEN A DISABILITY FIRST OCCURRED, RECORD '00.'

AGE_____

HOUSEHOLD ENVIRONMENT AND POSSESSIONS

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)

103. What kind of toilet facility do members of your household usually use?
IF FLUSH OR POUR FLUSH, PROBE: Where does it flush to?

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO VAULT (BAYARA) 12
FLUSH TO SEPTIC SYSTEM 13
FLUSH TO PIPE CONNECTED TO CANAL 14
FLUSH TO PIP CONNECTED TO GROUND WATER 15
FLUSH TO SOMEWHERE ELSE 16
FLUSH, DON'T KNOW WHERE 17
PIT TOILET/LATRINE TOILET
VENTILATED IMPROVED PUT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPENING PIPE 23
COMPOSTING TOIL 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY 61 (GO TO 106)
OTHER (SPECIFY)____________ 96

104. Do you share this facility with other households?

YES 1
NO 2 (GO TO 106)

105. How many households use this toilet?

NO. OF HOUSEHOLDS IF LESS THAN 10 __ __

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

106. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 109)
PIPED INTO YARD/PLOT 12 (GO TO 109)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 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
BOTTLED WATER 91
OTHER (SPECIFY) 96

107. Where is (SOURCE IN 106) located?

IN OWN DWELLING 1 (GO TO 109)
IN OWN YARD/PLOT (GO TO 109)
ELSEWHERE 3

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

MINUTES ______
DON'T KNOW 998

109. Do you treat your water in any way to make it safer to drink?

YES 1
NO 2 (GO TO 111)
DON'T KNOW 8 (GO TO 111)

110. What do you usually do to the water to make it safer to drink?
PROBE: 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

111. Does your household have:

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
COLOR TV
YES 1
NO 2
BLACK AND WHITE TV
YES 1
NO 2
VIDEO/DVD
YES 1
NO 2
SMART PHONE
YES 1
NO 2
OTHER MOBILE PHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
COMPUTER
YES 1
NO 2
SEWING MACHINE
YES 1
NO 2
ELECTRIC FAN
YES 1
NO 2
AIR CONDITIONER
YES 1
NO 2

112. Does your household own a satellite dish?
IF NO: In your home, are you connected to satellite from elsewhere?

YES, OWN DISH 1
NO, CONNECTED ONLY 2
NO 3

113. 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 CANAL/DRAINAGE 22
BURNED 31
FED TO ANIMALS 41
OTHER (SPECIFY)_____________96

114. Does your household have:

REFRIGERATOR
YES 1
NO 2
FREEZER
YES 1
NO 2
WATER HEATER
YES 1
NO 2
DISHWASHER
YES 1
NO 2
AUTOMATIC WASHER
YES 1
NO 2
OTHER WASHER
YES 1
NO 2
BED
YES 1
NO 2
SOFA
YES 1
NO 2
HANGING LAMP
YES 1
NO 2
TABLE
YES 1
NO 2
TABLIA
YES 1
NO 2
CHAIR
YES 1
NO 2
KOLLA/ZEER
YES 1
NO 2

115. How many rooms does your household use for sleeping?

ROOMS ______

116. 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

117. Does any member of this household own:

WATCH
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2

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

YES 1
NO 2

119. Does any member of this household own any land that can be used for agriculture?

YES 1
NO 2 (GO TO 121)

120. How many feddans or kirates of agricultural land do members of this household own?
IF MORE THAN 95 FEDDAN, ENTER '99.95'.

LAND AREA (FEDDAN)_______
LAND AREA (KIRATE)__________

DON'T KNOW 99.98

121. Does your household own any livestock, herds, or farm animals?

YES 1
NO 2 (GO TO 123)

122. 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?

Cattle (buffalo, calf)?
CATTLE____
Milk cows or bulls?
COWS/BULLS___
Horses, donkeys, or mules?
HORSES/DONKEYS/MULES____
Goats?
GOATS_____
Sheep?
SHEEP____

123. Does your household own any poultry or birds?

YES 1
NO 2 (GO TO 125)

124. How many of the following does your household have?
IF NONE, ENTER '00'
IF MORE THAN 95, ENTER '95.'
IF UNKNOWN, ENTER '98'.

Chickens?
Geese?
Ducks?
Pigeons?
Quail?
Turkey?
Ornamental/song birds?
Any other birds?

Chickens?
CHICKENS____
Geese?
GEESE____
Ducks?
DUCKS____
Pigeons?
PIGEONS_____
Quail?
QUAIL____
Turkey?
TURKEY______
Ornamental/song birds?
ORNAMENTAL/SONG BIRDS______
Any other birds?
OTHER_____

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

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

126. Please show me where members of your household most often was their hands?

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 129)
NOT OBSERVED, NO PERMISSION TO SEE 3(GO TO 129)
NOT OBSERVED, OTHER REASON 4(GO TO 129)

127. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

128. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE Y

129. CHECK IDENTIFICATION PAGE:

IN ANEMIA TESTING SUBSAMPLE (GO TO 130)
NOT IN ANEMIA TESTING SUBSAMPLE (GO TO 131)

130. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TESTING SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON)___________ 6

131. CHECK THE NUMBER OF HOUSEHOLD MEMBERS AGE 1-17 YEARS RECORDED IN 016.

NO MEMBER 1 (GO TO 300)
ONE MEMBER 2 (GO TO 204)
TWO OR MORE MEMBERS 3

CHILD LABOR AND DISCIPLINE MODULE

201. FOLLOW INSTRUCTIONS AND COMPLETE COLUMNS 1-5 IN TABLE 1

(a) Check Q. 016 in the household listing then list each of the never-married children aged 1-17 years below in the order they appear in the Household Listing Form. Do not include other household members outside the age range 1-17 years.

(b) Record the line number, name, sex and age for each child.

(c) Then record the total number of children aged 1-17 in Q202; if more than 9 children, record 9.

CHILDREN AGED 1-17 YEARS ELIGIBLE FOR CHILD LABOR AND DISCIPLINE QUESTIONS

1. RANK NUMBER

________

2. LINE NUMBER

_______

3. NAME

_______

4. SEX

MALE 1
FEMALE 2

5. AGE

____

202. RECORD THE TOTAL NUMBER OF CHILDREN IN TABLE 1

______

203. FOLLOW INSTRUCTIONS AND COMPLETE TABLE 2 IN ORDER TO IDENTIFY THE CHILD FOR WHOM THE CHILD LABOR AND DISCIPLINE MODULE WILL BE ADMINISTERED.

(b) Check the last digit of the household questionnaire serial number of the cover page. This is the number of the row you should go to in the table below.

(c) Check the total number of eligible children age 1-17 in Question 202 above. This is the number of the column you should go to.

(d) Find the box where the row and the column meet and circle the number that appears in the box. This is the rank number of the child (see Column 1 in Table 1) about whom the questions on child labor and/or child discipline may be asked, depending on the child's age.

TABLE 2: SELECTION OF RANDOM CHILD FOR CHILD LABOR AND DISCIPLINE QUESTIONS:

LAST DIGIT OF HOUSEHOLD NUMBER______
TOTAL NUMBER OF ELIGIBLE CHILDREN IN THE HOUSEHOLD______
RANK NUMBER OF CHILD _____

CHILD LABOR MODULE:

204. CHECK AGE Q012:

5-17 YEARS (GO TO 205)
1-4 YEARS (GO TO 231)

205. CHECK TABLE 2 AND RECORD THE RANK NUMBER SELECTED FOR THE MODULE. THEN CHECK TABLE 1 AND RECORD THE NAME OF THE CHILD CORRESPONDING TO THE RANK NUMBER. ASK QUESTIONS 206 TO 229 AS APPROPRIATE FOR THIS CHILD.

RANK NUMBER_____
NAME:_________

Now I would like to ask about any work children in the household may do. Since last (DAY OF THE WEEK), did (NAME) do any of the following activities, even for only one hour?

206. Did (NAME) do any work or help on his/her own or the household's plot/farm/food garden or look after animals? For example, growing farm produce, harvesting or feeding, grazing, or milking animals?

YES 1
NO 2

207. Did (NAME) help in family business or relative's business with or without pay, or run his/her business?

YES 1
NO 2

208. Did (NAME) produce or sell articles, handicrafts, clothes, food or agricultural products?

YES 1
NO 2

209. Since last (DAY OF THE WEEK), did (NAME) engage in any other activity in return for income in cash or in kind, even for only one hour?
IF NO: Please include any activity (NAME) performed as a regular or casual employee, self-employed, or employer, or as an unpaid family worker helping in household business or farm.

YES 1
NO 2

210. CHECK 206-209.

AT LEAST ONE 'YES' (GO TO 211)
ALL 'NO' (GO TO 220)

211. Since last (DAY OF THE WEEK), about how many hours did (NAME) engage in this activity (these activities), in total?
IF LESS THAN ONE HOUR, RECORD 00.
IF MORE THAN 95, RECORD 95.

HOURS ______

212. Does this activity (Do these activities) require carrying heavy loads?

YES 1 (GO TO 220)
NO 2

213. Does this activity (Do these activities) require working with dangerous tools (knives, etc.) or operating heavy equipment?

YES 1 (GO TO 220)
NO 2

How would you describe the work environment of (NAME)?

214. Is (NAME) exposed to dust, fumes, or gas?

YES 1 (GO TO 220)
NO 2

215. Is (NAME) exposed to extreme cold, heat, or humidity?

YES 1 (GO TO 220)
NO 2

216. Is (NAME) exposed to loud noise or vibration?

YES 1 (GO TO 220)
NO 2

217. Is (NAME) require to work at heights?

YES 1 (GO TO 220)
NO 2

218. Is (NAME) required to work with chemicals (pesticides, glues, etc. ) or explosives?

YES 1 (GO TO 220)
NO 2

219. Is (NAME) exposed to other things, processes or conditions bad for (NAME's) health or safety?

YES 1
NO 2

220. Since last (DAY OF THE WEEK), did (NAME) fetch water or collect firewood for the household?

YES 1
NO 2 (GO TO 222)

221. In total, how many hour, did (NAME) spend on fetching water or collecting firewood for household use, since last (DAY OF THE WEEK)?
IF LESS THAN ONE HOUR, RECORD 00.
IF MORE THAN 95, RECORD 95.

HOURS ______

Since last (DAY OF THE WEEK), did (NAME) do any of the following for the household:

222. Shopping for the household?

YES 1
NO 2

223. Repair any household equipment?

YES 1
NO 2

224. Cooking or cleaning utensils for the household?

YES 1
NO 2

225. Washing clothes?

YES 1
NO 2

226. Caring for children?

YES 1
NO 2

227. Caring for the old or sick?

YES 1
NO 2

228. Other household tasks?

YES 1
NO 2

228A. CHECK Q222-Q228:

AT LEAST ONE 'YES' (GO TO 229)
ALL "NO" (GO TO 230)

229. Since last (DAY OF THE WEEK), how many hours, did (NAME) engage in this activity (these activities), in total?
IF LESS THAN ONE HOUR, RECORD 00.
IF MORE THAN 95, RECORD 95.

HOURS_______

230. CHECK AGE Q012:

5-14 YEARS (GO TO 232)
15-17 YEARS (GO TO 300)

231. CHECK TABLE 2 AND RECORD THE RANK NUMBER SELECTED FOR THE MODULE. THEN CHECK TABLE 1 AND RECORD THE NAME OF THE CHILD CORRESPONDING TO THE RANK NUMBER.

ASK QUESTIONS 232 AND 233 FOR THIS CHILD.

RANK NUMBER _____
NAME:______________

232. Adults use certain ways to teach children the right behavior or to address a behavior problem. I will read various methods that are used. Please tell me if you are anyone else in your household has used this method with (NAME) in the past month.

a) Took away privileges, forbade something (NAME) liked, or did not allow him/her to leave the house?
YES 1
NO 2
b) Explained why (NAME)'s behavior was wrong?
YES 1
NO 2
c) Shook him/her?
YES 1
NO 2
d) Shouted, yelled at or screamed at him/her?
YES 1
NO 2
e) Gave him/her something else to do?
YES 1
NO 2
f) Spanked, hit or slapped him/her on the bottom with bare hand?
YES 1
NO 2
g) Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object?
YES 1
NO 2
h) Called him/her dumb, lazy, or another name like that?
YES 1
NO 2
i) Hit or slapped him/her on the face, head or ears?
YES 1
NO 2
j) Hit or slapped on the hand, arm or leg?
YES 1
NO 2
k) Beat him/her up, that is hit him/her over and over as hard as one could?
YES 1
NO 2

233. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?

YES 1
NO 2
DON'T KNOW/ NO OPINION 8

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

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

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 301.

IF ONLY ONE ELIGIBLE WOMAN WRITE THE NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO.

CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 014) IN THE HOUSEHOLD SCHEDULE. CIRCLE THIS NUMBER AT THE TOP OF THE TABLE TO DETERMINE THE COLUMN NUMBER YOU SHOULD USE.

FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER FO THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)______
TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 014_______
NUMBER OF WOMEN SELECTED_________
NAME OF WOMAN__________
LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE SECTION _______

WEIGHT AND HEIGHT MEASUREMENT

301. CHECK COLUMNS 014, 015, AND 015A IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL PERSONS ELIGIBLE FOR HEIGHT AND WEIGHT MEASUREMENT. BEGIN WITH EVER-MARRIED WOMEN AGE 15-49 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 014 CONTINUE WITH ALL MALES AGE 0-19 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015. THEN RECORD INFORMATION FOR ALL NEVER MARRIED FEMALES AGE 0-19 YEARS WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015A. IF MORE THAN NINE PERSONS, USE AN ADDITIONAL QUESTIONNAIRE.

302. LINE NUMBER FROM COLUMN 014-015 OR 015A
NAME FROM COLUMN 002

LINE NUMBER_______
NAME_________

303. What is (NAME)'s birth date?
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________

304. CHECK 303 MONTH AND YEAR OF BIRTH:
IS THE YEAR OF BIRTH 1994 OR LATER?

YES 1
NO 2 (GO TO 302A FOR NEXT PERSON OR, IF NO MORE PERSONS, GO TO 400)

305. WEIGHT IN KILOGRAMS

KG_____.____

NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6

306. HEIGHT IN CENTIMETERS

CM. _____.___

NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6

307. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

308. GO BACK TO 302A IN NEXT COLUMN OF THIS PAGE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE ELIGIBLE PERSONS, GO TO 309.

309. NAME OF MEASURER

__________

NAME OF ASSISTANT

___________

HEMOGLOBIN MEASUREMENT

400. CHECK: IF HOUSEHOLD IN THE ANEMIA SUBSAMPLE

IN ANEMIA TESTING SUBSAMPLE (GO TO 401)
NOT IN ANEMIA SUBSAMPLE (GO TO 501)

401. CHECK COLUMNS 014 , 015 AND 015A IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL PERSONS ELIGIBLE FOR ANEMIA TESTING. BEGIN WITH EVER-MARRIED WOMEN AGE 15-49 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 014 CONTINUE WITH ALL MALES AGE 0-19 WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015. THEN RECORD INFORMATION FOR ALL NEVER-MARRIED FEMALES AGE 0-19 YEARS WHOSE LINE NUMBER IS CIRCLED IN COLUMN 015A. IF MORE THAN NINE PERSONS, USE AN ADDITIONAL QUESTIONNAIRE.

402. CHECK 302: RECORD NAME AND LINE NUMBER.

LINE NUMBER_________
NAME_________

403. FROM 302 RECORD AGE

EVER MARRIED WOMAN AGE 15-49 YEARS 1 (GO TO 410)
AGE 0-19 2

404. RECORD FROM QUESTION 303 DATE OF BIRTH.

DAY________
MONTH_________
YEAR__________

405. CHECK 404: IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 402 FOR NEXT PERSON OR, IF NO MORE PERSONS, GO TO 501)
OLDER THAN 5 MONTHS 2

406. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD IN HOUSEHOLD SCHEDULE.

LINE NUMBER_________

407. ASK FOR CONSENT FOR ANEMIA TEST FOR ELIGIBLE CHILD OR ADOLESCENT FROM ADULT IDENTIFIED IN 406 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 1994 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 members 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.

408. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGN)___________1
REFUSED 2 (GO TO 414 AND CIRCLE 99.5)

409. CHECK COLUMN 012 AND RECORD AGE.

AGE 15-19 1
AGE 6 MONTH-14 YEARS 2 (GO TO 414)

410. ASK FOR CONSENT FOR ANEMIA TEST FOR ELIGIBLE ADULT.

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 testing, we will 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 your parent/guardian) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

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 members 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 take the anemia test?

411. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGN)________1
REFUSED 2 (GO TO 414 AND CIRCLE 99.5)

412. CHECK COLUMN 013 MARITAL STATUS

EVER-MARRIED WOMAN AGE 15-49 YEARS 1
OTHER 2 (GO TO 414)

413. PREGNANCY STATUS: CHECK 226 IN EVER-MARRIED WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

414. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

G/DL___.__

NOT PRESENT 99.4
REFUSED 99.5
OTHER 99.6

415. GO BACK TO 402 IN NEXT COLUMN OF THIS PAGE OR IN THE FIST COLUMN OF THE NEXT PAGE; IF NO MORE ELIGIBLE PERSON, GO TO 416.

416. NAME OF TECHNICIAN

__________

NAME OF ASSISTANT

____________

INTERVIEWER OBSERVATIONS:

TO BE FILLED IN AFTER COMPLETING INTERVIEW

501. COMMENTS ABOUT RESPONDENT:
_________________________________________________________________________
_________________________________________________________________________
______________________________

502. COMMENTS ON SPECIFIC QUESTIONS:
_________________________________________________________________________
_________________________________________________________________________
_____________________________

503. ANY OTHER COMMENTS:
_________________________________________________________________________
_________________________________________________________________________
_____________________________

504. TECHNICIAN'S OBSERVATIONS
_________________________________________________________________________
_________________________________________________________________________
_____________________________

NAME OF TECHNICIAN: ______________________
DATE:___________________________

505. SUPERVISOR'S OBSERVATIONS
_________________________________________________________________________
_________________________________________________________________________
_____________________________

NAME OF SUPERVISOR_________________
DATE______________________

506. EDITOR'S OBSERVATIONS
_________________________________________________________________________
_________________________________________________________________________
_____________________________

NAME OF EDITOR____________
DATE________________