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DEMOGRAPHIC AND HEALTH SURVEY-ETHIOPIA 2005-HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

LOCALITY NAME ____________________

NAME OF HOUSEHOLD HEAD __________________________

CLUSTER NUMBER ___ ___ ___

HOUSEHOLD NUMBER ___ ___

REGION ___ ___

LARGE CITY/SMALL CITY/TOWN/RURAL:

LARGE CITY 1
SMALL CITY 2
TOWN 3
RURAL 4

ALTITUDE ___ ___ ___ ___

HOUSEHOLD SELECTED FOR MALE INTERVIEW?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER'S NAME____
RESULT___

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

NEXT VISIT:
DATE____
TIME___

FINAL VISIT
DAY ___ ___
MONTH ___ ___
YEAR ___ ___ ___ ___
INTERVIEWER NUMBER __ ___
RESULT ___

TOTAL NUMBER OF VISITS ___

TOTAL PERSONS IN HOUSEHOLD ___ ___

TOTAL ELIGIBLE WOMEN ___ ___

TOTAL ELIGIBLE MEN ___ ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___ ___

LANGUAGE OF QUESTIONNAIRE:

AMARIGNA 1
OROMIGNA 2
TIGRIGNA 3
OTHER 6

LANGUAGE OF INTERVIEW:

AMARIGNA 1
OROMIGNA 2
TIGRIGNA 3
OTHER 6

LANGUAGE OF RESPONDENT:

AMARIGNA 1
OROMIGNA 2
TIGRIGNA 3
OTHER 6

TRANSLATOR USED:

YES 1
NO 2

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 NO.

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 the household.

NAME_____________________________

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

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

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

MALE 1
FEMALE 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)?

IN YEARS___ ___


ELIGIBILITY:

8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

8A) CHECK COVER PAGE. IF HOUSEHOLD SELECTED FOR MALE INTERVIEW: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

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

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

YES 1
NO 2 (GO TO 12)
DON'T KNOW 8 (GO TO 12)

11) Does (NAME)'s biological mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. RECORD '00' IF PARENT NOT LISTED IN THE HOUSEHOLD SCHEDULE.

LINE NUMBER___ ___

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

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

13) Does (NAME)'s biological father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. RECORD '00' IF PARENT NOT LISTED IN THE HOUSEHOLD SCHEDULE.

LINE NUMBER ___ ___

EDUCATION IF AGE 5 YEARS OLDER:

14) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

15) What is the highest grade (NAME) completed?

GRADE ___ ___
LESS THAN 1 YEAR COMPLETED 00
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE OR HIGHER 15
DON'T KNOW 98

EDUCATION IF AGE 5-24 YEARS:

16) Did (NAME) attend school at any time during the 1997 E.C. school year?

YES 1
NO 2 (GO TO 18)

17) During this/that school year, what grade [is/was] (NAME) attending?

GRADE ___ ___
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE OR HIGHER 15
DON'T KNOW 98

18) Did (NAME) attend school at any time during the previous school year, that is 1996 E.C.?

YES 1
NO 2 (GO TO NEXT LINE)

19) During that school year, what grade did (NAME) attend?

GRADE ___ ___
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE OR HIGHER 15
DON'T KNOW 98

BIRTH REGISTRATION IF AGE 0-4:

20) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the municipality/local authorities?

CERTIFICATE 1
REGISTRATION 2
NEITHER 3
DON'T KNOW 8

TICK HERE IF CONTINUATION SHEET USED___

Just to make sure that I have a complete household 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) 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 (ENTER EACH IN TABLE)
NO

3) Are there any guests or temporary visitors staying here, or anyone else who slept 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 household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 26)
PIPED INTO COMPOUND 12 (GO TO 26)
PIPED OUTSIDE COMPOUND 13 (GO TO 23)
TUBE WELL OR BOREHOLE 21 (GO TO 23)
DUG WELL
PROTECTED WELL 31 (GO TO 23)
UNPROTECTED WELL 32 (GO TO 26)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 23)
UNPROTECTED SPRING 42 (GO TO 23)
RAINWATER 51 (GO TO 26)
TANKER TRUCK 61 (GO TO 23)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 23)
BOTTLED WATER 91
OTHER (SPECIFY) ________________ 96 (GO TO 23)

22. 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 26)
PIPED INTO COMPOUND 12 (GO TO 26)
PIPED OUTSIDE COMPOUND 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 26)
TANKER TRUCK 61
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER (SPECIFY) ________________ 96

23. Where is that water source located?

IN OWN DWELLING 1 (GO TO 26)
IN OWN COMPOUND 2 (GO TO 26)
ELSEWHERE 3

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

MINUTES ___ ___ ___

ON PREMISES 996 (GO TO 26)
DON'T KNOW 998

25. Who usually goes to this source to fetch the water for your household?

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

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

YES 1
NO 2 (GO TO 27A)
DON'T KNOW 8 (GO TO 27A)

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

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY)______________ X

27A. How does your household primarily dispose of household waste?

COLLECTED BY MUNICIPALITY 1
COLLECTED BY PRIVATE ESTABLISHMENT 2
DUMPED IN STREET/OPEN SPACE 3
DUMPED IN RIVER 4
BURNED 5
OTHER (SPECIFY) _________ 6
DON'T KNOW 8

28. What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE (VIP) 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 31)
OTHER (SPECIFY) ___________ 96

29. Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 31)

30. How many households use this toilet facility?

NUMBER OF HOUSEHOLDS IF LESS THAN 10 ___

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

31. Does your household have:

Electricity?
YES 1
NO 2
A watch?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A mobile telephone?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A table?
YES 1
NO 2
A chair?
YES 1
NO 2
A bed?
YES 1
NO 2
An electric mitad?
YES 1
NO 2
A kerosene lamp/pressure lamp?
YES 1
NO 2

32. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01 (GO TO 34)
LPG 02 (GO TO 34)
NATURAL GAS 03 (GO TO 34)
BIOGAS 04 (GO TO 34)
KEROSENE 05
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
ANIMAL DUNG 11
OTHER (SPECIFY) _________ 96

33. In this 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

34. 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 36)
OUTDOORS 3 (GO TO 36)
OTHER (SPECIFY) _________ 6 (GO TO 36)

35. Do you have a separate room which is used as a kitchen?

YES 1
NO 2

36. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
REED/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL 32
CERAMIC TILES 33
CEMENT/BRICKS 34
CARPET 35
OTHER(SPECIFY) ____________ 96

37. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
THATCH/LEAF 12
RUDIMENTARY ROOFING
RUSTIC MAT/PLASTIC SHEETS 21
REED/BAMBOO 22
WOOD PLANKS 23
FINISHED ROOFING
CORRUGATED IRON 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CEMENT/CONCRETE 35
ROOFING SHINGLES 36
OTHER (SPECIFY)_____________ 96

38. MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/TRUNKS/BAMBOO/REED 12
RUDIMENTARY WALLS
BAMBOO/WOOD WITH 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARTON 25
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY)___________ 96

39. TYPE OF WINDOWS.
RECORD OBSERVATION.

ANY WINDOWS
YES 1
NO 2
WINDOWS WITH GLASS
YES 1
NO 2
WINDOWS WITH SCREENS
YES 1
NO 2
WINDOWS WITH CURTAINS OR SHUTTERS
YES 1
NO 2

40. How many rooms in this household are used for sleeping?

ROOMS ___ ___

41. Does any member of this household own:

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
A boat without a motor?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 44)

43. How many (LOCAL UNITS) of agricultural land do members of this household own?
IF MORE THAN 97, ENTER '97'. IF UNKNOWN, ENTER '98'

LOCAL UNITS (SPECIFY)_____

44. Does this household own any livestock, herds, or farm animals?

YES 1
NO 2 (GO TO 46)

45. How many of the following animals does this household own?
Cattle?
Milk cows, oxen, or bulls?
Horses, donkeys, or mules?
Camels?
Goats?
Sheep?
Chickens?

IF NONE, ENTER '00'
IF MORE THAN 97, ENTER '97'
IF UNKNOWN, ENTER '98'

CATTLE___
COWS/OXEN/BULLS____
HORSES/DONKEYS/MULES____
CAMELS____
GOATS___
SHEEP___
CHICKENS___

46. Does any member of this household have an account with a bank/credit association/micro finance?

YES 1
NO 2

48. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 48K)

48A. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS ___

48B. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

48C. How long ago did your household obtain the mosquito net?

MONTHS AGO ___ ___
MORE THAN 3 YEARS AGO 95

48D. OBSERVE OR ASK THE BRAND OF MOSQUITO NET.

PERMANENT NET
PERMANET 2 1 (GO TO 48H)
PRETREATED NET
SIAM DUTCH THAILAND 2 (GO TO 48F)
UNTREATED NET
A TO Z TANZANIA 3
OTHER 6
UNSURE 8

48E. When you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?

YES 1
NO 2
NOT SURE 8

48F. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?

YES 1
NO 2 (GO TO 48H)
NOT SURE 8 (GO TO 48H)

48G. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS AGO ___ ___

MORE THAN 2 YEARS AGO 95
NOT SURE 98

48H. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 48J)
NOT SURE 8 (GO TO 48J)

48I. Who slept under this mosquito net last night?

NAME ______
LINE NO. ___ ___

48J. GO BACK TO Q.48B FOR NEXT NET; OR IF NO MORE NETS, GO TO Q.48K.

48K. Has your house ever been sprayed with insecticide for malaria prevention by spraymen from the District Health Office?

YES 1
NO 2 (GO TO 49)
NOT SURE 8 (GO TO 49)

48L. How many months ago was your house sprayed?
IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS AGO ___ ___
NOT SURE 98

48M. OBSERVE THE INNER WALLS OF THE ROOMS USUALLY USED FOR SLEEPING FOR VISIBLE WHITE INSECTICIDE POWDER.

VISIBLE 1
NOT VISIBLE 2

49. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
LESS THAN 15 PPM 2
MORE THAN 15 PPM 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED (SPECIFY REASON) ______________ 5

WEIGHT AND HEIGHT MEASUREMENT

CHECK COVER PAGE:

HOUSEHOLD SELECTED FOR MALE SURVEY (GO TO 50)
HOUSEHOLD NOT SELECTED FOR MALE SURVEY (GO TO INTERVIEWER'S OBSERVATION ON LAST PAGE)

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

50) LINE NO. FROM COL. (8)

LINE NUMBER ___ ___

51) NAME FROM COL. (2)

NAME_________________________

52) AGE FROM COL. (7)

YEARS ___ ___

53) What is (NAME'S) date of birth?
[FOR CHILDREN UNDER AGE 6 ONLY]
FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

DAY____
MONTH____
YEAR____

54) WEIGHT (KILOGRAMS)

WEIGHT___ ___ ___.___

55) HEIGHT (CENTIMETERS)

HEIGHT___ ___ ___.___

56) MEASURED LYING DOWN OR STANDING UP
[FOR CHILDREN UNDER AGE 6 ONLY]

LYING 1
STANDING 2

57) RESULT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

TICK HERE IF CONTINUATION SHEET USED ___

HEMOGLOBIN MEASUREMENT

CHECK COVER PAGE:

HOUSEHOLD SELECTED FOR MALE SURVEY (GO TO 58)
HOUSEHOLD NOT SELECTED FOR MALE SURVEY (GO TO INTERVIEWER'S OBSERVATION ON LAST PAGE)

58) CHECK COLUMN (52):

AGE 15-17 1
AGE 18-49 2 (GO TO 60)

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

LINE NUMBER___ ___

60) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*

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

61) HEMOGLOBIN LEVEL (G/DL)

G/DL ___ ___. ___

62) CURRENTLY PREGNANT
[FOR WOMEN 15-49 ONLY]

YES 1
NO/DON'T KNOW 2

63) RESULT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

2005 Ethiopia Demographic and Health Survey Informed Consent Anemia Testing

Hello, my name is _____ and I am from the Population and Housing Census Commission Office, which, in collaboration with the Federal Ministry of Health is currently carrying out Demographic and Health Survey, all over the country, in scientifically, sampled enumeration areas. As part of this survey we are collecting information on Anemia prevalence among women and children in the sampled households by conducting Anemia testing.

Anemia is a serious health problem that results from poor nutrition. The Anemia testing is being done to help the government to find out how common it is. This enables the government to develop programs to prevent and treat anemia. But to do this it needs reliable information. That is why we are now collecting a few drops of blood from a finger from women and from children under six years of age for the test. The instruments I use for taking the blood are completely clean, sterile and 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.

Do you have any questions?

May I now ask that you and your child ___________ participate in the anemia test? However, if you decide not to have the test done, it is your right and I will respect your decision. Now please tell me if you agree to have the test done.

Yes ______ No __________
Signature of interviewer ________________________

64) CHECK 61 AND 62:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*

*The cutoff point is 9g/dl for pregnant women and ____ g/dl for children and for women who are not pregnant (or who don't know if they are pregnant), based on the altitude from the coverpage and the adjustment factor in the Editor's and Supervisor's Manual.

**If more than one woman or child is below the cutoff point, read the statement in Q.65 to each woman who is below the cutoff point and to each parent/responsible adult of a child who is below the cutoff point.

ONE OR MORE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH 65. **)
NONE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END INTERVIEW.)

65) We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This is indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the doctor at _____________________ about (your condition/the condition of NAME OF CHILD(REN)).
This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in (your blood/the blood of NAME OF (CHILD(REN)) may be given to the doctor?

AGREES TO REFERRAL?

YES 1
NO 2

HIV TESTING-WOMEN AND MEN

CHECK COVER PAGE

HOUSEHOLD SELECTED FOR MALE SURVEY (GO TO 66)
HOUSEHOLD NOT SELECTED FOR MALE SURVEY (GO TO INTERVIEWER'S OBSERVATION ON LAST PAGE)

CHECK COLUMNS (8) AND (8A): RECORD THE LINE NUMBER, SEX AND AGE OF ALL WOMEN AGE 15-49 AND MEN AGE 15-59. THIS PAGE WILL BE DESTROYED IN OFFICE BEFORE TEST RESULTS ARE ADDED TO DATA FILE

66) LINE NO. FROM COL. (8) OR (8A)

LINE NUMBER ___ ___

67) SEX FROM COL. (4)

MALE 1
FEMALE 2

68) AGE FROM COL. (7)

YEARS ___ ___

69) CHECK AGE FROM COL (68):

AGE 15-17 1
AGE 18+ 2 (GO TO 72)

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

LINE NUMBER ___ ___

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

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

72) READ CONSENT STATEMENT TO WOMAN/MAN
CIRCLE CODE (AND SIGN)

GRANTED 1 (SIGN________)
REFUSED 2 (GO TO NEXT LINE)

73) RESULT

SAMPLE TAKEN 1
REFUSED 2
NOT PRESENT 3
TECH. PROBLEM 4
OTHER (SPECIFY)_____ 6

74) SAMPLE BAR CODE

PASTE FIRST LABEL HERE
PASTE SECOND LABEL ON FILTER PAPER
PASTE THIRD LABEL ON BLOOD SAMPLE TRANSMITTAL FORM

2005 Ethiopia Demographic and Health Survey Informed Consent HIV testing

Hello, my name is ____________ and I am from the Population and Housing Census Commission Office, which, in collaboration with the Federal Ministry of Health, is currently carrying out the Demographic and Health Survey, all over the country, in scientifically, sampled enumeration areas. As part of this survey we are collecting information on HIV prevalence among women and men in sampled households by collecting blood for conducting an HIV test.

HIV is the virus that causes AIDS. The HIV test is being done to help the government to find out how common it is and its rate of spreading. This enables the government to devise means of controlling and preventing the spread of the disease and also provide care and support for those who have it. But to do this it needs reliable information. That is why we are now collecting a few drops of your blood from a finger for the HIV test.

The instruments I use for taking the blood are completely clean, sterile and safe. The samples will be coded so that all the information will be kept anonymous.

The blood sample will be sent to the Ethiopian Health and Nutrition Research Institute (EHNRI) Laboratory, in Addis Ababa. No identifiers such as names will be attached to the test. So we will not be able to tell you the result. No one else will be able to know your test results either.

If you want to know whether you have HIV, I can provide a voucher for you to go to the nearest health institution, which provides VCT, that is, counseling and a test for HIV.

Do you have any questions so far?

May I now ask you to participate in the test? You can say yes to the test or you can say no. It is up to you to decide.

Will you take the test?

Yes __________ No _____________
Signature of interviewer _____________________

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:______________________________________

COMMENTS ON SPECIFIC QUESTIONS:___________________________________

ANY OTHER COMMENTS: ____________________________

SUPERVISOR'S OBSERVATIONS: ____________________________________________

NAME OF THE SUPERVISOR: _______________________________ DATE:_____________________________