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ETHIOPIA DEMOGRAPHIC AND HEALTH SURVEY - 2010
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

LOCALITY NAME ______
NAME OF HOUSEHOLD HEAD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
REGION ______
ALTITUDE ______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULTS _____

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) ________

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER ______
RESULT _____

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

LANGUAGE OF QUESTIONNAIRE: 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 _____

INTRODUCTION AND CONSENT

Hello. My name is ______ and I am working with the Central Statistical Agency (CSA). We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 10 and 15 minutes to complete. As part of the survey we would first like to ask some questions about your household. Whatever information you provide will be kept strictly confidential, and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, and if we should come to any question 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. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER_____
DATE_____

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

HOUSEHOLD SCHEDULE

1. LINE NUMBER:

LINE NO. _____

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.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-19 FOR EACH PERSON.

NAME _____

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: 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 NIECE/NEPHEW BY BLOOD
10 NIECE/NEPHEW BY MARRIAGE
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NOT RELATED
98 DOESN'T KNOW

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

MALE 1
FEMALE 2

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

YES 1
NO 2

6. RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

7. AGE: How old is (NAME)?

AGE ____

MARITAL STATUS. IF AGE 15 OR OLDER:

8. What is (NAME'S) current marital status?

1 MARRIED
2 LIVING TOGETHER
3 DIVORCED/SEPARATED
4 WIDOWED
5 NEVER MARRIED AND NEVER LIVED TOGETHER

ELIGIBILITY:
9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

ELIGIBILITY:
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

ELIGIBILITY:
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

ELIGIBILITY:
11A. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 5-14.

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

12. Is (NAME)'s natural mother alive?

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

13. 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 NO. ____

14. Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 16)
DOESN'T KNOW 8 (GO TO 16)

15. 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 NO. _____

CHRONIC ILLNESS. IF AGE 18-59:

15A. Has (NAME) been very sick for at least 3 months in the last 12 months?
By very sick I mean (NAME) has been too sick to work or carry out normal activities at home?

YES 1
NO 2
DOESN'T KNOW 8

EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:

16. Has (NAME) ever attended school?

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

17. What is the highest level of school (NAME) has attended?
What is the highest grade/number of years (NAME) completed at that level?
IF PRIMARY OR SECONDARY, RECORD COMPLETED GRADE.
IF TECHNICAL/VOCATIONAL OR HIGHER, RECORD YEARS COMPLETED.

LEVEL______
1 PRIMARY
2 SECONDARY
3 TECHNICAL/VOCATIONAL
4 HIGHER
8 DOESN'T KNOW
GRADE ______
00 LESS THAN 1 YEAR COMPLETED
98 DOESN'T KNOW

CURRENT SCHOOL ATTENDANCE. IF AGE 5-24 YEARS:

18. Did (NAME) attend school at any time during the 2003 E.C. school year?

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

19. During this school year, what level and grade/year is (NAME) attending?
IF PRIMARY OR SECONDARY, RECORD COMPLETED GRADE.
IF TECHNICAL/VOCATIONAL OR HIGHER, RECORD YEARS COMPLETED.

LEVEL______
1 PRIMARY
2 SECONDARY
3 TECHNICAL/VOCATIONAL
4 HIGHER
8 DOESN'T KNOW
GRADE ______
98 DOESN'T KNOW

TICK HERE IF CONTINUATION SHEET USED _____

2A) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

2B) 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 TABLE)
NO

2C) Are there any guest or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

QUESTIONS ON CHILD LABOUR FOR CHILDREN AGE 5-14

20. CHECK COLUMN 11A. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 5-14 YEARS IN QUESTION 21. IF MORE THAN THREE CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). THEN PROCEED TO ASK QUESTIONS 22-28 OF MOTHERS OR CARETAKERS OF THE CHILDREN.

[ASK QUESTIONS 21-28 FOR ALL ELIGIBLE CHILDREN]

21. LINE NUMBER FROM COLUMN 1:
NAME FROM COLUMN 2:

LINE NO._____
NAME _____

22. During the past week, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: Was (NAME) paid in cash, kind, or not paid?

YES, PAID IN CASH/KIND 1
YES, UNPAID 2
NO 3 (GO TO 24)

23. During the past 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.

NO. OF HOURS _____

24. At any time during the past year, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: Was (NAME) paid in cash, kind, or not paid?

YES, PAID IN CASH/KIND 1
YES, UNPAID 2
NO 3

25. During the past week, did (NAME) help with household chores such as shopping, collecting fire wood, cleaning, or fetching water?

YES 1
NO 2 (GO TO 27)

26. During the past week, how many hours did (NAME) spend doing these chores?

NO. OF HOURS _____

27. During the past week, did (NAME) do any other family work, such as on the farm or in a business or selling goods in the street?

YES 1
NO 2 (GO BACK TO 22 FOR NEXT CHILD; IF NO MORE CHILDREN GO TO 101)

28. During the past week, how many hours did (NAME) do this work?

NO. OF HOURS_____ (GO BACK TO 22 FOR NEXT CHILD; IF NO MORE CHILDREN GO TO 101)

HOUSEHOLD CHARACTERISTICS

101. 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

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13 (GO TO 103)
BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK 71 (GO TO 103)
SURFACE WATER
RIVER/LAKE/POND/STREAM/DAM 81 (GO TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) _____ 96 (GO TO 103)

102A. What is the main source of water used by your household for other purposes such as cooking and hand washing?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER
RIVER/LAKE/POND/STREAM/DAM 81
OTHER (SPECIFY) _______ 96

103. Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES_____
DOESN'T KNOW 998

104A. 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

105. Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 107)
DOESN'T KNOW 8 (GO TO 107)

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

BOIL A
ADD BLEACH/CHLORINE/WATER GUARD/PUR/BISHAN GARI/AQUATABS B
STRAIN THROUGH A CLOTH C
BIO SAND/COMPOSITE/ CERAMIC POT FILTER D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z

107. What kind of toilet facility do members of your household usually use?
IF THE RESPONDENT DOES NOT UNDERSTAND WHICH TYPE OF TOILET THEY HAVE, ASK TO OBSERVE THE TOILET FACILITY AND CIRCLE THE APPROPRIATE CODE.

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, DOESN'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 110)
OTHER (SPECIFY) ______ 96

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

YES 1
NO 2 (GO TO 110)

109. How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN TEN ____

TEN OR MORE HOUSEHOLDS 95
DOESN'T KNOW 98

110. Does your household have:

Electricity?
A watch/clock?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
A table?
A chair?
A bed with cotton/sponge/spring mattress?
An electric mitad? A
A kerosene lamp/pressure lamp?

ELECTRICITY
YES 1
NO 2
WATCH/CLOCK
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
TABLE
YES 1
NO 2
CHAIR
YES 1
NO 2
A BED WITH COTTON/SPONGE/SPRING MATTRESS
YES 1
NO 2
ELECTRIC MITAD
YES 1
NO 2
KEROSENE LAMP/PRESSURE LAMP
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP 09
ANIMAL DUNG 10
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) ______ 96

112. 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 114)
OUTDOORS 3 (GO TO 114)
OTHER 6 (GO TO 114)

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

YES 1
NO 2

114. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.

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

115. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/LEAF/MUD 12
RUDIMENTARY ROOFING
RUSTIC MAT/PLASTIC SHEETS 21
REED/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
CORRUGATED IRON /METAL 31
WOOD 32
ASBESTOS/CEMENT FIBER 33
CEMENT/CONCRETE 34
ROOFING SHINGLES 35
OTHER (SPECIFY) _____ 96

116. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATIONS.

NATURAL WALLS
NO WALLS 11
CANE/TRUNKS/BAMBOO/REED 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO/WOOD WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) _____ 96

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

ROOMS_____

118. Does any member of this household own:

A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?

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

119. Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120. How many (LOCAL UNITS) of agricultural land do members of this household own?
IF '95' OR MORE, CIRCLE '950'.

LOCAL UNITS (SPECIFY) _____
LOCAL UNITS ______

95 OR MORE LOCAL UNITS 950
DOESN'T KNOW 980

121. Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 123)

122. How many of the following animals does this household own?
IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.

Milk cows, oxen or bulls?
Horses, donkeys, or mules?
Camels?
Goats?
Sheep?
Chickens?
Beehives?

COWS/BULLS/OXEN_____
HORSES/DONKEYS/MULES_____
CAMELS_____
GOATS_____
SHEEP_____
CHICKENS_____
BEEHIVES_____

123. Does any member of this household have a bank or microfinance saving account?

YES 1
NO 2

124. Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 127)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 127)
NOT OBSERVED, OTHER REASON 4 (GO TO 127)

125. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE SPECIFIC PLACE FOR HAND WASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

126. OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP.

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

127. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.

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

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

201. CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

[ASK QUESTIONS 202-212 FOR ALL ELIGIBLE CHILDREN]

202. LINE NUMBER FROM COLUMN 11:
NAME FROM COLUMN 2:

LINE NUMBER _____
NAME _____

203. IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

DAY _____
MONTH _____
YEAR _____

204. CHECK 203:
CHILD BORN IN MESKEREM 1998 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO Q214)

205. WEIGHT IN KILOGRAMS:

KG ______

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206. HEIGHT IN CENTIMETERS:

CM ____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208. CHECK 203:
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 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)

OLDER 2

209. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1 OF HOUSEHOLD SCHEDULE):
RECORD '00' IF NOT LISTED.

LINE NUMBER ____

210. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 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 request that all children born in Meskerem 1998 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking 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 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 allow (NAME(S) OF CHILD(REN)) to participate in the anemia test?

211. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
REFUSED 2 (SIGN) _____

212. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET:

G/DL_____

NOT PRESENT 994
REFUSED 995
OTHER 996

213. GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49

214. CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

[ASK QUESTIONS 215-242 FOR ALL ELIGIBLE WOMEN]

215. LINE NUMBER (COLUMN 9):
NAME (COLUMN 2):

LINE NUMBER ____
NAME _____

216. WEIGHT IN KILOGRAMS:

KG _____

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217. HEIGHT IN CENTIMETERS:

CM ____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

218. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 223)

219. MARITAL STATUS:
CHECK COLUMN 8.

CODE 5 (NEVER IN UNION) 1
OTHER 2 (GO TO 223)

220. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ____

221. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17:

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 in taking 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 told to you and to (NAME OF ADOLESCENT) 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 for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME OF ADOLESCENT) to take the anemia test?

222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) ______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 228)

223. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

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 in taking 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 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?

224. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 226)

225. PREGNANCY STATUS:
CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DOESN'T KNOW 8

226. AGE:
CHECK 218.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 230)

227. MARITAL STATUS:
CHECK 219.

CODE 5 (NEVER IN UNION) 1
OTHER 2 (GO TO 230)

228. ASK CONSENT FOR DBS COLLECTION FROM PARENT/ OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17:

As part of the survey we are also asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Ethiopia.

For the HIV test, we need a few (more) 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.

FOR SAMPLE CLUSTERS IN WHICH MOBILE VCT SERVICES WILL BE AVAILABLE: The Ministry of Health has also arranged for health workers to offer VCT services in this community shortly after our survey team leaves the area. The kebele leader will know when and where the VCT service will be available.

Do you have any questions?

If you want to ask more questions later or want to know who to talk with if (NAME OF ADOLESCENT) has any problem due to the study, I can give you information about how to contact the Regional Office of the CSA. PROVIDE CARD WITH CONTACT INFORMATION FOR CSA REGIONAL OFFICE IF REQUESTED.

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

229. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2(SIGN) ____ (GO TO 239)

230. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we are also asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Ethiopia.

For the HIV test, we need a few (more) 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know whether you have HIV, I can provide you with a list of (nearby) facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

FOR SAMPLE CLUSTERS IN WHICH MOBILE VCT SERVICES WILL BE AVAILABLE: The Ministry of Health has also arranged for health workers to offer VCT services in this community shortly after our survey team leaves the area. The kebele leader will know when and where the VCT service will be available.

Do you have any questions?

If you want to ask more questions later or want to know who to talk with if you have any problem due to the study, I can give you information about how to contact the Regional Office of the CSA. PROVIDE CARD WITH CONTACT INFORMATION FOR CSA REGIONAL OFFICE IF REQUESTED.

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 HIV test?

231. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER:

INTERVIEWER NUMBER _____
GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 239)

232. AGE:
CHECK 218.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 236)

233. MARITAL STATUS:
CHECK 219.

CODE 5 (NEVER IN UNION) 1
OTHER 2 (GO TO 236)

234. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER-IN-UNION WOMEN AGE 15-17:

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). Therefore, we will not be able to tell (NAME OF ADOLESCENT) the results of any test that is done. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

235. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 238)

236. ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

237. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) ____ (GO TO 239)
RESPONDENT REFUSED 2 (SIGN) _____

238. ADDITIONAL TESTS. CHECK 235 AND 237:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

239. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

240. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ____

NOT PRESENT 994
REFUSED 995
OTHER 996

241. BAR CODE LABEL
[PUT THE 1ST BAR CODE LABEL HERE]
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

242. GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 243.

MINIMUM HEMOGLOBIN LEVELS FOR ANEMIA

CHECK THE COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE FOR THE ALTITUDE MEASUREMENT OF THE HOUSEHOLD. ADJUST THE CUTOFF POINT OF THE READING FROM THE HEMOCUE MACHINE BASED ON THE ALTITUDE MEASUREMENT.

HEMOGLOBIN ADJUSTMENTS FOR ALTITUDE:

ALTITUDE: LESS THAN 1000 M
SEVERE: LESS THAN 7.0 g/dl
MODERATE: 7.0-9.9
MILD (NON-PREGNANT): 10.0-11.9
MILD (PREGNANT): 10.0-10.9
NOT ANEMIC (NON-PREGNANT): 12.0 OR GREATER
NOT ANEMIC (PREGNANT): 11.0 OR GREATER
ALTITUDE: 1000 M - 1499 M
SEVERE: LESS THAN 7.2 g/dl
MODERATE: 7.2-10.1
MILD (NON-PREGNANT): 10.2-12.1
MILD (PREGNANT): 10.2-11.1
NOT ANEMIC (NON-PREGNANT): 12.2 OR GREATER
NOT ANEMIC (PREGNANT): 11.2 OR GREATER
ALTITUDE: 1500 M - 1999 M
SEVERE: LESS THAN 7.5 g/dl
MODERATE: 7.5-10.4
MILD (NON-PREGNANT): 10.5-12.4
MILD (PREGNANT): 10.5-11.4
NOT ANEMIC (NON-PREGNANT): 12.5 OR GREATER
NOT ANEMIC (PREGNANT): 11.5 OR GREATER
ALTITUDE: 2000 M - 2499 M
SEVERE: LESS THAN 7.8 g/dl
MODERATE: 7.8-10.7
MILD (NON-PREGNANT): 10.8-12.7
MILD (PREGNANT): 10.8-11.7
NOT ANEMIC (NON-PREGNANT): 12.8 OR GREATER
NOT ANEMIC (PREGNANT): 11.8 OR GREATER
ALTITUDE: 2500 M - 2999 M
SEVERE: LESS THAN 8.3 g/dl
MODERATE: 8.3-11.2
MILD (NON-PREGNANT): 11.3-13.2
MILD (PREGNANT): 11.3-12.2
NOT ANEMIC (NON-PREGNANT): 13.3 OR GREATER
NOT ANEMIC (PREGNANT): 12.3 OR GREATER
ALTITUDE: 3000 M - 3499 M
SEVERE: LESS THAN 8.9 g/dl
MODERATE: 8.9-11.8
MILD (NON-PREGNANT): 11.9-13.8
MILD (PREGNANT): 11.9-12.8
NOT ANEMIC (NON-PREGNANT): 13.9 OR GREATER
NOT ANEMIC (PREGNANT): 12.9 OR GREATER
ALTITUDE: 3500 M - 3999 M
SEVERE: LESS THAN 9.7 g/dl
MODERATE: 9.7-12.6
MILD (NON-PREGNANT): 12.7-14.6
MILD (PREGNANT): 12.7-13.6
NOT ANEMIC (NON-PREGNANT): 14.7 OR GREATER
NOT ANEMIC (PREGNANT): 13.7 OR GREATER

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-59

243. CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

[ASK QUESTIONS 244-269 FOR ALL ELIGIBLE MEN]

244. LINE NUMBER (COLUMN 10):
NAME (COLUMN 2):

LINE NUMBER ____
NAME ____

245. WEIGHT IN KILOGRAMS:

KG _____

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

246. HEIGHT IN CENTIMETERS:

CM ____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

247. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 252)

248. MARITAL STATUS:
CHECK COLUMN 8.

CODE 5 (NEVER IN UNION) 1
OTHER 2 (GO TO 252)

249. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ___

250. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

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 in taking 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 to (NAME OF ADOLESCENT) 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 for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME OF ADOLESCENT) to take the anemia test?

251. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) ______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 256).

252. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

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 in taking 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.
Will you take the anemia test?

253. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____

254. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 258)

255. MARITAL STATUS:
CHECK COLUMN 8.

CODE 5 (NEVER IN UNION) 1
OTHER 2 (GO TO 258)

256. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 247 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

As part of the survey we are also asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Ethiopia.

For the HIV test, we need a few (more) 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know his HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

FOR SAMPLE CLUSTERS IN WHICH MOBILE VCT SERVICES WILL BE AVAILABLE: The Ministry of Health has also arranged for health workers to offer VCT services in this community shortly after our survey team leaves the area. The kebele leader will know when and where the VCT service will be available.

Do you have any questions?

If you want to ask more questions later or want to know who to talk with if (NAME OF ADOLESCENT) has any problem due to the study, I can give you information about how to contact the Regional Office of the CSA. PROVIDE CARD WITH CONTACT INFORMATION FOR CSA REGIONAL OFFICE IF REQUESTED.

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

257. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ____ (GO TO 267)

258. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we are also asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Ethiopia.

For the HIV test, we need a few (more) 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know whether you have HIV, I can provide you with a list of (nearby) facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

FOR SAMPLE CLUSTERS IN WHICH MOBILE VCT SERVICES WILL BE AVAILABLE: The Ministry of Health has also arranged for health workers to offer VCT services in this community shortly after our survey team leaves the area. The kebele leader will know when and where the VCT service will be available.

Do you have any questions?

If you want to ask more questions later or want to know who to talk with if you have any problem due to the study, I can give you information about how to contact the Regional Office of the CSA. PROVIDE CARD WITH CONTACT INFORMATION FOR CSA REGIONAL OFFICE IF REQUESTED.

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 HIV test?

259. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER:

INTERVIEWER NUMBER _____
GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 267)

260. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 264)

261. MARITAL STATUS:
CHECK COLUMN 8.

CODE 5 (NEVER IN UNION) 1
OTHER 2 (GO TO 264)

262. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER-IN-UNION MEN AGE 15-17:

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). Therefore, we will not be able to tell (NAME OF ADOLESCENT) the results of any test that is done. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

263. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) ____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 266)

264. ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

265. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 267)

266. ADDITIONAL TESTS. CHECK 263 AND 265:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

267. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

268. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

G/DL ____

NOT PRESENT 994
REFUSED 995
OTHER 996

269. BAR CODE LABEL:
[PUT THE 1ST BAR CODE LABEL HERE]
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

270. GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.