ETHIOPIA

IDENTIFICATION

PLACE NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

FIELDWORKER VISITS

FIRST VISIT
DATE
FIELDWORKER'S NAME

SECOND VISIT
DATE
FIELDWORKER'S NAME

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
FIELDWORKER'S VISIT

FINAL VISIT
DAY
MONTH
YEAR

TOTAL NUMBER OF VISITS

TOTAL ELIGIBLE WOMEN

TOTAL ELIGIBLE MEN

TOTAL ELIGIBLE CHILDREN

NOTES:

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR?

SUPERVISOR
NAME
FIELDWORKER NUMBER

FIELD EDITOR
NAME
FIELDWORKER NUMBER

OFFICE EDITOR
NUMBER

KEYED BY
NUMBER

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

101. CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRES.

102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.

103. IF MOTHER INTERVIEWED: COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED ASK: What is (NAME)'s date of birth?

104. CHECK 103: CHILD BORN IN 2003-2008?

105. WEIGHT IN KILOGRAMS.

106. HEIGHT IN CENTIMETERS.

107. MEASURED LYING DOWN OR STANDING UP?

108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

110. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.

RECORD '00' IF NOT LISTED

111. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER 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. We ask that all children born in 2003 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, 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 or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

112. CIRCLE THE CODE AND SIGN YOUR NAME.

113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

114. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.

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

201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204.

IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

202. CHECK HOUSEHOLD QUESTIONNAIRE:

LINE NUMBER FROM COLUMN 9. NAME FROM COLUMN 2.

203. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):

204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):

205. WEIGHT IN KILOGRAMS.

206. HEIGHT IN CENTIMETERS.

207. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

208. CHECK 203: AGE

209. CHECK 204: MARITAL STATUS

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

210. ASK CONSENT FOR ANEMIA TEST.

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 we take your blood. 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 or no. It is up to you to decide.
Will you take the anemia test?

211. CIRCLE THE CODE AND SIGN YOUR NAME.

211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

212. ASK CONSENT FOR DBS COLLECTION.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.

For the HIV testing, 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 we take your blood. 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.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?

213. CIRCLE THE CODE AND SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

214. ASK CONSENT FOR ADDITIONAL TESTING.

We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.

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 you can still participate in the HIV testing in this survey.

Will you allow us to keep the blood sample stored for additional testing?

215. CIRCLE THE CODE AND SIGN YOUR NAME.

216. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

RECORD '00' IF NOT LISTED

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST

217. ASK CONSENT FOR ANEMIA TEST FROM PARENT/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 we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF MINOR) 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 or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to take the anemia test?

218. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

219. 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 to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) 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 or no. It is up to you to decide.
Will you take the anemia test?

220. CIRCLE THE CODE AND SIGN YOUR NAME.

220A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

221. ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.

For the HIV testing, 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 we take your blood. 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 MINOR)'s test results either. If (NAME OF MINOR) 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.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the HIV testing?

222. CIRCLE THE CODE, SIGN YOUR NAME AND ENTER YOUR FIELDWORKER NUMBER.

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

223. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.

For the HIV testing, 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 we take your blood. 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.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?

224. CIRCLE THE CODE AND SIGN YOUR NAME

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

225. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.

We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.

The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.

Will you allow us to keep the blood sample stored for additional testing?

226. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

227. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.

We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.

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?

228. CIRCLE THE CODE AND SIGN YOUR NAME.

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

230. ADDITIONAL TEST.

IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 226 AND 228.

IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.

231. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

232. PLACE BAR CODE LABEL.

PUT THE 1ST BAR COE LABEL HERE.

PUT 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

233. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.

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

301. CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303, AND 304.

IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

302. CHECK HOUSEHOLD QUESTIONNAIRE:

LINE NUMBER FROM COLUMN 11. NAME FROM COLUMN 2.

303. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):

304. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):

305. WEIGHT IN KILOGRAMS.

306. HEIGHT IN CENTIMETERS.

307. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

308. CHECK 203: AGE

309. CHECK 204: MARITAL STATUS

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

310. ASK CONSENT FOR ANEMIA TEST.

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 we take your blood. 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 or no. It is up to you to decide.
Will you take the anemia test?

311. CIRCLE THE CODE AND SIGN YOUR NAME.

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

312. ASK CONSENT FOR DBS COLLECTION.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.

For the HIV testing, 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 we take your blood. 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.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?

313. CIRCLE THE CODE AND SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

314. ASK CONSENT FOR ADDITIONAL TESTING.

We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.

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 you can still participate in the HIV testing in this survey.

Will you allow us to keep the blood sample stored for additional testing?

315. CIRCLE THE CODE AND SIGN YOUR NAME.

316. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

RECORD '00' IF NOT LISTED

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST

317. ASK CONSENT FOR ANEMIA TEST FROM PARENT/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 we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF MINOR) 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 or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to take the anemia test?

318. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

319. 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 to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) 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 or no. It is up to you to decide.
Will you take the anemia test?

320. CIRCLE THE CODE AND SIGN YOUR NAME.

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

321. ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.

For the HIV testing, 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 we take your blood. 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 MINOR)'s test results either. If (NAME OF MINOR) 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.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the HIV testing?

322. CIRCLE THE CODE, SIGN YOUR NAME AND ENTER YOUR FIELDWORKER NUMBER.

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

323. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.

For the HIV testing, 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 we take your blood. 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.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?

324. CIRCLE THE CODE AND SIGN YOUR NAME

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

325. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.

We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.

The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.

Will you allow us to keep the blood sample stored for additional testing?

326. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

327. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.

We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.

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?

328. CIRCLE THE CODE AND SIGN YOUR NAME.

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

330. ADDITIONAL TEST.

IF ADULT RESPONDENT, CHECK 315; IF MINOR RESPONDENT, CHECK 326 AND 328.

IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.

331. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

332. PLACE BAR CODE LABEL.

PUT THE 1ST BAR COE LABEL HERE.

PUT 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

333. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

FIELDWORKER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING BIOMARKER

SUPERVISOR'S OBSERVATIONS

EDITOR'S OBSERVATIONS