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DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE
MAY 2012
REPUBLIC OF GUINEA
NATIONAL OFFICE OF STATISTICS

IDENTIFICATION

NAME OF PLACE________

NAME OF HEAD OF HOUSEHOLD____________

CLUSTER NUMBER___________

HOUSEHOLD NUMBER____________

ADMINISTRATIVE REGION__________

URBAN/RURAL

URBAN 1
RURAL 2

CONAKRY/NATURAL CAPITAL REGION/OTHER CITY/RURAL

CONAKRY 1
CAPITAL REGION 2
OTHER CITY 3
RURAL 4

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

DATE_____________

INTERVIEWER'S NAME______________
RESULT* _______________

1COMPLETED
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)

FINAL VISIT
DAY_________
MONTH___________
YEAR _________
INTERVIEWER CODE___________
RESULT___________

NEXT VISIT_________________
DATE ____________
TIME___________

TOTAL NO. OF VISITS________________

TOTAL PERSONS IN HOUSEHOLD______________
TOTAL ELIGIBLE WOMEN___________
TOTAL ELIGIBLE MEN_____________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___________

SUPERVISOR_____________
NAME____________
DATE__________

FIELD EDITOR____________
NAME_______________
DATE_________

OFFICE EDITOR____________

KEYED BY_______________

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Office of Statistics. We are conducting a survey about health all over Guinea. The information we collect will help the government to 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 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.

In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

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

SIGNATURE OF INTERVIEWER___________ DATE__________
RESPONDENT AGREES TO BE INTERVIEWED_________ 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END

HOUSEHOLD SCHEDULE

1) 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 5-20 FOR EACH PERSON
.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

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
11 STEPCHILD
12 CO-SPOUSE
13 NOT RELATED
98 DON'T KNOW

4) SEX
Is (NAME) male or female?

M 1
F 2

RESIDENCE

5) 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)?
IF 95 OR MORE, RECORD 95.

IN YEARS____________

IF AGE 15 OR OLDER

8) MARITAL STATUS
What is (NAME)'s current marital status?

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

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CHECK THE COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY YES=1

CIRCLE LINE NUMBER OF ALL MEN 15-49

11) CHECK THE COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY YES=1

CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
12) Is (NAME)'s natural mother alive?

YES 1
NO 2 (GO TO 14)
DK 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.

_______

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

YES 1
NO 2 (GO TO 16)
DK 8 (GO TO 16)

15) Does (NAME)'s natural father 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.

____________

IF AGE 3 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20)

17) What is the highest level of school (NAME) has attended?
SEE CODES BELOW.
What is the highest grade (NAME) completed at that level?
SEE CODES BELOW

LEVEL
0 NURSERY SCHOOL
1 PRIMARY
2 SECONDARY 1
3 SECONDARY 2
4 PROFESSIONAL A
5 PROFESSIONAL B
6 HIGHER
8 DON'T KNOW LEVEL
GRADE
NURSERY SCHOOL
0 LESS THAN 1 YEAR
1 SMALL SECTION
2 MEDIUM SECTION
3 LARGE SECTION

PRIMARY
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR

SECONDARY 1
0 LESS THAN 1 YEAR
1 7TH YEAR
2 8TH YEAR
3 9TH YEAR
4 10TH YEAR

SECONDARY 2
0 LESS THAN 1 YEAR
1 11TH YEAR
2 12TH YEAR
3 FINAL

PROFESSIONAL A
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR

PROFESSIONAL B
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR

HIGHER
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR

98 DON'T KNOW GRADE

IF AGE 3-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the (2011-2012) school year?

YES 1
NO 2 (GO TO 20)

19) During this/that school year, what level and grad (is/was) (NAME) attending?
SEE CODES BELOW.
(USE 00 FOR Q 17 ONLY. THIS CODE NOT ALLOWED FOR Q 19)

LEVEL
0 NURSERY SCHOOL
1 PRIMARY
2 SECONDARY 1
3 SECONDARY 2
4 PROFESSIONAL A
5 PROFESSIONAL B
6 HIGHER
8 DON'T KNOW LEVEL
GRADE
NURSERY SCHOOL
0 LESS THAN 1 YEAR
1 SMALL SECTION
2 MEDIUM SECTION
3 LARGE SECTION

PRIMARY
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR

SECONDARY 1
0 LESS THAN 1 YEAR
1 7TH YEAR
2 8TH YEAR
3 9TH YEAR
4 10TH YEAR

SECONDARY 2
0 LESS THAN 1 YEAR
1 11TH YEAR
2 12TH YEAR
3 FINAL

PROFESSIONAL A
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR

PROFESSIONAL B
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR

HIGHER
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR

98 DON'T KNOW GRADE

IF AGE 0-4 YEARS

BIRTH REGISTRATION

20) 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

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 EACH IN TABLE)
NO

2B) In addition, are there any other people who many not be members of your family, such as domestic servants, lodgers or friends who usually live here?

YES (ADD EACH IN TABLE)
NO

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

YES (ADD EACH IN TABLE)
NO

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 INTO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
TAP AT NEIGHBOR'S HOUSE 14
TUBE WELL OR BOREHOLD 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/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED/BAGGED WATER 91
OTHER (SPECIFY) 96

103) Where is the 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 you to go there, get water, and come back?

MINUTES
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 107)
DK 8 (GO TO 107)

106) What do you usually do to make the water safer to drink?

Anything else?

RECORD ALL MENTIONED

A BOIL
B ADD BLEACH/CHLORINE
C STRAIN THROUGH A CLOTH
D USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.)
E SOLAR DISINFECTION
F LET IT STAND AND SETTLE
X OTHER (SPECIFY)
Z DON'T KNOW

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

FLUSH OR POUR FLUSH TOILET
CONNECTED FLUSH
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 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 10_______
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110) Does your household have:

ELECTRICITY?

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 WARDROBE/BOOKCASE?

YES 1
NO 2

A STOVE/PORTABLE STOVE?

YES 1
NO 2

A FREEZER?

YES 1
NO 2

A HUNTING RIFLE?

YES 1
NO 2

A PLOW?

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
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
SAW/SHRUBS/GRASS 09
AGRICULTURAL CROP/SAWDUST 10
ANIMAL DUNG 11

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 (SPECIFY) 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
GRAVEL 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
OTHER PLANT 22
FINISHED FLOOR
PARQUET OR WAXED WOOD 31
VINYL/ASPHALT 32
TILE 33
CEMENT 34
OTHER (SPECIFY) 96

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS/LEAVES 12
SOD 13
RUDIMENTARY FLOOR
PLASTIC/CANVAS 21
CARDBOARD 22
FINISHED FLOOR
SHEET METAL 31
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
OTHER (SPECIFY) 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
BAMBOO/WOOD WITH MUD 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT BRICKS 31
COOKED/STABILIZED BRICKS 32
STONE WITH CEMENT 33
WOOD PLANKS 34
OTHER (SPECIFY) 96

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

ROOMS________

118) Does any member of your household own:

A CANOE?

YES 1
NO 2

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 WITH A MOTOR?

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 hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950

HECTARES
95 OF MORE HECTARES 950
DON'T KNOW 998

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 95 OR MORE, ENTER 95
IF UNKNOWN, ENTER 98

CATTLE?______________
MILK COWS OR BULLS?_________________
HORSES, DONKEYS, OR MULES? __________________
GOATS?__________________
SHEEP?_________________
PIGS?_________________
DUCKS?________________
CHICKENS?________________
DONKEYS?_______________

123) Does any member of this household have a bank account?

YES 1
NO 2

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES 1
NO 2 (GO TO 126)
DK 8 (GO TO 126)

125) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) X
DON'T KNOW Z

126) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 136D)

127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD 7.

NUMBER OF NETS______

128) Ask the respondent to show you the nets in the household.
If more than 3 nets, use additional questionnaire(s).

OBSERVED 1
NOT OBSERVED 2

129) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00

MONTHS AGO
MORE THAN 36 MONTHS AGO 95
NOT SURE 97

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
OLYSET 11 (GO TO 134)
PERMENET 12 (GO TO 134)
INTERCEPTOR 13 (GO TO 134)
SERENA 14 (GO TO 134)
OTHER/DK BRAND 16 (GO TO 134)
'PRETEATED' NET
ALL BRANDS 21 (GO TO 132)
OTHER/DK BRAND 26 (O TO 132)
PLAIN NET 31
OTHER BRAND 96
DK BRAND 98

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
NOT SURE 8

132) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD 00.

MONTHS AGO
MORE THAN 24 MONTHS AGO 95
NO SURE 98

134) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 136)
DK 8 (GO TO 136)

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

NAME
LINE NUMBER

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 136A

136a) FILTER
CHECK Q 131.

IF ANSWER IS YES, CODE 1 CIRCLED, OR IF Q 131 NOT ASKED (GO TO 136B)
IF NO OR NOT SURE, CODE 2 OR CODE 8 CIRCLED (GO TO 136G)

136b) When you received the insecticide-soaked mosquito net (MII), were you given advice?

YES 1
NO 2 (GO TO 136E)
DON'T KNOW 8 (GO TO 136E)

136c) What advice/information were you given?
PROBE: What else?

A IMPORTANCE OF INSTALLING AND USING THE NET
B HOW TO INSTALL NET
C HOW TO WASH NET
D WHERE TO RE-SOAK NET
E WHEN TO RE-SOAK NET
X OTHER (SPECIFIC REASON)

136d) Do you think the insecticide-soaked mosquito net is an effective protection against malaria?

YES 1
NO 2
DON'T KNOW 8

136e) How much would you spend on a long-lasting insecticide-treated net?

AMOUNT GUINEAN FRANCS
FREE 99995

136f) What shape of mosquito net do you prefer?

RECTANGLE 1 (GO TO 137)
CONIC/CIRCULAR 2 (GO TO 137)
DOESN'T MATTER 3 (GO TO 137)

136g) Why don't you use a insecticide-soaked mosquito net?
PROBE: What else?

A DON'T KNOW WHERE TO FIND ONE
B NET CAUSES SUFFOCATION
C NET COSTS TOO MUCH/NOT ENOUGH MONEY TO BUY
X OTHER (SPECIFY)

137) How does one get malaria?
PROBE: Any other way?
RECORD ALL MENTIONED

A EXCESSIVE OIL CONSUMPTION
B MOSQUITO BIT
C FATIGUE DUE TO WORK
D INSUFFICIENT SLEEP
E DIRECT EXPOSURE TO SUN
F CONSUMPTION OF MANGOES/SWEET FRUITS
W OTHER (SPECIFY)
X OTHER (SPECIFY)
Z DON'T KNOW

138) What do you believe is the main symptom of malaria?

FEVER 11
LOSS OF APPETITE AND VOMITING 12
HIGH TEMPERATURE WITH CONVULSIONS 13
HIGH TEMPERATURE AND FAINTING 14
PERSISTENT TEMPERATURE 15
CONVULSIONS 16
JAUNDICE 17

OTHER (SPECIFY) 96
DON'T KNOW 98

138a) What are effective ways to prevent malaria?
PROBE: Any other way?
RECORD ALL MENTIONED

A SLEEPING UNDER A MOSQUITO NET
B SLEEPING UNDER AN INSECTICIDE-SOAKED MOSQUITO NET
C TAKING PREVENTATIVE DRUGS
D ENEMA WITH INSECTICIDE/DIFFUSERS/CREAMS/LOTIONS/REPELLENTS
E USING AN ANTI-MOSQUITO STEAMER
F BREW/PLANT JUICE/ROOT
G BY AVOIDING DIRECT EXPOSURE TO SUNLIGHT WHILE DRINKING PROTECTIVE DRINK
H CLEANING SURROUNDINGS
I DOMICILIARY SPRAYING
J NOT CONSUMING FAT
K REST
W OTHER (SPECIFY)
X OTHER (SPECIFY)
Z DON'T KNOW

139) What people are most vulnerable to malaria?
PROBE: Anyone else?
RECORD ALL MENTIONED.

A CHILDREN UNDER 5 YEARS OLD
B CHILDREN
C YOUNG PEOPLE
D PREGNANT WOMEN
E WOMEN
F MEN
G ELDERLY PEOPLE
H EVERYONE
X OTHER (SPECIFY)
Z DON'T KNOW

140) When was your last malaria outbreak?

NUMBER OF DAYS
MORE THAN 180 DAYS AGO 995 (GO TO 146)

141) In your research on malaria treatment, did you go to a health care establishment?

YES 1
NO 2 (GO TO 144)

142) How much time after the beginning of the outbreak did you go to a health care establishment?

THE SAME DAY 1
THE NEXT DAY 2
MORE THAN A DAY LATER 3

143) Where you healed upon receiving care?

YES 1 (GO TO 146)
NO 2 (GO TO 145)

144) Why didn't you go to a health care establishment?
PROBE: What else?

A NOT ENOUGH MONEY
B PREFERRED TRADITIONAL MEDICINE
C BAD WELCOME AT THE HOSPITAL
D NOT HEALTH CARE ESTABLISHMENT NEARBY
X OTHER (SPECIFY)

145) What did you go to get better and heal?
PROBE: What else?

A TOOK DRUGS PURCHASED FROM A VENDOR
B TOO DRUGS PURCHASED FROM A PHARMACY/HOSPITAL
C TREATED BY A TRADITIONAL PRACTITIONER
D PERFORMED AN ENEMA
E DRANK BREWS
F TREATED WITH PLANT/BARK/ROOT VAPORS
G NOTHING

X OTHER (SPECIFY)

146) How do members of your family deal with mosquitoes?
PROBE: What else?

A INSECTICIDE BOMBS
B SMOKE COILS
C MOSQUITO NET
D INSECTICIDE-SOAKED MOSQUITO NET
E SANITATION
F FAN
G NOTHING

X OTHER (SPECIFY)
Z DON'T KNOW

147) 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 150)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 150)
NOT OBSERVED, OTHER REASON 4 (GO TO 150)

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

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

149) OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

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

150) 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

WORK OF CHILDREN AGE 5-14 YEARS

151) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD (COLUMN 5=1):

TOTAL NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD____________

151a) CHECK Q 151: NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

ONE OR MORE (FILL OUT THE FOLLOWING TABLE FOR EACH CHILD BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD)

NO CHILDREN (GO TO 200)

ASK THE FOLLOWING QUESTIONS TO THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE FEWER THAN 8 CHILDREN, USE THE ADDITIONAL QUESTIONNAIRE):

Now I would like to ask you some questions on the type of work that children in your household did last week.

152) RECORD THE LINE NUMBER FOR EACH CHILD LIVING IN THE HOUSEHOLD IN THE ORDER OF COLUMN 1 OF THE HOUSEHOLD SCHEDULE.

__________

153) RECORD THE NAME OF EACH CHILD

__________

154) Since the last (DAY OF THE WEEK OF THE INTERVIEW), did (NAME) do any work for anyone who is not a member of this household?
IF YES: Was he/she paid in cash or in kind?

YES PAID 1
YES UNPAID 2
NO 2 (GO TO 156)

155) Since the last (DAY OF THE WEEK OF THE INTERVIEW), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

____________

156) In the last week, did (NAME) go get water or wood for the household?

YES 1
NO 2 (GO TO 157)

156a) Since the last (DAY OF THE WEEK), approximately how many hours did he/she spend getting water or wood for the household?

________________

157) In the last week, did (NAME) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?

YES 1
NO 2 (GO TO 159)

158) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing work for his/her family or him/herself?

_______________

159) In the last week, did (name) do any household chores, such as shopping, cleaning, clothes washing, cooking, or taking care of children, old people, or sick people?

YES 1
NO 2 (GO TO NEXT LINE)

160) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?

______________


WEIGHT, HEIGHT, ANEMIA, AND MALARIA TEST FOR CHILDREN AGE 0-5

200) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANTHROPOMETRY, ANEMIA AND HIT TEST?

YES
NO (END HOUSEHOLD QUESTIONNAIRE)

201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202 ACCORDING TO LINE NUMBER ORDER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

AT LEAST ONE CHILD 0-5 YEARS (GO TO 202)
NO CHILDREN 0-5 YEARS (GO TO 241)

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER
NAME

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

DAY
MONTH
YEAR

204) CHECK 203:
CHILD BORN IN JANUARY 2007 OR LATER?

YES 1
NO 2 (GO TO 603 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO END INTERVIEW)

205) WEIGHT IN KILOGRAMS

KG___________
NOT PRESENT 994
REFUSED 995
OTHER 996

206) HEIGHT IN CENTIMETERS
IF CHILD IS LESS THAN 2 YEARS OLD, MEASURE THE CHILD LYING DOWN, IF NOT STANDING UP

CM
NOT PRESENT 994
REFUSED 995
OTHER 996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203:
IF 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 END INTERVIEW)

OLDER 2

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

LINE NUMBER_________

210) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE 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 ask that all children born in 2007 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 member 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 OF CHILD) to take the anemia test?

NAME FROM COLUMN 2

NAME_________

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGN_______________
REFUSED 2 SIGN_______________
ABSENT 5
OTHER 6

212) ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

We are asking all of the children in this country to participate in a malaria test. Malaria a serious health problem that can result from mosquito bites. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2007 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. (We use the blood from the same needle prick as for the anemia test)

The blood will be tested for malaria immediately, and the result will be told to you right away. Some drops will be saved on one or more slides and sent to a laboratory to be tested. You will not find out the results of the lab test. The result will be kept strictly confidential and will not be shared with anyone other than member 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 OF CHILD) to take the anemia test?

213) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 SIGN____________
REFUSED 2 SIGN____________
ABSENT 5
OTHER 6

214) PREPARE THE INSTRUMENTS NECESSARY ONLY FOR THE TEST(S) FOR WHICH CONSENT WAS OBTAINED AND PROCEED WITH THE TEST(S).

215) BAR CODE STICKER FOR MALARIA TEST

PUT FIRST BAR CODE HERE

_________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND ON THE SLIDE, AND THE 3RD ON THE TRANSMISSION SHEET

216) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA AND MALARIA BROCHURE

G/DL ___________
NOT PRESENT 994
REFUSED 995
OTHER 996

217) RECORD THE RESULT CODE FROM THE MALARIA TDR (RAPID DIAGNOSTIC TEST) HERE

TESTED 1
ABSENT 2 (GO TO 219)
REFUSED 3 (GO TO 219)
OTHER 6 (GO TO 219)

218) RECORD THE RESULT CODE FROM THE MALARIA TDR (RAPID DIAGNOSTIC TEST) HERE AND ON THE ANEMIA AND MALARIA BROCHURE.

POSITIVE FALCIPARUM 1
POSITIVE TYPE 2
POSITIVE P (F AND OMV) 3
ALL SKIP TO 221
NEGATIVE 4
OTHER 6

219) CHECK 216:
HEMOGLOBIN LEVEL

BELOW 8.0 G/DL SEVERE ANEMIA 1
8.0 G/DL OR HIGHER 2 (GO TO 232)
ABSENT 4 (GO TO 232)
REFUSED 5 (GO TO 232)
OTHER 6 (GO TO 232)

220) REFERENCE DECLARATION FOR SEVERE ANEMIA
The anemia diagnostic test show that (NAME OF CHILD) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.
(GO TO 232)

221) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms: IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y
NONE OF ABOVE SYMPTOMS Y

A EXTREME WEAKNESS?
B HEART PROBLEMS?
C LOSS OF CONSCIOUSNESS?
D RAPID OR DIFFICULTY BREATHING?
E CONVULSIONS?
F ABNORMAL BLEEDING?
G JAUNDICE/YELLOW SKIN?
H DARK URINE?
Y NONE OF THE SYMPTOMS

222) CHECK 221:
IS A CODE A-H CIRCLED

ONE CODE A-H CIRCLED 1 (GO TO 224)
ONLY CODE Y CIRCLED 2

223) CHECK 216:
HEMOGLOBIN LEVEL

UNDER 6.0 G/DL 1
6.0 D/DL OR HIGHER 2 (GO TO 225)
NOT PRESENT 4 (GO TO 225)
REFUSED 5 (GO TO 225)
OTHER 6 (GO TO 225)

224) REFERENCE DECLARATION FOR SERIOUS MALARIA

The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. Your child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. Your child is seriously ill and must be taken to a health care establishment immediately. (GO TO 231)

225) In the last two weeks, has (NAME) taken or was (NAME) given CTA [##translator note: CTA is an antimalarial drug, combination therapy] by a doctor or health care establishment to treat malaria?
CHECK BY ASKING TO SEE THE TREATMENT

YES 1
NO 2 (GO TO 227)

226) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.

You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment to ask for further testing.
(GO TO 231)

227) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.

The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

228) CIRCLE THE APPROPRIATE CODE AND SIGN.

DRUG ACCEPTED 1 ________________(SIGNATURE)
REFUSED 2 (GO TO 231)
OTHER 6 (GO TO 231)

230) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST

CHILD LESS THAN ONE YEAR OLD OR LESS THAN 8 KGS.

25 mg tablet of Artesunate and 67.5 mg of Amodiaquine (Rose striped brochure)
Day 1 (1 tablet)
Day 2 (1 tablet)
Day 3 (1 tablet)

CHILD AGE 1-5 YEARS OR 8-17 KGS.

50 mg tablet of Artesunate and 135 mg of Amodiaquine (Purple striped brochure)
Day 1 (1 tablet)
Day 2 (1 tablet)
Day 3 (1 tablet)

TELL THE PARENTS/ADULT RESPONSIBLE FOR CHILD: If (NAME) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you must take him/her to a health professional for treatment immediately.

231) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET

DRUG GIVEN 1
DRUG REFUSED 2
REFERRED FOR SEVERE MALARIA 3
REFERRED BECAUSE CHILD ALREADY TOOK CTA 4
OTHER 6

232) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, END THE INTERVIEW
.

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

241) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN FROM QUESTION 242. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

AT LEAST ONE WOMAN AGE 15-49
NOT A SINGLE WOMAN AGE 15-49 (GO TO 280)

242) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN

LINE NUMBER___________
NAME____________

243) WEIGHT IN KILOGRAMS

KG__________
ABSENT 9994
REFUSED 9995
OTHER 9996

244) HEIGHT IN CENTIMETERS

CM___________
ABSENT 9994
REFUSED 9995
OTHER 9996

245) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 250)

246) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 250)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT__________

248) Ask consent for the anemia test from the parent/other adult identified in 247 as responsible for women age 15-17 who have never been in a union.

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 test, we 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 to (name of adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member 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?

249) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_______________(SIGNATURE)
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2 _______________(SIGNATURE)

(IF REFUSED, SKIP TO 255)

250) ASK CONSENT FROM RESPONDENT FOR THE 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 test, we 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 right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes, or you can say no to the test. It is up to you to decide.
Will you take the anemia test?

251) CIRCLE APPROPRIATE CODE AND SIGN

GRANTED 1____________(SIGNATURE)
RESPONDENT REFUSED 2 ____________(SIGNATURE)
(IF REFUSED, SKIP TO 253)

252) PREGNANCY: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
ARE YOU PREGNANT?

YES 1
NO 2
DON'T KNOW 8

253) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 257)

254) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 257)

255) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 247 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As part of the survey we also are 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 Guinea.

For the HIV test, we 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. 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 the results of (NAME OF ADOLESCENT) test 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 you a voucher for free services for you that you can use at any of these facilities.

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 OF ADOLESCENT) to take the HIV test?

256) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1____________(SIGNATURE)
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2 ___________(SIGNATURE)
(IF REFUSED, SKIP TO 266)

257) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

As part of the survey we also are 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 Guinea.

For the HIV test, we 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. 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 you HIV status, I can provide 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 you can say no to the test. It is up to you to decide.

Will you take in the HIV test?

258) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.

GRANTED 1___________(SIGNATURE)
RESPONDENT REFUSED 2 ___________(SIGNATURE)
(IF REFUSED, SKIP TO 266)

259) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 263)

260) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 263)

261) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 247 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.

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

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

262) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_____________(SIGNATURE)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 __________(SIGNATURE)
(IF REFUSED, GO TO 265)

263) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow NATIONAL STATISTICAL INSTITUTE/MINISTRY OF PLANNING to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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?

264) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1________(SIGNATURE)
RESPONDENT REFUSED 2 __________(SIGNATURE)
(IF REFUSED, GO TO 266)

265) ADDITIONAL TESTS

CHECK 262 AND 264: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

267) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL__________
NOT PRESENT 994
REFUSED 995
OTHER 996

268) BAR CODE LABEL
PUT THE 1ST BAR CODE HERE

__________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

269) GO BACK TO 242 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 280.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

280) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 281. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

AT LEAST ONE MAN AGE 15-59 YEARS (GO TO 281)
END QUESTIONNAIRE

281) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

LINE NUMBER_____________
NAME______________

284) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-59 YEARS 2 (GO TO 289)

285) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 289)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ______

287) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 286 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 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 (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than member 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 participate in the anemia test?

288) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_____________(SIGNATURE)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2__________(SIGNATURE)
(IF REFUSED, GO TO 293)

289) 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 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 right away. The result will be kept strictly confidential and will not be shared with anyone other than member 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 in the anemia test?

290) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1____________(SIGNATURE)
RESPONDENT REFUSED 2__________(SIGNATURE)

291) AGE: CHECK COLUMN 7

15-17 years 1
18-49 years 2 (GO TO 295)

292) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 295)

293) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 286 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

As part of the survey we also are 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 Guinea.

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 him with 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 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?

294) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1___________(SIGNATURE)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2_____________(SIGNATURE)
(IF REFUSED, GO TO 304)

295) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

As part of the survey we also are 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 Guinea.

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 you HIV status, I can provide 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 to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

296) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1______________(SIGNATURE)
RESPONDENT REFUSED 2___________(SIGNATURE)
(IF REFUSED, GO TO 304)

297) AGE: CHECK COLUMN 284

15-17 YEARS 1
18-59 YEARS 2 (GO TO 301)

298) MARITAL STATUS: CHECK COLUMN 285

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 301)

299) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 286 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

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

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

300) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1___________(SIGNATURE)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2__________(SIGNATURE)
(IF REFUSED, GO TO 303)

301) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow National Statistical Institute/Ministry of Planning to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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?

302) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1______(SIGNATURE)
RESPONDENT REFUSED 2__________(SIGNATURE)
(IF REFUSED, GO TO 304)

303) ADDITIONAL TESTS

CHECK 300 AND 302: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

305) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ___________
NOT PRESENT 994
REFUSED 995
OTHER 996

306) BAR CODE LABEL

PUT THE 1ST BAR CODE HERE __________

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

307) GO BACK TO 281 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.

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 SUPERVISOR___________________
DATE_______________

EDITOR'S OBSERVATIONS__________________
NAME OF EDITOR____________________
DATE_______________