HOUSEHOLD QUESTIONNAIRE

Survey Contents Confidential by Statistical Law

IDENTIFICATION

GOVERNORATE: _______________

DISTRICT: ______________

SUB-DISTRICT: _______________

LOCALITY: _________________

AREA: ________________

SUB-AREA: _______________

STRATUM: _____________

URBAN/RURAL

QUESTIONAIRE NO.: _____

BLOCK NO:. ___

BUILDING NO.: __________

HOUSING UNIT NO.: _________

CLUSTER NO.: ___

HOUSEHOLD NO.: ___

TELEPHONE/MOBILE NO. (IF AVAILABLE)

___________________

HOUSEHOLD SELECTED FOR ANTHROPOMETRY AND ANEMIA TESTING

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT*

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT*

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR 2009
INT. NUMBER
RESULT*

TOTAL NUMBER OF VISITS

*RESULT CODES

TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONAIRE

SUPERVISOR
NAME _____________

FIELD EDITOR
NAME _____________

OFFICE EDITOR
_____________

KEYED BY
_____________

Introduction and Consent

Hello. My name is ___________________________________ and I am working with the Department of Statistics. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The interview 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 the survey is completely voluntary. 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:_____________________

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 5-18 FOR EACH PERSON.

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?

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?

2C) ARE THERE ANY GUESTS OR TEMPORARY VISITORS STAYING HERE, OR ANYONE ELSE WHO STAYED HERE LAST NIGHT, WHO HAVE NOT BEEN LISTED?

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

4) SEX
Is (NAME) male or female?

RESIDENCE

5) Does (NAME) usually live here?

5A) Did (NAME) stay here last night?

6) DATE OF BIRTH
In what month and year was (NAME) born?
IF DON'T KNOW MONTH, RECORD 98' FOR MONTH.
IF DON'T KNOW YEAR, RECORD 9998' FOR YEAR.

6A) AGE
How old is (NAME)?
IF AGE=95+. RECORD 95.
COMPARE AND CORRECT 6A AND/OR 6 IF INCONSISTENT.

7) NATIONALITY
What is (NAME's) nationality?

8) MARITAL STATUS IF AGE 15 OR OLDER

What's is (NAME)'s current marital status?

ELIGIBILITY

9) INDIVIDUAL INTERVIEW
CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL SURVEY (EVER-MARIIED WOMAN AGE 15-49).

CHECK COVER PAGE IF THIS HOUSEHOLD IS SELECTED FOR ANTHROPOMETRY AND ANEMIA

ANTHROPOMETRY AND ANEMIA MEASUREMENTS

10) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

11) CIRCLE LINE NUMBER OF ALL CHILDREN BORN IN 2004 OR LATER, OR CHILDREN AGE 0-5 YEARS (IF DATE OF BIRTH NOT KNOWN).

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

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

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?

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'.

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

16) Has (NAME) ever attended school?

16A) Can (NAME) read and write?

17) What is the highest level of school (NAME) has attended?

17A) What is the highest grade (NAME) completed at the level?

00 = LESS THAN ONE YEAR COMPLETED
98 = DON'T KNOW

IF AGE 5-24 YEARS

18) Did (NAME) attend school at any time during the (2008-2009) school year?

HOUSING UNIT AND HOUSEHOLD CHARACTERISTICS

100) TYPE OF HOUSING UNIT.
RECORD OBSERVATION

101) What is the main source of drinking water for members of your household?

101A) Is water normally available all day from this source?

101B) In the last two weeks, was water unavailable for an entire day or longer?

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

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

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

IF FLUSH TOILET: Is your toilet connected to public sewer system, a pit latrine or somewhere else?

109) Do you share this toilet facility with other households?

110A) Is your house connected with electricity?

110B) Does your household have a bed or sofa bed?

IF YES: How many beds or sofa beds does your household have?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

111) Does your household have?

111A) Does your household have a computer?

IF YES: How many?
IF NONE, RECORD '0'. If 7 OR MORE, RECORD 7.

111B) Does your household have a mobile?

IF YES: How many?
IF NONE, RECORD '0'. If 7 OR MORE, RECORD 7.

111C) CHECK 111A and 111B:

111A OR 111B = 1 OR MORE (GO TO 111D)
111A AND 111b = 0 (GO TO 112)

111D) Do you have internet access at home?

112) What type of fuel does your household mainly use for cooking?

116) Do you have separate room which is used as a kitchen?

116A) Do you have an independent bathroom?

117) MAIN MATERIAL OF THE FLOOR

119) MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

119A) How many rooms do you have in your house?

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

120A) Does your household own a private car or pickup?

IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

126A) Does any member of this household have a credit card?

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

201) CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALLL ELLIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN. USE ADDITIONA; QUESTIONAIRE(S). A FINAL OUTCAOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN208 AND FOR THE ANEMIA PROCEDURE IN 213

ANSWER 202-213 FOR ALL CHILDREN BETWEEN THE AGES 0-5.

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY: IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birthdate?

204) CHECK 203:
CHILD BORN IN JANUARY 2004 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

208) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

209) CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

210) LINE NUMBER OR PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1)
RECORD '00' IF NOT LISTED.

211) READ CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD.
CIRCLE CODE AND SIGN.

212) RECORD RESULT CODE OF HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

213) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

214) GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 215.

CONSENT STATEMENT FOR ANEMIA FOR CHILDREN
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 2004 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?

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

215) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELLGIBLE WOMEN IN 216.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONAIRE(S).

A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 219 AND FOR THE ANEMIA TEST PROCEDURE IN 227

ANSWER 216-223 FOR ALL WOMEN BETWEEN THE AGES 15-49.

216) LINE NUMBER (COLUNM 10)
NAME (COLUMN 2)

217) WEIGHT IN KILOGRAMS

218) HEIGHT IN CENIMETERS

219) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

220) AGE: CHECK COLUMN 6A.

221) MARITAL STATUS: CHECK COLUMN 8.

222) FROM COLUMN 1 RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

223) READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 222 BEFORE ASKING RESPONDENT'S CONSENT.

(IF REFUSED, GO TO 227).

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 223 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 222) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 223 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 2004 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 OF ADOLESCENT to) take the anemia test?

224) PREGNANCY STATUS: CHECK COLUMN 8:

225) CHECK 223 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST. A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 227 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

226) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

227) RECORD RESULT OF HEMOGLOBIN MEASUREMENT.

228) GO BACK TO 217 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, END.