IDENTIFICATION

NAME OF COUNTY ___
NAME OF DISTRICT___
NAME OF CLAN/TOWNSHIP___
NAME OF CITY/TOWN/VILLAGE___

LDHS CLUSTER NUMBER___
LDHS STRUCTURE NUMBER___
HOUSEHOLD NUMBER___

URBAN:

NAME OF HOUSEHOLD HEAD___

INTERVIEWER VISITS

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
INTERVIEWER NAME___

RESULT___

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__

FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
RESULT__

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HHOLD QUEST.___

SUPERVISOR
NAME___
DATE___

FIELD EDITOR
NAME__
DATE__

OFFICE EDITOR__
KEYED BY___

Introduction and Consent

Hello. My name is ______. I am working with the Liberia Institute for Statistics and Geo-Information Services (LISGIS). We are conducting a National Demographic and Health Survey. We would very much like your participation in this survey. The survey interview takes a few minutes to complete.

As part of this survey, we would first like to ask some questions about your household. All of the answers you give will be confidential.

Participation in the survey is completely voluntary. If I ask any question you do not want to answer, let me know and I will go 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 visitors who slept 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 IN COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-22 FOR EACH PERSON.

2A) Just to make sure that I have a complete list. Are there any other persons, like small children or infants that we have not listed?

2B) Are there any other people who may not be members of your family, like lodgers, domestic servants, 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?

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

6) RESIDENCE:
Did (NAME) sleep here last night?

7) AGE:
How old is (NAME)?

IF LESS THAN 1 YEAR, WRITE '00'.

8) IF AGE 15 OR OLDER:
MARITAL STATUS:
What is (NAME'S) current marital status?

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

10) ELIGIBILITY:
CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

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

IF AGE 0-17 YEARS:

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

13) SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:
Does (NAME)'s natural mother usually live in the household or was she a guest last night?

IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD '00'.

14) SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:
Is (NAME)'s natural father still living?

15) SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:
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'.

IF AGE 3 YEARS OR OLDER:

16) EVER ATTENDED SCHOOL:
Has (NAME) ever been to school?

17) EVER ATTENDED SCHOOL:
What is the highest level of school (NAME) attended?
What is the highest grade (NAME) completed at that level?

IF AGE 3-24 YEARS:

18) CURRENT/RECENT SCHOOL ATTENDANCE:
Did (NAME) go to school any time during this school year?

19) CURRENT/RECENT SCHOOL ATTENDANCE:
During this school year, what level and grade [is/was] (NAME) attending?

20) CURRENT/RECENT SCHOOL ATTENDANCE:
Did (NAME) go to school any time during the last school year, that is, 2005-2006?

21) CURRENT/RECENT SCHOOL ATTENDANCE:
During that school year, what grade was (NAME) in?

IF AGE 0-4 YEARS:

22) BIRTH REGISTRATION:
Does (NAME) have a birth certificate?

SHOW EXAMPLE.

THIS IS NOT A ROAD TO HEALTH CARD.

HOUSEHOLD CHARACTERISTICS

101) Where do you people get your drinking water from?

102) Where do you get your water from for washing and cooking?

103) Where is that water source located?

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

105) Who usually goes to get the water?

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

107) What do you do to make the water safe for drinking?

Anything else?

RECORD ALL MENTIONED.

108) What type of toilet do you use here?

109) Do other households use this toilet?

110) How many households use this toilet?

111) Does your household have:

112) What do you use for cooking--coal, gas, wood?

113) Where do you usually do your cooking?

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

115) MAIN MATERIAL OF THE FLOOR OF THE HOUSEHOLD.

RECORD OBSERVATION.

IF DIFFERENT ROOMS HAVE DIFFERENT FLOOR MATERIAL, CIRCLE THE CODE FOR THE MOST COMMON, i.e., WHAT COVERS THE LARGEST AREA.

116) MAIN MATERIAL OF THE ROOF OF THE HOUSEHOLD.

RECORD OBSERVATION.

117) MAIN MATERIAL OF THE OUTSIDE WALLS OF THE HOUSEHOLD.

RECORD OBSERVATION.

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

119) Does any member of this household own:

120) Does this household own any livestock, other farm animals, or poultry?

121) How many of the following animals does this household own?

IF NONE, ENTER '00'.
OF MORE THAN 95, ENTER '95'.
IF UNKNOWN, ENTER '98'.

122) Does anyone in this household have a bank account?

123) What do you do with the dirt from this household?

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

125) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

SCHOOL ABSENCE AND CHILD LABOR FOR ALL CHILDREN AGED 5 THROUGH 14

200) CHECK COLUMN (7) AGE:

201) LINE NUMBER:
WRITE CHILD'S LINE NUMBER FROM COL. 1 IN THE HOUSEHOLD SCHEDULE.

202) CHILD'S NAME:
WRITE CHILD'S NAME FROM COL. 2 IN THE HOUSEHOLD SCHEDULE.

203) SCHOOL ABSENCE:
Is (NAME) going to school these days?

204) SCHOOL ABSENCE:
How many days was (NAME) absent from school last week?

205) SCHOOL ABSENCE:
Why was (NAME) absent from school (or not going to school)?

206) WORK LAST WEEK:
During the past week, did (NAME) do any kind of work for someone who us not a member of this household?

IF YES: Was that for pay or unpaid?

207) WORK LAST WEEK:
Since last (DAY OF THE WEEK), about how many hours did (NAME) do this work for someone who is not a member of this household?

INCLUDE ALL HOURS AT ALL JOBS.

208) WORK IN LAST YEAR:
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 that for pay or unpaid?

209) HOUSEHOLD CHORES:
During the past week, did (NAME) help with household chores like shopping, collecting firewood, cleaning, fetching water, or caring for children?

210) HOUSEHOLD CHORES:
Since last (DAY OF THE WEEK), about how many hours did (NAME) spend doing these chores?

211) WORK IN FAMILY BUSINESS OR FARM:
During the past week, did (NAME) do any other family work, on the farm, or in a business or selling goods in the street?

212) WORK IN FAMILY BUSINESS OR FARM:
Since last (DAY OF THE WEEK), about how many hours did (NAME) spend doing this work?

CHILD DISCIPLINE FOR ONE CHILD AGE 2 THROUGH 14

301) CHECK COLUMN 7:

302) CHECK HOUSEHOLD QUESTIONNAIRE, LAST PAGE SELECT THE CHILD AGE 2-14 AS DESCRIBED.

303) WRITE NAME AND LINE NUMBER OF SELECTED CHILD.

304) All adults use certain ways to teach children the right behavior or to correct a behavior problem.
I will read various methods that are used and I want you to tell me if you or anyone else in your household has used this method with (NAME) in the past month.

305) Do you believe that in order to bring up (NAME) properly, you need to physically punish him/her?

WEIGHT AND HEIGHT FOR CHILDREN AGE 0-5

501) CHECK COLUMN 11. RECORD LINE NUMBER AND AGE FOR ALL CHILDREN 0-5 YEARS IN QUESTION 502. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRES. A FINAL OUTCOME MUST BE RECORDED IN QUESTION 508.

502) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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

504) CHECK 503: CHILD BORN IN JANUARY 2001 OR LATER?

505) WEIGHT IN KILOGRAMS

506) HEIGHT IN CENTIMETERS

507) MEASURED LYING DOWN OR STANDING UP?

508) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

509) GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

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

515) CHECK COL. 9. WRITE THE LINE NUMBER AND NAME FOR ALL WOMEN AGE 15-49 IN 516. IF MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES. A FINAL OUTCOME MUST BE RECORDED IN 519 AND 530.

516) LINE NUMBER (COLUMN 9)
NAME (COLUMN 9)

517) WEIGHT IN KILOGRAMS

518) HEIGHT IN CENTIMETERS

519) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

520) AGE: CHECK COLUMN 7.

521) MARITAL STATUS: CHECK COLUMN 8.

522) LINE NO. OF PARENTS/GUARDIAN. RECORD '00' IF NOT LISTED.

525) READ HIV TEST CONSENT. FOR NEVER-IN-UNION WOMEN 15-17, ASK CONSENT FROM PARENT/GUARDIAN IN 522 BEFORE ASKING WOMAN.

526) IF CODE '1' OR '2'. PROCEED WITH TAKING BLOOD SPOTS. A FINAL OUTCOME MUST BE RECORDED IN 530 FOR EACH WOMAN.

529) BAR CODE LABEL

PUT FIRST BARCODE LABEL HERE
PUT SECOND BARCODE LABEL ON RESPONDENT'S FILTER PAPER
AND THIRD ON TRANSMITTAL FORM

IF CODE '2' (HIV ONLY), WRITE 'NO ADDITIONAL TEST' ON FILTER PAPER.

530) OUTCOME OF HIV TEST PROCEDURE

530D) GO BACK TO 517 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, GO TO 531

HIV TESTING FOR MEN AGE 15-49

531) CHECK COLUMN 10. WRITE LINE NUMBER AND NAME FOR ALL MEN AGE 15-49 IN 532. IF MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE. A FINAL OUTCOME MUST BE RECORDED IN 539.

532) LINE NUMBER (COLUMN 10)
NAME (COLUMN 2)

533) AGE: CHECK COLUMN 7.

534) MARITAL STATUS: CHECK COLUMN 8.

535) LINE NUMBER OF PARENT/GUARDIAN. RECORD '00' IF NOT LISTED.

536) READ HIV TEST CONSENT*. FOR NEVER-IN-UNION MEN 15-17, ASK CONSENT FROM PARENT/GUARDIAN IDENTIFIED IN 535 BEFORE ASKING RESPONDENT.

*CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 536 IF HE CONSENTS TO THE HIV TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CONDUCT THE TEST ONLY IF BOTH PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 Liberia.

For the HIV test, we 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.

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 test results either.

If you want to know whether you have HIV, I can tell you the nearby facilities that offer counseling and testing for HIV.

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 give some drops of blood for the HIV test? (allow NAME OF ADOLESCENT to take the HIV test?)

We would also like to store part of the blood sample at the laboratory for further tests in the future. We are not certain about what tests might be done.

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

537) IF CODE 1 OR 2, PROCEED WITH TAKING BLOOD SPOTS. A FINAL OUTCOME MUST BE RECORDED IN 539 FOR EACH MAN.

538) BAR CODE LABEL

PUT THE FIRST BAR CODE LABEL HERE
PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER
AND THIRD ON THE TRANSMITTAL FORM

IF CODE '2' (HIV ONLY), WRITE 'NO ADDITIONAL TEST' ON FILTER PAPER.

539) OUTCOME OF HIV TEST PROCEDURE

540) GO BACK TO 533 FOR NEXT MAN; IF NO MORE MEN, END INTERVIEW.