11 January 2013

IDENTIFICATION

PLACE NAME_____

NAME OF HOUSEHOLD HEAD_____

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MALE SURVEY, ANTHROPOMETRY, AND BLOOD COLLECTION?

INTERVIEWER VISITS

FIRST VISIT
DATE_____
INTERVIEWER NAME_____
RESULT*_____

*RESULT CODES

NEXT VISIT:
DATE _____
TIME_____

(REPEAT FOR SECOND AND THIRD VISITS)

TOTAL NUMBER OF VISITS_____

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME_____

FIELD EDITOR
NAME_____

OFFICE EDITOR

KEYED BY

Introduction and Consent

Hello. My name is ______________________________. I am working with the Liberia Institute of Statistics and Geo-Information Services (LISGIS). We are conducting a survey demographics and health all over Liberia. 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 30 minutes. All of the answers you give will be confidential and will not be shared with anyone other than the 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 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 ON PAGE HH-6 TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-25 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?

6) Did (NAME) stay here last night?

7) AGE
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

IF AGE 15 OR OLDER

8) CURRENT MARITAL STATUS OF (NAME)?

ELIGIBILITY

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

IF HH IS SELECTED FOR MALE SURVEY ANTHROPOMETRY, AND BLOOD COLLECTION:

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

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

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

12) Is (NAME)'s mother still living?

13) Does (NAMES)'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'.

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

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

What is this highest grade (NAME) completed at that level?
SEE CODES BELOW.

CODES FOR Qs. 17 AND 19: EDUCATION

IF AGE 5-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the 2012-2013 school year?

19) During this/that school year, what level and grade [is/was] (NAME) attending?

SEE CODES BELOW.

IF AGE 0-4 YEARS

BIRTH REGISTRATION

20) Does (NAME) have a birth certificate?

INPATIENT

21) In the last six months, was (NAME) admitted overnight to stay at a health facility?

22) CIRCLE LINE NUMBER OR HOUSEHOLD MEMBER ELIGIBLE FOR INPATIENT MODULE

CHECK COLUMN 21: CODE 1 "YES" CIRCLED.

OUTPATIENT

23) In the last four weeks, did (NAME) receive care from a health provider, a pharmacy, or a traditional healer without staying overnight?

24) The last time (NAME) received care, was any money paid?

25) CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR OUTPATIENT MODULE

CHECK COLUMN 24: CODE 1 "YES" CIRCLED.

HOUSEHOLD CHARACTERISTICS

101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?

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

103) Where is that water source located?

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

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

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

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

Anything else?

RECORD ALL MENTIONED.

107) What type of toilet do you use here?

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

109) How many households use this toilet facility?

110) Does your household have:

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

112) Where do you usually do your cooking? In the house, on a porch, in a separate building, or outdoors?

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

114) What is the main source of energy for lighting in this household?

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 EXTERIOR 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 any member of this household farm any agricultural land?

121) How many acres of agricultural land do members of this household farm?

IF 95 OR MORE, CIRCLE '950'

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

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

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

125) What is the distance from your home to the nearest health facility?

IF LESS THAN ONE MILE, ENTER '00'
IF MORE THAN 95 MILES, ENTER '95'

126) If you were to go to the nearest health facility, how would you go there?

127) How long does it take you to get to the nearest health facility by (MEANS OF TRANSPORTATION RECORDED IN 126?)

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

129) Who sprayed the dwelling?

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

PROBE: Any mosquito nets at all?

127) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

132) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

133) How many months did you household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

134) 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.

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

136) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD '00'.

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

138) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

139) GO BACK TO 132 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 140

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

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

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

143) Can you please provide me with a teaspooNful of cooking salt? I will conduct a test to determine the prescence of iodine. Iodine prevents goiter.

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

INPATIENT HEALTH EXPENDITURES

201) CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE:

202) CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE: ENTER THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO WAS AN INPATIENT.

Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last six months. (IF THERE ARE MORE THAN 3 INPATIENTS, USE ADDITIONAL QUESTIONNAIRE)

203) LINE NUMBER FROM COLUMN 22 IN HOUSEHOLD SCHEDULE

204) NAME FROM COLUMN 2 IN HOUSEHOLD SCHEDUEL

205) Where did (NAME) most recently stay overnight for health care?

206) What was the main reason for (NAME) to seek care this most recent time?

207) How much money was spent on treatment and services (NAME) received during the most recent overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

208) Did (NAME) stay overnight at a health facility another time in the last six months?

INPATIENT NAME________

209) Where did (NAME) stay the next-to-last time he/she stayed overnight for health care?

210) What was the main reason for (NAME) to seek care this next-to-last time?

211) How much money was spent on treatment and services (NAME) received during the next-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

212) Besides the two stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

INPATIENT NAME________

213) Where did (NAME) stay the second-to-last time he/she stayed overnight for health care?

214) What was the main reason for (NAME) to seek care this second-to-last time?

215) How much money was spent on treatment and services (NAME) received during the second-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

216) Besides the three stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

217) In total, how many times did (NAME) stay overnight in a health facility in the last six months?

INPATIENT NAME___________

218) Is (NAME) covered by any health insurance?

219) What is (NAME)'s main type of health insurance?

220) GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 301

OUTPATIENT HEALTH EXPENDITURES

301)

TABLE FOR SELECTION OF OUTPATIENT WHO PAID FOR CARE THE LAST TIME SOUGHT CARE IN THE LAST FOUR WEEKS

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE HOUSEHOLD QUESTIONNAIRE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO.

CHECK THE TOTAL NUMBER OF ELIGIBLE OUTPATIENTS (COLUMN 25) IN THE HOUSEHOLD SCHEDULE.

THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL.

THIS IS THE NUMBER OF THE PERSON SELECTED FOR THE OUTPATIENT QUESTIONS FROM THE LIST OF ELIGIBLE OUTPATIENTS IN COLUMN 25 OF THE HOUSEHOLD SCHEDULE.

WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q302.

EXAMPLE: THE HOUSEHOLD NUMBER IS '116' AND THE HOUSEHOLD SCHEDULE COLUMN 25 SHOWS THAT THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05).

SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' AND SINCE THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD, GO TO COLUMN '3'.

FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER.

NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND OUTPATIENT WHO IS ELIGIBLE FOR THE OUTPATIENTS QUESTIONS (LINE NUMBER '04' IN THIS EXAMPLE).

WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q302.

TABLE COLUMN HEADING: LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER

TABLE ROW HEADING: TOTAL NUMBER OF ELIGIBLE OUTPATIENTS IN HOUSEHOLD SCHEDULE COLUMN 25

302)

NAME OF SELECTED OUTPATIENT_____________________
HH LINE NUMBER OF SELECTED OUTPATIENT_____

303) Now I would like to ask some questions about health care that (NAME IN 302) received in the last four weeks, without having to stay overnight. Where did (NAME) get care most recently without staying overnight?

304) How much money was spent on treatment and services (NAME) received from (NAME OF PROVIDER IN 303)? Please include the consulting fee and any expenses for other items including drugs and test.

305) What was the main reason for (NAME) to seek care this most recent time?

306) Did (NAME) get care another time in the last four weeks from a health provider, a pharmacy, or a traditional healer, without staying overnight?

307) How many other times did (NAME) get care in the last four weeks?

308) How many times was money spent?

309) Is (NAME) covered by any health insurance?

310) What is (NAME)'s main type of health insurance?

311) Sometimes people buy vitamins, medicines, and herbal remedies without consulting with a health provider, pharmacy, or traditional healer. They may also buy other health-related items such as band-aids/plasters, thermometers, or other medical devices, and so on without a consultation. In the last four weeks, how much money was spent on these types of health-related items for members of your household?

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5

400) CHECK COVER PAGE: IS HOUSEHOLD SELECTED FOR ANTHROPOMETRY AND BLOOD COLLECTION?

YES (GO TO 401)
NO (END OF HOUSEHOLD QUESTIONNAIRE)

401) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 402. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

402) LINE NUMBER FROM COLUMN 11

NAME FROM COLUMN 2

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

404) CHECK 403: CHILD BORN IN JANUARY 2008 OR LATER?

405A) CONFIRM SCALE IS SET TO KG.

405) WEIGHT IN KILOGRAMS

406) HEIGHT IN CENTIMETERS

407) MEASURED LYING DOWN OR STANDING UP?

408) GO BACK TO 403 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 409.

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

409) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 410. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

410) LINE NUMBER FROM COLUMN 9

NAME FROM COLUMN 2

410A) CHECK SCALE

411) WEIGHT IN KILOGRAMS

412) HEIGHT IN CENTIMETERS

413) AGE: CHECK COLUMN 7.

414) MARITAL STATUS: CHECK COLUMN 8.

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

416) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 415 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 Liberia.

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 (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV.

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?

417) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

NAME FROM COLUMN 2

418) ASK FOR CONSENT FOR DBS COLLECTION FROM RESPONDENT.

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

420) AGE: CHECK COLUMN 7.

421) MARITAL STATUS: CHECK COLUMN 8.

422) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT INDENTIFIED IN 415 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

423) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

424) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

425) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

426) ADDITIONAL TESTS

427) PREPARE EQUIPMENT AND SUPPLIES AND PROCEED WITH THE TEST.

428) BAR CODE LABEL

429) GO BACK TO THE 410A IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 430.

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

430) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 431. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

431) LINE NUMBER FROM COLUMN 10

NAME FROM COLUMN 2

431A) CHECK SCALE

432) WEIGHT IN KILOGRAMS

433) HEIGHT IN CENTIMETERS

434) AGE: CHECK COLUMN 7.

435) MARITAL STATUS: CHECK COLUMN 8.

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

437) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 436 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

438) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

NAME FROM COLUMN 2

439) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

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

441) AGE: CHECK COLUMN 7

442) MARITAL STATUS: CHECK COLUMN 8.

443) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 436 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

444) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

NAME FROM COLUMN 2

445) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

446) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

447) ADDITIONAL TESTS

448) PREPARE EQUIPMENT AND SUPPLIES AND PROCEED WITH THE TEST.

449) BAR CODE LABEL

450) GO BACK TO 431A IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.