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LESOTHO DEMOGRAPHIC AND HEALTH SURVEY 2004
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME ___________________

NAME OF HOUSEHOLD HEAD ______________

EA NUMBER

HOUSEHOLD NUMBER

LESOTHO ECOLOGICAL ZONE

LOWLANDS=1
FOOTHILLS=2
MOUNTAINS=3
SENQU RIVER VALLEY=4

DISTRICT

01=BUTHA-BUTHE
02=LERIBE
03=BEREA
04=MASERU
05=MAFETENG
06=MOHALE'S HOEK
07=QUTHING
08=QASHA'S NEK
09=MOKHOTLONG
10=THABA-TSEKA

URBAN/RURAL

URBAN=1
RURAL=2

HOUSEHOLD SELECTED FOR MALE SURVEY

YES=1
NO=2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME __________
RESULT* ________

1 COMPLETED
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) ________

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE _______
TIME _______

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER ______
RESULT _____

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

SUPERVISOR
NAME _______
DATE _______

FIELD EDITOR
NAME _______
DATE _______

OFFICE EDITOR ___ ___
KEYED BY ___ ___

HOUSEHOLD SCHEDULE
Now we would like some information about the people who usually live in your household or who are staying with you now.

(1) LINE NO.

LINE NUMBER____

(2) USUAL RESIDENT 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.

NAME_____________________

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

01=HEAD
02=SPOUSE
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=DOMESTIC EMPLOYEE
11=HERDBOY
12=ADOPTED/FOSTER/STEPCHILD
13=NOT RELATED
98=DON'T KNOW

(4) RESIDENCE: Does (NAME) usually live here or elsewhere in Lesotho outside Lesotho?

USUAL RESIDENT 1 ((GO TO 7)
ELSEWHERE IN LESOTHO 2 ((GO TO 7)
OUTSIDE LESOTHO 3

(5)In which country outside Lesotho does (NAME) lived in (COUNTRY)? ***

01 = RSA
02 = SWAZILAND
03 = BOTSWANA
04 = NAMIBIA
05 = ZIMBABWE
06 = ZAMBIA
07 = MOZAMBIQUE
08 = ANGOLA
09 = TANZANIA
10 = MALAWI
11 = OTHER AFRICA
12 =UNITED STATES OF AMERICA
13 = ASIA
14 = EUROPE
96 = OTHER
98 = DON'T KNOW

(6) How long has (NAME) lived in (CONTRY)?
IF LESS THAN 1 YEAR, RECORD 00' RECORD 98' FOR DON'T KNOW.

IN YEARS ___ ___

(7) Did (NAME) stay here last night?

YES 1
NO 2

(8) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

(9) AGE: How old is (NAME)?

IN YEARS ___ ___

ELIGIBILITY
(10) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 WHO ARE USUAL RESIDENTS (COL 5) AND/OR SLEPT THERE LAST NIGHT (COL 8)
01-20

(11) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49 WHO ARE USUAL RESIDENTS (COL 5) AND/OR SLEPT THERE LAST NIGHT (COL 8)
01-20

(12) CIRCLE LINE NUMBER OF ALL CHILREN 0-5 WHO ARE USUAL RESIDENTS (COL 5) AND/OR SLEPT THERE LAST NIGHT(COL 8)
01-20

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD***

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

YES 1
NO 2 (GO TO 15)
DON'T KNOW 8 (GO TO 15)

(14)IF ALIVE: Does (NAME)'s natural mother live in this household?
If yes: What is her name?
RECORD MOTHER'S LINE NUMBER

LINE NUMBER___ ___

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

YES 1
NO 2 (GO TO 17)
DON'T KNOW 8 (GO TO 17)

(16)IF ALIVE: Does (NAME)'s natural father live in this household?
If yes: What is her name?
RECORD FATHER'S LINE NUMBER

LINE NUMBER___ ___

IF AGE 5 YEARS OR OLDER

(17) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

(18) What is the highest level of school (NAME) has attended? *****
What is the highest standard/form/year (NAME) completed at that level? ****

LEVEL ___
LEVEL 1 = PRIMARY
LEVEL 2 = VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY .
LEVEL 3 = SECONDARY/HIGH
LEVEL 4 = VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY
LEVEL 5 = COLLEGE
LEVEL 6 = GRADUATE/POST GRADUATE
8 = DON'T KNOW 98
STND/FRM/YR___ ___
00 = LESS THAN 1 YEAR COMPLETED
STANDARD 01-07 = LEVEL 1 (PRIMARY) .
YEAR 01-06 = LEVEL 2 (VOC/TECHN. AFTER PRIMARY)
FORM 01-05 = LEVEL 3 (SECONDARY/HIGH) .
YEAR 01-06 = LEVEL 4 (VOC/TECHN. AFTER SECONDARY)
YEAR 01-03 = LEVEL 5 (COLLEGE) .
YEAR 01-06 = LEVEL 6 (GRADUATE/POST GRADUATE) .
98= DON'T KNOW

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

(19) Is (NAME) currently attending school?

YES 1 (GO TO 21)
NO 2

(20) During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 22)

(21) During the school year, what level and standard/form/year is (NAME) attending? ******

LEVEL ____
LEVEL 1 = PRIMARY
LEVEL 2 = VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY .
LEVEL 3 = SECONDARY/HIGH
LEVEL 4 = VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY
LEVEL 5 = COLLEGE
LEVEL 6 = GRADUATE/POST GRADUATE
8 = DON'T KNOW 98
STND/FRM/YR ___ ___

(22) During the previous school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO NEXT LINE)

(23) During that school year, what level and standard/form/year did (NAME) attend? ******

LEVEL ___
LEVEL 1 = PRIMARY
LEVEL 2 = VOCATIONAL/TECHNICAL TRAINING AFTER PRIMARY .
LEVEL 3 = SECONDARY/HIGH
LEVEL 4 = VOCATIONAL/TECHNICAL TRAINING AFTER SECONDARY
LEVEL 5 = COLLEGE
LEVEL 6 = GRADUATE/POST GRADUATE
8 = DON'T KNOW 98
STND/FRM/YR ___ ___
STANDARD 01-07 = LEVEL 1 (PRIMARY) .
YEAR 01-06 = LEVEL 2 (VOC/TECHN. AFTER PRIMARY)
FORM 01-05 = LEVEL 3 (SECONDARY/HIGH) .
YEAR 01-06 = LEVEL 4 (VOC/TECHN. AFTER SECONDARY)
YEAR 01-03 = LEVEL 5 (COLLEGE) .
YEAR 01-06 = LEVEL 6 (GRADUATE/POST GRADUATE) .
98= DON'T KNOW

TICK HERE IF CONTINUATION SHEET USED

Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 26)
PIPED INTO YARD/PLOT 12 (GO TO 26)
PIPED INTO SOMEONE ELSE'S YARD/PLOT 13
PUBLIC TAP 14
WATER FROM OPEN WELL
OPEN WELL IN DWELLING 21 (GO TO 26)
OPEN WELL IN YARD/PLOT 22 (GO TO 26)
OPEN PUBLIC WELL 23
WATER FROM COVERED WELL OR BOREHOLE
PROTECTED WELL/BOREHOLE IN DWELLING 31 (GO TO 26)
PROTECTED WELL/BOREHOLE IN YARD/PLOT 32 (GO TO 26)
PROTECTED WELL/BOREHOLE IN SOMEONE ELSE'S YARD/PLOT 33
PROTECTED PUBLIC WELL/BOREHOLE 34
SURFACE WATER
SPRING 41
RIVER/STREAM 42
DAM 43
RAINWATER 51 (GO TO 26)
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 26)
OTHER (SPECIFY) _______ 96

25 How long does it take you to go there, get water, and come back?

MINUTES ___ ___ ___
ON PREMISES 996

26 What kind of main toilet facilities does your household have?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31 (GO TO 28)
OTHER _______________(SPECIFY) 96

27 Do you share these facilities with other households?

YES 1
NO 2

28 Does your household have:

Electricity that is connected?
YES 1
NO 2
A battery or generator for power?
YES 1
NO 2
A radio in working condition?
YES 1
NO 2
A television in working condition?
YES 1
NO 2
A telephone in working condition?
YES 1
NO 2
A refrigerator in working condition?
YES 1
NO 2
A sofa or mattress?
YES 1
NO 2

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

ELECTRICITY 01
LPG/NATURAL GAS 02
PARAFFIN 03
COAL, LIGNITE 04
CHARCOAL 05
FIREWOOD, STRAW 06
DUNG 07
CROP WASTE 08
OTHER _____________(SPECIFY) 96

30 MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
MUD/EARTH/DUNG 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
BRICK TILES 32
TILES 33
CEMENT 34
CARPET 35
VINYL/LINOLEUM 36
OTHER ____________(SPECIFY) 96

32 Does any member of your household own:

A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A horse/donkey/mule?
YES 1
NO 2
A scotch cart?
YES 1
NO 2

33 ASK RESPONDENT FOR A TEASPOONFUL OF SALT.
TEST SALT FOR IODINE:
RECORD PPM (PARTS PER MILLION).

0 PPM (NO IODINE) 1
BELOW 15 PPM 2
ABOVE 15 PPM (STRONG COLOR) 3
NO SALT IN HH 4
SALT NOT TESTED ________________ (SPECIFY REASON) 5

34 What is the name of the nearest health facility that provides health services to this community?

(NAME OF HEALTH FACILITY)________________________________________
DON'T KNOW 99998 (GO TO 37)

35 How do you get from here to (HEALTH FACILITY NAME)?

CAR/TRUCK/BUS/TAXI 01
MOTORCYCLE/SCOOTER 02
BICYCLE 03
HORSE/DONKEY/MULE 04
SCOTCH CART 05
WALKING 06
OTHER _____________(SPECIFY) 96

36 How long does it take you to get from here to (HEALTH FACILITY NAME)?

HOURS ___ ___
MINUTES ___ ___

HEIGHT, WEIGHT, AND HEMOGLOBIN MEASUREMENT

CHECK COLUMNS (10) AND (11): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
WOMEN 15-49

(37)LINE NO. FROM COL. (10)

LINE NUMBER___ ___

(38) NAME FROM COL.(2)

NAME__________________________

(39) AGE FROM COL. (9)

YEARS ___ ___

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49

(41) WEIGHT (KILOGRAMS)

WEIGHT___ ___ ___. ___

(42) HEIGHT (CENTIMETERS)

HEIGHT___ ___ ___. ___

(44) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHN PROB
6 OTHER

CHILDREN UNDER AGE 6

(37)LINE NO. FROM COL. (10)

LINE NUMBER___ ___

(38) NAME FROM COL.(2)

NAME__________________________

(39) AGE FROM COL. (9)

YEARS ___ ___

(40) What is (NAME)'s date of birth?*

DAY ___ ____
MONTH ___ ___
YEAR ___ ___ ___ ___

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER

(41) WEIGHT (KILOGRAMS)

WEIGHT___ ___ ___. ___

(42) HEIGHT (CENTIMETERS)

HEIGHT___ ___ ___. ___

(43) MEAUSRED LYING DOWN OR STANDING UP

LYING 1
STAND 2

(44) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHN PROB
6 OTHER

TICK HERE IF CONTINUATION SHEET IS USED:

* FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY (SECTION 2), SUCH AS ORPHANS, ADOPTED CHILDREN, ETC.), ASK
DAY, MONTH AND YEAR OF BIRTH. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM Q.215 IN MOTHER'S BIRTH
HISTORY (SECTION 2) AND ASK DAY OF BIRTH.

HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER
(45) LINE NO. FROM COL. (11)

LINE NUMBER___ ___

(46) NAME FROM COL (2)

NAME____________________

(47) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUEHOLD SCHEDULE

LINE NUMBER___ ___

(48) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT*

GRANTED 1 SIGN ____________
REFUSED 2 (GO TO NEXT LINE)

(49)HEMOGLOBIN LEVEL (G/DL)

G/DL___ ___. ___

(50) RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHN PROB
6 OTHER

* INFORMED CONSENT STATEMENT FOR ANEMIA TESTING FOR CHILDREN
As part of this survey, we are studying anemia among women, men and children under age 6 years. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that all children born since 1999 participate in the anemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.
Now I would like to ask that you (and NAME OF CHILD[REN]) agree to participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test done.
(GO TO COLUMN (48), CIRCLE THE APPROPRIATE CODE (AND SIGN).
Consent Statement for Anemia and HIV for Adults

** INTRODUCTION
Hello, my name is_______________. I'm from the Ministry of Health and Social Welfare. As part of this survey, we are studying anemia among women, men and children under age 6 years. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We are also studying HIV. HIV is the virus that causes AIDS. The government of Lesotho is trying to find out how common HIV is, so that they can develop programs to prevent AIDS and care for those who have it.
REQUEST FOR CONSENT FOR ANEMIA TEST
We are asking if you will participate in the anemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.
Do you have any questions?
May I now ask that you participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test done.
(GO TO COLUMN (58) AND CIRCLE THE APPROPRIATE CODE (AND SIGN).
IF RESPONDENT IS AGE 15-17: ASK PARENT/GUARDIAN: Now, will you tell me if you accept that (NAME OF YOUTH) to participate in the anemia test? (GO TO COLUMN (56) AND WRITE THE LINE NUMBER OF THE PARENT/GUARDIAN, ASK FOR THEIR CONSENT AND CIRCLE THE APPROPRIATE CODE (AND SIGN) IN COLUMN (57). IF PARENT/GUARDIAN AGREES, READ THE PRECEDING
PARAGRAPHS TO YOUTH FOR HIS/HER CONSENT AND RECORD THE APPROPRIATE CODE IN COLUMN (58).

REQUEST FOR CONSENT FOR HIV TEST
We would also ask you to participate in the HIV test by allowing us to collect a few drops of blood from the finger at the same time.
This blood will be tested later in the laboratory. To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your test and no one will be able to trace the test back to you.
However, if you want to know whether you have HIV, I can tell you where you can (GO TO get tested.
Do you have any questions?
I hope you will agree to participate in the HIV testing. However, if you decide not to have the test done, it is your right and we will respect your decision.
Will you accept to participate in the HIV test?
(GO TO COLUMN (58) AND CIRCLE THE APPROPRIATE CODE (AND SIGN).
IF RESPONDENT IS AGE 15-17: ASK PARENT/GUARDIAN: Now, will you tell me if you accept that (NAME OF YOUTH) to participate in the HIV test? (GO TO COLUMN (56) AND WRITE THE LINE NUMBER OF THE PARENT/GUARDIAN, ASK FOR THEIR CONSENT AND CIRCLE THE APPROPRIATE CODE (AND SIGN) IN COLUMN (57). IF PARENT/GUARDIAN AGREES, READ THE PRECEDING PARAGRAPHS TO
YOUTH FOR HIS/HER CONSENT AND RECORD THE APPROPRIATE CODE IN COLUMN (58).
* DON'T FORGET TO GIVE EACH ELIGIBLE PERSON A LIST OF THE NEAREST VCT SERVICES.

HEMOGLOBIN AND HIV TESTING -- WOMEN AND MEN Number of blood samples: _____

CHECK COLUMNS (10) AND (12) FROM HOUSEHOLD SCHEDULE: RECORDTHE LINE NUMBER, NAME, SEX AND AGE OF ALL WOMEN AGE 15-49 AND ALL MEN AGE 15-59 YEARS. THIS
FORM MUST BE DESTROYED BEFORE THE RESULTS OF THE TEST ARE LINKED TO THE LDHS DATABASE.

(51)LINE NUMBER FROM COLUMN (10) OR COLUMN (12)

LINE NUMBER___ ____

(52)NAME FROM COL.(2)

NAME _____________________

(53)SEX FROM COL. (8)

MALE 1
FEMALE 2

(54)AGE FROM COL.(9)

AGE___ ___

(55)CHECK AGE IN COLUMN (54)

AGE 15-17 1
AGE 18+ 2 (GO TO 58)

(56) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

LINE NUMBER___ ___

(57)READ THE CONSENT TO THE PARENT OR RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)

CONSENT FOR ANEMIA TESTING 1 (INTERVIEWER SIGNS _______)
REFUSED 2
NOT READ 3

CONSENT FOR HIV TESTING 1 (INTERVIEWER SIGNS _______)
REFUSED 2
NOT READ 3

(58)READ THE CONSENT TO PARENT OR RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)

CONSENT FOR ANEMIA TESTING 1 (INTERVIEWER SIGNS _______)
REFUSED 2
NOT READ 3

CONSENT FOR HIV TESTING 1 (INTERVIEWER SIGNS _______)
REFUSED 2
NOT READ 3

(59) HEMOGLOBIN LEVEL (G/DL)

G/DL___ ___.___

(60) FOR WOMEN: CURRENTLY PREGNANT

YES 1
NO 2
DON'T KNOW 3

(61)ANEMIA RESULT

1 MEASURED
2 ABSENT
3 REFUSED
4 TECHNICAL
PROBLEMS
6 OTHER (SPECIFY) __________________

(62)HIV RESULT

1 BLOOD TAKEN
2 ABSENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER (SPECIFY) _____________________

(63)PLACE BAR CODES
[1st DROP IS WIPED AWAY; 3 DROPS ARE COLLECTED FOR HIV; 1 (LAST) DROP IS COLLECTED FOR ANEMIA]
PUT 1ST BAR CODE HERE
PUT THE 2ND BAR CODE ON THE RESPONSENT'S FILTER PAPER , AND THE 3RD ON THE BLOOD SAMPLE TRANSMITTAL FORM

TICK HERE IS ANOTHER SHEET IS USED : ____

64 CHECK COLUMNS (49) FOR CHILDREN, (59) FOR ADULTS AND (60) FOR WHETHER THE WOMAN IS CURRENTLY PREGNANT:

NUMBER OF HOUSEHOLD MEMBERS FOR WHICH THE LEVEL OF HEMOGLOBIN IS BELOW THE CUT-OFF POINTS :
LESS THAN 7G/DL FOR CHILDREN, FOR MEN, AND FOR WOMEN WHO ARE NOT PREGNANT (OR WHO DO NOT KNOW IF THEY ARE PREGNANT); LESS THAN 9G/DL FOR PREGNANT WOMEN.

ONE OR MORE
GIVE EACH WOMAN, MAN OR RESPONSIBLE ADULT THE RESULTS OF THE HEMOGLOBIN TEST. READ THE DECLARATION BELOW (Q.65) TO THESE PERSONS WITH HEMOGLOBIN LEVELS BELOW CUT-OFF POINTS.

NONE
GIVE EACH WOMAN, MAN OR RESPONSIBLE ADULT THE RESULTS OF THE HEMOGLOBIN TEST AND THE ANEMIA BROCHURE.

65 The results of the test show that (YOUR BLOOD/THE BLOOD OF NAME OF CHILD/CHILDREN) has a very low level of hemoglobin. This indicates that (YOU/NAME OF CHILD/CHILDREN) are severely anemic, which is a serious health problem. We recommend that you visit a health facility as soon as possible to be examined and obtain the proper treatment. GIVE THE ADULT THE HEMOGLOBIN TEST RESULTS AND THE ANEMIA BROCHURE.