IDENTIFICATION

PLACE NAME ___________________

NAME OF HOUSEHOLD HEAD ______________

EA NUMBER

HOUSEHOLD NUMBER

LESOTHO ECOLOGICAL ZONE

DISTRICT

URBAN/RURAL

HOUSEHOLD SELECTED FOR MALE SURVEY

INTERVIEWER VISITS

INTERVIEWER VISIT 1 (REPEAT FOR VISITS 2 AND 3)
DATE __________
INTERVIEWER'S NAME __________
RESULT___

RESULT* ________

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 _______

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ and I am working with the Ministry of Health and Social Welfare.
We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey.
This information will help the government to plan health services. The survey 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 this survey is voluntary, and 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 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.
AFTER LISTING THE NAMES AND RECORDING THE RELATION SHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE UESTIONS IN COLUMNS 5-38 FOR EACH PERSON

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

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

RESIDENCE
(5)Does (NAME) usually live here or elsewhere in Lesotho outside Lescotho?

(6)In which country outside Lesotho does (NAME) lived in (COUNTRY)?
IF LESS THAN 1 YEAR, RECORD '00'
RECORD 98 FOR DON'T KNOW

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

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

AGE
(9) How old is (NAME)?

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

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

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

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

IF AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
(14) Is (NAME's) natural mother alive?

(15)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 NUMER. IF NO, RECORD '00'

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

(17) 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
(18) Has (NAME) ever attended school?

(19) 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

IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE
(20) Did (NAME) attend school at any time during the 2009 school year?

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

BIRTH REGISTRATION IF AGE 0-4 YEARS
(22) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been reported with the civil authority?:

HOUSEHOLD CHARACTERISTICS

100 How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

101 Has any member of this household age 18 or older been very sick for at least 3 months?

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

102 What is the main source of water used by your household for other purposes such as cooking and hand washing?

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 this source to fetch the water for your household?

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?

e

109 Do you share this toilet facility with other households?

110 How many households use this toilet facility?

111 Does your household have:

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

113 In this household, is food cooked on an open fire, an open stove or a closed stove?

114 Does this (fire/stove) have a chimney, a hood, or neither of these?

115 Is the cooking usually done in the house, in a separate building, or outdoors?

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

117 MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

118 MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

119 MAIN MATERIAL OF THE EXTERIRO WALLS. RECORD OBSERVATIONS

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

121 Does any member of this household own:

122 Does any member of this household own any agricultural land?

123 How many hectares of agricultural land do members of this household own?

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

125 How many of the following animals does this household own? I'll ask about each type of animal.
IF NONE, ENTER 0'00'. IF MORE THAN 95, ENTER '095'. IF UNKNOWN, ENTER '098'.

126 Does any member of this household have a bank account?

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

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

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

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

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

201 CHECK COLUMN 13. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202.
IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 208 AND FOR THE ANAEMIA PROCEDURE IN 213.

202 LINE NUMBER FROM COLUMN 13
NAME FROM COLUMN 2

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

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

205 WEIGHT IN KILOGRAMS

206 HEIGHT IN CENTIMETRES

207 MEASURED LYING DOWN OR STANDING UP?

208 RECORD MUAC HERE AND IN THE MUAC PAMPHLET

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 OF 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.
CONSENT STATEMENT FOR ANAEMIA FOR CHILDREN
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. We request that all children born in 2004 or later participate in the anaemia 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 anaemia 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 anaemia test?

211A CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212 RECORD HAEMOGLOBIN LEVEL HERE AND IN THE ANAEMIA PAMPHLET.

214 GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST

COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 215.

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

215 CHECK COLUMN 11 RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 216. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 219, FOR THE ANEMIA TEST PROCEDURE IN 227, AND FOR THE HIV TEST PROCEDURE IN 229.

216 LINE NUMBER (COLUMN 11)
NAME (COLUMN 2)

215 WEIGHT IN KILOGRAMS

218 HEIGHT IN CENTIMETRES

220 AGE:CHECK COLUMN 9

221 MARITAL STATUS:
CHECK COLUMN 10

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

223A ASK CONSENT STATEMENT FOR ANAEMIA TEST. FOR NEVER-MARRIED WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED
IN 222 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANAEMIA TEST.
As part of this survey, we are asking people all over the country to take an anaemia test.
Anaemia 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 anaemia.
For the anaemia testing, we will 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. The blood will be tested for anaemia 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?

223B CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

224 PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

225A READ THE HIV TEST CONSENT STATEMENT.
FOR NEVERMARRIED WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 222 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR HIV TEST
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 Lesotho.
For the HIV test, we need a few more drops of blood from a finger. Again 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 (your/NAME OF ADOLESCENT's) test results either.
If you want to know whether you have HIV, I can provide you with 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?

225B CIRCLE THE
APPROPRIATE CODE ANDSIGN YOUR NAME.

226 CHECK 223B AND 225B AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
A FINAL OUTCOME FOR THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 227 AND FOR THE HIV TEST PROCEDURE IN 229 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

227 RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET

229 BAR CODE LABEL

230 GO BACK TO 216 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, GO TO 231.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-59

231 CHECK COLUMN 11 RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 232. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT MEASUREMENT IN 233 AND HEIGHT MEASUREMENT IN 234, FOR THE ANEMIA TEST PROCEDURE IN 242, AND FOR THE HIV TEST PROCEDURE IN 244.

232 LINE NUMBER (COLUMN 11)
NAME (COLUMN 2)

233 WEIGHT IN KILOGRAMS

234 HEIGHT IN CENTIMETRES

236 AGE:CHECK COLUMN 9

237 MARITAL STATUS:
CHECK COLUMN 10

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

239 ASK CONSENT CONSENT STATEMENT FOR ANAEMIA TEST. FOR NEVER-MARRIED WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED
IN 238 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANAEMIA TEST.
As part of this survey, we are asking people all over the country to take an anaemia test.
Anaemia 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 anaemia.
For the anaemia testing, we will 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. The blood will be tested for anaemia 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?

240 CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

240A READ THE HIV TEST CONSENT STATEMENT.
FOR NEVERMARRIED MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 238 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR HIV TEST
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 Lesotho.
For the HIV test, we need a few more drops of blood from a finger. Again 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 (your/NAME OF ADOLESCENT's) test results either.
If you want to know whether you have HIV, I can provide you with 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?

240B CIRCLE THE
APPROPRIATE CODE ANDSIGN YOUR NAME.

241 CHECK 240 AND 240B AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
A FINAL OUTCOME FOR THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 242 AND FOR THE HIV TEST PROCEDURE IN 244 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

242 RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET

244 BAR CODE LABEL

245 GO BACK TO 232 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE MEN, END INTERVIEW.