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2009 LESOTHO DEMOGRAPHIC AND HEALTH SURVEY
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

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

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 _______

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: ________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

HOUSEHOLD SCHEDULE

(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.
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

NAME_____________________

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

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) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

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

USUAL RESIDENT 1 (GO TO 8)
ELSEWHERE IN LESOTHO 2 (GO TO 8)
OUTSIDE LESOTHO 3

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

1=RSA
2=OTHER COUNTRY

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

IN YEARS ___ ___

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

YES 1
NO 2

AGE
(9) How old is (NAME)?

IN YEARS ___ ___

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

1=MARRIED OR LIVING TOGETHER
2=DIVORCED/SEPARATED
3=WIDOWED
4=NEVER-MARRIED AND NEVER LIVED TOGETHER
_____

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?

YES 1
NO 2 (GO TO 16)
DON' T KNOW 8 (GO TO 16)

(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'

LINE NUMBER___ ___

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

YES 1
NO 2 (GO TO 18)
DON' T KNOW 8 (GO TO 18)

(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'

LINE NUMBER___ ___

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER
(18) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

(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

LEVEL ___
1=PRIMARY
2=VOC./TECH. TRAINING AFTER PRIMARY
3=SECONDARY/HIGH
4=VOC./TECH. TRAINING AFTER SECONDARY/HIGH
5=COLLEGE
6=GRADUATE/POST GRADUATE
8=DON'T KNOW
GRADE___ ___
00=LESS THAN 1 YEAR COMPLETED
STANDARD 01-07=LEVEL 1 (PRIMARY SCHOOL)
YEAR 01-06=LEVEL 2 (VOC/TECH. AFTER PRIMARY)
FROM 01-05=LEVEL 3 (SECONDARY/HIGH)
YEAR 01-06=LEVEL 4 (VOC./TECH. AFTER SECONDARY)
YEAR 01-03=LEVEL 5 (COLLEGE)
YEAR 01-06=LEVEL 6 (GRAD./POST GRAD).
98=DON'T KNOW

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

YES 1
NO 2 (GO TO NEXT LINE)

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

LEVEL ___
1=PRIMARY
2=VOC./TECH. TRAINING AFTER PRIMARY
3=SECONDARY/HIGH
4=VOC./TECH. TRAINING AFTER SECONDARY/HIGH
5=COLLEGE
6=GRADUATE/POST GRADUATE
8=DON'T KNOW
GRADE ___ ___
STANDARD 01-07=LEVEL 1 (PRIMARY SCHOOL)
YEAR 01-06=LEVEL 2 (VOC/TECH. AFTER PRIMARY)
FROM 01-05=LEVEL 3 (SECONDARY/HIGH)
YEAR 01-06=LEVEL 4 (VOC./TECH. AFTER SECONDARY)
YEAR 01-03=LEVEL 5 (COLLEGE)
YEAR 01-06=LEVEL 6 (GRAD./POST GRAD).
98=DON'T KNOW

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?:

1=HAS CERTIFICATE
2=REPORTED
3=NEITHER
8=DON'T KNOW

HOUSEHOLD CHARACTERISTICS

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

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

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

YES 1
NO 2
DONT KNOW 8

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

PIPED WATER
PIPED INTO DWELLING 11 GO TO 106
PIPED TO YARD/PLOT 12 GO TO 106
PUBLIC TAP/STANDPIPE 13 GO TO 103
TUBE WELL OR BOREHOLE 21 GO TO 103

DUG WELL
PROTECTED WELL 31 GO TO 103
UNPROTECTED WELL 32 GO TO 103
WATER FROM SPRING
PROTECTED SPRING 41 GO TO 103
UNPROTECTED SPRING 42 GO TO 103
RAINWATER 51 GO TO 106
TANKER TRUCK 61 GO TO 106
SURFACE WATER (RIVE/DAM LAKE/POND/STREAM)
RIVER/STREAM 71
DAM/LAKE/POND 72
BOTTLED WATER 81
OTHER 96 GO TO 103

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

PIPED WATER
PIPED INTO DWELLING 11 GO TO 106
PIPED TO YARD/PLOT 12 GO TO 106
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 GO TO 106
TANKER TRUCK 61
SURFACE WATER (RIVE/DAM LAKE/POND/STREAM)
RIVER/STREAM 71
DAM/LAKE/POND 72
BOTTLED WATER 81 GO TO 106
OTHER 96

103 Where is that water source located?

IN OWN DWELLING 1
IN OWN YARD/PLOT 2
ELSEWHERE 3 GO TO 106

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

MINUTES ___ ___ ___
DON'T KNOW 998

105 Who usually goes to this source to fetch the water for your household?

ADULT WOMAN 1
ADULT MAN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER 6

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

YES 1
NO 2 GO TO 108
DON'T KNOW 8 GO TO 108

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

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/ SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER X
DON'T KNOW Z

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
NO FACILITY/BUSH/FIELD 51 GO TO 111
OTHER 96

e

109 Do you share this toilet facility with other households?

YES 1
NO 2 GO TO 111

110 How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10_______
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

111 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 mobile telephone in working condition?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A bed/mattress?
YES 1
NO 2
A computer?
YES 1
NO 2
Internet access?
YES 1
NO 2

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

ELECTRICITY 01 GO TO 115
LPG 02 GO TO 115
NATURAL GAS 03 GO TO 115
BIOGAS 04 GO TO 115
PARAFFIN 05 GO TO 115
COAL 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 GO TO 117
OTHER 96

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

OPEN FIRE 1
OPEN STOVE 2
CLOSED STOVE WITH CHIMNEY GO TO 115
OTHER GO TO 115

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

CHIMNEY 1
HOOD 2
NEITHER 3

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

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 117)
OUTDOORS 3 (GO TO 117)
OTHER 6 (GO TO 117)

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

YES 1
NO 2

117 MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR MUD/EARTH 11
RUDIMENTARY FLOOR WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
BRICK TILES 34
CEMENT 35
CARPET 36
OTHER 96

118 MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

NATURAL ROOFING
THATCH/GRASS 11
SOD 12
RUDIMENTARY ROOFING
WOOD PLANKS 21
CARDBOARD 22
FINISHED ROOFING
METAL 31
WOOD 32
ASEESTOS/CEMENT FIBER 33
CERAMIC/CLAY TIES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER 96

119 MAIN MATERIAL OF THE EXTERIRO WALLS. RECORD OBSERVATIONS

NATURAL WALLS
CANE/TREE TRUNKS 11
SOD 12
RUDIMENTARY WALLS
STONE WITH MUD 21
PLYWOOD 22
CARDBOARD 23
REUSED WOOD 24
FINISHED WALLS
CEMENT31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
OTHER 96

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

ROOMS ___ ___

121 Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A scotch cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2

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

YES 1
NO 2

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

HECTARES ___ ___

95 OR MORE HECTARES 95
DON'T KNOW 98

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

YES 1
NO 2

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'.

Cattle?
NUMBER___
Milk cows?
NUMBER___
Horses, donkeys, or mules?
NUMBER___
Goats? Sheep?
NUMBER___
Improved chickens?
NUMBER___
Ordinary free range chickens?
NUMBER___
Ordinary pigs?
NUMBER___
Improved pigs?
NUMBER___
Rabbits?
NUMBER___

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

YES 1
NO 2

127 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 130)

128 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 96

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

HOURS ___ ___
MINUTES ___ ___

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

0 PPM (NO IODINE) 1
BELOW 15 PPM 2
15 PPM AND ABOVE 3
NO SALT IN HH 4
SALT NOT TESTED 5

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

LINE NUMBER ___ ___
NAME _______________

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

DAY ___ ___
MONTH ___ ___
YEAR ___ ___ ___ ___

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

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)

205 WEIGHT IN KILOGRAMS

KG ___ ___.___

NOT PRESENT 994
REFUSED 995
OTHER 996

206 HEIGHT IN CENTIMETRES

CM ___ ___ ___.___

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207 MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208 RECORD MUAC HERE AND IN THE MUAC PAMPHLET

CM ___ ___.___

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

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

0-5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)
OLDER 2

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

LINE NUMBER ___ ___

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.

GRANTED 1 ((SIGN)___________________)
REFUSED 2 ((SIGN)___________________) (GO TO 214)

212 RECORD HAEMOGLOBIN LEVEL HERE AND IN THE ANAEMIA PAMPHLET.

G/DL ___ ___.___

NOT PRESENT 994
REFUSED 995
OTHER 996

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)

LINE NUMBER ___ ___
NAME ______________

215 WEIGHT IN KILOGRAMS

KG ___ ___ ___.___

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

218 HEIGHT IN CENTIMETRES

CM ___ ___ ___.___

NOT PRESENT 9994
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

220 AGE:CHECK COLUMN 9

15-17 YEARS 1
18-49 YEARS 2 GO TO 223A

221 MARITAL STATUS:
CHECK COLUMN 10

CODE 4 (NEVER MARRIED) 1
OTHER 2 GO TO 223A

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

LINE NUMBER OF PARENT OR OTHR RESPONSIBLE ADULT ___ ___

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

GRANTED 1 (SIGN) _________________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ___ (GO TO 225A)
RESPONDENT REFUSED 3 (SIGN) _________________ (GO TO 225A)

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

YES 1
NO 2
DON'T KNOW 8

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.

GRANTED 1 (SIGN)_________________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)_______________
RESPONDENT REFUSED 3 (SIGN)_____________________________

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

G/DL ___ ___.___

NOT PRESENT 994
REFUSED 995
OTHER 996

229 BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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)

LINE NUMBER ___ ___
NAME ______________

233 WEIGHT IN KILOGRAMS

KG ___ ___ ___.___

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

234 HEIGHT IN CENTIMETRES

CM ___ ___ ___.___

NOT PRESENT 9994
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

236 AGE:CHECK COLUMN 9

15-17 YEARS 1
18-49 YEARS 2 GO TO 239

237 MARITAL STATUS:
CHECK COLUMN 10

CODE 4 (NEVER MARRIED) 1
OTHER 2 GO TO 239

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

LINE NUMBER OF PARENT OR OTHR RESPONSIBLE ADULT ___ ___

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

GRANTED 1(SIGN) ___________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _________ (GO TO 225A)
RESPONDENT REFUSED 3 (SIGN) ___________ (GO TO 225A)

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.

GRANTED 1(SIGN)____________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)____________
RESPONDENT REFUSED 3 (SIGN)____________

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

G/DL ___ ___.___

NOT PRESENT 994
REFUSED 995
OTHER 996

244 BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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.