PLANNING AND STATISTICAL UNIT/M-HEALTH
NATIONAL DEPARTMENT OF STATISTICS AND INFORMATION
REPUBLIC OF MALI
PLACE NAME_____
COMMUNE_____
CLUSTER NUMBER______
NAME OF HEAD OF HOUSEHOLD AND HOUSEHOLD NUMBER______
REGION_____
VILLAGE ______
RURAL 2
BAMAKO, OTHER CITIES, OTHER VILLAGES, OR RURAL?
OTHER CITIES 2
OTHER VILLAGES 3
RURAL 4
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
NO 2
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____
DAY____
MONTH____
YEAR 2001
INTERVIEWER NAME____
2 NO MEMBER OF THE HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT THE TIME OF THE VISIT
3 HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME
4 POSTPONED
5 REFUSED
6 EMPTY DWELLING OR NO DWELLING AT THE ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____
NEXT VISIT
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH__
YEAR 2001
INTERVIEWER_____
RESULT_____
TOTAL IN THE HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____
SUPERVISOR
NAME_____
DATE_____
FIELD EDITOR
NAME_____
DATE_____
OFFICE EDITOR_____
KEYED BY_____
We would now like information on the persons who usually live in your household and who are currently living with you.
1. LINE NUMBER
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 slept here last night, starting with the head of the household.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDSON OR GRANDDAUGHTER
06 FATHER OR MOTHER
07 FATHER-IN-LAW OR MOTHER-IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DOESN'T KNOW
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
8. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN RESIDENTS OR VISITORS BETWEEN 15-49 YEARS.
9. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL MEN RESIDENTS OR VISITORS BETWEEN 15-59 YEARS.
9A. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL THE CHILDREN RESIDENTS OR VISITORS LESS THAN 6 YEARS.
SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:
10. Is (NAME'S) biological mother still alive?
NO 2
DOESN'T KNOW 8
11. IF ALIVE: Does the (NAME'S) biological mother live in the household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. RECORD '00' IF THE FATHER IS NOT MEMBERS OF THE HOUSEHOLD.
12. Is (NAME'S) biological father still alive?
NO 2
DOESN'T KNOW 8
13. IF ALIVE: Does the (NAME'S) biological father live in the household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. RECORD '00' IF THE FATHER IS NOT MEMBERS OF THE HOUSEHOLD.
EDUCATION. IF 5 YEARS OR MORE:
14. Has (NAME) attended school?
FOR THE FIRST PERSON AGED 5 TO 17 YEARS, GO TO THE NEXT LINE OR COLUMN 20C.
NO 2 (GO TO NEXT LINE)
15. What is the highest level of education attained by (NAME)? What is the last class completed by (NAME) at this level?
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
5 DOESN'T KNOW
8 DOESN'T KNOW
16. Does (NAME) currently attend school?
NO 2
17. Has (NAME) attended school during the current school at any time?
NO 2 (GO TO 19)
18. During the current school year which level did (NAME) achieve and in which class?
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
5 DOESN'T KNOW
8 DOESN'T KNOW
19. Did (NAME) attend school at any time during the previous school year?
FOR THE FIRST PERSON AGED 5 TO 17 YEARS, GO TO THE NEXT LINE OR COLUMN 20C.
NO 2 (GO TO THE NEXT LINE)
20. During the current school year which level did (NAME) achieve and in which class?
FOR THE FIRST PERSON AGED 5 TO 17 YEARS, GO TO THE NEXT LINE OR COLUMN 20C.
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
5 DOESN'T KNOW
8 DOESN'T KNOW
MARK HERE IF ANOTHER SHEET WAS USED_____
Just to be sure that I have a complete list:
1) Are there other persons such as small children or infants that we have not recorded on the list?
NO 2
2) Are there other persons who maybe are not members of your family such as domestic workers, renters or friends who usually live here?
NO 2
3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?
NO 2
IF BETWEEN THE AGES OF 5 AND 17 YEARS:
20C. RECORD THE NAME OF EACH ELIGIBLE CHILD FOLLOWING THE CORRESPONDING LINE NUMBER
20D. Who is the mother of the main person in charge of (NAME)?
RECORD THE LINE MOTHER/OR THIS PERSON'S LINE NUMBER
20E. CHILD LABOR: Did (NAME) do any kind of work for someone who is not a member of this household last week?
IF YES: to be paid?
NO PAY 2
NO 3 (GO TO 20G)
20F. CHILD LABOR. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she work for someone who is not a member of the household?
IF MORE THAN ONE JOB, TAKE THE SUM OF ALL THE HOURS.
20G. During the last year did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: to be paid?
YES, UNPAID 2
NO 3
20H. Did (NAME) help with household work last week? For example: get groceries, cook, clean, get water, watch children, wash clothes??
NO 2 (GO TO 20J)
20I. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she spend doing this household work?
20J. Did (NAME) do other work for the family last week (such as farm work, commerce, business,?) ?
GO TO THE NEXT LINE OR TO QUESTION 2 IF THERE IS NO ELIGIBLE CHILD FOR COLUMNS 20C TO 20K
NO 2 (GO TO NEXT LINE)
20K. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she spend doing this work?
GO TO THE NEXT LINE OR TO QUESTION 2 IF THERE IS NO ELIGIBLE CHILD FOR COLUMNS 20C TO 20K
21. What is the main source of water for members of your household?
PIPED INTO THE YARD/PLOT 12 (GO TO 23)
PUBLIC TAP/STANDPIPE 13
IN THE YARD/PLOT 22 (GO TO 23)
OPEN PUBLIC WELL 23
IN THE YARD/PLOT 32 (GO TO 23)
PROTECTED PUBLIC WELL 33
RIVER/STREAM 42
SWAMP/LAKE 43
DAM 44
TANKER 61
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY) ______ 96
22. How long does it take to go there, get water, and come back?
ON SITE 998
23. What kind of toilet facility do the majority of the members of your household use?
IMPROVED 22
OTHER (SPECIFY) _____ 96
24. Do you share this toilet facility with other households?
NO 2
Electricity?
Radio?
Television?
Telephone?
Refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
26. What type of fuel does your household mainly use for cooking?
BOTTLED GAS/NATURAL GAS 02
BIOGAS 03
KEROSENE/PETROL 04
CHARCOAL/LIGNITE (HARD FOSSIL CHARCOAL) 05
WOOD CHARCOAL 06
WOOD/STRAW 07
ANIMAL DUNG 08
OTHER (SPECIFY) _____ 96
27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
28. Is there anyone in your household who owns:
A bicycle?
A scooter or motorcycle?
A car or truck?
A cart?
A plow?
A horse?
A camel?
A donkey?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
29. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 33)
30. CHECK COLUMNS (6) AND (7):
NUMBER OF CHILDREN LESS THAN 5 YEARS WHO SLEPT IN THE HOUSEHOLD THE LAST NIGHT.
TWO OR MORE (GO TO 32)
ONLY ONE (GO TO 31)
31. Did (NAME) sleep under a mosquito net last night?
NO 2 (GO TO 33)
32. Among the children less than 5 years old who slept in the household last night, did they all sleep under a mosquito net, some of them, or none?
SOME 2
NONE 3
33. Where do members of your household most often wash their hands?
SOMEWHERE ELSE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)
34. ASK TO SEE THE PLACE MOST OFTEN USED FOR HAND WASHING AND CHECK TO SEE IF THE FOLLOWING OBJECTS ARE THERE.
NO 2
NO 2
NO 2
35. Ask the respondent for a teaspoon of cooking salt, then test for iodide. Record the PPM (Proportion per million).
Test in the following order: iodate, iodide, alkaline.
Code '1' should only be used if the test is negative for all 3 reactions. If the test is positive for iodide or alkaline, circle code '6'.
1-25 PPM 2
26-50 PPM 3
51-75 PPM 4
76-100 PPM 5
1-75 PPM (IODINE/ALKALINE) 6
NO SALT IN HOUSEHOLD 8
WEIGHT AND HEIGHT AND HEMOGLOBIN MEASUREMENTS
CHECK COLUMNS (8) AND (9A), (2) AND (7) FROM THE HOUSEHOLD TABLE: RECORD THE LINE NUMBER, NAME AND AGE OF ALL OF THE WOMEN 15-49 AND OF ALL OF THE CHILDREN LESS THAN 6.
36. LINE NUMBER FROM COLUMN (8):
WEIGHT AND HEIGHT OF WOMEN 15-49:
40. WEIGHT (KILOGRAMS):
2 ABSENT
3 REFUSED
6 OTHER
36. LINE NUMBER OF COL. (9A):
39. What is the birthdate of (NAME)?
MONTH _____
YEAR _____
WEIGHT AND HEIGHT OF CHILDREN BORN IN 1996 OR AFTER:
40. WEIGHT (KILOGRAMS):
42. MEASURED LYING DOWN OR STANDING:
STANDING 2
2 ABSENT
3 REFUSED
6 OTHER
43A. REGISTERED WITH THE STATE:
NO 2
DOESN'T KNOW 8
CHECK HERE IF ANOTHER SHEET WAS USED _____
MEASUREMENT OF HEMOGLOBIN LEVEL OF WOMEN 15-49 YEARS:
44. CHECK COLUMN (38):
AGE 18-49 YEARS 2 (GO TO 46)
45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
46. READ THE CONSENT STATEMENT TO THE WOMAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN)
REFUSED 2 (GO TO NEXT LINE)
NO/DOESN'T KNOW 2
2 ABSENT
3 REFUSED
6 OTHER
MEASUREMENT OF HEMOGLOBIN LEVEL OF CHILDREN BORN IN 1996 OR LATER:
45. LINE NUMBER OF THE PARENT/RESPONSIBLE ADULT.
RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
46. READ THE CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN).
REFUSED 2 (GO TO NEXT LINE)
2 ABSENT
3 REFUSED
6 OTHER
MEASUREMENT OF HEMOGLOBIN LEVEL OF MEN 15-59 YEARS:
CHECK COLUMNS (8), (9), (2) AND (7) OF THE HOUSEHOLD TABLE: RECORD THE LINE NUMBER, THE NAME AND AGE OF ALL MEN 15-59
49A. LINE NUMBER FROM COLUMN (9):
AGE 18-59 YEARS 2 (GO TO 49F)
49E. LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
49F. READ THE CONSENT STATEMENT TO THE MAN/PARENT/RESPONSIBLE ADULT CIRCLE THE CODE (AND SIGN)
REFUSED 2 (GO TO NEXT LINE)
2 ABSENT
3 REFUSED
6 OTHER
MARK HERE IS ANOTHER SHEET WAS USED____
50. CHECK 47, 48 AND 49(G):
NUMBER OF USUAL RESIDENTS WHOSE HEMOGLOBIN IS BELOW THE CRITICAL THRESHOLD. THE CRITICAL THRESHOLD IS 7 G/DL.
NONE: GIVE EVERY WOMAN/MAN/ADULT RESPONSIBLE TEST RESULTS. END OF HOUSEHOLD QUESTIONNAIRE.
51. We have detected a low level of hemoglobin in (your blood/ the blood of NAME OF CHILD/CHILDREN). The means that (you/ NAME OF CHILD/CHILDREN) are severely anemic, this is a serious health problem. We wish to inform the doctor of ______ about (your condition /the condition of NAME OF CHILD/CHILDREN). This will help you to get the appropriate treatment for your condition Do you accept to have this information concerning the hemoglobin level of (your blood/ the blood of NAME OF CHILD/CHILDREN) given to the doctor?
NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD
ACCEPT THAT THE INFORMATION IS SHARED?
NO 2
MEN AND WOMEN 15-17 AND CHILDREN LESS THAN 6 YEARS:
NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD:
NAME OF PARENT/RESPONSIBLE ADULT:
ACCEPT THAT THE INFORMATION IS SHARED?
NO 2
CHECK COLUMNS (8) AND (9) OF THE HOUSEHOLD TABLE: RECORD THE LINE NUMBER, NAME, AGE AND MARITAL STATUS OF ALL THE WOMEN 15-49 YEARS AND ALL THE MEN 15-59 YEARS.
52. LINE NUMBER FROM COL. (8) OR COL (9):
2 SINGLE
3 DIVORCED/WIDOWED/SEPARATED
18-49 YEARS 2 (GO TO 58)
57. LINE NUMBER OF PARENT/ADULT RESPONSIBLE.
RECORD '00' IF THEY ARE NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
58. READ CONSENT STATEMENT TO THE WOMAN/MAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN).
REFUSED 2 (GO TO NEXT LINE)
2 NOT TESTED
6 OTHER
52. LINE NUMBER FROM COL. (8) OR COL (9)
53. NAME FROM COL. (2)
54. MARITAL STATUS:
2 SINGLE
3 DIVORCED/WIDOWED/SEPARATED
55. AGE FROM COL. (7):
56. CHECK COLUMN (55): AGE?
18-49 YEARS 2 (GO TO 58)
57. LINE NUMBER OF PARENT/ADULT RESPONSIBLE.
RECORD '00' IF THEY ARE NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.
58. READ CONSENT STATEMENT TO THE WOMAN/MAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN).
REFUSED 2 (GO TO NEXT LINE)
59. RESULT:
2 NOT TESTED
6 OTHER
MARK HERE IS ANOTHER SHEET WAS USED ____
VOLUNTARY CONSENT STATEMENT FOR ANEMIA AND HIV TESTS
As part of this survey, we would like to know the level of anemia in women, men, and children. Anemia, which is due to poor nutrition, is a serious health problem. The results of this survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all of your children/children you care for) take an anemia test by giving a few drops of blood from a finger. For this test we use sterile, non-reusable instruments that are clean and risk-free. Blood will be analyzed with new equipment and the results will be given to you immediately. The results are confidential.
Do you have any questions?
May I request now that you (and all of your children/children you care for) take this anemia test? However, if you decide to refuse, know that you have this right and that we respect your decision.
Now, can you tell me if you (and all of your children/children you are for) accept to take this test?
FOR EACH PERSON, RETURN TO COLUMN (46) FOR WOMEN 15-49 AND CHILDREN BORN SINCE JANUARY 1996 AND TO COLUMN (49F) FOR MEN 15-59, ON THE LINE OF THE CORRESPONDING PERSON AND CIRCLE THE APPROPRIATE CODE. SIGN AND FOLLOW THE SKIP CODE.
As part of this survey, we are doing a study of HIV/AIDS among women and men. HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. This survey will help the government develop programs to prevent this illness.
For the HIV test we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is no reusable. It has never been used before and will be thrown away after the test.
The blood will then be sent to a lab to be analyzed. No name will be linked to the result. Thus, we will not be able to tell you your test results. No else will know that result of the blood test either.
Do you have any questions?
Now, do you agree to take this HIV test? However, if you choose to refuse, know that you have the right and we will respect your decision.
Now, can you tell me if you agree to participate in the HIV test?
FOR EACH PERSON, RETURN TO COLUMN (58) AND THE LINE OF THE CORRESPONDING PERSON AND CIRCLE THE APPROPRIATE CODE. SIGN AND FOLLOW THE SKIP INSTRUCTIONS.
BE SURE TO GIVE EACH ELIGIBLE PERSON WHETHER OR NOT SHE/HE ACCEPTED THE HIV TEST, A CARD "ADVICE AND FREE HIV TESTS." TELL HIM/HER: "This card allows you to get free advice and HIV tests. If you would like to get tested, bring this card to the appropriate health facility. At this facility, information about HIV and ways to avoid it will be given to you. Also a few drops of blood will be taken which will allow you to know the results of your test. Do you have questions about this card and the place to go?"