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DEMOGRAPHIC AND HEALTH SURVEY IN MALI (EDSM-V, 2012), HOUSEHOLD QUESTIONNAIRE

COMMITTEE OF PLANNING AND STATISTICS/MINISTRY OF HEALTH
NATIONAL OFFICE OF STATISTICS AND INFORMATION
REPUBLIC OF MALI

IDENTIFICATION:

PLACE NAME___
CLUSTER NUMBER_____
PLOT NUMBER___
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD___
HOUSEHOLD NUMBER___
REGION___

URBAN/RURAL/ MILIEU___

URBAN 1
RURAL 2

BAMAKO, OTHER CITIES, OTHER TOWNS, RURAL/ MILIEU (DETAILED)_____

BAMAKO 1
OTHER CITIES 2
OTHER TOWNS 3
RURAL 4

HOUSEHOLD SELECTED FOR:
MEN'S SURVEY/HIV TEST/ANEMIA TEST/MALARIA TEST/HEALTH EXPENSES:

YES 1
NO 2

INTERVIEWER VISITS

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE___
INTERVIEWER'S NAME___
RESULT*____

NEXT VISIT
(REPEAT FOR INTERVIEWER 2)
DATE___
TIME___

FINAL VISIT
DAY___
MONTH___
YEAR 2012
NAME___
RESULT___

TOTAL NO. OF VISITS___

RESULT CODES:

1Completed
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)____

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESP. TO HOUSEHOLD INTERVIEW___

SUPERVISOR
NAME___
DATE_______

FIELD EDITOR
NAME___
DATE___

OFFICE EDITOR___

KEYED BY___

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with INFO-STAT, which is executing this survey in collaboration with the Committee of Planning and Statistics of the Ministry of Health (CPS) and the National Office of Statistics and Information (INSTAT). We are conducting a survey about health all over Mali. 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 15 to 20 minutes. All of the answers you give will be confidential and will Not be shared with anyone other than 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?

SIGNATURE OF INTERVIEWER___
DATE___

Respondent agrees to be interviewed 1
Respondent does not agree to be interviewed 2 (END)

HOUSEHOLD SCHEDULE

1) LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

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 TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

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

01 HEAD
02 WIFE OR HUSBAND
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 ADOPTED/FOSTER/STEPCHILD
11 NOT RELATED
98 DON'T KNOW

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

MALE 1
FEMALE 2

5) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

6) RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

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

IN YEARS____

8) IF AGE 15 OR OLDER: MARITAL STATUS: 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:

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-49

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

11A) CHECK COVER PAGE:
IF HOUSEHOLD WAS SELECTED FOR HOUSEHOLD HEALTH EXPENSES (HOUSEHOLD SELECTION=3),
Please tell me if a member of your household is currently ill, or suffering from a long term condition or injury, or was ill in the last 30 days.

IF YES, CIRCLE THE LINE NUMBER.

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

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

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

13) 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 NUMBER.
IF NO, RECORD 00.

LINE NO. ____

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

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

15) Does (NAME)'s natural father 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 NO. ____

IF AGE 5 YEARS OR OLDER, EVER ATTENDED SCHOOL:

16) Has (NAME) ever attended school?

YES 1
NO 2 (NEXT LINE)

17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

LEVEL ___
1 FUNDAMENTAL 1 (1ST CYCLE)
2 FUNDAMENTAL 2 (2ND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 HIGHER
6 NURSERY SCHOOL/PRE-PRIMARY
8 DON'T KNOW
GRADE ___
00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

IF AGE 5-25 YEARS, CURRENT/RECENT SCHOOL ATTENDANCE:

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

YES 1
NO 2 (NEXT LINE)

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

LEVEL ___
1 FUNDAMENTAL 1 (1ST CYCLE)
2 FUNDAMENTAL 2 (2ND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 HIGHER
6 NURSERY SCHOOL/PRE-PRIMARY
8 DON'T KNOW
GRADE ___
98 DON'T KNOW

CODES FOR QUESTIONS. 17 AND 19 ON EDUCATION:

LEVEL
1=FUNDAMENTAL 1 (1ST CYCLE)
2=FUNDAMENTAL 2 (2ND CYCLE)
3=SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4=HIGHER
6=NURSERY SCHOOL/PRE-PRIMARY
8=DON'T KNOW

GRADE
00=LESS THAN 1 YEAR COMPLETED (USE 00 FOR Q. 17 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 19)
98=DON'T KNOW

IF AGE 0-4 YEARS, BIRTH REGISTRATION:

20) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

1 HAS CERTIFICATE
2 REGISTERED
3 NEITHER
8 DON'T KNOW

Just to make sure that I have a complete listing:

2A) Are there any other persons such as small children or infants that we have NOT listed?

YES (ADD EACH IN TABLE)
NO

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?

YES (ADD EACH IN TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have NOT been listed?

YES (ADD EACH IN TABLE)
NO

WORK OF CHILDREN AGE 5-14 YEARS

21) CHECK COLUMN 7
RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

___

21A) CHECK Q.21:

IF AT LEAST ONE CHILD (GO TO 21B)
IF NO CHILDREN (GO TO 101)

21B) LIST OF CHILDREN AGE 5-14 YEARS:

CHECK COLUMN 7 OF HOUSEHOLD TABLE.
RECORD THE NAMES AND LINE NUMBERS OF ALL THE CHILDREN AGE 5-14 YEARS IN THE ORDER OF THE HOUSEHOLD TABLE.

LINE NO. ____

21C) NAME___

Now I would like to ask you some questions on the type of work that children in your household did last week.

IF AGE 5-14 YEARS:

21D) In the last week, did (NAME) do any work for anyone who is NOT a member of this household? IF YES: Was he/she paid in cash or in kind?

1 PAID WORK
2 UNPAID WORK
3 NO WORK (GO TO 21F)

21E) IF YES: Since last (day of the week), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

NUMBER OF HOURS ____

21F) In the last week, did (NAME) go get water or wood for the household?

YES 1
NO 2 (GO TO 21H)

21G) IF YES: Since last (day of the week), approximately how many hours did he/she spend getting water or wood for the household?
IF MORE THAN ONE TIME, ADD UP ALL THE HOURS.

NUMBER OF HOURS_____

21H) In the last week, did (NAME) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?
INCLUDE WORK DONE FOR A BUSINESS DONE BY THE CHILD ALONE OR DONE WITH ONE OR SEVERAL PARTNERS.

YES 1
NO 2 (GO TO 21J)

21I) IF YES: Since last (day of the week), approximately how many hours did he/she spend doing work for his/her family or him/herself?
IF MORE THAN ONCE, ADD UP ALL THE HOURS.

NUMBER OF HOURS______

21J) In the last week, did (NAME) do any household chores, such as shopping, cleaning, clothes washing, cooking, or taking care of children, old people, or sick people?

YES 1
NO 2 (NEXT LINE)

21K) IF YES: Since last (day of the week), approximately how many hours did he/she spend doing these household chores?
IF MORE THAN ONCE, ADD UP ALL THE HOURS.

NUMBER OF HOURS_____

HOUSEHOLD CHARACTERISTICS

101) 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

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED INTO YARD/PLOT 12 (GO TO 105)
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 105)
TANKER TRUCK 61
CART WITH SMALL TANK/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER______ (SPECIFY) 96

103) Where is the water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES____
DON'T KNOW 998

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.

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_______ (SPECIFY) X
DON'T KNOW Z

106A) How do you usually store drinking water in your household?
Anything else? RECORD ALL MENTIONED.

OPEN CONTAINER (BARREL, WATER JUG, PAIL, BOWL) A
CLOSED CONTAINER (BARREL, WATER JUG, PAIL, BOWL) B
CONTAINERS/BOTTLES C
OTHER_____________ (SPECIFY) X
DON'T KNOW Z

107) 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 SOMETHING 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
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/OUTDOORS 61- (GO TO 110)
OTHER____________ (SPECIFY) 96

107A) Where is this toilet facility located?

IN DWELLING 1
IN YARD/PLOT 2
ELSEWHERE 3

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

YES 1
NO 2 (GO TO 110)

109) How many households use this toilet facility?

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

110) Does your household have:

Electricity?
A radio?
A television?
A mobile telephone?
A Non-mobile telephone?
A refrigerator?
A TV5 antenna?
A subscription to Canal?
A washing machine?
A portable stove or a gas or electric stove?
An improved fireplace?
A CD/DVD player?
An air conditioner?
A computer?
Internet at home?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
TV5 ANTENNA
YES 1
NO 2
SUBSCRIPTION TO CANAL
YES 1
NO 2
WASHING MACHINE
YES 1
NO 2
PORTABLE/GAS OR ELECTRIC STOVE
YES 1
NO 2
IMPROVED FIREPLACE
YES 1
NO 2
CD/DVD PLAYER
YES 1
NO 2
AIR CONDITIONER COMPUTER
YES 1
NO 2
INTERNET AT HOME
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER ____________ (SPECIFY) 96

112) 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 114)
OUTDOORS 3(GO TO 114)
OTHER_________ (SPECIFY) 6 (GO TO 114)

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

YES 1
NO 2

114) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL/ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER____________ (SPECIFY) 96

115) MAIN MATERIAL OF ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALMS/LEAVES 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILE 34
CEMENT 35
ROOFING SHINGLES 36
OTHER_______ (SPECIFY) 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
RECYCLED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER_____ (SPECIFY) 96

117) In this household, how many places/rooms in this household are used for sleeping?

ROOMS ____A
PLACES_____ B
UNDER A TREE 95 C

117a) Do you use beds, mattresses, mats, rugs, or anything else to sleep in this household?
IF YES: How many of each?
RECORD ALL IN THE LIST.

NUMBER OF BEDS______
NUMBER OF MATTRESSES______
NUMBER OF MATS______
NUMBER OF RUGS______
OTHER______ (SPECIFY)
OTHER______ (SPECIFY)

118) Does any member of your household own:

A watch?
Plows?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A canoe/or fishing nets?
A tractor?
A car or truck?
A boat with a motor?

WATCH
YES 1
NO 2
PLOWS
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CANOE/FISHING NETS
YES 1
NO 2
TRACTOR
YES 1
NO 2
CAR OR TRUCK
YES 1
NO 2
A BOAT WITH A MOTOR
YES 1
NO 2

119) Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120) How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950

HECTARES______
95 OR MORE HECTARES 950
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 123)

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

Cattle?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens?

CATTLE ____
MILK COWS OR BULLS_____
HORSES, DONKEYS, OR MULES_____
GOATS______
SHEEP_____
CHICKENS_____

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

YES 1
NO 2

123A) In the last 4 weeks, was there a time when there was nothing to eat in the household, regardless of the nature, due to a lack of resources to obtain food?

YES 1
NO 2 (GO TO 123C)

123B) How many times did this happen; rarely (one or two times in the last 4 weeks), sometimes (three to ten times in the last 4 weeks), or often (more than ten times in the last 4 weeks)?

RARELY (ONE OR TWO TIMES IN THE LAST 4 WEEKS) 1
SOMETIMES (THREE TO TEN TIMES IN THE LAST 4 WEEKS) 2
OFTEN (MORE THAN TEN TIMES IN THE LAST 4 WEEKS) 3

123C) In the last 4 weeks, did you or someone else in your household go to bed hungry because there wasn't anything to eat?

YES 1
NO 2 (GO TO 123E)

123D) How many times did this happen; rarely (one or two times in the last 4 weeks), sometimes (three to ten times in the last 4 weeks), or often (more than ten times in the last 4 weeks)?

RARELY (ONE OR TWO TIMES IN THE LAST 4 WEEKS) 1
SOMETIMES (THREE TO TEN TIMES IN THE LAST 4 WEEKS) 2
OFTEN (MORE THAN TEN TIMES IN THE LAST 4 WEEKS) 3

123E) In the last 4 weeks, did you or someone else in your household spend an entire day and night without eating anything because there wasn't enough food?

YES 1
NO 2 (GO TO 124)

123F) How many times did this happen; rarely (one or two times in the last 4 weeks), sometimes (three to ten times in the last 4 weeks), or often (more than ten times in the last 4 weeks)?

RARELY (ONE OR TWO TIMES IN THE LAST 4 WEEKS) 1
SOMETIMES (THREE TO 10 TIMES IN THE LAST 4 WEEKS) 2
OFTEN (MORE THAN TEN TIMES IN THE LAST 4 WEEKS) 3

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

YES 1
NO 2 (GO TO 126)
DON'T KNOW 8 (GO TO 126)

125) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER_____ (SPECIFY) X
DON'T KNOW Z

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

YES 1
NO 2 (GO TO 137)

127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD 7.

NUMBER OF NETS_____

128) ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD. ASK QUESTIONS 128-136 FOR EACH NET. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

129) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00

MONTHS _____
MORE THAN 36 MONTHS 95
NOT SURE 98

130) 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

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
OLYSET 11 (GO TO 134)
PERMANET 12 (GO TO 134)
OTHER/DON'T KNOW BRAND 16 (GO TO 134)
'PRETEATED' NET
PERMETHRINE 21 (GO TO 132)
DELTA METHRINE 22 (GO TO 132)
CYFULTRINE 23 (GO TO 132)
OTHER/DON'T KNOW BRAND 26 (GO TO 132)
OTHER BRAND 96
DON'T KNOW BRAND 98

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
NOT SURE 8

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

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD 00.

MONTHS______
MORE THAN 24 MONTHS AGO 95
NOT SURE 98

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

YES 1
NO 2 (GO TO 136)
DON'T KNOW 8 (GO TO 136)

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

NAME________
LINE NUMBER_______

136) Where did you get this mosquito net?

HEALTH STRUCTURE 1
PRIVATE PHARMACY 2
BUSINESS/MARKET 3
COMMERCIAL ASSOCIATION 4
OTHER NON-COMMERCIAL 5
DISTRIBUTION CAMPAIGN 6
OTHER______ (SPECIFY) 7
DON'T KNOW 8

136A) How did you purchase this mosquito net?

PURCHASE WITHOUT COUPON 1
PURCHASE WITH COUPON 2
FREE 3
OTHER _____ (SPECIFY) 6
DON'T KNOW 8

136B) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

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

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

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

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE C

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

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED _______ (SPECIFY REASON) 6

141) SELECTION TABLE FOR WOMEN FOR "DOMESTIC VIOLENCE"

THIS SECTION APPLIES TO ALL THE SAMPLING HOUSEHOLDS, MEANWHILE ONE WOMAN WILL BE INTERVIEWED PER HOUSEHOLD FOR THIS SECTION: THE SCHEDULE BELOW WILL ALLOW YOU TO RANDOMLY SELECT THIS WOMAN IN THE HOUSEHOLD.

TAKE THE LAST DIGIT OF THE NUMBER OF THE SET OF THE HOUSEHOLD QUESTIONNAIRE ON THE COVER PAGE. THIS IS THE LINE NUMBER WHERE YOU SHOULD GO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER WHERE YOU SHOULD GO. FOLLOW THE LINE AND COLUMN SELECTED UP TO THE SPACE WHERE THEY MEET AND CIRCLE THE NUMBER IN THIS SPACE. THIS IS THE ORDER NUMBER OF THE WOMAN SELECTED TO RESPOND TO THE QUESTIONS ON DOMESTIC VIOLENCE STARTING FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. RECORD THE NAME AND LINE NUMBER OF THE WOMAN SELECTED IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE NUMBER OF THE SET OF THE HOUSEHOLD QUESTIONNAIRE IS '716' AND COLUMN 9 OF THE HOUSEHOLD SCHEDULE SHOWS THAT THERE ARE 3 ELIGIBLE WOMEN FROM AGE 15-49 AND IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). GIVEN THAT THE LAST DIGIT OF THE NUMBER OF THE SET OF THE HOUSEHOLD QUESTIONNAIRE IS 6, GO TO THE LINE 6 AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD GO TO COLUMN 3. FOLLOW THE LINE AND THE COLUMN TO FIND THE SPACE NUMBER WHERE THEY CROSS ('2'), CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND ELIGIBLE WOMEN FOR THE INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). RECORD HER NAME AND LINE NUMBER IN THE SPACE PROVIDED BELOW THE SCHEDULE.

LAST DIGIT OF NUMBER OF SET OF HOUSEHOLD SCHEDULE: 0-9

TOTAL NUMBER OF WOMEN ELIGIBLE FROM AGE 15-49 IN COLUMN 9 OF HOUSEHOLD SCHEDULE: 1-8

NAME OF SELECTED WOMAN ____

LINE NUMBER OF WOMAN SELECTED FORM HOUSEHOLD SCHEDULE ____

WEIGHT, HEIGHT HEMOGLOBIN MEASUREMENT, AND MALARIA TEST FOR CHILDREN AGE 0-5 IN THE HOUSEHOLD

201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER_______
NAME________

203) 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 day?

DAY ______
MONTH ______
YEAR ______

204) CHECK 203:
CHILD BORN IN JANUARY 2007 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 222)

205) WEIGHT IN KILOGRAMS

KG_____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CM _____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

207A) PRESENCE OF BILATERAL EDEMA ON FEET

YES 1
NO 2

208) CHECK 203:
IF 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 CHILDREN, GO TO 222)
Older 2

209) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD 00 IF NOT LISTED.

LINE NUMBER______

210) READ THE DECLARATION OF CONSENT FOR THE ANEMIA AND MALARIA TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

DECLARATION OF CONSENT FOR ANEMIA AND MALARIA TEST

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that results from poor nutrition, infection, or chronic disease.

Within the framework of the survey, we are also doing a survey of malaria among children under age 5. As you may know, malaria is a serious health problem that results from an exposure to mosquito bites.

This survey will assist the government to develop and set up programs to prevent and treat anemia and malaria.

We ask that all children born in 2007 or later take part in anemia and malaria testing in this survey by giving few drops of blood from a finger or heel. For this test, the equipment used to 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 anemia and malaria immediately, and the result will be 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 your decision.

211) ASK FOR CONSENT FOR THE ANEMIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD. REQUEST FOR CONSENT FOR ANEMIA TEST. Will you allow (NAME(S) OF CHILD(S)) to participate in the anemia test?

212) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

GRANTED 1_________ (SIGNATURE)
REFUSED 2

213A) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD. REQUEST FOR CONSENT FOR MALARIA TEST. Will you allow (NAME(S) OF CHILD(S)) to participate in the malaria test?

213) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE MALARIA TEST AND SIGN YOUR NAME.

GRANTED 1_______ (SIGNATURE)
REFUSED 2

214) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT WAS GIVEN FOR THE CHILD AND CONTINUE WITH THE TESTS. PREPARE THICK DROPS OF BLOOD ON TWO MICROSCOPE SLIDES IF CONSENT WAS OBTAINED FOR THE MALARIA TEST, AND CONTINUE TO 215.

215) RECORD THE HEMOGLOBIN LEVEL HERE ON THE ANEMIA PAMPHLET.

G/DL_________

NOT PRESENT 994
REFUSED 995
OTHER 996

216) RECORD RESULT BASED ON TDR MALARIA PAMPHLET. [##translator Note: TDR may refer to the "Special Program for Research and Training in Tropical Diseases" affiliated with the WHO, but I couldn't figure out how to make that fit with the sentence logically. Otherwise, I couldn't find what it stands for).

POSITIVE 1
NEGATIVE 2 (GO TO 221)
NOT PRESENT 994
REFUSED 995
OTHER 996
994-996 (GO TO 222)

217) ASK FOR CONSENT FOR THE TREATMENT OF MALARIA FROM THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

CONSENT FOR TREATMENT OF MALARIA

The diagnostic test for malaria shows that your child has malaria. We can offer you free medications. These medications are called CTA [##translator note: Combinaison Thérapeutique à base d'artemisinine--Artemisinine-based combination therapy]. CTA are very effective and in a few days, should eliminate the fever and other symptoms. CTA is also very safe. However, like with all medications, there are side effects, and this medication can have some. The most common side effects are dizziness, fatigue, loss of appetite, and palpitations. CTA should never be taken by people with serious heart problems or with severe malaria (for example, cerebral malaria) or problems regulating salts in the body. You do not have to give your child this medication.

ASK IF THE MOTHER IS AWARE THAT THE CHILD HAS ANY OF THESE PROBLEMS. IF YES, DO NOT OFFER THE CTA. EXPLAIN THE RISKS OF MALARIA, AND REFER THE CHILD TO THE CLOSEST HEALTH ESTABLISHMENT.

Do you have any questions?
You can say YES to the test, or you can say NO. It is your decision.
Will you allow (NAME OF CHILD/CHILDREN) to receive malaria treatment?

218) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 _______ (SIGNATURE)
REFUSED 2

219) ASK IF THE CHILD IS CURRENTLY RECEIVING TREATMENT FOR MALARIA PRESCRIBED BY A DOCTOR OR ANOTHER HEALTH PROFESSIONAL.
Is the child currently receiving treatment prescribed by a doctor or another health professional?
CIRCLE A CODE AND CONTINUE.

YES, ALREADY RECEIVED MEDICAL TREATMENT 1 (GO TO 221)
NO 2

220) RECORD THE RESULT OF MALARIA TREATMENT.

TREATED 1
NOT TREATED, BUT REFERRED 2
NOT TREATED AND NOT REFERRED 3

221) BAR CODE LABEL
PUT THE 1ST BAR CODE LABEL HERE
PUT ONE LABEL ON EACH OF THE TWO SLIDES
PUT ONE ON THE TDR.
PUT THE FIFTH ON THE SAMPLE TRANSMITTAL FORM

PUT THE 1ST BAR CODE LABEL HERE_________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

222) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN, END HOUSEHOLD QUESTIONNAIRE.

NOTE (1): EXAMPLE LIST OF CTA (ARTEMISININE-BASED COMBINATION THERAPY) IN MALI

Laboratory: Novartis
Commercial name(s):Coatem
Common International Denomination: Artemether + lumefantrine
Laboratory: GVC
Commercial Name(s): Lonart syrup fl/60ml; Lonart Suppo B/6
Common International Denomination: Artemether + lumefantrine
Laboratory: Macleodes
Commercial Name(s): Lumiter
Common International Denomination: Artemether + lumefantrine
Laboratory: EGR
Commercial Name(s): Cofantrine B/24cp; Cofantrine syrup 2fl/60 ml; Cofantrine suppoB/6
Common International Denomination: Artemether + lumefantrine
Laboratory: Dafra Pharma
Commercial Name(s): Co Arinate FDC (adult, adolescent child)/
Common International Denomination: artesunate + SP
Laboratory: Dafra Pharma
Commercial Name(s): Co Artesiane syrup fl/120ml
Common International Denomination: Artemether + lumefantrine
Laboratory: CIPLA
Commercial Name: Falcimon (Adult, adolescent child)
Common International Denomination: artesunate + amodiaquine
Laboratory: Sanofi/Aventis
Commercial Name(s): Arsucam (Adult, adolescent child); Coarsucam (Adult, adolescent child)/ Common International Denomination: artesunate + amodiaquine
Mepha
Commercial Name(s): Artequin
Common International Denomination: artesunate + Mefloquine
Laboratory: IPCA
Commercial Name(s): Larimal FD 400 B/3 and B/6
Common International Denomination: artesunate + amodiaquine
Laboratory: Pfizer
Commercial Name(s): Camoquine plus (Adult, adolescent child); Dualkin
Common International Denomination: artesunate + amodiaquine
Laboratory: Stallion
Commercial Name(s): Kesunate
Common International Denomination: artesunate + amodiaquine
Laboratory: Beo Pharma
Commercial Name(s): Aremin
Common International Denomination: Artemether
Laboratory: Beo Pharma
Commercial Name(s): Arimal FD
Common International Denomination: artesunate + amodiaquine
Laboratory: Beo Pharma
Commercial Name(s): Duocotexcin; P-Alaxin; Coartema
Common International Denomination: dihydroartemisinin + piperaquine

MALARIA TREATMENT TIMETABLE FOR CHILDREN ACCORDING TO NATIONAL PROTOCOL FOR TREATMENT IN MALI.

Artemether + lumefantrine (AL) will be administered to those who have malaria detected based on the following timetable:

Approximate age/Dosage *
Less than 3 years/1 pill two times a day for 3 days
3 to 5 years/2 pills two times a day for 3 days

*The first day, the second does is taken 8 hours after the first, the next day, the dose is taken in the "morning" and "evening"

WEIGHT, HEIGHT HEMOGLOBIN MEASUREMENT, AND MALARIA TEST FOR WOMEN 15-49

230) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 231. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

231) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER________
NAME__________

232) WEIGHT IN KILOGRAMS

KG________

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

233) HEIGHT IN CENTIMETERS

CM________

NOT PRESENT 99994
REFUSED 9995
OTHER 99996

234) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 249)

235) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 249)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT __________

237) READ THE CONSENT FOR ANEMIA AND HIV TEST TO PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 236 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

DECLARATION OF CONSENT FOR ANEMIA AND MALARIA TEST

TO BE READ TO PARENT/OTHER RESPONSIBLE ADULT OF ADOLESCENT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease.

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 in this survey to see how significant of a problem AIDS is in Mali.

This survey will assist the government to develop and set up programs to prevent and treat anemia and HIV.

For the HIV test, we need a few drops of blood from a finger. For these tests, 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.

For anemia, the blood will be tested immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

For the HIV test, No names will be attached to the blood sample, 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. I will also give her a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say YES, or you can say NO to the test for (NAME OF ADOLESCENT). It is your decision.

238) ASK FOR CONSENT FOR THE ANEMIA TEST FROM THE PARENT/OTHER ADULT. REQUEST FOR CONSENT FOR ANEMIA TEST. Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?

238A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 _________ (SIGNATURE)
REFUSED 2

239) ASK FOR CONSENT FOR THE HIV TEST FROM THE PARENT/OTHER ADULT.
REQUEST FOR CONSENT FOR HIV TEST. Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?

239A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_________(SIGNATURE)
REFUSED 2

240) CHECK 238A AND 239A:

CODE 1 CIRCLED IN AT LEAST ONE SPACE (IN 238A, 239A)
CODE 2 CIRCLED IN BOTH SPACES (IN 238A, 239A) (GO TO 254)

241) CHECK 238A AND 239A:

CODE 1 CIRCLED IN ONLY ONE SPACE (IN 238A, 239A)
CODE 1 CIRCLED IN BOTH SPACES (IN 238A, 239A) (GO TO 249)

242) CHECK 238A AND 239A:

CODE 1 CIRCLED ONLY IN 238A (ANEMIA TEST)
CODE 1 CIRCLED ONLY IN 239A (HIV TEST) (GO TO 247)

243) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.

DECLARATION OF CONSENT FOR ANEMIA TEST

TO BE READ TO RESPONDENT (NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE CONSENT FOR THE ANEMIA TEST HAS BEEN GRANTED BY THE RESPONDENT'S PARENT/OTHER RESPONSIBLE ADULT)

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. The results of this survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need few drops of blood from a finger. For this test, 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.

The blood will be tested for anemia immediately, and the result will be 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 your decision.

244) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT. REQUEST FOR CONSENT FOR ANEMIA TEST.

Will you take in the anemia test?

244a) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_____________(SIGNATURE)
REFUSED 2

246) GO TO 253
.

WOMAN (1-3) CONTINUED:

247) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

DECLARATION OF CONSENT FOR HIV TEST

TO BE READ TO RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE CONSENT FOR THE HIV TEST HAS BEEN GRANTED BY THE RESPONDENT'S PARENT/OTHER RESPONSIBLE ADULT)

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 in this survey to see how significant of a problem AIDS is in Mali.

For the HIV test, we need a few drops of blood from a finger. For this test, 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 to the blood sample so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know you HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you wish) that you can use at any of these facilities.

Do you have any questions?
You can say YES to the test, or you can say NO. It is your decision.

248) GO TO 251.

249) READ CONSENT FOR ANEMIA AND HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST

TO BE READ TO RESPONDENT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease.

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 in this survey to see how significant of a problem AIDS is in Mali.

This survey will assist the government to develop and set up programs to prevent and treat anemia and HIV.

For the anemia and HIV test, we need a few drops of blood from a finger. For these tests, 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.

For the anemia test, the blood will be tested immediately, and the result will be 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.

For the HIV test, No names will be attached to the blood sample, so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know your HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say YES to the test, or you can say NO. It is your decision.

250) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT. REQUEST FOR CONSENT FOR ANEMIA TEST. Will you take in the anemia test?

250A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1___________ (SIGNATURE)
REFUSED 2

251) ASK CONSENT FOR HIV TEST FROM RESPONDENT. REQUEST FOR CONSENT FOR HIV TEST. Will you take in the HIV test?

251A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

GRANTED ____________1 (SIGNATURE)
REFUSED 2

252) CHECK 250A AND 251A:

RESPONDENT ACCEPTED AT LEAST ONE OF THE TWO TESTS, CODE 1 CIRCLED IN AT LEAST ONE SPACE (IN 250A, 251A)

RESPONDENT REFUSED BOTH TESTS, CODE 2 CIRCLED IN BOTH SPACES (IN 250A, 251A) (GO TO 254)

253) CHECK 244A, 250A, AND 251A ONE MORE TIME, AND PREPARE THE NECESSARY INSTRUMENTS FOR THE TEST(S) FOR WHICH YOU HAVE RECEIVED CONSENT. THEN CONDUCT THE TESTS. FOR EACH ELIGIBLE WOMAN, THE RESULT CODE FOR THE HIV TEST SHOULD BE RECORDED IN 254 AND FOR THE ANEMIA TEST IN 255, EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR OTHER REASONS.

254) BAR CODE LABEL.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

PUT THE 1ST BAR CODE LABEL HERE___________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

255) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA PAMPHLET.

G/DL_______

NOT PRESENT 994
REFUSED 995
OTHER 996

256) GO BACK TO Q. 215 IN NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT WOMAN.

IF THERE ARE MORE THAN 3 WOMEN, USE THE ADDITIONAL QUESTIONNAIRE THAT FOLLOWS. IF THERE ARE NO MORE WOMEN, GO TO 274.

HIV TEST FOR MEN AGE 15-59

274) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 275. IF THERE ARE MORE THAN SIX MEN, USE ADDITIONAL QUESTIONNAIRE(S).

275) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER______
NAME_____

278) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 284)

279) MARITAL STATUS: CHECK COLUMN 8

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 284)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT_______

281) ASK FOR CONSENT FOR HIV TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 280 AS RESPONSIBLE FOR MEN AGES 15-17 WHO HAVE NEVER BEEN IN UNION.

DECLARATION OF CONSENT FOR HIV TEST

TO BE READ TO PARENT/OTHER RESPONSIBLE ADULT OF ADOLESCENT.

As part of the survey we 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 in this survey to see how significant of a problem AIDS is in Mali.

The results of this survey will assist the government to develop and set up programs to prevent and treat anemia and HIV.

For this test, we need a few drops of blood from a finger. We use equipment that is clean and safe. It has never been used before and will be thrown away after each test.

For the HIV test, No names will be attached to the blood sample, 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 his HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say YES, or you can say NO to the test for (NAME OF ADOLESCENT). It is your decision.

282) ASK FOR CONSENT FOR THE HIV TEST FROM THE PARENT/OTHER RESPONSIBLE ADULT. REQUEST FOR CONSENT FOR HIV TEST. Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?

282A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1________ (SIGNATURE)
REFUSED 2

283) CHECK 282A:

CODE 1 CIRCLED IN 282A
CODE 2 CIRCLED IN 282A (GO TO 288)

284) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

DECLARATION OF CONSENT FOR HIV TEST

TO BE READ TO RESPONDENT.

As part of the survey we 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 in this survey to see how significant of a problem AIDS is in Mali.

For the HIV test, we need a few drops of blood from a finger. For this test, the equipment used is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached to the blood sample, so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know you HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you wish) that you can use at any of these facilities.

Do you have any questions?
You can say YES, or you can say NO to the test. It is your decision.

285) ASK CONSENT FOR HIV TEST FROM RESPONDENT. REQUEST FOR CONSENT FOR HIV TEST.

Will you take in the HIV test?

285A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_________ (SIGNATURE)
REFUSED 2

286) CHECK 285A:

CODE 1 CIRCLED IN 285A
CODE 2 CIRCLED IN 285A (GO TO 288)

287) CHECK 282A AND 285A ONE MORE TIME, AND PREPARE THE NECESSARY INSTRUMENTS FOR THE HIV TEST. THEN CONDUCT THE TESTS. FOR EACH ELIGIBLE MAN, THE RESULT CODE FOR THE HIV TEST SHOULD BE RECORDED IN 288, EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR OTHER REASONS.

288) BAR CODE LABEL
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

PUT THE 1ST BAR CODE LABEL HERE___________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

289) GO BACK TO Q. 275 IN NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT MAN.

IF THERE ARE MORE THAN 3 MEN, USE THE ADDITIONAL QUESTIONNAIRE THAT FOLLOWS. IF THERE ARE NO MORE MEN, GO TO Q900.

HOUSEHOLD HEALTH EXPENSES

900) CHECK COVER PAGE AND COLUMN 11A:

IF HOUSEHOLD IS SELECTED FOR HOUSEHOLD HEALTH EXPENSES (HOUSEHOLD SELECTION=3)
IF HOUSEHOLD SELECTION IS NOT 3 (GO TO 914)

900a) Now, I would like to ask you some questions about each person who has been sick or injured at one time or another in the last 30 days. Could you tell me the name of each person? Then we will talk in detail about each person, one after the other.

CHECK COLUMN 11A:
IF LINE NUMBER IS CIRCLED: ONE COLUMN PER SICK PERSON. IF THERE ARE MORE THAN 3 SICK PEOPLE IN THE HOUSEHOLD, USE ADDITIONAL QUESTIONNAIRES.

901) NAME:
LINE NUMBER CIRCLED IN COLUMN 11A:

NAME____
LINE NUMBER____

902) In your opinion, was (NAME)'s illness serious, moderate, or mild?

SERIOUS 1
MODERATE 2
MILD 3
DON'T KNOW 8

903) Did you perform self-medication?

YES 1
NO 2 (GO TO 904)

903A) Where did you go to obtain the drugs for (NAME)'s self-medication?

PHARMACY 1
DRUG VENDOR (TRAVELLING, MARKET) 2
HARVESTING PLANTS 3
DRUGS AVAILABLE AT HOME 4 (GO TO 903C)
OTHERS___________ (SPECIFY) 8

903B) How much did the drugs for (NAME)'s self-medication cost?
Sum in CFA

FCFA 1________

FREE 2 00000
PAID IN KIND 3 999995
DON'T KNOW 4 999996

903C) After the self-medication, did you have access to a consultation or other care elsewhere to heal (NAME)'s illness (injury)?

YES 1 (GO TO 905)
NO 2 (GO TO 912)

904) Did you seek advice or treatment to treat (NAME)'s illness?

YES 1
NO 2 (GO TO 912)

905) From whom did you seek advice or treatment for (NAME)'s illness (injury)?
IF RESPONDENT SAYS "HOSPITAL," CHECK THE NAME AND TYPE OF HOSPITAL OR HEATH CENTER AND CIRCLE THE APPROPRIATE CODE.

IF THE RESPONDENT SAYS "DOCTOR," CHECK IF THE PATIENT WENT TO THE DOCTOR OR IF THE "DOCTOR" CAME TO THE PATIENT'S HOME AND CIRCLE THE APPROPRIATE CODE.

PUBLIC SECTOR
NATIONAL HOSPITAL (POINT G, GABRIEL TOURNE, KATI) [##translator note: these are the names of the national hospitals] 11
REGIONAL HOSPITAL 12
OTHER PUBLIC HOSPITAL 13
REFERRAL HEALTH CENTER (CSREF) 14
COMMUNITY HEALTH CENTER (CSCOM) OR REVITALIZED NEIGHBORHOOD HEALTH CENTER (CSAR) 15
OTHER PUBLIC 16
PRIVATE SECTOR
PRIVATE CLINIC/OFFICE 21
DWELLING OF A HEALTH PROFESSIONAL 22
HEALTH PROFESSIONAL'S VISIT TO SICK PERSON'S HOME 23
OTHER PRIVATE 24
NON-MEDICAL SECTOR
PHARMACY 31
DRUG VENDOR (TRAVELLING, MARKET) 32
TRADITIONAL PRACTITIONER 33
RELIGIOUS HEALER 34
OTHER____________ (SPECIFY) 96

905A) What was the total sum of the expenses for transportation to go to and return from (LOCATION OF CARE IN Q. 905)?
SUM IN FCFA

FCFA______

FREE 000000
PAID IN KIND
DON'T KNOW 999998

905B) What was the total sum of the expenses for the consultation and care at (LOCATION OF CARE IN Q. 905)?
SUM IN FCFA

FCFA ________

FREE 000000
PAID IN KIND
DON'T KNOW 999998

905C) What was the total sum of expenses for drugs, exams, and other products prescribed at (LOCATION OF CARE IN Q. 905)?
SUM IN FCFA

FCFA ______

FREE 000000
PAID IN KIND
DON'T KNOW 999998

905D) Was (NAME) admitted to the hospital for at least one night to treat his/her illness (injury)?

YES 1
NO 2 (GO TO 906)

905E) What was the total sum of expenses for this hospitalization?
SUM IN FCFA

FCFA ________

FREE 000000
PAID IN KIND
DON'T KNOW 999998

905F) What was the total sum of expenses for transportation to this hospitalization ?
SUM IN FCFA

FCFA _______

FREE 000000
PAID IN KIND
DON'T KNOW 999998

906) After the first visit to (LOCATION OF CARE FROM Q. 905), was there a second consultation at the same place or were there other visits to seek care to treat (NAME)'s illness (injury) elsewhere?

YES 1
NO 2 (GO TO 912)

907) For this second visit, from whom did you seek advice or treatment to treat (NAME)'s illness (injury)?

IF RESPONDENT SAYS "HOSPITAL," CHECK THE NAME AND TYPE OF HOSPITAL OR HEATH CENTER AND CIRCLE THE APPROPRIATE CODE.

IF THE RESPONDENT SAYS "DOCTOR," CHECK IF THE PATIENT WENT TO THE DOCTOR OR IF THE "DOCTOR" CAME TO THE PATIENT'S HOME AND CIRCLE THE APPROPRIATE CODE.

PUBLIC SECTOR
NATIONAL HOSPITAL (POINT G, GABRIEL TOURNE, KATI) [##translator note: these are the names of the national hospitals] 11
REGIONAL HOSPITAL 12
OTHER PUBLIC HOSPITAL 13
REFERRAL HEALTH CENTER (CSREF) 14
COMMUNITY HEALTH CENTER (CSCOM) OR REVITALIZED NEIGHBORHOOD HEALTH CENTER (CSAR) 15
OTHER PUBLIC 16
PRIVATE SECTOR
PRIVATE CLINIC/OFFICE 21
DWELLING OF A HEALTH PROFESSIONAL 22
HEALTH PROFESSIONAL'S VISIT TO SICK PERSON'S HOME 23
OTHER PRIVATE 24
NON-MEDICAL SECTOR
PHARMACY 31
DRUG VENDOR (TRAVELLING, MARKET) 32
TRADITIONAL PRACTITIONER 33
RELIGIOUS HEALER 34
OTHER______ (SPECIFY) 96

907A) What was the total sum of the expenses for transportation to go to and return from (LOCATION OF CARE IN Q. 907)?
SUM IN FCFA

FCFA_________

FREE 000000
PAID IN KIND
DON'T KNOW 999998

907B) What was the total sum of expenses for the consultation and care from (LOCATION OF CARE FROM Q. 907)?
SUM IN FCFA

FCFA ______

FREE 000000
PAID IN KIND
DON'T KNOW 999998

907C) What was the total sum of expenses for the drugs, exams, and other products prescribed at (LOCATION OF CARE FROM Q. 907)?
SUM IN FCFA

FCFA ______

FREE 000000
PAID IN KIND
DON'T KNOW 999998

907D) Was (NAME) admitted to the hospital for at least one night to treat his/her illness (injury)?

YES 1
NO 2 GO TO 912

907E) What was the total sum of expenses for this hospitalization?
SUM IN FCFA

FCFA ______

FREE 000000
PAID IN KIND
DON'T KNOW 999998

907F) What was the total sum of expenses for transportation to this hospitalization?
SUM IN FCFA

FCFA _____

FREE 000000
PAID IN KIND
DON'T KNOW 999998

912) CHECK Q. 903B, Q.905A, Q. 905B, Q. 905C, Q. 905E, Q. 905F, Q907A, Q. 907B, Q. 907C, Q. 907E, AND Q. 907F
IF THERE ARE MONETARY EXPENSES (IN FCFA), GO TO Q. 912A.
IF NO, GO TO Q. 913

912A) Who paid the expenses for the care and treatment of (NAME)'s illness?
RECORD THE NAME AND LINE NUMBER OF THE PERSON(S).

NAME (1)____________________
LINE NUMBER_______________
NAME (2)____________
LINE NUMBER________
NAME (3)___________
LINE NUMBER________

912B) Where did (NAME (1) FROM Q. 912A) get the money to pay for the expenses incurred for the care and treatment of (NAME Q. 901)'s illness?

Where did (NAME (2) FROM Q. 912A) get the money to pay for the expenses incurred for the care and treatment of (NAME Q. 901)'s illness?

Where did (NAME (3) FROM Q. 912A) get the money to pay for the expenses incurred for the care and treatment of (NAME Q. 901)'s illness?

SALARY/AVAILABLE MONEY A
SAVINGS B
LOAN WITH NO INTEREST C
LOAN WITH INTEREST D
SALE OF GOODS OR ASSETS E
OTHER SOURCES F

913) GO BACK TO Q. 900 IN NEXT COLUMN; OR, IF NO MORE SICK PEOPLE, GO TO 914.

914) END OF HOUSEHOLD QUESTIONNAIRE
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