IDENTIFICATION

PLACE NAME ________________________

DISTRICT ____________________

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

URBAN/RURAL ___

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE ___

HOUSEHOLD SELECTED FOR MALE SURVEY AND BLOOD WORK?

NAME OF HOUSEHOLD HEAD ___

INTERVIEWER VISITS

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

NEXT VISIT:
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INTERVIEWER CODE ____
RESULT* _____

TOTAL NUMBER OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL WOMEN 15-49__

TOTAL MEN 15-54 __

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 3

LANGUAGE OF INTERVIEW***:

NATIVE LANGUAGE OF RESPONDENT***:

WAS A TRANSLATOR USED?

SUPERVISOR
NAME ________
DATE ________

FIELD EDITOR
NAME ________
DATE ________

OFFICE EDITOR____

KEYED BY____

HOUSEHOLD SCHEDULE

1) 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.

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

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

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

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

ELIGIBILITY:

8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

8A) CIRCLE LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE.

9) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54.

10) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.

10A) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 5-14.

11) IF AGE 5-54 YEARS: Has (NAME) been very sick for at least three months during the past 12 months? By very sick, I mean that (NAME) was too sick to work or do normal activities around the house for at least three of the past 12 months.

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**

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

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

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

15) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

EDUCATION:

16) IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

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

18) IF AGE 5-24 YEARS: Is (NAME) currently attending school?

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

20) During the current school year, what level and class [is/was] (NAME) attending? ***

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

22) During that school year, what level and class did (NAME) attend?

** CODES FOR Q.12 THROUGH Q.15
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.13 AND Q.15, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

TICK HERE IF CONTINUATION SHEET USED __

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

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

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

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

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

25. What kind of toilet facilities does your household have?

26. Do you share these facilities with other households?

27. Does your household have:

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

29. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

29A. How many rooms in your household are used for sleeping?

29B. Does this household own any agricultural land?

29C. How much agricultural land does this household own?

29D. Does this household own any livestock?

29E. How many of the following types of animals are owned by this household?

30. Does any member of your household own:

31. Does your household have any mosquito nets that can be used while sleeping?

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

33. ASK THE RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

33A. OBSERVE THE CONDITION OF THE MOSQUITO NET:
DOES THE NET HAVE HOLES IN IT (HOLES THE SIZE OF THE TIP OF YOUR THUMB OR LARGER)?

33B. OBSERVE (OR ASK) THE COLOR OF THE MOSQUITO NET.

33C. OBSERVE (OR ASK) THE SHAPE OF THE MOSQUITO NET.

34. How long ago did your household obtain the mosquito net?

35. Where did you get this mosquito net?

35A. When you got the net, did it come with an insecticide treatment kit?

35B. Since you got the mosquito net, was it ever soaked or dipped in an insecticide to kill or repel mosquitos?

35C. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

35D. Did anyone sleep under this mosquito net last night?

35E. Who slept under this mosquito net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

35F. GO BACK TO 33 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 36.

36. What color of mosquito net do you prefer?

37. What shape of mosquito net do you prefer?

CHILD LABOUR

Now I would like to ask you about any work children in this household may do.

39) LINE NO.
COPY LINE NUMBER OF CHILDREN AGE 5-14 FROM COLUMN (1)

40) CHILD'S NAME
COPY THE NAMES OF THE CHILDREN AGE 5-14 FROM COLUMN (2)

41) During the past week, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: For pay?

42) Since last (DAY OF THE WEEK), about how many hours did he/she do this work for someone who is not a member of the household?*
* IF MORE THAN ONE JOB, INCLUDE ALL HOURS AT ALL JOBS.

43) During the past week, did (NAME) help with house-keeping chores such as cooking, shopping, cleaning, washing clothes, fetching water, or caring for children?

44) Since last (DAY OF THE WEEK), about how many hours did he/she spend doing these chores?

45) During the past week, did (NAME) do any other family work on the farm or in a business?

46) Since last (DAY OF THE WEEK), about how many hours did he/she do this work?

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
THEN, GO TO COLUMN 8A IN THE HOUSEHOLD SCHEDULE AND CIRCLE THE LINE NUMBER OF THE ELIGIBLE WOMAN.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.
FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE BOX ('2').
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07', THEN THE ELIGIBLE WOMAN FOR DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE ONE ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)

1 2 3 4 5 6 7 8
0 1 2 2 4 3 6 5 4
1 1 1 3 1 4 1 6 5
2 1 2 1 2 5 2 7 6
3 1 1 2 3 1 3 1 7
4 1 2 3 4 2 4 2 8
5 1 1 1 1 3 5 3 1
6 1 2 2 2 4 6 4 2
7 1 1 3 3 5 1 5 3
8 1 2 1 4 1 2 6 4
9 1 1 2 1 2 3 7 5

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT

CHECK COLUMN (10): RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN UNDER AGE 6.

CHILDREN UNDER AGE 6:

47) LINE NUMBER FROM COLUMN (10)

48) NAME FROM COLUMN (2)

49) AGE FROM COLUMN (7)

50) What is (NAME'S) date of birth?*
*FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER

51) WEIGHT (KILOGRAMS)

52) HEIGHT (CENTIMETERS)

53) MEASURED LYING DOWN OR STANDING UP

54) RESULT

TICK HERE IF CONTINUATION SHEET USED __

HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1999 OR LATER

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

57) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

58) HEMOGLOBIN LEVEL (G/DL)

60) RESULT

*CONSENT STATEMENT

As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem.
You do not have to participate; however, if you do, it will help the government to develop programs to prevent and treat anemia.

We request that you agree to let me test (NAME OF CHILDREN BORN IN 1999 OR LATER) for anemia.
For the test, I will take a few drops of blood from a finger or from the heel of the child.
The test uses disposable sterile instruments that are clean and completely safe.
The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

Do you have any questions? Do you agree to have the test done?

61) CHECK 58 AND 59:
NUMBER OF CHILDREN WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*
*The cutoff point is 7 g/dl for children.

**If more than one child is below the cutoff point, read the statement in Q.62 to each woman who is below the cutoff point and to each parent/responsible adult of a child who is below the cutoff point.

62) We detected a low level of hemoglobin in the blood of (NAME OF CHILD(REN)).
This indicates that (NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem.
We would like to inform the doctor at ________________ about the condition of (NAME OF CHILD(REN)).
This will assist you in obtaining appropriate treatment for the condition.
Do you agree that the information about the level of hemoglobin in the blood of (NAME OF CHILD(REN)) may be given to the doctor?

NAME OF CHILD WITH HEMOGLOBIN BELOW THE CUTOFF POINT

NAME OF PARENT/RESPONSIBLE ADULT

AGREES TO REFERRAL?