IDENTIFICATION

NAME OF HOUSEHOLD HEAD_________

PLACE NAME_________

PROVINCE_________

URBAN/RURAL

NAME AND NUMBER OF ENUMERATION AREA (DHS I.D.)_____

HOUSEHOLD NUMBER______

HOUSEHOLD SELECTED TO INTERVIEW MEN____

HOUSEHOLD SELECTED TO TEST CHILDREN___

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_________
INTERVIEWER'S NAME_________
RESULT___

RESULT_________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_________
TIME_________

FINAL VISIT
DAY_________
MONTH_________
YEAR 2011
CODE _________
RESULT_________

TOTAL NUMBER OF VISITS_________

TOTAL PERSONS IN HOUSEHOLD_________

TOTAL NO. OF WOMEN 15-49_________

TOTAL NO. OF MEN 15-64_________

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_________

SUPERVISOR
NAME_________
DATE_________

INFORMED CONSENT

Good morning/afternoon. My name is _________and I am working with the INE [NATIONAL INSTITUTE OF STATISTICS] and this is my identification (SHOW YOUR IDENTIFICATION). We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The information we collect will help the government to plan health services. I would like to ask you 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, however extremely important. If I ask you any questions 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. We hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey?

In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________ DATE:________________

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.

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 5-32 FOR EACH PERSON.

2A) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed?

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?

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

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

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

8) MARITAL STATUS IF AGE 15 OR OLDER: What is (NAME)'s current marital status?

9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-64

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

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

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

14) 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'

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

17) Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER:

23) Has (NAME) ever attended school?

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

25) Did (NAME) attend school at any time during the current school year?

26) During the current school year, what level and grade [is/was] (NAME) attending?

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

HOUSEHOLD CHARACTERISTICS

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

101. What is the principal source of drinking water for members of your household?

103. Where is that water source located?

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

104A. What is the distance on foot from your home to the location of the water source?
IF ANSWER IS GIVEN IN KILOMETERS, MULTIPLY IT BY 1,000

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

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

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

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

109. How many households use this toilet facility?

110. Does your household have:

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

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

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

114. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

115. MAIN MATERIAL OF THE ROOF
RECORD OBSERVATION

116. MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

117. How many divisions/rooms in this household are used for sleeping?

118. Does any member of your household own:

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

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

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

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'

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

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

125. Who sprayed the dwelling?

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

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

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

129. How many months ago did your households get the (1st, 2nd, 3rd) mosquito net?
IF LESS THAN A ONE MONTH AGO, RECORD '00'.

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.

131. When you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

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

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

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

135. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

136. 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.

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

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

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

WEIGHT, HEIGHT, HEMOGLOBIN AND MALARIA MEASUREMENT FOR CHILDREN AGE 0-5

201. INTERVIEWER: RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILD FOR THE TEST AND THEN GO TO THE NURSE/TECHNICIAN OR SUPERVISOR

202. LINE NUMBER AND NAME

203. ASK THE RESPONDENT:
What is (NAME)'s birth date?

204. CHECK 203:
CHILD BORN IN JANUARY 2006 OR LATER?

205. WEIGHT IN KILOGRAMS

206. HEIGHT IN CENTIMETERS

207. MEASURED LYING DOWN OR STANDING UP?

207A. CHECK:

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

209. ASK FOR THE ADULT RESPONSIBLE FOR THE CHILD, RECORD THE NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD

210. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD

211. ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD

(TEST CHILDREN WITH GRANTED CONSENT AND THEN CONTINUE WITH 212)

212. RECORD THE RESULT OF ANEMIA TESTING

213. RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

214. RECORD THE CODE OF THE RESULT OF MALARIA TESTING

215. BAR CODE LABEL:
PASTE HERE THE BAR CODE LABEL AND ALSO IN THE CARD OF SAMPLES

216. MALARIA TEST RESULTS

217. READ THE INFORMATION ABOUT MALARIA TREATMENT AND ASK CONSENT FROM PARENT/OTHER ADULT RESPONSIBLE FOR CHILD, THEN ASK IS THE CHILD HAS RECEIVED ANY ANTI-MALARIAL TREATMENT.

218. GO BACK TO 203 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN GO TO 219.

CONSENT FOR ANEMIA

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 diseases. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2006 or later take part in the anemia testing in this survey and give a few drops of blood from a finger. 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 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 CHILD) to participate in the anemia test?

CONSENT FOR MALARIA
As part of this survey we are asking people all over the country to take a malaria test. Malaria is a serious health problem that usually is caused by parasites transmitted by mosquito bites This survey will assist the government to develop programs to prevent and treat malaria.

We ask that all children born in 2006 or later take part in the malaria testing in this survey and give a few drops of blood from a finger. 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 malaria 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 CHILD) to participate in the malaria test?

TREATMENT FOR CHILDREN WHO RESULTED POSITIVE IN MALARIA TEST

IF THE MALARIA TEST RESULTED POSITIVE: The malaria test indicates that your child has malaria. We can give you treatment for free. The treatment is a medicine called THERAPY COMBINING A BASE OF ARTEMISININ "TCA". This medicine is very efficiently and in a few days will eliminate any fever and other symptoms.

ASK IF THE CHILD HAS TAKEN OR IS TAKING OTHER MEDICINE BEFORE YOU OFFER TCA. IN CASE THAT THE CHILD HAS TAKEN OR IS TAKING OTHER MEDICINE, ASK TO SEE THE MEDICINE, IF THE CHILD IS TAKING TCA, VERIFY THE GIVEN DOSE. BE MINDFUL OF NOT GIVING AN EXCESS OF MEDICINE TO THE CHILD.

You do not have to give the medicine to the child. It is up to you to decide. Please tell me if you accept or not the medicine.

WEIGHT, HEIGHT AND HEMOGLOBIN TESTING FOR WOMEN AGE 15-49

219. INTERVIEWER: RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN, THEN GO TO THE NURSE/TECHNICIAN OR SUPERVISOR.

220. WOMAN'S LINE NUMBER AND NAME

221. WEIGHT IN KILOGRAMS

222. HEIGHT IN CENTIMETERS

223. AGE: CHECK 220

224. ASK WOMAN'S MARITAL STATUS

225. ASK ABOUT THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD THE NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

226. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 225 AS RESPONSIBLE FOR 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 diseases. This survey will assist the government to develop programs to prevent and treat anemia.

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

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 participate in the anemia test?

227. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

228. ASK CONSENT FOR ANEMIA TEST FROM 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 diseases. This survey will assist the government to develop programs to prevent and treat anemia.

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

229. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

230. Are you pregnant?

240. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

242. GO BACK TO 221 IN THE COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO SELECTED QUESTIONNAIRES.