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DEMOGRAPHIC AND HEALTH SURVEYS-MOZAMBIQUE 2011- HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

NAME OF HOUSEHOLD HEAD_________

PLACE NAME_________

PROVINCE_________

URBAN/RURAL

URBAN 1
RURAL 2

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_________

1 COMPLETED
2 ENTIRE HOUSEHOLD ABSENT OR NO COMPETENT RESPONDENT AT HOME AT THE 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 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:________________

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 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.

NAME____

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?

YES (ADD TO 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 TO 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 TO TABLE)
NO

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

HEAD 01
HUSBAND OR WIFE 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
FATHER/MOTHER 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER CHILD 10
NOT RELATED 11
DON’T KNOW 98

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

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

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?

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

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’

LINE NUMBER____

16) Is (NAME)’s natural FATHER alive?

YES 1
NO 2 (GO TO 23)
DON'T KNOW 8 (GO TO 23)

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:

23) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

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

LEVEL
00 = LITERACY
01 = PRIMARY EP1
02 = PRIMARY EP2
03 = SECONDARY ESG1
04 = SECONDARY ESG2
05 = TECHNICAL ELEMENTARY
06 = TECHNICAL BASIC
07 = TECHNICAL ADVANCED
08 = TEACHER PREP
09 = HIGHER
GRADE
00 = LESS THAN 1 YEAR COMPLETED
98 = DON’T KNOW

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

YES 1
NO 2 (GO TO NEXT LINE)

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

LEVEL
00 = LITERACY YEAR 01-02-03
01 = PRIMARY EP1 GRADE 01-05
02 = PRIMARY EP2 GRADE 06-07
03 = SECONDARY ESG1 GRADE 08-10
04 = SECONDARY ESG2 GRADE 11-12
05 = TECHNICAL ELEMENTARY YEAR 01-03
06 = TECHNICAL BASIC YEAR 01-03
07 = TECHNICAL ADVANCED YEAR 01-03
08 = TEACHER PREP YEAR 01-03
09 = HIGHER YEAR 01-07
GRADE
98 = DON’T KNOW

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?

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

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. What is the principal 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)
PIPED INTO NEIGHBOR’S RESIDENCE 13 (GO TO 104)
PUBLIC TAP/STANDPIPE 14 (GO TO 104)
WELL WATER
PROTECTED WELL 31
UNPROTECTED WELL 32
GROUND HOLE WITH MANUAL PUMP 33
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61 (GO TO 105)
SURFACE WATER
RIVER/LAKE/POND/STREAM/CANAL 81 (GO TO 104)
BOTTLED WATER 91 (GO TO 107)
OTHER (SPECIFY)___ 96

103. Where is that water source located?

IN OWN DWELLING 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES______
DON’T KNOW 998

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

DISTANCE IN METERS __________

10,000 METERS OR MORE 9995
DON’T KNOW 9998

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
ADD “CERTEZA” [LOCAL WATER PURIFIER] C
STRAIN THROUGH A CLOTH D
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) E
SOLAR DISINFECTION F
LET IT STAND AND SETTLE G
OTHER (SPECIFY)___ X
DON’T KNOW Z

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

FLUSH TOILET 11
TOILET WITHOUT FLUSHING SYSTEM 12
VENTILATED IMPROVE PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB 23
NO FACILITY/BUSH 61 (GO TO 110)
OTHER (SPECIFY)___ 96

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?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A mobile phone?
YES 1
NO 2
A non-mobile phone?
YES 1
NO 2
A refrigerator/freezer?
YES 1
NO 2

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

ELECTRICITY 01
NATURAL GAS 03
PETROLEUM/PARAFFIN/KEROSENE 04
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
ANIMAL DUNG 09
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

DUNG 11
EARTH/SAND 12
WOOD PLANKS 21
ADOBE 22
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 34
OTHER (SPECIFY)___96

115. MAIN MATERIAL OF THE ROOF
RECORD OBSERVATION

NO ROOF 11
THATCH/PALM LEAF/BAMBOO ROOF 12
METAL ROOF 31
FIBRE CEMENT SHEET 33
ROOFING SHINGLES 34
CONCRETE SLAB 35
OTHER (SPECIFY)___96

116. MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NO WALLS 11
CANE/PALM/TRUNKS 12
ALUMINUM/CARDBOARD/PAPER/ PLASTIC 13
BAMBOO WITH MUD 21
REUSED WOOD 22
WOOD/METAL SHEET 23
ADOBE 24
BRICKS 31
CEMENT 32
OTHER (SPECIFY)___96

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

ROOMS____

118. Does any member of your household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A boat with 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’

Milk cows/bulls?
NUMBER OF MILK COWS/BULLS ___
Horses, donkeys?
NUMBER OF HORSES, DONKEYS__
Goats?
NUMBER OF GOATS___
Sheep/rams?
NUMBER OF SHEEP/RAMS__
Pigs?
NUMBER OF PIGS__
Chickens/ducks?
CHICKENS/DUCKS___

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

YES 1
NO 2

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
PRIATE 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 ALL THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S)

OBSERVED WITH HOLES 1
OBSERVED WITH NO HOLES 2
NOT OBSERVED 3

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

MONTHS AGO___

MORE THAN 36 MONTHS AGO 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.

PERMANENT 1 (GO TO 134)
NET PROTECT 2 (GO TO 134)
OLYSET 3 (GO TO 134)
OTHER TREATED NET BRAND 4 (GO TO 134)
OTHER_____ 6
DON'T KNOW BRAND/ DON’T KNOW 8

131. When you got the net, was it ever soaked or dipped in a liquid 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 AGO ___

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)
NOT SURE 8 (GO TO 136)

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

NAME_____
LINE NO. ___

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.

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) 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

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

LINE NUMBER____
NAME___

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

DAY ___
MONTH__
YEAR__

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

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD, IF NO MORE CHILDREN, GO TO 214)

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. CHECK:

HOUSEHOLD SELECTED TO TEST CHILDREN (GO TO 208)
HOUSEHOLD NOT SELECTED TO TEST CHILDREN (GO TO 219)

208. CHECK 203:
IS CHILD AGE 0-5? 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 218)
6 MONTHS OR OLDER 2

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

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

GRANTED 1 (SIGN)___________
REFUSED 2 (SIGN)_____

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

GRANTED 1 (SIGN)___________
REFUSED 2 (SIGN)_____

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

212. RECORD THE RESULT OF ANEMIA TESTING

TESTED 1
NOT PRESENT 2 (GO TO 214)
REFUSED 3 (GO TO 214)
OTHER 6 (GO TO 214)

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

G/DL____.__

214. RECORD THE CODE OF THE RESULT OF MALARIA TESTING

TESTED 1
NOT PRESENT 2 (GO TO 218)
REFUSED 3 (GO TO 218)
OTHER 6 (GO TO 218)

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

216. MALARIA TEST RESULTS

POSITIVE 1
NEGATIVE 2 (GO TO 218)
OTHER 6 (GO TO 218)

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.

ACCEPTED MEDICINE 1 (SIGN)_____
REFUSED 2
HAS RECEIVED TCA (THERAPY COMBINING A BASE OF ARTEMISININ) 3
NOT ELIGIBLE 4
OTHER 5

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

LINE NUMBER____
AGE____
NAME____

221. WEIGHT IN KILOGRAMS

KG.____

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

222. HEIGHT IN CENTIMETERS

CM.____

NOT PRESENT 99994
REFUSED 9995
OTHER 9996

223. AGE: CHECK 220

15-17 YEARS 1 (GO TO 224)
18-49 YEARS 2 (GO TO 228)

224. ASK WOMAN’S MARITAL STATUS

CODE 4 (NEVER IN UNION)
OTHER 2 (GO TO 228)

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

NAME____

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

GRATED 1 (SIGN)____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)____ (GO TO 242)

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

GRATED 1 (SIGN)____
REFUSED 2 (SIGN)____ (GO TO 242)

230. Are you pregnant?

YES 1
NO 2
DON’T KNOW 8

240. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL____.__

NOT PRESENT 994
REFUSED 995
OTHER 996

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.