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REPUBLIC OF NIGER 2006
DEMOGRAPHIC AND HEALTH SURVEYS - HOUSEHOLD QUESTIONNAIRE

NATIONAL INSTITUTE OF STATISTICS
DEMOGRAPHIC AND HEALTH AND MULTIPLE INDICATORS SURVEY (EDSN-MICIII, 2006)

IDENTIFICATION
PLACE NAME __________
CLUSTER NUMBER __________
COMPOUND NUMBER __________
FIRST AND LAST NAME OF HEAD OF HOUSEHOLD_____

HOUSEHOLD NUMBER ___
REGION __________

URBAN/RURAL:

URBAN 1
RURAL 2

NIAMEY/OTHER REGION CAPITAL/OTHER CITY/RURAL:

NIAMEY 1
OTHER REGION CAPITAL 2
OTHER CITY 3
RURAL 4

HOUSEHOLD SELECTED FOR MEN'S SURVEY? (YES 1, NO 2) ___

MEASURE WEIGHT/HEIGHT, HEMOGLOBIN AND HIV TEST? (YES 1, NO 2) ___

INTERVIEWER VISITS

INTERVIEWER 1
DATE _____
DAY _____
MONTH _____
YEAR 2006
INTERVIEWER NAME __________
RESULT * __________

INTERVIEWER 2
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________

INTERVIEWER 3
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________

*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER OR COMPETENT RESPONDENT 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
7 OTHER (SPECIFY) __________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE _____
TIME _____

TOTAL NUMBER OF VISITS ___

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

LANGUAGE OF INTERVIEW __________

1 FRENCH
2 HAOUSSA
3 ZARMA
4 TMASHEQ
5 FULFULDE
6 OTHERS __________

INTERPRETER

YES 1
NO 2

SUPERVISOR:
NAME ____
DATE____

FIELD EDITOR
NAME __________
DATE _____

OFFICE EDITOR __________
KEYED BY __________

HOUSEHOLD SCHEDULE

We would now like information on the persons who usually live in your household and who are currently living with you.

1. LINE NUMBER (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 slept here last night, starting with the head of the household.

NAME _____

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

HEAD 1
WIFE OR HUSBAND 2
SON OR DAUGHTER 3
SON-IN-LAW OR DAUGHTER-IN-LAW 4
GRANDSON OR GRANDDAUGHTER 5
FATHER OR MOTHER 6
FATHER-IN-LAW OR MOTHER-IN-LAW 7
BROTHER OR SISTER 8
CO-WIFE 9
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
NOT RELATED 12
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) in completed years?
IF LESS THAN ONE YEAR RECORD 00. FOR 95 OR MORE, RECORD 95.

IN YEARS ___

7A. CHRONIC ILLNESS: (IF AGE IS 15-59 YEARS) Has (NAME) been very sick during the past 12 months? By "very sick" I mean too sick to work, or to do his or her normal household activities.

YES 1
NO 2

8. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN BETWEEN 15-49 YEARS.

9. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL THE CHILDREN LESS THAN 6 YEARS.

9A. ELIGIBILITY: CHECK TO SEE IF THE HOUSEHOLD WAS CHOSEN FOR A MEN'S SURVEY. CIRCLE THE LINE NUMBER OF ALL THE MEN AGED 15-59 YEARS.

SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:

10. Is (NAME)'s biological mother still alive?

YES 1
NO 2
DON'T KNOW 8

11. Does the (NAME)'s biological mother live in the household?

YES 1
NO 2

(IF YES) What is her name?
RECORD MOTHER'S LINE NUMBER. RECORD 00 IF THE BIOLOGICAL PARENTS ARE NOT LISTED IN THE HOUSEHOLD TABLE.

NAME __________
LINE NUMBER ___

SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:

12. Is (NAME)'s biological father still alive?

YES 1
NO 2
DON'T KNOW 8

13. (IF ALIVE) Does the (NAME)'s biological father live in the household?

YES 1
NO 2

(IF YES) What is his name?
RECORD FATHER'S LINE NUMBER. RECORD 00 IF THE BIOLOGICAL PARENTS ARE NOT LISTED IN THE HOUSEHOLD TABLE.

NAME __________
LINE NUMBER ___

13A. BIRTH CERTIFICATE: (IF 0-4 YEARS) Does (NAME) have a birth certificate?
(IF NO, INSIST) Was (NAME)'s birth recorded by the state?

YES 1
NO 2
DON'T KNOW 8

14. EDUCATION: (IF 5 YEARS OR MORE) Has (NAME) attended school?

YES 1
NO 2 (GO TO THE NEXT LINE)

15. EDUCATION: (IF 5 YEARS OR MORE) What is the highest level of education attained by (NAME)? What is the last class completed by (NAME) at this level?

LEVEL OF INSTRUCTION ____
0 PRESCHOOL
1 ELEMENTARY 1 (FIRST CYCLE)
2 ELEMENTARY 2 (SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
8 DON'T KNOW
CLASS ____
00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

16. EDUCATION: (IF 5-20 YEARS OLD) Does (NAME) currently attend school?

YES 1 (GO TO 18)
NO 2

17. EDUCATION: (IF 5-20 YEARS OLD) Has (NAME) attended school during the current school at any time?

YES 1
NO 2 (GO TO 19)

18. EDUCATION: (IF 5-20 YEARS OLD) During the current school year which level did (NAME) achieve, and in which class?

LEVEL OF INSTRUCTION ____
0 PRESCHOOL
1 ELEMENTARY 1 (FIRST CYCLE)
2 ELEMENTARY 2 (SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
8 DON'T KNOW
CLASS ____
00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

19. EDUCATION: (IF 5-20 YEARS OLD) Did (NAME) attend school at any time during the previous school year?

YES 1
NO 2 (GO TO THE NEXT LINE)

20. EDUCATION: (IF 5-20 YEARS OLD) During the current school year which level did (NAME) achieve and in which class?

LEVEL OF INSTRUCTION ____
0 PRESCHOOL
1 ELEMENTARY 1 (FIRST CYCLE)
2 ELEMENTARY 2 (SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
8 DON'T KNOW
CLASS ____
00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

MARK HERE IF ANOTHER SHEET WAS USED ___

Just to be sure that I have a complete list:

1) Are there other persons such as small children or infants that we have not recorded on the list?

YES ___ (write each one in the table)
NO ___

2) Are there other persons who maybe are not members of your family, such as domestic workers, renters or friends who usually live here?

YES ___ (write each one in the table)
NO ___

3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?

YES ___ (write each one in the table)
NO ___

CARE OF CHILDREN 3-5 YEARS, AND WORK OF CHILDREN 5-14 YEARS:

20A. CARE OF CHILDREN 3-5 YEARS: Has (NAME) attended a place of education outside of the home such as a preschool, daycare, kindergarten, community center, or other?

YES 1
NO 2
DON'T KNOW 8

20B. CARE OF CHILDREN 3-5 YEARS: (If YES) Which one?

1 PRESCHOOL
2 KINDERGARTEN
3 PRIMARY SCHOOL
4 KORANIC SCHOOL
5 COMMUNITY CENTER
7 OTHER

20C. CARE OF CHILDREN 3-5 YEARS: For which year?

1 CURRENT YEAR
2 LAST YEAR
3 THE YEAR BEFORE LAST
7 OTHER

Now I would like to ask you about all the types of work done by the children living in your household last week.

20D. (IF 5-14 YEARS OLD) Did (NAME) do any kind of work for someone who is not a member of this household last week?

YES, PAID 1
YES, UNPAID 2
NO 3 (GO TO 20f)

20E. (If YES) Since last (day of the week), about how many hours did he/she work for someone who is not a member of the household? IF MORE THAN ONE JOB, TAKE THE SUM OF ALL OF THE HOURS.

NUMBER OF HOURS ___

20F. Did (NAME) help with household work last week? For example: buy groceries, cook, clean, get water, watch children, wash clothes, etc.?

YES 1
NO 2 (GO TO 20h)

20G. Since last (day of the week) about how many hours did he/she spend doing this household work? IF MORE THAN ONE JOB, TAKE THE SUM OF ALL THE HOURS.

NUMBER OF HOURS ___

20H. Did (NAME) do other work for the family last week? For example: farm work, commerce, business, etc.?

YES 1 (GO TO NEXT LINE)
NO 2 (GO TO NEXT LINE)

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 22B)
PIPED INTO THE YARD/PLOT 12 (GO TO 22B)
PUBLIC TAP/STANDPIPE 13
OPEN WELL
OPEN WELL IN THE DWELLING 21 (GO TO 22B)
IN THE YARD/PLOT 22 (GO TO 22B)
OPEN PUBLIC WELL 23
COVERED OR BOREHOLE WELLS
PROTECTED WELL IN THE DWELLING 31 (GO TO 22B)
IN THE YARD/PLOT 32 (GO TO 22B)
PROTECTED PUBLIC WELL 33
SURFACE WATER
SPRING 41
RIVER/STREAM 42
SWAMP/LAKE 43
DAM 44
RAINWATER 51 (GO TO 22B)
TANKER 61 (GO TO 22B)
BOTTLED WATER 71 (GO TO 22A)
OTHER (SPECIFY) __________ 96

21A.Who usually goes to this source to fetch water?

MOTHERS 1
GIRLS 2
BOYS 3
FATHERS 4
OTHER (SPECIFY) __________ 5

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

MINUTES ___
ON SITE 996

22A. Do you do anything to make the water more safe to drink? For example, do you boil it, filter it or even add some product before using it as drinking water?

NO/NOTHING Y
BOIL A
STRAIN THROUGH A CLOTH B
USE A WATER FILTER C
ADD BLEACH/CHLORINE D
OTHER (SPECIFY) __________ X

22B. You said that the water that members of your household primarily drink comes mainly from (SOURCE INDICATED IN QUESTION 21) Were there interruptions in availability of water at this source during the past two weeks?

YES 1
NO 2 (GO TO 23)

22C. Did these interruptions in water availability happen every day, many days a week, some days a week or rarely?

EACH DAY 1
MANY DAYS/WEEK 2
SOME DAYS/WEEK 3
RARELY 4

22D. How long did these interruptions in water availability during the past two weeks last?

MANY HOURS 1
MORE THAN A DAY 2
MORE THAN A WEEK 3
NO WATER DURING THE 2 WEEKS 4

23. What kind of toilet facility do the majority of the members of your household use?

FLUSH 11
PIT/LATRINE
RUDIMENTARY 21
IMPROVED 22
NO FACILITY/BUSH/FIELD 31 (GO TO 24B)
OTHER (SPECIFY) __________ 96

23A. Is the toilet facility inside or outside of the yard/plot or dwelling?

INSIDE 1
OUTSIDE 2
BOTH 3
OTHER (SPECIFY) __________ 6

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

YES 1
NO 2 (GO TO 24b)

24A. How many other households use this toilet facility?
IF THERE ARE 5 HOUSEHOLDS OR MORE, RECORD '5'.

NUMBER OF HOUSEHOLDS ___

24B. What is the main method of disposing of household garbage for your household?

GARBAGE TRUCK 1
CARRIAGE/WAGON 2
AUTHORIZED DUMP 3
DUMP IN THE WILD 4
BURIAL 5
INCINERATION 6
OTHER (SPECIFY) __________ 7

24C. What is the main method of disposing of dirty water of your household?

BY SEWER/WASTEPIPE 1
CLOSED DUCT 2
OPEN DUCT 3
GRATED OR OPEN MANHOLE 4
IN THE SEA/RIVER 5
HOLE 6
IN NATURE 7
OTHER (SPECIFY) __________ 8

25. Does your household have:
(ONLY FUNCTIONAL MATERIAL AND EQUIPMENT)

Electricity?
YES 1
NO 2
Radio?
YES 1
NO 2
Television?
YES 1
NO 2
TV5 antenna?
YES 1
NO 2
Telephone (land line)?
YES 1
NO 2
Cellular telephone?
YES 1
NO 2
Refrigerator?
YES 1
NO 2

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

ELECTRICITY 01
GAS CANISTER 02
CHARCOAL 03
WOOD TO BURN/STRAW 04
ANIMAL DUNG 05
OTHER (SPECIFY) __________ 96

27. MAIN MATERIAL OF THE FLOOR:
(RECORD OBSERVATION)

NATURAL MATERIAL
EARTH/SAND 11
MODERN MATERIAL
PARQUET OR POLISHED WOOD 31
VINYL OR LINO/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) __________ 96

27A. How many rooms in this household are used for sleeping?

ROOMS ___

28. Is there anyone in your household who owns:

Bicycles?
YES 1
NO 2
Scooters or motorcycles?
YES 1
NO 2
Personal cars?
YES 1
NO 2
Commercial cars or trucks?
YES 1
NO 2
Carts?
YES 1
NO 2
Boats/fishing nets?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 33)

29A. How many mosquito nets does your household have?
If 7 or more nets, record '7'.

NUMBER OF NETS ___

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

OBSERVED 1
NOT OBSERVED 2

31. How long ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO ___
MORE THAN 36 MONTHS AGO 96
NOT SURE 98

32. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

SIMPLE 11 (GO TO 32B)
TREATED 12 (GO TO 32B)
OTHER 18
DON'T KNOW/NOT SURE 98

32A. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
DON'T KNOW 8

32B. 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 32D)
DON'T KNOW (GO TO 32D)

32C. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO ___
MORE THAN 36 MONTHS AGO 96
NOT SURE 98

32D. Did someone sleep under this net last night?

YES 1
NO 2 (GO TO 32f)
DON'T KNOW 8 (GO TO 32f)

32E. Who slept under this net last night?
RECORD THE LINE NUMBER FROM THE HOUSEHOLD TABLE.

NAME __________
LINE NUMBER _______

32F. RETURN TO THE FIRST COLUMN OF LINE NUMBER 30 OF A NEW QUESTIONNAIRE; SKIP TO QUESTION 33 IF THERE ARE NO MORE NETS IN THE HOUSEHOLD.

33. Where do members of your household most often wash their hands?

IN THE DWELLING/YARD/ON THE PLOT 1
SOMEWHERE ELSE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)

33a Do most of the members of your household wash their hands with soap when leaving the toilet facility?

YES1
NO 2

34. ASK TO SEE THE PLACE USED MOST OFTEN FOR HAND WASHING AND CHECK TO SEE IS THE FOLLOWING OBJECTS ARE THERE.

WATER/FAUCET
YES 1
NO 2
SOAP, ASH OR OTHER CLEANING PRODUCT
YES 1
NO 2
WASHBOWL, BUCKET, JAR
YES 1
NO 2

35. ASK THE RESPONDENT FOR A TEASPOON OF COOKING SALT, THEN TEST FOR IODIDE. RECORD THE PPM (PROPORTION PER MILLION).

NOTE: BEGIN BY USING THE CONTAINER WITH THE VIOLET COVER TO SEE IF THE SALT IS IODIZED WITH IODIDE. IF THE RESULT OF THE IODIDE TEST IS 0 PPM (NO IODIDE), USE THE CONTAINER WITH THE BLACK COVER FOR IODATE.

0 PPM (NO IODINE) 1
LESS THAN 15 PPM 2
MORE THAN 15 PPM 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED (GIVE THE REASON) __________ 6

MEASUREMENT OF WEIGHT AND HEIGHT:

CHECK COLUMNS (8) AND (9).
RECORD THE LINE NUMBER, NAME AND AGE OF ALL OF THE WOMEN 15-49 AND OF ALL OF THE CHILDREN LESS THAN 6.

36. LINE NUMBER FROM COLUMN (8)

LINE NO. ___

37. FIRST AND LAST NAME FROM COLUMN (2)

FIRST NAME __________
LAST NAME __________

38. AGE FROM COLUMN (7)

YEARS _____

WEIGHT AND HEIGHT OF WOMEN 15-49:

40. WEIGHT (KILOGRAMS)

KG ___

41. HEIGHT (CENTIMETERS)

___

43 RESULT:

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

CHILDREN LESS THAN 6:

36. LINE NUMBER FROM COLUMN (9)

LINE NO. ___

37. NAME FROM COLUMN (2)

NAME__________

38. AGE FROM COLUMN (7)

AGE ___

39. What is the birthday of (NAME)?

DAY ____
MONTH ____
YEAR_____

*FOR CHILDREN NOT INCLUDED IN ANY SECTION 2 ON THE REPRODUCTION OF A WOMAN'S QUESTIONNAIRE (ORPHANS, ADOPTED CHILDREN, ETC.), REQUEST THE DAY, MONTH AND YEAR OF THE BIRTH(S). FOR ALL THE OTHER CHILDREN, COPY THE MONTH AND THE YEAR, FROM QUESTION 215 IN SECTION 2 OF THEIR MOTHER AND ASK THE DAY OF BIRTH.

WEIGHT AND HEIGHT OF CHILDREN BORN IN 2001 (9) OR AFTER:

40. WEIGHT (KILOGRAMS)

KG ___

41. HEIGHT:

(CENTIMETERS) ___

42. MEASURED LYING DOWN OR STANDING

LYING 1
STANDING 2

43. RESULT?

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

CHECK HERE IF ANOTHER SHEET WAS USED ___

CONSENT STATEMENT:

As part of this survey, we would like to know the level of anemia in women and children. Anemia, which is due to poor nutrition, is a serious health problem. The results of this survey will assist the government to develop programs to prevent and treat anemia.

We request that you (you and all of your children born in 2000 or later) take an anemia test. For this test we use sterile, non-reusable instruments that are clean and risk-free. Blood will be analyzed with new equipment and the results will be given to you immediately. The results are confidential.

May I request now that you (and first and last names of children) take this anemia test? However, if you decide to refuse, know that you have this right and that we respect your decision. Now, can you tell me if you accept to take this test?

MEASUREMENT OF HEMOGLOBIN LEVEL (ANEMIA TEST):

MEASUREMENT OF HEMOGLOBIN LEVEL OF WOMEN 15-49 YEARS:

44. CHECK COLUMN (38):

AGE 15-17 1
AGE 18-49 2 (GO TO 46)

45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT: RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NUMBER ___

46. READ THE CONSENT STATEMENT TO THE WOMAN/PARENT/RESPONSIBLE ADULT: CIRCLE THE CODE AND SIGN.

CONSENTED 1 (PLEASE SIGN) __________
REFUSED 2 (GO TO NEXT LINE)

47. HEMOGLOBIN LEVEL (G/DL)

_____

48. CURRENTLY PREGNANT?

YES 1
NO/DON'T KNOW 2

49. RESULT

1 MEASURED
2 ABSENT
3 REFUSED
4 TECHNICAL PROBLEM
6 OTHER

MEASUREMENT OF HEMOGLOBIN LEVEL OF CHILDREN BORN IN 2000 (9) OR LATER:

45. LINE NUMBER OF THE PARENT/RESPONSIBLE ADULT. RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NUMBER ___

46. READ THE CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT: CIRCLE CODE AND SIGN.

CONSENTED 1 (PLEASE SIGN) __________
REFUSED 2 (GO TO NEXT LINE)

47. HEMOGLOBIN LEVEL (G/DL)

___

49. RESULT

1 MEASURED
2 ABSENT
3 REFUSED
4 TECHNICAL PROBLEM
6 OTHER

NOTE: IN THE COUNTRIES OR CERTAIN SURVEY ZONES AT AN ALTITUDE OF MORE THAN 1,000 METERS, INFORMATION ON THE ALTITUDE MUST BE COLLECTED FOR EACH ZONE WITH AN ALTITUDE OF MORE THAN 1,000 METERS SO THAT ESTIMATES OF ANEMIA LEVELS CAN BE ADJUSTED APPROPRIATELY.

MEASUREMENT OF HEMOGLOBIN LEVEL IN MEN 15-59 YEARS:

CHECK COLUMNS (9A), (2) AND (7) IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER, NAME AND AGE OF ALL MEN AGES 15-59.

50. LINE NUMBER FROM COLUMN (9A):

LINE NO. ____

51. NAME FROM COLUMN (2)

__________

52. AGE FROM COLUMN (7)

IN YEARS ___

53. CHECK COLUMN (52)

AGE 15-17 1
AGE 18-59 2 (GO TO 46)

54. LINE NUMBER OF PARENT/RESPONSIBLE ADULT: RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NUMBER ___

55. READ THE CONSENT STATEMENT TO THE WOMAN/PARENT/RESPONSIBLE ADULT: CIRCLE THE CODE AND SIGN.

CONSENTED 1 (PLEASE SIGN) __________
REFUSED 2 (GO TO 57)

56. HEMOGLOBIN LEVEL (G/DL)

___

57. RESULT:

1 MEASURED
2 ABSENT
3 REFUSED
4 TECHNICAL PROBLEM
6 OTHER

CHECK HERE IF ANOTHER SHEET WAS USED ___

CONSENT STATEMENT:

As part of this survey, we would like to know the level of anemia in women, men and children. Anemia, which is due to poor nutrition, is a serious health problem. The results of this survey will assist the government to develop programs to prevent and treat anemia.
We request that you (you and all of your children born in 2000 or later) take an anemia test. For this test we use sterile, non-reusable instruments that are clean and risk-free. Blood will be analyzed with new equipment and the results will be given to you immediately. The results are confidential.

May I request now that you (and first and last names of children) take this anemia test? However, if you decide to refuse, know that you have this right and that we respect your decision. Now, can you tell me if you accept to take this test?

GO TO COLUMN (55) AND CIRCLE THE APPROPRIATE CODE.

58. CHECK 47, 48 AND 56:
NUMBER OF USUAL RESIDENTS WHOSE HEMOGLOBIN IS BELOW THE CRITICAL THRESHOLD ___

THE CRITICAL THRESHOLD IS 9G/DL FOR PREGNANT WOMEN AND 1 G/DL FOR CHILDREN, MEN AND WOMAN WHO ARE NOT PREGNANT (OR WHO DON'T KNOW IF THEY ARE PREGNANT).

ONE OR MORE: GIVE THE TEST HEMOGLOBIN RESULTS TO EACH WOMAN/PARENT/RESPONSIBLE ADULT AND CONTINUE WITH QUESTION 51 (IF THERE IS MORE THAN ONE WOMAN OR CHILD WHO IS BELOW THE CRITICAL THRESHOLD, READ THE STATEMENT IN QUESTION 51 TO EACH WOMAN WHO IS BELOW THE CRITICAL THRESHOLD AND TO EACH WOMAN/PARENT/RESPONSIBLE ADULT OF A CHILD WHO IS BELOW THE CRITICAL THRESHOLD).
NONE: GIVE THE HEMOGLOBIN TEST RESULTS TO THE WOMAN/PARENT/RESPONSIBLE ADULT AND FILL OUT THE HIV SHEET

59. We have detected a low level of hemoglobin in (your blood/ the blood of name of child/children). This means that (you/name of child/children) are severely anemic, this is a serious health problem. We wish to inform the doctor about your condition /the condition of name of child/children). This will help you to get the appropriate treatment for your condition. Do you accept to have this information concerning the hemoglobin level of (your blood/ the blood of name of child/children) given to the doctor?

WOMEN 18-49:

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD:

NAME ____

ACCEPT THAT THE INFORMATION IS SHARED?

YES 1
NO 2

MEN AGES 18-59:

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD:

NAME _______

ACCEPTS THAT THE INFORMATION WILL BE SHARED>

YES 1
NO 2

WOMEN 15-17 AND CHILDREN:

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD

NAME ______

NAME OF PARENT/RESPONSIBLE ADULT

NAME______

ACCEPT THAT THE INFORMATION IS SHARED?

YES 1
NO 2

MEN 15-17 YEARS:

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD

NAME ________

NAME OF PARENT/RESPONSIBLE ADULT

NAME ________

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD:

YES 1
NO 2

INFORMED CONSENT STATEMENT (HIV TEST)

CONSENT FOR ADULT 18 YEARS OR MORE:

As part of this survey, we are doing a study of HIV/AIDS among women aged 15-49 years and men aged 15-59 years. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. We are currently giving HIV tests to see how serious a problem AIDS is in Niger.

For the HIV test we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is not reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. NO name will be linked to the result. Thus, we will not be able to tell you your test results. NO one else will know that result of the blood test either. However, I will give a reference paper to go to a Centre de Dépistage Volontaire (voluntary testing center) to have a free test if you wish.

Do you have any questions?
Now, do you agree to take this HIV test?

PROCEED TO COLUMN (67) AND CIRCLE THE APPROPRIATE CODE.

INFORMED CONSENT STATEMENT FOR YOUTH 15-17 YEARS:

FIRST STEP: ASK THE INFORMED CONSENT OF THE PARENT/RESPONSIBLE ADULT.

The study of HIV/AIDS included young women and men 15 years or older. For the HIV test of these young persons from 15-17 years we ask that their parent or responsible adult give their consent, as well as the youth.

We ask that the youth, (NAME), take an HIV test by giving us a few drops of blood from a finger. To take this blood we use sterile instruments, new material which is not reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. NO name will be linked to the result. Thus, we will not be able to tell you your test results. NO one else will know that result of the blood test either. However, if (name or youth) wishes, I will give a reference paper to go to a Centre de Dépistage Volontaire (voluntary testing center) to have a free test.

Now, do you accept that (NAME) take this HIV test?
PROCEED TO COLUMN (66) AND CIRCLE THE APPROPRIATE CODE.

SECOND STEP: INFORMED CONSENT OF THE YOUTH.IF THE PARENT/RESPONSIBLE ADULT ACCEPTED THAT HE TAKE THE TEST, READ THE CONSENT STATEMENT TO THE YOUTH.

As part of this survey, we are doing a study of HIV/AIDS among women aged 15-49 years and men aged 15-59 years. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. We are currently giving HIV tests to see how serious a problem AIDS is in Mali.

For the HIV test we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is not reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. NO name will be linked to the result. Thus, we will not be able to tell you your test results. NO one else will know that result of the blood test either. However, I will give a reference paper to go to a Centre de Dépistage Volontaire (voluntary testing center) to have a free test if you wish.

Do you have any questions?
Now, do you agree to take this HIV test?

YES 1
NO 2

HIV TEST: WOMEN AND MEN

60. LINE NUMBER FROM COLUMN (8) OR COLUMN (9A):

LINE NO. ___

61. NAME FROM COLUMN (2):

NAME __________

62. SEX FROM COLUMN (4):

MALE 1
FEMALE 2

63. AGE FROM COLUMN (7):

IN YEARS____

64. CHECK AGE FROM COLUMN (63):

AGE 15-17 1
AGE 18+ 2 (GO TO 67)

65. LINE NUMBER OF PARENT/RESPONSIBLE ADULT ___

66. READ THE CONSENT STATEMENT TO THE PARENT OR RESPONSIBLE ADULT: CIRCLE THE CODE AND SIGN.

AGREED 1 (SIGN) __________
REFUSED 2
NOT READ 3

67. READ THE CONSENT STATEMENT TO THE WOMAN/MAN OR YOUTH: CIRCLE THE CODE AND SIGN.

AGREED 1 (SIGN) __________
REFUSED 2
NOT READ 3

68 STICKER WITH BARCODE:

[STICK THE FIRST STICKER HERE]

STICK THE SECOND ON THE RESPONDENT'S CARBON PAPER AND THE THIRD ON THE BLOOD TEST TRANSMISSION SHEET.

CHECK HERE IF ANOTHER SHEET WAS USED ___