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REPUBLIC OF NIGER

NATIONAL INSTITUTE OF STATISTICS

DEMOGRAPHIC AND HEALTH SURVEY WITH MULTIPLE INDICATORS (EDSN-MICS IV), 2012

HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION
NAME OF PLACE ______

CLUSTER NUMBER_____

CONCESSION NUMBER_____

FIRST AND LAST NAME OF HEAD OF HOUSEHOLD______

HOUSEHOLD NUMBER_______

REGION______

URBAN/RURAL _____

URBAN 1
RURAL 2

NIAMEY/REGIONAL ADMINISTRATIVE CENTER/OTHER CITY/RURAL____

NIAMEY 1
REGIONAL ADMINISTRATIVE CENTER 2
OTHER CITY 3
RURAL 4

UNICEF INTERVENTION ZONE______

YES 1
NO 2
COMMUNE 3

HOUSEHOLD SELECTED FOR MEN'S SURVEY______

YES 1
NO 2

HEIGHT/WEIGHT MEASUREMENT, HEMOGLOBIN AND HIV TEST, SALT SAMPLE (LABORATORY)?

MEN'S SURVEY_____

INTERVIEWER VISITS

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

NEXT VISIT________
DATE_________
TIME_______

FINAL VISIT
DAY_______
MONTH_______
YEAR 2012
NAME________
RESULT__________

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 NO. OF VISITS_________

TOTAL PERSONS IN HOUSEHOLD________
TOTAL ELIGIBLE WOMEN__________
TOTAL ELIGIBLE MEN_________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE________

SUPERVISOR________
NAME_______
DATE_______

FIELD EDITOR________
NAME_______
DATE________

OFFICE EDITOR_______

KEYED BY__________

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Office of Statistics. We are conducting a survey about health all over Niger. 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 between 1 hour and 1 hour and 30 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.

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

HOUSEHOLD SCHEDULE

1) LINE NO.

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.

NAME __________________

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.

TICK HERE IF CONTINUATION SHEET USED _____

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 EACH IN TABLE
NO

2B) In addition, are there any other people who many 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

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20A 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 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 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) Did (name) stay here last night?

YES 1
NO 2

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

IN COMPLETED YEARS___________

IF AGE 10 OR OLDER:

8) MARITAL STATUS: What is (name)'s current marital status?

1 MARRIED OR LIVING TOGETHER
2 DIVORCED/SEPARATED
3 WIDOWED
4 SINGLE/NEVER MARRIED
5 LIVING TOGETHER

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

10) IF HOUSEHOLD SELECTED FOR MEN'S SURVEY.
CIRCLE LINE NUMBER OF ALL MEN 15-49
IF NOT, LEAVE COLUMN BLANK

11) IF HOUSEHOLD SELECTED FOR MEN'S SURVEY
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
IF NOT, LEAVE COLUMN BLANK

LINE NO._________

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)
DK 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.

MOTHER'S LINE NO. ____

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

YES 1
NO 2 (GO TO 16)
DK 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.

FATHER'S LINE NO. ____

IF AGE 5 YEARS OR OLDER:

16) EVER ATTENDED SCHOOL: Has (NAME) ever attended school?

YES 1
NO 2 (NEXT LINE)

17) What is the highest level of school (NAME) has attended?

LEVEL ____
0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
4 BRIDGE/PREPARATORY YEAR
5 "SECOND CHANCE" SCHOOL PROGRAM
6 ALTERNATIVE EDUCATION CENTER
7 COMMUNITY TRAINING AND DEVELOPMENT CENTER
8 DON'T KNOW

What is the highest grade (NAME) completed at that level?

GRADE ____
PRESCHOOL REGISTRATION
00 PRESCHOOL CLASS
PRIMARY
00 EN C1
01 C1
02 CP
03 CE1
04 CE2
05 CM1
06 CM2
SECONDARY
00 EN 6TH
01 6TH
02 5TH
03 4TH
04 3RD
05 SECONDARY
06 PRIMARY
07 FINAL
INFORMAL INSTRUCTION
00 BRIDGE CLASS
00 "SECOND CHANCE" CLASS
ALTERNATIVE EDUCATION CENTER (CEA)
00 FIRST YEAR CEA
01 ENTIRE TRAINING 1 YEAR
02 ENTIRE TRAINING 2 YEARS
03 ENTIRE TRAINING 3 YEARS
04 ENTIRE TRAINING 4 YEARS
HIGHER INSTRUCTION
00 HIGH SCHOOL + 1 YEAR
01 HIGH SCHOOL + 1 YEAR
02 HIGH SCHOOL + 2 YEARS
03 HIGH SCHOOL + 3 YEARS
04 HIGH SCHOOL + 4 YEARS
05 HIGH SCHOOL + 5 YEARS
06 HIGH SCHOOL + 6 YEARS
07 HIGH SCHOOL + 7 YEARS
08 HIGH SCHOOL + 8 YEARS
COMMUNITY TRAINING AND DEVELOPMENT CENTER (CFDC)
00 FIRST YEAR OF CFDC
01 ENTIRE TRAINING 1 YEAR
02 ENTIRE TRAINING 2 YEARS
03 ENTIRE TRAINING 3 YEARS
04 ENTIRE TRAINING 4 YEARS
99 LENGTH OF TRAINING NOT SPECIFIED

IF AGE 7-24 YEARS:

17a) CURRENT/RECENT SCHOOL ATTENDANCE: Did (name) attend school at any time during the current (2011-2012) school year?

YES 1
NO 2 (GO TO 17C)

17b) During this/that school year (2011-2012), what level and grad (is/was) (NAME) attending?

LEVEL ____
0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
4 BRIDGE/PREPARATORY YEAR
5 "SECOND CHANCE" SCHOOL PROGRAM
6 ALTERNATIVE EDUCATION CENTER
7 COMMUNITY TRAINING AND DEVELOPMENT CENTER
8 DON'T KNOW
GRADE ____ (GO TO 18)
PRESCHOOL REGISTRATION
00 PRESCHOOL CLASS
PRIMARY
00 EN C1
01 C1
02 CP
03 CE1
04 CE2
05 CM1
06 CM2
SECONDARY
00 EN 6TH
01 6TH
02 5TH
03 4TH
04 3RD
05 SECONDARY
06 PRIMARY
07 FINAL
INFORMAL INSTRUCTION
00 BRIDGE CLASS
00 "SECOND CHANCE" CLASS
ALTERNATIVE EDUCATION CENTER (CEA)
00 FIRST YEAR CEA
01 ENTIRE TRAINING 1 YEAR
02 ENTIRE TRAINING 2 YEARS
03 ENTIRE TRAINING 3 YEARS
04 ENTIRE TRAINING 4 YEARS
HIGHER INSTRUCTION
00 HIGH SCHOOL + 1 YEAR
01 HIGH SCHOOL + 1 YEAR
02 HIGH SCHOOL + 2 YEARS
03 HIGH SCHOOL + 3 YEARS
04 HIGH SCHOOL + 4 YEARS
05 HIGH SCHOOL + 5 YEARS
06 HIGH SCHOOL + 6 YEARS
07 HIGH SCHOOL + 7 YEARS
08 HIGH SCHOOL + 8 YEARS
COMMUNITY TRAINING AND DEVELOPMENT CENTER (CFDC)
00 FIRST YEAR OF CFDC
01 ENTIRE TRAINING 1 YEAR
02 ENTIRE TRAINING 2 YEARS
03 ENTIRE TRAINING 3 YEARS
04 ENTIRE TRAINING 4 YEARS
99 LENGTH OF TRAINING NOT SPECIFIED

17c) What is the main reason for which (name) did not go to school?

01 FOR PERSONAL REASONS
02 MARRIAGE
03 DISTANCE FROM SCHOOL
04 EXODUS
05 DIETARY INSECURITY
06 INSECURITY
07 PARENTAL DIVORCE/SEPARATION
08 GOT PREGNANT
09 WANT TO HELP PARENTS
10 LACK OF TUTOR
11 SCHOLASTIC FAILURE
12 REFUSAL BY FAMILY
13 LACK OF FINANCIAL MEANS
14 PHYSICAL INFIRMITY
97 OTHER
98 DON'T KNOW

18) Did (NAME) attend school at any time during the (2010-2011) school year?

YES 1
NO 2 (GO TO NEXT LINE)

19) During this/that school year (2010-2011), what level and grade (is/was) (NAME) attending?

LEVEL _____
0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
4 BRIDGE/PREPARATORY YEAR
5 "SECOND CHANCE" SCHOOL PROGRAM
6 ALTERNATIVE EDUCATION CENTER
7 COMMUNITY TRAINING AND DEVELOPMENT CENTER
8 DON'T KNOW
GRADE _____
PRESCHOOL REGISTRATION
00 PRESCHOOL CLASS
PRIMARY
00 EN C1
01 C1
02 CP
03 CE1
04 CE2
05 CM1
06 CM2
SECONDARY
00 EN 6TH
01 6TH
02 5TH
03 4TH
04 3RD
05 SECONDARY
06 PRIMARY
07 FINAL
INFORMAL INSTRUCTION
00 BRIDGE CLASS
00 "SECOND CHANCE" CLASS
ALTERNATIVE EDUCATION CENTER (CEA)
00 FIRST YEAR CEA
01 ENTIRE TRAINING 1 YEAR
02 ENTIRE TRAINING 2 YEARS
03 ENTIRE TRAINING 3 YEARS
04 ENTIRE TRAINING 4 YEARS
HIGHER INSTRUCTION
00 HIGH SCHOOL + 1 YEAR
01 HIGH SCHOOL + 1 YEAR
02 HIGH SCHOOL + 2 YEARS
03 HIGH SCHOOL + 3 YEARS
04 HIGH SCHOOL + 4 YEARS
05 HIGH SCHOOL + 5 YEARS
06 HIGH SCHOOL + 6 YEARS
07 HIGH SCHOOL + 7 YEARS
08 HIGH SCHOOL + 8 YEARS
COMMUNITY TRAINING AND DEVELOPMENT CENTER (CFDC)
00 FIRST YEAR OF CFDC
01 ENTIRE TRAINING 1 YEAR
02 ENTIRE TRAINING 2 YEARS
03 ENTIRE TRAINING 3 YEARS
04 ENTIRE TRAINING 4 YEARS
99 LENGTH OF TRAINING NOT SPECIFIED

IF AGE 0-4 YEARS:

20) BIRTH REGISTRATION: 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

20a) REASONS FOR NOT REGISTERING: Why was (NAME)'s birth not registered/declared?

IF MORE THAN ONE REASON, RECORD THE MAIN ONE.

1 COSTS TOO MUCH
2 TOO FAR
3 DIDN'T KNOW SHE SHOULD REGISTER
4 DIDN'T WANT TO PAY A FIND
5 DIDN'T KNOW WHERE TO REGISTER
6 DIDN'T KNOW HOW TO REGISTER

CARE OF CHILDREN AGE 4-6 YEARS AND WORK OF CHILDREN AGE 5-14 YEARS

21) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 4 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

RECORD THE NAME OF EACH CHILD BETWEEN 4 AND 14 YEARS OLD FROM HIS/HER LINE NUMBER IN THE HOUSEHOLD SCHEDULE

ONE OR MORE_______
NONE (GO TO 23)

21a) CARE FOR CHILDREN BETWEEN 4 AND 6 YEARS: During the 2011-2012 school year, did (NAME) go to an establishment outside of the home such as a nursery school, day care, community center or other?

YES 1
NO 2 (GO TO 22A)
DON'T KNOW 8 (GO TO 22A)

21b) What type of establishment did he/she go to?

1 NURSERY SCHOOL
2 PRIMARY SCHOOL
3 MUSLIM RELIGIOUS SCHOOL
4 COMMUNITY CENTER
5 OTHER (SPECIFY)

21c) Since when has he/she gone to this establishment?

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

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

22a) IF AGE 5-14 YEARS:

Since last week, did (NAME) do any work for anyone who is not a member of this household?

IF YES: Was he/she paid?

1 YES, PAID WORK
2 YES, UNPAID WORK
3 NO WORK (GO TO 22C)

22b) IF YES:

Since the 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__________

22c) In the last week, did (name) go get water or wood for the household?

YES 1
NO 2 (GO TO 22E)

22d) Since the last (day of the week), approximately how many hours did he/she spend getting water or wood for the household?

NUMBER OF HOURS________

22e) 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?

YES 1
NO 2- (GO TO 22G)

22f) Since last (day of the week), approximately how many hours did he/she spend doing work for his/her family or him/herself?

NUMBER OF HOURS__________

22g) In the last week, did (name) do any household chores, such as shopping, cooking, cleaning, taking care of children, washing clothesÂ…?

YES 1
NO 2 - NEXT LINE

22h) Since last (day of the week), approximately how many hours did he/she spend doing these household chores?

NUMBER OF HOURS__________

DISCIPLINE OF CHILD

23) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 4 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

ONE OR MORE________ (GO TO 23A)
NONE_______(GO TO 102)

TABLE 1: CHILDREN AGE 2-14 YEARS ELIGIBLE FOR QUESTIONS REGARDING DISCIPLINE

RECORD EACH CHILD AGE 2-14 YEARS BELOW IN THE SAME ORDER FROM THE HOUSEHOLD REGISTRATION SHEET. DO NOT INCLUDE MEMBERS OF THE HOUSEHOLD WHOSE AGE IS OUTSIDE OF 2-14 YEARS.

RECORD THE LINE NUMBER, NAME, SEX AND AGE FOR EACH CHILD.

THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS IN THE SPACE PROVIDED (23F)

23a. RANK NUMBER

RANK_______

23b. LINE NUMBER FROM (1)

LINE________

23c. FIRST NAME FROM (2)

FIRST NAME____

23d) SEX FROM (4)

M 1
F 2

23e) AGE FROM (7)

AGE______

23f. TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS_________

IF THERE IS ONLY ONE CHILD AGE 2-14 YEARS IN THE HOUSEHOLD, SKIP TABLE 2 AND GO TO 23H; RECORD 1 AND CONTINUE TO 23I.

TABLE 2: RANDOM SELECTION OF THE CHILD FOR QUESTIONS ON DISCIPLINE

USE TABLE 2 TO SELECT A CHILD BETWEEN 2 AND 14 YEARS IF, IN THE HOUSEHOLD, THERE ARE MORE THAN ONE CHILD IN THIS AGE GROUP.

CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE. THIS IS THE LINE NUMBER THAT YOU MUST GO TO IN THE TABLE BELOW.

CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN (2-14 YEARS) IN 23F BELOW. THIS IS THE COLUMN NUMBER YOU SHOULD USE.

FIND THE SPACE WHERE THE LINE AND COLUMN MEET AND CIRCLE THE NUMBER BELONGING IN THE SPACE. THIS IS THE RANK NUMBER OF THE CHILD 23A TO WHOM YOU SHOULD ASK THE QUESTIONS.

23G. LAST DIGIT FROM HOUSEHOLD NUMBER
0-9

TOTAL NUMBER OF ELIGIBLE CHILDREN IN THE HOUSEHOLD (23f)
1 - 8+

23H. RECORD THE RANK NUMBER OF THE SELECTED CHILD_____

23I RECORD THE FIRST NAME AND LINE NUMBER OF THE CHILD SELECTED FOR THE MODULE BASED ON 23C AND 23B, ACCORDING TO THE RANK NUMBER FROM 23H

FIRST NAME______
LINE NUMBER_______

23J) Adults use certain methods to teach child how to behave well or to treat behavioral problems. I will read you a list of methods that are used and I'd like you to tell me if you or someone else in your household has used one of these methods with (NAME) in the last month.

23J1) Revoking privileges, not allowing (NAME) to do something that he/she likes or not allowing him/her to leave the house

YES 1
NO 2

23J2) Explain to (NAME) why his/her behavior is not acceptable

YES 1
NO 2

23J3) Shake him/her

YES 1
NO 2

23J4) Yell at him/her

YES 1
NO 2

23J5) Give him/her something else to do

YES 1
NO 2

23J6) Spank him/her, hit him/her, or slap him/hers buttock with bare hands

YES 1
NO 2

23J7) Hit him/her on the buttock or other body part with something like a belt, a hairbrush, stick, or other hard object

YES 1
NO 2

23J8) Call him/her an idiot, lazy, or a similar word

YES 1
NO 2

23J9) Hit or slap him/her on the face, head, or ears

YES 1
NO 2

23J10) Hit him/her on the hands, arms, or legs

YES 1
NO 2

23J11) Beat him/her with an object
PROBE IF NECESSARY:
Hit as hard as possible without stopping

YES 1
NO 2
DON'T KNOW/NO OPINION 8

23K) Do you think that to properly raise and educate (NAME), you must punish him/her physically or psychologically?

YES 1
NO 2
DON'T KNOW/NO OPINION 8

HOUSEHOLD FEATURES

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

103A) Who generally goes to retrieve water?

WOMEN (15 YEARS OF AGE OR OLDER) 1
GIRLS (LESS THAN 15 YEARS OLD) 2
MEN (15 YEARS OF AGE OR OLDER) 3
BOYS (LESS THAN 15 YEARS OLD) 4
OTHER (SPECIFY) 7

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

MINUTES___________
ON PREMISES 996
DON'T KNOW 998

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

Yes 1
No 2 (GO TO 106B)
DK 8 (GO TO 106B)

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
ADDS AQUATABS G
OTHER (SPECIFY) X
DON'T KNOW Z

106a) CHECK 106:

HAS NOT USED AQUATABS
HAS USED AQUATABS- (GO TO 106B)

106a1) Have you ever heard of a product called Aquatabs?

YES 1
NO 2 (GO TO 106B)

106a2) What are Aquatabs?

A PRODUCT TO PURIFY/TREAT WATER 1
OTHER (SPECIFY) 6
DK 8

106b) You said that the water your household drinks comes mainly from (source from q 102). Has that water source been interrupted or has there been a shortage of water from this source in the last two weeks?

YES 1
NO 2 (GO TO 107)

106c) Do these interruptions or shortages occur every day, several day s a week, a few days a week, or rarely?

EVERY DAY 1
BETWEEN 4 TO 6 DAYS/WEEK 2
BETWEEN 1 AND 3 DAYS/WEEK 3
RARELY 4

106d) In the last two weeks, how many days have you had interruptions or shortages of water that affected your household?

SEVERAL HOURS 1
MORE THAN A DAY 2
MORE THAN A WEEK 3
FOR THE ENTIRE 2 WEEKS 4

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

FLUSH OR POUR FLUSH TOILET
CONNECTED FLUSH
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
NO FACILITY/BUSH/FIELD 61- (GO TO 109A)
OTHER (SPECIFY) 96

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

YES 1
NO 2 (GO TO 109A)

109) How many households use this toilet facility?

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

109a) What is the main method of evacuation for your household's waste?

GARBAGE TRUCK 1
CART 2
AUTHORIZED DUMP 3
OUTDOOR DUMP 4
BURYING 5
BURNING 6
OTHER 7

109b) What is the main method of evacuation for your household's used water?

CLOSED CANAL 1
OPEN CANAL 2
IN THE RIVER 3
HOLE 4
OUTDOORS 5
OTHER 7

110) Does your household have:

ELECTRICITY?
YES 1
NO 2
A RADIO?
YES 1
NO 2
A TELEVISION?
YES 1
NO 2
DVD PLAYER
YES 1
NO 2
A MOBILE TELEPHONE?
YES 1
NO 2
A NON-MOBILE TELEPHONE?
YES 1
NO 2
A REFRIGERATOR?
YES 1
NO 2
AN AIR CONDITIONER?
YES 1
NO 2
A STOVE?
YES 1
NO 2
A SATELLITE DISH?
YES 1
NO 2
A COMPUTER?
YES 1
NO 2
A CART?
YES 1
NO 2
A PLOW?
YES 1
NO 2
MOTOR-PUMP?
YES 1
NO 2

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

ELECTRICITY 01 (GO TO 112)
NATURAL GAS 02 (GO TO 112)
KEROSENE, OIL LAMP 05 (GO TO 112)
COAL, LIGNITE 06 (GO TO 112)
CHARCOAL 07 (GO TO 112)
WOOD 08
SAW/SHRUBS/GRASS 09 (GO TO 112)
AGRICULTURAL CROP 10 (GO TO 112)
ANIMAL DUNG 11 (GO TO 112)
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) 96________ (GO TO 112) 112

111a) How much time does it take to get to the place where you usually get wood, get the wood, and come back?

MINUTES________
DON'T KNOW 998

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
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR WAXED WOOD 31
VINYL/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS/LEAVES 12
SOD 13
RUDIMENTARY FLOOR
MAT 21
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
HIDE 25
FINISHED FLOOR
SHEET METAL 31
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
OTHER (SPECIFY) 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 13
STRAW 14
RUDIMENTARY WALLS
STONE WITH MUD 22
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT BRICKS 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 35
WOOD PLANKS 36
SHEET METAL 37
OTHER (SPECIFY) 96

117) How many 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
A CAR OR TRUCK?
YES 1
NO 2
A fishing vessel/a canoe?
YES 1
NO 2
A MOPED?
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 OF 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 OR BULLS?____________
HORSES, DONKEYS, OR MULES? ____________
GOATS? ____________
SHEEP? ____________
CAMELS? ____________
CHICKENS, GUINEA FOWL, PIGEONS? ____________
DUCKS/GEESE? ____________

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)
DK 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 136D)

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 THE FOLLOWING QUESTIONS 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 AGO____________
MORE THAN 36 MONTHS AGO 95
NOT SURE 97

130a) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

LONG-LASTING INSECTICIDE-TREATED NET 10- (GO TO 134)
PRE-TREATED 20- (GO TO 132)
SIMPLE 30
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 AGO
MORE THAN 24 MONTHS AGO 95
NO SURE 98

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

YES 1
NO 2 (GO TO 136)
DK 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) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 140

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT USED FOR HOUSEHOLD NEEDS. TEST SALT FOR IODINE. RECORD THE PPM (PARTS PER MILLION).

NO IODINE 1
LESS THAN OR EQUAL TO 15 PPM 2
ABOVE 15 PPM 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED___________ (SPECIFY REASON) 6

141) In the last three years, has there been any event that affected life in your household?

YES 1
NO 2 (GO TO 201)

142) What was the main event for your household?

ILLNESS 01
DEATH 02
LOSS OF EMPLOYMENT/UNEMPLOYED 03
LOWERED REVENUE/REMITTANCE RECEIVED 04
FLOOD/DRAUGHT/LOSS OF HARVEST 05
CONFLICT/INSECURITY/THEFT OR LOSS OF LIVESTOCK 06
FIRE 07
LOSS OF MONEY 08
OTHER___________ (SPECIFY) 96

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

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 ACCORDING TO LINE NUMBER ORDER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11

LINE NUMBER _________

NAME FROM COLUMN 2

NAME_________

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF CHILD'S 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 214)

205) WEIGHT IN KILOGRAMS

KG_________
NOT PRESENT 994
REFUSED 995
OTHER 996

206) HEIGHT IN CENTIMETERS

CM
NOT PRESENT 994
REFUSED 995
OTHER 996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203:
IS THE CHILD'S AGE 0-5 MONTHS, I.E. WAS THE CHILD BORN IN THE MONTH OF INTERVIEW OR THE FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)
OLDER 2

208a) CHECK FOR PRESENCE OF BILATERAL EDEMA ON FEET

CHECKED:

EDEMA PRESENT 1
EDEMA NOT PRESENT 2
NOT SURE 3
NOT CHECKED:___________(SPECIFY REASON) 7

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

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

We ask that all children born in 2007 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. 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 member 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 take the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1-SIGN_________
REFUSED 2-SIGN_________

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

G/DL________
ABSENT 994
REFUSED 995
OTHER 996

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

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

214) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN FROM QUESTION 215. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

215) LINE NUMBER FROM COLUMN 9

LINE NUMBER__________

NAME FROM COLUMN 2

NAME_________

216) WEIGHT IN KILOGRAMS

KG
ABSENT 9994
REFUSED 9995
OTHER 9996

217) HEIGHT IN CENTIMETERS

CM
ABSENT 9994
REFUSED 9995
OTHER 9996

218) AGE: CHECK COLUMN 7

15-17 years 1
18-49 years 2 (GO TO 223)

219) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 223)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT_________

221) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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

For the anemia test, we 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 will be told to you and to (name of adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes to the test for (name of adolescent), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1- SIGN___________
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2- SIGN__________
(IF REFUSED, GO TO 228)

223) 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 disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia test, we 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 will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes, or you can say no to the test. It is up to you to decide.
Will you take the anemia test?

224) CIRCLE APPROPRIATE CODE AND SIGN

GRANTED 1- SIGN__________
RESPONDENT REFUSED 2- SIGN___________
(IF REFUSED, GO TO 226)

225) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

226) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2- GO TO 230

227) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 230)

228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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 to see how big the AIDS problem is in Niger.

For the HIV test, we 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know the results of (name of adolescent's) test 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 you a voucher for free services for you 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 up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1- SIGN____________
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2- SIGN__________
(IF REFUSED, GO TO 239)

230) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
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 to see how big the AIDS problem is in Niger.

For the HIV test, we 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. No names will be attached 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 want) 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 up to you to decide.

Will you take in the HIV test?

231) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.

GRANTED 1 SIGN______________
RESPONDENT REFUSED 2 SIGN______________

239) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL_____________
NOT PRESENT 994
REFUSED 995
OTHER 996

241) BAR CODE LABEL

PUT THE 1ST BAR CODE HERE__________

NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 243.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

243) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

244) LINE NUMBER FROM COLUMN 10

LINE NUMBER ____________

NAME FROM COLUMN 2

NAME___________

247) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-59 YEARS 2- (GO TO 252)

248) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 252)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT____________

250) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

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. 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. 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 and (name of adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?

251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1-SIGN_________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2-SIGN__________
(IF REFUSED, GO TO 256)

252) 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 disease. 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. 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 member 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 in the anemia test?

253) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1-SIGN
RESPONDENT REFUSED 2-SIGN

254) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2- (GO TO 258)

255) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2- (GO TO 258)

256) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

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 to see how big the AIDS problem is in Niger.

For the HIV test, we need a few (more) 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. No names will be attached 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 him with 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 to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1-SIGN___________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2-SIGN____________
(IF REFUSED, GO TO 267)

258) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

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 to see how big the AIDS problem is in Niger.

For the HIV test, we need a few more 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. No names will be attached 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 want) 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 up to you to decide.
Will you take the HIV test?

259) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1-SIGN____________
RESPONDENT REFUSED 2-SIGN___________

267) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

268) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL____________
NOT PRESENT 994
REFUSED 995
OTHER 996

269) BAR CODE LABEL

PUT THE 1ST BAR CODE HERE

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

270) GO BACK TO 247 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.