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NEPAL DEMOGRAPHIC AND HEALTH SURVEY 2006 HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

NAME AND CODE OF DISTRICT ______

NAME AND CODE OF VILLAGE/MUNICIPALITY ______

WARD NUMBER ______

CLUSTER NUMBER ______

HOUSEHOLD NUMBER ______

CITY/TOWN RURAL

CITY 1
TOWN 2
RURAL 3

NAME OF HOUSEHOLD HEAD ______

NAME OF RESPONDENT _____

HOUSEHOLD SELECTED FOR MALE SURVEY

YES 1
NO 2

ALTITUDE ______

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT*

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT*

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*

TOTAL NUMBER OF VISITS

*RESULT CODES

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLD 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)_________

LANGUAGE OF QUESTIONNAIRE

ENGLISH 5

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

YES 1
NO 2

LANGUAGE CODES

NEPAL 1
BHOJPURI 2
MAITHILI 3
THARU 4
OTHER 5

SUPERVISOR

NAME ____
DATE ____

FIELD EDITOR

NAME ____
DATE ____

OFFICE EDITOR

___

KEYED BY

___

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ and I am working with the MINISTRY OF HEALTH AND POPULATION. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey.
The survey usually takes between 20 and 30 minutes to complete.
As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.
At this time, do you want to ask me anything about the survey? May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________________________ DATE:______________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

1. LINE NO.

--------

2. USUAL RESIDENTS AND VISITORS: Please give the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

--------

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

HEAD 1
WIFE/HUSBAND 2
SON/DAUGHTER 3
SON/DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
SIBLING 8
BROTHER/SISTER-IN-LAW 9
NIECE/NEPHEW 10
CO-WIFE 11
OTHER RELATIVE 12
ADOPTED/FOSTER/STEPCHILD 13
NOT RELATED 14
DON'T KNOW 96

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 YEARS ____

MARTIAL STATUS IF (NAME) IS 10 YEARS OR OLDER:

8. What is (NAME's) current marital status?

CURRENTLY MARRIED 1
MARRIED, BUT GAUNA NOT PERFORMED 2
DIVORCED/SEPARATED 3
WIDOWED 4
NEVER-MARRIED 5
DON'T KNOW 8

ELIGIBILITY

9. CIRCLE LINE NUMBER OF ALL WOMEN AGED 15-49

10. CIRCLE LINE NUMBER OF ALL MEN AGED 15-49

11. CIRCLE LINE NUMBER OF ALL CHILDREN AGED 0-5

12. LINE NO.

___

IF (NAME) IS AGE 0-17 YEARS:

13. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Is (NAME's) natural mother alive?

YES 1
NO 2 (GO TO 15)
DON'T KNOW 8 (GO TO 15)

14. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Does (NAME's) natural mother live in this household or was a guest last night?
If yes, what is (NAME'S) natural mother's name?
RECORD MOTHER'S LINE NUMBER.

LINE NO ___

15. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Is (NAME's) natural father alive?

YES 1
NO 2 (GO TO 17)
DON'T KNOW 8 (GO TO 17)

16. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Does (NAME's) natural father live in this household or was a guest last night?
If yes, what is his name?
RECORD FATHER'S LINE NUMBER.

LINE NO ___

IF (NAME's) AGE IS 3 YEARS OR OLDER:

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

YES 1 (GO TO 18)
NO 2

17A. EVER ATTENDED SCHOOL: Has (NAME) ever participated in a literacy program or any other program that involves learning to read and write (not including primary school)?

YES 1
NO 2

18. EVER ATTENDED SCHOOL: What is the highest grade (NAME) has completed?

LESS THAN 1 YEAR COMPLETED 00
GRADE 1- GRADE 9 01-09
COMPLETED SLC 10
GRADE 11 11
GRADE 12 12
BACHELOR's NOT COMPLETE 13
BACHELOR's COMPLETE/HIGHER 14
SCHOOL BASED PRE-PRIMARY CENTERS 94
INFORMAL PRESCHOOL 95
DON'T KNOW 98

IF (NAME's) AGE IS 3-24 YEARS:

19. CURRENT/RECENT SCHOOL ATTENDENCE: Did (NAME) attend school at any time during the 2061 -- 2062 (2062/63) year?

YES 1
NO 2 (GO TO 21)

20. CURRENT/RECENT SCHOOL ATTENDENCE: During this/that school year, what grade [is/was] (NAME) attending?

LESS THAN 1 YEAR COMPLETED 00
GRADE 1- GRADE 9 01-09
COMPLETED SLC 10
GRADE 11 11
GRADE 12 12
BACHELOR's NOT COMPLETE 13
BACHELOR's COMPLETE/HIGHER 14
SCHOOL BASED PRE-PRIMARY CENTERS 94
INFORMAL PRESCHOOL 95
DON'T KNOW 98

21. CURRENT/RECENT SCHOOL ATTENDENCE: Did (NAME) attend school at any time during the previous school year, that is, 2060-2061 (2061/62)?

YES 1
NO 2 (GO TO 23)

22. During that school year, what grade did (NAME) attend?

LESS THAN 1 YEAR COMPLETED 00
GRADE 1- GRADE 9 01-09
COMPLETED SLC 10
GRADE 11 11
GRADE 12 12
BACHELOR's NOT COMPLETE 13
BACHELOR's COMPLETE/HIGHER 14
SCHOOL BASED PRE-PRIMARY CENTERS 94
INFORMAL PRESCHOOL 95
DON'T KNOW 98

IF (NAME's) AGE IS 0-4 YEARS:
23. BIRTH REGISTRATION: Does (NAME) have a birth certificate?
If no, has (NAME) ever been registered with the VDC/municipality?

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

MIGRATION

24. MIGRATION: Are there any member of head of household's family who lived here in the last 12 months but are now away?

YES 1
NO 2 (GO TO 101)
DON'T KNOW 8 (GO TO 101)

25. LINE NO.

___

26. MIGRANTS: Please give me the names of the persons who are living outside of this household?

_____

27. AGE: How old is (NAME)?

IN YEARS ___

IF AGE IS 15 AND ABOVE

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

HEAD 1
WIFE/HUSBAND 2
SON/DAUGHTER 3
SON/DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
SIBLING 8
BROTHER/SISTER-IN-LAW 9
NIECE/NEPHEW 10
CO-WIFE 11
OTHER RELATIVE 12
ADOPTED/FOSTER/STEPCHILD 13
NOT RELATED 14
DON'T KNOW 96

29. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

30. MARTIAL STATUS: What is (NAME's) current marital status?

CURRENTLY MARRIED 1
MARRIED, BUT GAUNA NOT PERFORMED 2
DIVORCED/SEPARATED 3
WIDOWED 4
NEVER-MARRIED 5
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 33)

32. EVER ATTENDED SCHOOL: What is the highest grade (NAME) has completed?

LESS THAN 1 YEAR COMPLETED 00
GRADE 1- GRADE 9 01-09
COMPLETED SLC 10
GRADE 11 11
GRADE 12 12
BACHELOR's NOT COMPLETE 13
BACHELOR's COMPLETE/HIGHER 14
SCHOOL BASED PRE-PRIMARY CENTERS 94
INFORMAL PRESCHOOL 95
DON'T KNOW 98

33. MONTHS AWAY: How many months has (NAME) been away in total in the last 12 months?

IN MONTHS ___

34. PLACES TRAVELLED: Where has (NAME) travelled in the last 12 months? CIRCLE ALL PLACES MENTIONED.
IF 'INDIA' ASK FOR NAME OF CITY AND STATE; IF OTHER THAN INDIA OR NEPAL CIRCLE CODE C AND WRITE NAME OF COUNTRY.

NEPAL A
INDIA SPECIFY CITY ___ B
OTHER SPECIFY COUNTRY ___ X
DON'T KNOW Z

HOUSEHOLD CHARACTERISTICS

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

PIPED WATER
PIPED WATER INTO HOUSE 11 (GO TO 106)
PIPED WATER TO YARD/PLOT 12 (GO TO 106)
PIPED WATER TO PUBLIC TAP/STAND PIPE 13 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED DUG WELL 31 (GO TO 103)
UNPROTECTED DUG WELL 32 (GO TO 103)
WATER FROM SPRING
WATER FROM PROTECTED SPRING 41 (GO TO 103)
WATER FROM UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 106)
TANKER TRUCK 61 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CANAL) 71 (GO TO 103)
STONE TAP/DHARA 81 (GO TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) ____ 96

102. What is the main source of water used by your household for other purposes such as cooking and handwashing?

PIPED WATER
PIPED WATER INTO HOUSE 11 (GO TO 106)
PIPED WATER TO YARD/PLOT 12 (GO TO 106)
PIPED WATER TO PUBLIC TAP/STAND PIPE 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 106)
TANKER TRUCK 61
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CANAL) 71
STONE TAP/DHARA 81
BOTTLED WATER 91
OTHER (SPECIFY) ____ 96

103. Where is that water source located?

IN OWN HOUSE 1 (GO TO 106)
IN OWN YARD/PLOT 2 (GO TO 106)
ELSEWHERE 3

104. How long does it take to go there, get water, and comeback?

IN MINUTES ____
ON PREMISES 996 (GO TO 106)
DON'T KNOW 998

105. Who usually goes to this source to fetch the water for your household?

ADULT WOMAN 1
ADULT MAN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) _____ 6

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

YES 1
NO 2 (GO TO 108)
DON'T KNOW 8 (GO TO 108)

107. What do you usually do to make the water safer to drink?

BOIL A
ADD BLEACH/CHLORINE/PIYUSH/WATERGUARD B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ___ X
DON'T KNOW Z

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41 (GO TO 46)
NO FACILITY/BUSH/FIELD 51 (GO TO 111)
OTHER (SPECIFY) ____ 96

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

YES 1
NO 2 (GO TO 111)

110. How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 ___
10 OR MORE HOUSEHOLDS 96
DON'T KNOW 98

111. Does your household have:

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
TABLE
YES 1
NO 2
CHAIR
YES 1
NO 2
BED
YES 1
NO 2
SOFA
YES 1
NO 2
CUPBOARD
YES 1
NO 2
COMPUTER
YES 1
NO 2
WATCH/CLOCK
YES 1
NO 2
FAN
YES 1
NO 2
DHIKI/JANTO
YES 1
NO 2

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

ELECTRICITY 1 (GO TO 115)
LPG 2 (GO TO 115)
NATURAL GAS 3 (GO TO 115)
BIOGAS 4 (GO TO 115)
KEROSENE 5
COAL, LIGNITE 6
CHARCOAL 7
WOOD 8
STRAW/SHRUBS/GRASS 9
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 117)
OTHER (SPECIFY) _____ 96

113. In this household, is food cooked on an open fire, a stove, or a chulo?

OPEN FIRE 1
STOVE 2
CHULO 3
OTHER (SPECIFY) _____ 6

114. Does this (fire/stove/chulo/other) have a chimney, a hood, or neither of these?

CHIMNEY 1
HOOD 2
NEITHER 3

115. 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 117)
OUTDOORS 3 (GO TO 117)
OTHER (SPECIFY) ____ 6 (GO TO 117)

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

YES 1
NO 2

117. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATIONS

NATURAL FLOOR
EARTH/MUD 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY)_____ 96

118. MAIN MATERIAL OF THE ROOF:
RECORD OBSERVATIONS

NATURAL ROOFING
NO ROOF 11
THATCH/STRAW 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
GALVANIZED SHEET 31
WOOD 32
ASBESTOS 33
CERAMIC TILES/SLLATE 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY) _____ 96

119. MAIN MATERIAL OF THE EXTERIOR WALLS:
RECORD OBSERVATIONS

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
MUD/SAND 13
RUDIMENTARY ROOFING
BAMBOO WITH MUD 21
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
REUSED WOOD 25
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS 35
OTHER (SPECIFY) _____ 96

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

ROOMS ___

121. Does any member of this household own:

BICYCLE/RICKSHAW
YES 1
NO 2
MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
TEMPO
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2

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

YES 1
NO 2 (GO TO 59)

123. How many bighas/ropani of agricultural land do members of this household own?

BIGHAS ___ 1
ROPANI ___ 2
99 OR MORE BIGHAS/ROPANI 995
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 61)

125. How many of the following animals does this household own? (IF NONE, ENTER '00', IF MORE THAN 95, ENTER '95', IF UNKNOWN, ENTER '98')

BUFFALO ___
COWS/BULLS ___
HORSES/DONKEYS/MULES ___
GOATS ___
SHEEP ___
CHICKENS ___
DUCKS ___
PIGS ___
YAKS ___

126. Does any member of this household have a bank/cooperative/or other savings account?

YES 1
NO 2

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

YES 1
NO 2

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

NUMBER OF NETS ___

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

201. CHECK COLUMN 11. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202.

LINE NUMBER _____
NAME _____

203. What is (NAME's) birth date? (IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM PREGNANCY HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH AND YEAR)

DAY ____
MONTH ____
YEAR ____

204. CHECK 203:
IF CHILD BORN IN BAISKH 2057 OR LATER

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)

205. WEIGHT IN KILOGRAMS:

WEIGHT IN KILOGRAMS ____. ____ KG

206. HEIGHT IN CENTIMETERS

HEIGHT IN CENTIMETERS ____. ____ CM

207. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

208. RESULT OF WEIGHT AND HEIGHT MEASUREMENT:

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

209. CHECK 203: IS CHILD AGE 0-5 MONTHS I.E., WAS CHILD BORN IN THE MONTH OF INTERVIEW OF FIVE PREVIOUS MONTHS?
0-5 MONTHS 1 (GO TO203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)
OLDER 2

210. What is the number of parents/other adults responsible for child? RECORD '00' IF NOT LISTED

LINE NUMBER ___
NUMBER OF ADULTS ___

211. READ CONSENT STATEMNET TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD CIRCLE CODE AND SIGN.

GRANTED (SIGN) ____ 1
REFUSED 2 (GO TO 213)
CONSENT STATEMENT FOR ANEMIA FOR CHILDREN

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 request that all children born in 2057 or later aged at least 6 months participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking 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 confidential.

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(S) OF CHILD(REN) to participate in the anemia test?

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

G/DL .___. ____

213. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

214. GO BACK TO 203 IF THERE'S MORE CHILDREN, ELSE GO TO 215

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

215. CHECK AND RECORD THE LINE NUMBER AND NAME FOR ALL ELGIBLE WOMEN IN QUESTION 9 FOR NEXT QUESTIONS

216. LINE NUMBER AND NAME:

LINE NUMBER ___
NAME ___

217. WEIGHT IN KILOGRAMS:

WEIGHT IN KILOGRAMS ___. ___ KG

218. HEIGHT IN CENTIMETERS:

HEIGHT IN CENTIMETERS ___. ___ CM

219. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

220. AGE: CHECK COLUMN 7:

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

221. MARTIAL STATUS (QUESTION 8)

CODE 2 AND 5 (NOT IN UNION/GAUNA NOT PERFORMED) 1
OTHER 2 (GO TO 223)

222. RECORD LINE NUMBE ROF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR ANOTHER RESPONSIBLE ADULT ___

223. READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION/NO GUANA WOMEN AGE 15-17. ASK CONSENET FROM PARENT/OTHER ADULT IDENTIFIED IN 222 BEFORE ASKING RESPONDENT'S CONSENT.

GRANTED (SIGN) ____ 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3 (GO TO 228)
CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 223 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION/NO GAUNA WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 222) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE '2' IN 223 IF THE PARENT (OR OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 a few drops of blood from a finger. The equipment used in taking 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 confidential.

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 anemia test?

224. LINE NUMBER (QUESTION 9) AND NAME (QUESTION 2)

LINE NUMBER ___
NAME ___

225. PREGNANCY STATUS: CHECK 236 IN WOMAN'S QUESTIONAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DK 8

226. CHECK 223 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE ANEMIA TEST FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 228 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

227. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

G/DL ___. ___

228. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6