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NEPAL DEMOGRAPHIC AND HEALTH SURVEY 2011 HOUSEHOLD QUESTIONNAIRE

NAME AND CODE OF DISTRICT _________________

NAME AND CODE OF VILLAGE/MUNICIPALITY __________________

WARD NUMBER ______________

CLUSTER NUMBER _______________

HOUSEHOLD NUMBER _______________

NAME OF THE HOUSEHOLD HEAD _________________

NAME OF RESPONDENT _______________

HOUSEHOLD SELECTED FOR MALE SURVEY

YES 1
NO 2

ALTITUDE _____________

INTERVIEWER VISITS

VISIT 1

DATE __________
INTERVIEWER???S NAME _____________
RESULT* ___________

1 COMPLETED
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) ________________

NEXT VISIT:
DATE _________
TIME _________

VISIT 2

DATE __________
INTERVIEWER???S NAME _____________
RESULT* ___________

NEXT VISIT:
DATE _________
TIME _________

VISIT 3

DATE __________
INTERVIEWER???S NAME _____________
RESULT* ___________

NEXT VISIT:
DATE _________
TIME _________

FINAL VISIT

DAY ___________
MONTH __________
YEAR __________
INT. NUMBER __________
RESULT _________

TOTAL NUMBER OF VISITS __________

TOTAL PERSONS IN HOUSEHOLD _________

TOTAL ELIGIBLE WOMEN ________

TOTAL ELIGIBLE MEN ________

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ________

SUPERVISOR

NAME __________

DATE __________

OFFICE EDITOR __________

KEYED BY __________

INTRODUCTION AND CONSENT

Hello. My name is ____________________________. I am working with MINISTRY OF HEALTH AND POPULATION. We are conducting a survey about health all over Nepal. 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 about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey tam. No part of this interview is being recorded in tape or video. 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 now?

SIGNATURE OF INTERVIEWER: __________________

DATE: ___________

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

HOUSEHOLD SCHEDULE

1) LINE NO.

2) USUAL RESIDENTS AND VISITORS

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

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

YES _____(ADD TO TABLE)
NO _____

2B) Are there any other people who may not be memberss 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 may 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?
SEE CODES BELOW.
CODES FOR Q. 3: RELATIONSHIP TO HEAD OF 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 BROTHER-IN-LAW OR SISTER-IN-LAW
10 NIECE/NEPHEW
11 CO-WIFE
12 OTHER RELATIVE
13 ADOPTED/FOSTER/STEPCHILD
14 NOT RELATED
98 DON???T KNOW

4) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE
5) 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 YEARS __________

IF AGE 10 OR OLDER
8) MARITAL STATUS

What is (NAME)???s current marital status?

1 CURRENTLY MARRIED
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER-MARRIED

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

9A) CIRCLE LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE QUESTIONS IN Q. 31.

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

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

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)
DON???T KNOW (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.

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

YES 1
NO 2 (GO TO 16)
DON???T KNOW 8 (GO TO 16)

15) Does (NAME)???s natural father uually 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???.

_____________

IF AGE 3 YEARS OR OLDER
EVER ATTENDED SCHOOL
16) Has (NAME) ever attended school?

YES 1 (GO TO 17)
NO 2

16A) 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 (GO TO 20)
NO 2 (GO TO 20)

17) What is the highest grade (NAME) has completed?
SEE CODES BELOW.

GRADE __________

IF AGE 3-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during the (2067)/2068) school year?

YES 1
NO 2 (GO TO 20)

19) During this/that school year, what grade [is/was] (NAME) attending?
SEE CODES BELOW.
CODES FOR Qs. 17 AND 19: EDUCATION

00 LESS THAN 1 YEAR COMPLETED (USE ???00??? FOR Q. 17 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 19)
01-10 GRADE 1-GRADE 10
11 GRADE 11 AND ABOVE

GRADE 94 SCHOOL BASED PRE-PRIMARY CENTERS
95 INFORMAL PRESCHOOL
98 DON???T KNOW

GRADE __________

IF AGE 0-4 YEARS
BIRTH REGISTRATION
20) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)???s birth ever been registered with the VDC/municipality?

1 HAS CERTIFICATE
2 REGISTERED
3 NEITHER
8 DON???T KNOW

____________

MIGRATION
21) Now I would like to ask you about members of this household who lived here in the past 10 years but have since moved away.

Are there any members of your household who lived here in the past 10 years but who have since moved away?

YES 1
NO 2 (GO TO 30)
DON???T KNOW 8 (GO TO 30)

22) LINE NO.

23) MIGRANTS
Please give me the names of the persons who are living outside of this household?
AFTER LISTING THE NAMES AND RECORDING ???THE SEX FOR EACH PERSON, ASK QUESTIONS 25-28 FOR EACH PERSON.

__________

24) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

25) MONTH AND YEAR MOVED AWAY
In what month and year did (NAME) move away?

MONTH __________
YEAR _________

26) AGE
How old was (NAME) when s/he moved away?
IF AGE 95 OR MORE, RECORD 95???.
IF AGE LESS THAN 1 YEAR RECORD ???00???.

YEARS __________

27) REASON FOR MOVING
What was the main reason that (NAME) moved away?

WORK 1
STUDY 2
MARRIAGE 3
FAMILY 4
SECURITY 5
OTHER (SPECIFY) _________ 6
DON???T KNOW 8

28) PLACE TRAVELLED TO
Where has (NAME) travelled to?
IF ???INDIA??? AND NEPAL ASK FOR NAME OF THE CITY AND CODE; IF OTHER THAN INDIA OR NEPAL ASK FOR NAME OF THE COUNTRY. RECORD THE CODES AS PROVIDED.

NEPAL 1 __________
INDIA 2 _________
OTHER COUNTRY 3 __________
DON???T KNOW 998

29) TOTAL NUMBER OF MIGRANTS __________

TICK HERE IF CONTINUATION SHEET USED _________

30) CHECK THE FRONT COVER OF HOUSEHOLD QUESTIONNAIRE. IS HOUSEHOLD SELECTED FOR MALE SURVEY?

HOUSEHOLD SELECTED__________
HOUSEHOLD NOT SELECTED 101

31) TABLE FOR SELCTINO OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE

LOOK A THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE FEMALE RESPONDENTS ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. FOR EACH NON-ZERO NUMBER, THIS IS THE COLUMN

CIRCLE THE LINE NUMBER FOR THIS WOMAN IN COLUMN 91

FOR EXAMPLE, IF THE HOUSEHOLD NUMBER IS ???16???, GO TO ROW ???6???. IF THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD, GO TO COLUMN ???3???. FIND THE NUMBER IN THE BOX WHERE THE ROW MEETS THE COLUMN (???2???). NOW GO TO THE HOUSEHOLD SCHEDULE AND CIRCLE THE LINE NUMBER OF THE SELECTED WOMAN

LAST DIGIT OF THE HOUSEHOLD NUMBER (0-9) _____________
TOTAL NUMBER OF ELIGIBLE WOMEN 15-49 IN THE HOUSEHOLD (1-8) _________

HOUSEHOLD CHARACTERISTICS

101) 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

102) What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 104A)
PIPED TO YARD/PLOT 12 (GO TO 104A)
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
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 71
STONE TAP/DHARA 81
BOTTLED WATER 91
OTHER (SPECIFY) _____________ 96

103) Where is that water source located?

IN OWN DWELLING 1 (GO TO 104A)
IN OWN YARD/PLOT 2 (GO TO 104A)
ELSEWHERE 3

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

MINUTES ____________
DON???T KNOW 998

104A) Do you use the main water source all year or only part of the year?

ALL YEAR 1 (GO TO 105)
PART OF THE YEAR 2

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.

BIOL 1
ADD BLEACH/CHLORINE/PIYUSH/WATER GUARD B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/BIOSAND/COLLOIDAL FILTER) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ____________ X
DON???T KNOW Z

107) 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
NO FACILITY/BUSH/FIELD 51 (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 in total 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 telephone?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A table?
YES 1
NO 2
A chair?
YES 1
NO 2
A bed?
YES 1
NO 2
A sofa?
YES 1
NO 2
A cupboard?
YES 1
NO 2
A computer?
YES 1
NO 2
A clock?
YES 1
NO 2
A fan?
YES 1
NO 2
A dhiki/janto?
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
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.

NATURAL FLOOR
EARTH/SAND 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

115) MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

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

116) MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
MUD/SAND 13
RUDIMENTARY WALLS
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/SHINGLES 35
OTHER (SPECIFY) ______________ 96

117) How many rooms in this household are used for sleeping?

ROOMS __________

118) Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle/rickshaw?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A three wheel tempo?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
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 bigha/ropani of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE ???995???.

BIGHA 1 ___________
ROPANI 2 ____________
95 OR MORE BIGHA/ROPANI 995

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???.

Buffalo? __________
Milk cows or bulls? ___________
Horses, donkeys, or mules? ___________
Goats? ___________
Sheep? ___________
Chickens? ___________
Ducks? ___________
Pigs? ___________
Yaks? ___________

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

YES 1
NO 2

124) Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 126)

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

NUMBER OF NETS ________

126) Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YEARS/PLOT 2 (GO TO 129)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 129)
NOT OBSERVED, OTHER REASON 4 (GO TO 129)

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

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE C

129) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.

NO IODINE 1
LESS THAN 15 PPM 2
GREATER THAN OR EQUAL TO 15 PPM 3
SALT NOT TESTED (SPECIFY REASON) _____________ 6

HOUSEHOLD FOOD SECURITY
130) In the past 12 months, how frequently did you worry that your household would not have enough food?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

131) In the past 12 months, how often were you or any household member not able to eat the kinds of foods you preferred because of a lack of resources?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

132) In the past 12 months, how often did you or any household member have to eat a limited variety of food due to a lack of resources?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

133) In the past 12 months, how often did you or any household member have to eat a smaller meal than you felt you felt you needed because there was not enough food?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

134) In the past 12 months, how often did you or any household member eat fewer meals in a day because of resources to get food?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

135) In the past 12 months, how often was there with no food to eat of any kind in your household because of lack of resources to get food?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

136) In the past 12 months, how often did you or any household member go to sleep at night hungry because there was not enough food?

YES 1
NO 2

137) CHECK Qs 130-136

ALL CODE ???1??? NOT CIRCLED (GO TO 138)
ALL CODE ???1??? CIRCLED (GO TO 201)

138) Did your household have to adopt the following to meet the household food need in the last 12 months?

Take loan?
YES 1
NO 2
Collect wild food?
YES 1
NO 2
Consume seed stock for next season?
YES 1
NO 2
Sell household assets?
YES 1
NO 2
Sell livestock?
YES 1
NO 2
Sell land?
YES 1
NO 2

PROBE: Any other steps taken? If yes, specify.

YES 1 (SPECIFY) ______________
NO 2

139) What was the cause of food deficiency in your household in the last 12 months?

SHOCK FACTORS
DROUGHT A
LANDSLIDE B
CROP FAILURE C
FLOOD D
TEMPORAL FACTORS
FINANCIAL PROBLEM E
NOT AVAILABLE IN MARKET F
OTHER (SPECIFY) ____________ X

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

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. 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 FROM COLUMN 11__________

NAME FROM COLUMN 2__________

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NO INTERVIEWED, ASK: What is (NAME)???s birth date?

DAY __________
MONTH__________
YEAR ________

204) CHECK 203:
CHILD BORN IN BAISAKH 2062 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 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CM. __________._____
NOT PRESENT 9994 (GO TO 212)
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E., 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 214)
OLDER 2

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD ???00??? IF NOT LISTED.

LINE NUMBER __________

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

As part of this survey, we are asking people from 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 2062 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 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/NAMES OF CHILDREN) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOU NAME.

GRANTED 1 (SIGN) ______________
REFUSED 2 (SIGN) _____________

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

G/DL ____.__
NOT PRESENT 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, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15-49

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

215) LINE NUMBER FROM COLUMN 9 __________
NAME FROM COLUMN 2 __________
216) WEIGHT IN KILOGRAMS

KG. __________. ______
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217) HEIGHT IN CENTIMETERS

CM. ________. ____
NOT PRESENT 9994 (GO TO 226)
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 ADULT RESPONSIBLE FOR ADOLESCENT. RECORD ???00??? IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ________

221) ASK CONSENT OR 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 from 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 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 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 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?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ____________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ____________
(IF REFUSED, GO TO 226)

223) ASK FOR CONSENT FOR ANEMIA TEST FROM RESPONDENT.

As part of this survey, we are asking people from 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 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 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?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) _____________
RESPONDENT REFUSED 2 (SIGN) _____________
(IF REFUSED, GO TO 226)

225) PREGNANCY STATUS: CHECK 234 IN WOMAN???S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON???T KNOW 8

226) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL _____.___
NOT PRESENT 994
REFUSED 995
OTHER 996

227) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, THEN END HERE.