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RWANDA DEMOGRAPHIC AND HEALTH SURVEYS 2010 HOUSEHOLD QUESTIONNAIRE

MINECOFIN

MINISTRY OF HEALTH

NATIONAL INSTITUTE OF STATISTICS

IDENTIFICATION

PLACE NAME

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD STRUCTURE NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MALE INTERVIEW, HIV, MALARIA TEST, ANTHROPOMETRIC MEASUREMENTS AND SECTION 12 OF THE WOMAN'S QUESTIONNAIRE

YES 1
NO2

INTERVIEWER VISITS

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

RESULT

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT IN HOUSEHOLD AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9

NEXT VISIT (FOR INTERVIEWERS 1 AND 2(
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

FIELD EDITOR
NAME

OFFICE EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________. I am working with National Institute of Statistics of Rwanda. We are conducting a survey about health all over Rwanda. 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 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. In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER:_______________________ DATE:______________

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

HOUSEHOLD SCHEDULE

1) LINE NO.

LINE NUMBER___

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

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. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-36 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 members of your family, such as domestic servants, lodgers, or friends who usually live here?

YES (ADD TO TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

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

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 = OTHER RELATIVE
10 = ADOPTED/FOSTER/STEPCHILD
11 = NOT RELATED
12 = DOMESTIC WORKER
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) RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

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

AGE IN YEARS___


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

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

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

10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-54

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

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 AGES:

12) Is (NAME)'s natural mother alive?

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

13) Does (NAMES)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER.

IF NO, RECORD '00'.

LINE NUMBER___

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 usually live in this household or was he a guest last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

IF NO, RECORD '00'.

LINE NUMBER___

EVER ATTENDED SCHOOL IF AGE 3 YEARS OR OLDER:

16) Has (name) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

17) What is the highest level of school (NAME) has attended? SEE CODES BELOW.
What is this highest grade (NAME) completed at that level? SEE CODES BELOW.

LEVEL
PRIMARY 1
POST-SECONDARY/VOCATIONAL 2
SECONDARY 3
TERTIARY 4
PRE-PRIMARY 6
DON'T KNOW 8
GRADE
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 3-24:

18) Did (NAME) attend school at any time during the (2009-2010) (3) school year?

YES 1
NO 2 (GO TO 20)

19) During this/that school year, what level and grade [is/was] (NAME) attending? SEE CODES BELOW.

LEVEL
PRIMARY 1
POST-SECONDARY/VOCATIONAL 2
SECONDARY 3
TERTIARY 4
PRE-PRIMARY 6
DON'T KNOW 8
GRADE
DON'T KNOW 98

BIRTH REGISTRATION IF AGE 0-4 YEARS:

20) Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

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

HOUSEHOLD HEALTH EXPENDITURE

21) HEALTH INSURANCE: Is (NAME) covered by any health insurance?

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

22) What is (NAME)'s main type of health insurance?

MUTUELLE HEALTH INSURANCE/COMMUNITY BASED HEALTH INSURANCE 1
RAMA 2
MMI 3
PRIVATELY PURCHASED/COMMERCIAL HEALTH INSURANCE 4
OTHER 6
DON'T KNOW 8

23) INPATIENT: In the last six months, was (NAME) admitted overnight to stay at a health facility?

YES 1
NO 2 (GO TO 25)
DON'T KNOW (GO TO 25)

24) CIRCLE LINE NUMBER OF PERSON ELIGIBLE FOR INPATIENT MODULE

25) OUTPATIENT: In the last four weeks, did (NAME) receive health care from a health provider, a pharmacy, or a traditional healer without staying overnight?

YES 1
NO 2 (GO TO 28)
DON'T KNOW 8 (GO TO 28)

27) CIRCLE LINE NUMBER OF PERSON ELIGIBLE FOR OUTPATIENT MODULE

28) ILLNESS/INJURY: Was (NAME) ill or injured in the last four weeks?

YES 1
NO 2
DON'T KNOW 8

CHILD LABOR IF AGE 5-16 YEARS:

29) During the past week, did (NAME) do any kind of work for someone who is not a member of this household?

IF YES: For pay in cash or kind?

YES FOR PAY (IN CASH/KIND) 1
YES, UNPAID 2
NO 3 (GO TO 31)

29A) What kind of work did (NAME) do for someone who is not a member of this household during the past week? SEE CODES BELOW.

HOUSEHOLD CHORE (COOKING, FETCHING, WATER/FIRE WOOD, WASHING CLOTHES, HOUSE CLEANINGS, BABY SITTING, ETC.) 01
CULTIVATION/HARVESTING IN GARDEN OR FIELD 02
IN PLANTATION (TEA, RICE, COFFEE, OTHER) 03
FISHERY 04
IN MINE/QUARRIES (BREAKING STONES, MOLDING BRICKS, LOADING TRUCK, OTHER) 05
SELLING GOODS ON THE MARKETS/STREET/SHOP 06
PROSTITUTION 07
SELLING ALCOHOL, DRUG, AND CIGARETTES 08
OTHER 96

30) Since last (DAY OF THE WEEK), about how many hours did he/she do this work for someone who is not a member of this household?

IF MORE THAN ONE JOB, INCLUDE ALL HOURS IN ALL JOBS.

HOURS___

31) During the past week, did (NAME) fetch water or collect firewood, for household use?

YES 1
NO 2 (GO TO 33)

32) Since last (DAY OF THE WEEK), about how many hours did he/she fetch water or collect firewood, for household use?

HOURS___

33) During the past week, did (NAME) do any other family work (on the farm or in a business, or selling goods in the street)?

INCLUDE WORK FOR A BUSINESS RUN BY THE CHILD, ALONE OR WITH ONE OR MORE PARTNERS.

YES 1
NO 2 (GO TO 35)

34) Since last (DAY OF THE WEEK), about how many hours did he/she spend doing this work for his/her family or himself/herself?

HOURS___

35) During the past week, did (NAME) help with household chores such as shopping, cleaning, washing clothes, cooking, or caring for children or sick people?

YES 1
NO 2 (GO TO NEXT LINE)

36) Since last (DAY OF THE WEEK), about how many hours did he/she spend doing these chores?

HOURS___

HOUSEHOLD CHARACTERISTICS

101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, 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 105)
PIPED TO 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 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY)___ 96

103) Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT (GO TO 105)
ELSEWHERE 3

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

MINUTES___
DON'T KNOW 998

104A) What is the distance from your home to that water source?

LESS THAN 200 M 1
200 M - 500 M 2
MORE THAN 500 M 3
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 106A)
DON'T KNOW 8 (GO TO 106A)

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
OTHER (SPECIFY) X
DON'T KNOW Z

106A) Is the water this household uses for drinking stored?

YES 1
NO 2 (GO TO 107)
DON'T KNOW 8 (GO TO TO 107)

106B) ASK TO SEE THE CONTAINER(S) IN WHICH WATER IS STORED.

RECORD OBSERVATION.

JERRY CAN 1
POT 2
BOTTLE 3
COOKING POT 4
OTHER (SPECIFY) 6
NOT AVAILABLE TO BE OBSERVED 8

106C) How many times per week does your household wash these containers?

NUMBER OF TIMES PER WEEK IF LESS THAN 7___
7 OR MORE TIMES PER WEEK 7
DON'T KNOW 8

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
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
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?

NUMBER OF HOUSEHOLDS IF LESS THAN 10___
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

109A) CLEANLINESS OF THE TOILET FACILITY

RECORD OBSERVATION.

TOILET'S PLATE FORM IS:
DRY AND CLEAN A
WITH URINE OR EXCRETA B
WITH FLIES C

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 computer?
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
CHARCOAL 07
WOOD 08
STRAWS/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 ROOFING
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOORS
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/LEAF 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT/PLASTIC 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
METAL/IRON 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 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
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?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A boat without a motor?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2

119) Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120) How many hectares of agricultural land do members of this household own?

IF 95 OR MORE, CIRCLE '950'

HECTARES___
95 OR MORE HECTARES 95.0
DON'T KNOW 99.8

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'.

Cows (traditional)?
COWS__
Milk cows (modern)?
MILK COWS___
Bulls?
BULLS___
Goats?
GOATS___
Sheep?
SHEEP___
Chickens?
CHICKENS___
Pigs?
PIGS___
Rabbits?
RABBITS___
Horses, donkeys, or mules?
HORSES/DONKEYS/MULES___

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

YES 1
NO 2

123A) CHECK 21:

AT LEAST ONE 'YES' (GO TO 123C)
OTHER (GO TO 126)

123C) ASK TO SEE INSURANCE CARD(S)

YES, CARD SEEN 1
NO, CARD NOT SEEN 2

123D) Are all members of this household covered by this health insurance?

ALL HOUSEHOLD MEMBERS 1 (GO TO 126)
SOME HOUSEHOLD MEMBERS 2

123E) Does your household plan to obtain health insurance for members that are currently not covered?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 137)

127) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS___

128) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 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 98

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

IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET/MAMA NET/TUZANET OLYSET/ NET PROTECT 11 (GO TO 133A)
OTHER LLIN DON'T KNOW BRAND (GO TO 133A)
'PRETREATED' NET BUT NOT PERMANENT 22 (GO TO 132)
OTHER 96
DON'T KNOW BRAND 98

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitos?

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 mosquitos?

YES 1
NO 2
NOT SURE 8

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 HOURS AGO 95
NOT SURE 98

133A) How did you obtain the net?

DURING IMMUNIZATION OF CHILDRE 11
DURING IMMUNIZATIO CAMPAIGN 12
DURING ANC VISIT 13
FROM A COMMUNITY HEALTH WORKER 14
FROM PHARMACY 15
FROM SHOP 16
OTHER (SPECIFY) 96

133B) OBSERVE CONDITION OF MOSQUITO NET: DOES IT HAVE HOLES THAT ARE EQUAL TO OR LARGER THAN THE TIP OF YOUR THUMB?

YES 1
NO 2

133C) OBSERVE OR ASK THE SHAPE OF THE MOSQUITO NET.

CONICAL 1
RECTANGLE 2

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

YES 1
NO 2 (GO TO 136)
NOT SURE 8 (GO TO 136)

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

NAME___
LINE NO.___

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

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

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

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

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

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

140) ASK RESPONDENT FOR A TEASPOON OF COOKING SALT. TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE 2
NO SALT IN THE HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON)___ 6


141) FOR HOUSEHOLD SELECTED FOR MALE INTERVIEW, HIV, MALARIA TEST, ANTHROPOMETRIC AND SECTION 12 OF WOMEN QUESTIONNAIRE

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD STRUCTURE NUMBER ON THE COVER PAGE. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE
HOUSEHOLD QUESTIONNAIRE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE.

FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE ELIGIBLE WOMAN WHO WILL BE ASKED THE HOUSEHOLD RELATIONS QUESTIONS. THEN, GO TO COLUMN (9) IN THE HOUSEHOLD SCHEDULE AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED ELIGIBLE WOMAN AND RECORD THIS HOUSEHOLD LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

FOR EXAMPLE, IF THE HOUSEHOLD STRUCTURE NUMBER IS ‘716’, GO TO COLUMN 6 AND CIRCLE THE COLUMNNUMBER ('6'). IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO ROW 3 AND CIRCLE THE ROW NUMBER ('3'). DRAW LINES FROM COLUMN 6 AND ROW 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT (‘3'). THIS MEANS YOU HAVE TO SELECT THE THIRD ELIGIBLE WOMAN. SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE WOMEN ARE ‘02', ‘03', AND ‘07’; THEN THE ELIGIBLE WOMAN FOR THE HOUSEHOLD RELATIONS QUESTIONS IS THE THIRD ELIGIBLE WOMAN, I.E., THE WOMAN WITH HOUSEHOLD LINE NUMBER ‘07'. PUT A * NEXT TO THIS WOMAN'S LINE NUMBER IN COLUMN (9) OF THE HOUSEHOLD SCHEDULE AND ALSO ENTER THE TWO DIGIT LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

HEADER FOR LEFT-HAND COLUMN: "LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)" (VALUES 0-9 BELOW THIS)

HEADER FOR TOP ROW OF TABLE: TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)

COLUMNS WITH 1'S, 2'S, 3'S, 4'S, 5'S, 6'S, 7'S, AND 8'S FILL THE CELLS OF THE TABLE.

HOUSEHOLD NUMBER OF WOMAN SELECTED FOR HOUSEHOLD RELATIONS SECTION___

INPATIENT HEALTH EXPENDITURES

142) RECORD THE TIME

HOURS___
MINUTES___

142A) CHECK HHQ24:

ONE OR MORE INPATIENTS (GO TO 143)
NO INPATIENTS (GO TO 160)

143) CHECK HHQ24: ENTER THE LINE NUMBER OF EACH HOUSEHOLD MEMBER WHO WAS AN INPATIENT.

Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last six months.

144) LINE NUMBER FROM HHQ24 IN HOUSEHOLD SCHEDULE

LINE NUMBER___

145) NAME FROM HHQ1 IN HOUSEHOLD SCHEDULE

INPATIENT NAME___

146) Where did (NAME) most recently stay overnight for health care?

PUBLIC/AGREE SECTOR
REFERAL HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTER 23
HEALTH POST 24
OTHER PUBLIC FACILITY (SPECIFY) 26
PRIVATE MEDICAL SECTOR
POLYCLINIC 31
CLINIC 32
DISPENSARY 33
OTHER PRIVATE MEDICAL FACILITY (SPECIFY) 36
OTHER (SPECIFY) 96

147) What was the main reason for (NAME) to seek care this most recent time?

PREGNANCY/DELIVERY 1
DELIVERY COMPLICATIONS 2
ILLNESS 3
ACCIDENT 4
OTHER (SPECIFY) 6

148) How much money in total did (NAME) spend on treatment and services received during the most recent overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

TOTAL COST___

NO COST/FREE 000000 (GO TO 149)
IN KIND 999995 (GO TO 149)
DON'T KNOW 999998 (GO TO 149)

148A) How much of the total cost did (NAME) spend on the following items:

Consultation fees?
AMOUNT__
Ticket moderators?
AMOUNT__
Drugs?
AMOUNT__
Laboratory tests?
AMOUNT__
Other diagnostic tests?
AMOUNT__
Anything else (SPECIFY)?
AMOUNT__
Total
TOTAL__

148B) CHECK THE TOTAL IN 148A: IF IT EQUALS THE TOTAL COST IN 148 GO TO 148C; IF NOT GO BACK TO 148 AND CORRECT IT.

148C) From which of the following sources did you raise money to pay for the most recent payment? Please specify how much was contributed from each source:

Income?
AMOUNT__
Borrowing from friend/family?
AMOUNT__
Borrowing from other sources?
AMOUNT__
Assistance from friend/family?
AMOUNT__
Selling assets?
AMOUNT__
Total
TOTAL__

148D) CHECK THE TOTAL IN 148C: IF IT EQUALS THE TOTAL COST IN 148 GO TO 149; IF NOT GO BACK TO 148C AND CORRECT IT.

149) Did (NAME) stay overnight at a medical facility another time in the last six months?

YES 1
NO 2 (GO BACK TO 146 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 160)

150) Where did (NAME) stay the next-to-last time he/she stayed overnight for health care?

PUBLIC/AGREE SECTOR
REFERAL HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTER 23
HEALTH POST 24
OTHER PUBLIC FACILITY (SPECIFY) 26
PRIVATE MEDICAL SECTOR
POLYCLINIC 31
CLINIC 32
DISPENSARY 33
OTHER PRIVATE MEDICAL FACILITY (SPECIFY) 36
OTHER (SPECIFY) 96

151) What was the main reason for (NAME) to seek care this next-to-last time?

PREGNANCY/DELIVERY 1
DELIVERY COMPLICATIONS 2
ILLNESS 3
ACCIDENT 4
OTHER (SPECIFY) 6

152) How much money in total did (NAME) spend on treatment and services received during the next-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

TOTAL COST___

NO COST/FREE 000000 (GO TO 149)
IN KIND 999995 (GO TO 149)
DON'T KNOW 999998 (GO TO 149)

152A) How much of the total cost did (NAME) spend on the following items:

Consultation fees?
AMOUNT__
Ticket moderators?
AMOUNT__
Drugs?
AMOUNT__
Laboratory tests?
AMOUNT__
Other diagnostic tests?
AMOUNT__
Anything else (SPECIFY)?
AMOUNT__
Total
TOTAL__

152B) CHECK THE TOTAL IN 148A: IF IT EQUALS THE TOTAL COST IN 152 GO TO 152C; IF NOT GO BACK TO 152 AND CORRECT IT.

152C) From which of the following sources did you raise money to pay for the next-to-last? Please specify how much was contributed from each source:

Income?
AMOUNT__
Borrowing from friend/family?
AMOUNT__
Borrowing from other sources?
AMOUNT__
Assistance from friend/family?
AMOUNT__
Selling assets?
AMOUNT__
Total
TOTAL__

152D) CHECK THE TOTAL IN 152C: IF IT EQUALS THE TOTAL COST IN 148 GO TO 153; IF NOT GO BACK TO 152C AND CORRECT IT.

153) Besides the two stays you have told me about, did (NAME) stay overnight in a medical facility another time in the last six months?

YES 1
NO 2 (GO BACK TO 146 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 160)

154) Where did (NAME) stay the second-to-last time he/she stayed overnight for health care?

PUBLIC/AGREE SECTOR
REFERAL HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTER 23
HEALTH POST 24
OTHER PUBLIC FACILITY (SPECIFY) 26
PRIVATE MEDICAL SECTOR
POLYCLINIC 31
CLINIC 32
DISPENSARY 33
OTHER PRIVATE MEDICAL FACILITY (SPECIFY) 36
OTHER (SPECIFY) 96

155) What was the main reason for (NAME) to seek care this most second-to-last time?

PREGNANCY/DELIVERY 1
DELIVERY COMPLICATIONS 2
ILLNESS 3
ACCIDENT 4
OTHER (SPECIFY) 6

156) How much money in total did (NAME) spend on treatment and services received during the second-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.

TOTAL COST___

NO COST/FREE 000000 (GO TO 149)
IN KIND 999995 (GO TO 149)
DON'T KNOW 999998 (GO TO 149)

156A) How much of the total cost did (NAME) spend on the following items:

Consultation fees?
AMOUNT__
Ticket moderators?
AMOUNT__
Drugs?
AMOUNT__
Laboratory tests?
AMOUNT__
Other diagnostic tests?
AMOUNT__
Anything else (SPECIFY)?
AMOUNT__
Total
TOTAL__

156B) CHECK THE TOTAL IN 156A: IF IT EQUALS THE TOTAL COST IN 156 GO TO 156C; IF NOT GO BACK TO 156 AND CORRECT IT.

156C) From which of the following sources did you raise money to pay for the second-to-last treatment? Please specify how much was contributed from each source:

Income?
AMOUNT__
Borrowing from friend/family?
AMOUNT__
Borrowing from other sources?
AMOUNT__
Assistance from friend/family?
AMOUNT__
Selling assets?
AMOUNT__
Total
TOTAL__

156D) CHECK THE TOTAL IN 156C: IF IT EQUALS THE TOTAL COST IN 156 GO TO 157; IF NOT GO BACK TO 156C AND CORRECT IT.

157) Besides the three stays you have told me about, did (NAME) stay overnight in a medical facility another time in the last six months?

YES 1
NO 2 (GO BACK TO 146 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 160)

158) In total, how many times did (NAME) stay overnight in a medical facility in the last six months?

NUMBER OF INPATIENT VISITS__

159) GO BACK TO 146 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 160

OUTPATIENT HEALTH EXPENDITURES

160) CHECK HHQ27:

ONE OR MORE OUTPATIENTS (GO TO 161)
NO OUTPATIENTS (GO TO 178)

161) CHECK HHQ27: ENTER THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO WAS AN OUTPATIENT.

Now I would like to ask some questions about the household members who consulted a provider for health care in the last four weeks, without having stayed overnight.

162) LINE NUMBER FROM HHQ27 IN HOUSEHOLD SCHEDULE

LINE NUMBER___

163) NAME FROM HHQ1 IN HOUSEHOLD SCHEDULE

OUTPATIENT NAME___

164) From what type of health provider did (NAME) get care most recently without staying overnight?

PUBLIC/AGREE SECTOR
REFERAL HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTER 23
HEALTH POST 24
OUTREACH 25
COMMUNITY HEALTH WORKER 26
OTHER PUBLIC FACILITY (SPECIFY) 27
PRIVATE MEDICAL SECTOR
POLYCLINIC 31
CLINIC 32
DISPENSARY 33
PHARMACY 34
OTHER PRIVATE MEDICAL FACILITY (SPECIFY) 36
OTHER SOURCE
KIOSK 41
TRADITIONAL PRACTITIONER 42
CHURCH 43
FRIEND/RELATIVE 44
OTHER (SPECIFY) 96

165) What was the main reason for (NAME) to seek care this most recent time?

RESPIRATORY ILLNESS 01
TUBERCULOSIS 02
DIARRHEA 03
INTESTINAL WORMS 04
MALARIA 05
FEVER 06
SKIN DISEASE 07
STD 08
HIV/AIDS 09
VCT 10
FAMILY PLANNING 11
DIABETES 12
EYE INFECTION 13
DENTAL 14
ACCIDENT/INJURY 15
REGULAR CHECK-UP 16
VACCINATION 17
DELIVERY 18
ANTENATAL CARE 19
POSTNATAL CARE 20
PHYSIOTHERAPY 21
OTHER (SPECIFY) 96

166) How much money in total did (NAME) spend on treatment and services received during the most recent consultation? Please include the consulting fee and any expenses for other items including drugs and tests.

TOTAL COST__

NO COST/FREE 000000 (GO TO 167)
IN KIND 999995 (GO TO 167)
DON'T KNOW 999998 (GO TO 167)

166A) How much of the total cost did (NAME) spend on the following items:

Consultation fees?
AMOUNT__
Ticket moderators?
AMOUNT__
Drugs?
AMOUNT__
Laboratory tests?
AMOUNT__
Other diagnostic tests?
AMOUNT__
Anything else (SPECIFY)?
AMOUNT__
Total
TOTAL__

166B) CHECK THE TOTAL IN 166A: IF IT EQUALS THE TOTAL COST IN 166 GO TO 166C; IF NOT GO BACK TO 166 AND CORRECT.

166C) From which of the following sources did you raise money to pay for the most recent consultation? Please specify how much was contributed from each source:

Income?
AMOUNT__
Borrowing from friend/family?
AMOUNT__
Borrowing from other sources?
AMOUNT__
Assistance from friend/family?
AMOUNT__
Selling assets?
AMOUNT__
Total
TOTAL__

166D) CHECK THE TOTAL IN 166C: IF IT EQUALS THE TOTAL COST IN 166 GO TO 167; IF NOT GO BACK TO 166C AND CORRECT IT.

167) Did (NAME) get care another time in the last four weeks without staying overnight?

YES 1
NO 2 (GO BACK TO 164 IN NEXT COLUMN; OR, IF NO MORE OUTPATIENTS, GO TO 178)

168) From what type of health provider did (NAME) get care the next-to-last time without staying overnight?

PUBLIC/AGREE SECTOR
REFERAL HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTER 23
HEALTH POST 24
OUTREACH 25
COMMUNITY HEALTH WORKER 26
OTHER PUBLIC FACILITY (SPECIFY) 27
PRIVATE MEDICAL SECTOR
POLYCLINIC 31
CLINIC 32
DISPENSARY 33
PHARMACY 34
OTHER PRIVATE MEDICAL FACILITY (SPECIFY) 36
OTHER SOURCE
KIOSK 41
TRADITIONAL PRACTICIONER 42
CHURCH 43
FRIEND/RELATIVE 44
OTHER (SPECIFY) 96

169) What was the main reason for (NAME) to seek care this next-to-last time?

RESPIRATORY ILLNESS 01
TUBERCULOSIS 02
DIARRHEA 03
INTESTINAL WORMS 04
MALARIA 05
FEVER 06
SKIN DISEASE 07
STD 08
HIV/AIDS 09
VCT 10
FAMILY PLANNING 11
DIABETES 12
EYE INFECTION 13
DENTAL 14
ACCIDENT/INJURY 15
REGULAR CHECK-UP 16
VACCINATION 17
DELIVERY 18
ANTENATAL CARE 19
POSTNATAL CARE 20
PHYSIOTHERAPY 21
OTHER (SPECIFY) 96

170) How much money in total did (NAME) spend on treatment and services received during the next-to-last consultation? Please include the consulting fee and any expenses for other items including drugs and tests.

TOTAL COST__

NO COST/FREE 000000 (GO TO 171)
IN KIND 999995 (GO TO 171)
DON'T KNOW 999998 (GO TO 171)

170A) How much of the total cost did (NAME) spend on the following items:

Consultation fees?
AMOUNT__
Ticket moderators?
AMOUNT__
Drugs?
AMOUNT__
Laboratory tests?
AMOUNT__
Other diagnostic tests?
AMOUNT__
Anything else (SPECIFY)?
AMOUNT__
Total
TOTAL__

170B) CHECK THE TOTAL IN 170A: IF IT EQUALS THE TOTAL COST IN 170 GO TO 170C; IF NOT GO BACK TO 170 AND CORRECT IT.

170C) From which of the following sources did you raise money to pay for the next-to-last consultation? Please specify how much was contributed from each source:

Income?
AMOUNT__
Borrowing from friend/family?
AMOUNT__
Borrowing from other sources?
AMOUNT__
Assistance from friend/family?
AMOUNT__
Selling assets?
AMOUNT__
Total
TOTAL__

170D) Besides the two visits you have told me about, did (NAME) get care another time in the last four weeks without staying overnight?

YES 1
NO 2 (GO BACK TO 164 IN NEXT COLUMN; OR, IF NO MORE OUTPATIENTS, GO TO 178)

171) Besides the two visits you have told me about, did (NAME) get care another time in the last four weeks without staying overnight?

YES 1
NO 2 (GO BACK TO 164 IN NEXT COLUMN; OR, IF NO MORE OUTPATIENTS, GO TO 178)

172) From what type of health provider did (NAME) get care the second-to-last time without staying overnight?

PUBLIC/AGREE SECTOR
REFERAL HOSPITAL 21
DISTRICT HOSPITAL 22
HEALTH CENTER 23
HEALTH POST 24
OUTREACH 25
COMMUNITY HEALTH WORKER 26
OTHER PUBLIC FACILITY (SPECIFY) 27
PRIVATE MEDICAL SECTOR
POLYCLINIC 31
CLINIC 32
DISPENSARY 33
PHARMACY 34
OTHER PRIVATE MEDICAL FACILITY (SPECIFY) 36
OTHER SOURCE
KIOSK 41
TRADITIONAL PRACTICIONER 42
CHURCH 43
FRIEND/RELATIVE 44
OTHER (SPECIFY) 96

173) What was the main reason for (NAME) to seek care this second-to-last time?

RESPIRATORY ILLNESS 01
TUBERCULOSIS 02
DIARRHEA 03
INTESTINAL WORMS 04
MALARIA 05
FEVER 06
SKIN DISEASE 07
STD 08
HIV/AIDS 09
VCT 10
FAMILY PLANNING 11
DIABETES 12
EYE INFECTION 13
DENTAL 14
ACCIDENT/INJURY 15
REGULAR CHECK-UP 16
VACCINATION 17
DELIVERY 18
ANTENATAL CARE 19
POSTNATAL CARE 20
PHYSIOTHERAPY 21
OTHER (SPECIFY) 96

174) How much money in total did (NAME) spend on treatment and services during the second-to-last consultation? Please include the consulting fee and any expenses for other items including drugs and tests.

TOTAL COST__

NO COST/FREE 000000 (GO TO 171)
IN KIND 999995 (GO TO 171)
DON'T KNOW 999998 (GO TO 171)

174A) How much of the total cost did (NAME) spend on the following items:

Consultation fees?
AMOUNT__
Ticket moderators?
AMOUNT__
Drugs?
AMOUNT__
Laboratory tests?
AMOUNT__
Other diagnostic tests?
AMOUNT__
Anything else (SPECIFY)?
AMOUNT__
Total
TOTAL__

174B) CHECK THE TOTAL IN 174A: IF IT EQUALS THE TOTAL COST IN 174 GO TO 174C; IF NOT GO BACK TO 174 AND CORRECT IT.

174C) From which of the following sources did you raise money to pay for the second-to-last treatment? Please specify how much was contributed from each source:

Income?
AMOUNT__
Borrowing from friend/family?
AMOUNT__
Borrowing from other sources?
AMOUNT__
Assistance from friend/family?
AMOUNT__
Selling assets?
AMOUNT__
Total
TOTAL__

174D) CHECK THE TOTAL IN 174C: IF IT EQUALS THE TOTAL COST IN 174 GO TO 175; IF NOT GO BACK TO 174C AND CORRECT IT.

175) Besides the three visits you have told me about, did (NAME) get care another time in the last four weeks without staying overnight?

YES 1
NO 2 (GO BACK TO 164 IN NEXT COLUMN; OR, IF NO MORE OUTPATIENTS, GO TO 178)

176) In total, how many times did (NAME) get care from a health provider in the last four weeks, without staying overnight?

NUMBER OF OUTPATIENT VISITS__

177) GO BACK TO 164 IN NEXT COLUMN; OR, IF NO MORE OUTPATIENTS, GO TO 178

178) (Not including the costs for the health care consultations you told me about), how much did all members of your household spend on health-related items in the last four weeks? We want to include all health-related items such as drugs, vitamins, herbal remedies, family planning methods, and so on.

SPENT ON HEALTH LAST FOUR WEEKS___

178A) RECORD THE TIME

HOURS__
MINUTES__

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENTS, AND MALARIA TESTING FOR CHILDREN AGE 0-5

CHECK HOUSEHOLD COVER PAGE TO SEE IF HOUSEHOLD IS SELECTED FOR MALE INTERVIEW, ANEMIA, HIV, MALARIA AND ANTHROPOMETRY

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 AND NAME FROM COLUMN 2

LINE NUMBER__
NAME___

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

DAY
MONTH
YEAR

204) CHECK 203:
CHILD BORN IN JANUARY 2005 OR LATER?

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

205) WEIGHT IN KILOGRAMS

KILOGRAMS__

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CENTIMETERS__

NOT PRESENT 9994
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 THE 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) READ ANEMIA CONSENT TO PARENT OR OTHER ADULT RESPONDISBLE FOR CHILD. CIRCLE CODE AND SIGN.

GRANTED 1
REFUSED 2
SIGN___

211) RECORD HEMEGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

G/DL__

NOT PRESENT 994
REFUSED 995
OTHER 996

212) READ MALARIA CONSENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

GRANTED 1
REFUSED 2
SIGN___

212A) RECORD RESULT CODE OF MALARIA TEST

TESTED 1
NOT PRESENT 2 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)
REFUSED 3 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)
OTHER 6 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)

212B) BAR CODE LABEL

PUT THE 2ND BAR CODE ON THE SLIDE AND THE 3RD ON TRANSMITTAL FORM

[PUT THE 1ST BAR CODE HERE]

212C) RESULT OF MALARIA TEST

POSITIVE 1
NEGATIVE 2 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)
OTHER 6 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)

212D) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. ASK ABOUT ANY TREATMENT THE CHILD HAS ALREADY RECEIVED.

ACCEPTED MEDICINE 1 (SIGN NAME)
REFUSED 2
ALREADY HAS ACT 3
NOT ELIGIBLE 4
OTHER 6
SIGN___

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.

CONSENT STATEMENT FOR ANEMIA TEST

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 2005 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?

CONSENT STATEMENT FOR MALARIA TEST

As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent malaria.

We ask that all children born in 2005 or later participate in the malaria testing part of 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 malaria immediately, and the result will be 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 malaria test?

TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS

IF MALARIA TEST IS POSITIVE: The malaria test shows that your child has malaria. We can give you free medicine.
The medicine is called ACT. ACT is very effective and in a few days it should get rid of the fever and other symptoms.

BEFORE PROVIDING ACT, FIRST ASK IF THE CHILD IS ALREADY TAKING OTHER DRUGS AND IF SO, ASK TO SEE THEM. IF CHILD IS ALREADY TAKING ACT, CHECK ON THE DOSE ALREADY AVAILABLE. BE CAREFUL NOT TO OVERTREAT.

You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.

TREATMENT WITH ACT
Arthemeter (20mg)+Lumefantrine(120mg)
A 3-day treatment schedule with a total of 6 doses is recommended as below

Weight (in Kg)

05.0-14.9 kg

Treatment

One tablet as an initial dose, 1 tablet again after 8 hours and then 1 tablet twice daily (morning and evening) for the following two days (total course of 6 tablets).

Weight (in Kg)

15.0-24.9 kg

Treatment

Two tablets as an initial dose, 2 tablets again after 8 hours and then 2 tablets twice daily (morning and evening) for the following two days (total course of 12 tablets).

Weight (in Kg)

25.0-34.9 kg

Treatment

Three tablets as an initial dose, 3 tablets again after 8 hours and then 3 tablets twice daily (morning and evening) for the following two days (total course of 18 tablets).

Weight (in Kg)

35 kg and above

Treatment

Four tablets as a single initial dose, 4 tablets again after 8 hours and then 4 tablets twice daily (morning and evening) for the following two days (total course of 24 tablets).

WEIGHT, HEIGHT MEASUREMENT, MALARIA AND HIV TESTING 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 AND NAME FROM COLUMN 2

LINE NUMBER___
NAME___

216) WEIGHT IN KILOGRAMS

KILOGRAMS_______

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217) HEIGHT IN CENTIMETERS

CENTIMETERS__

NOT PRESENT 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 ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

LINE NUMBER 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 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 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 take the anemia test?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN NAME)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN NAME) (GO TO 224D)
SIGN___

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 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 NAME)
RESPONDENT REFUSED 2 (SIGN NAME)
SIGN__

224A) AGE: CHECK 218.

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

224B) MARITAL STATUS: CHECK 219

CODE 4 (NEVER IN UNIO) 1
OTHER 2 (GO TO 224F)

224D) ASK CONSENT FOR MALARIA 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 a Malaria test. Malaria is a serious health problem that caused by a parasite transmitted by a mosquito bite This survey will assist the government to develop programs to prevent and treat Malaria. For the Malaria 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 Malaria 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 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 take the Malaria test?

224E) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN NAME)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN NAME) (GO TO 228)
SIGN__

224F) ASK CONSENT FOR MALARIA TEST FROM RESPONDENT.

As part of this survey, we are asking people all over the country to take a Malaria test. Malaria is a serious health problem that caused by a parasite transmitted by a mosquito bite This survey will assist the government to develop programs to prevent and treat Malaria. For the Malaria 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 Malaria 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 Malaria test?

224G) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN NAME)
RESPONDENT REFUSED 2 (SIGN NAME)
SIGN___

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

YES 1
NO 2
DON'T KNOW 8

226) AGE: CHECK 218.

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

227) MARITAL STATUS: CHECK 219.

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

228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER 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 Rwanda.

For the HIV test, we need a few (more) drops of blood from a finger. Again 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 her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her 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?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN NAME)
PARENT/OTHER RESPONSIBEL ADULT REFUSED 2 (SIGN NAME) (GO TO 239)
SIGN___

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 Rwanda.

For the HIV test, we need a few (more) drops of blood from a finger. Again 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 whether you have HIV, I can provide you with 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?

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

GRANTED RESPONSE 1 (SIGN NAME)
RESPONDENT REFUSED 2 (SIGN NAME) (GO TO 239)
SIGN__
INTERVIEWER NUMBER___

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

240A) RECORD RESULT CODE OF MALARIA TEST

TESTED 1
NOT PRESENT 2 (GO TO 241)
REFUSED 3 (GO TO 241)
OTHER 6 (GO TO 241)

240B) RESULT OF MALARIA TEST

POSITIVE 1
NEGATIVE 2
OTHER 6

240C) RECORD RESULT CODE OF DBS COLLECTION

COLLECTED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

241) BAR CODE LABEL

(PUT THE 1ST BAR CODER LABEL HERE)

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE ON THE RESPONDENT'S FILTER PAPER, THE 3RD ON THE BLOOD SLIDE FOR MALARIA TEST AND THE 4TH ON THE TRANSMITTAL FORM.

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

WEIGHT, HEIGHT MEASUREMENT AND HIV TESTING 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 AND NAME FROM COLUMN 2

LINE NUMBER___
NAME___

245) WEIGHT IN KILOGRAMS

KILOGRAMS

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

246) HEIGHT IN CENTIMETERS

CENTIMETERS__

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

247) AGE: CHECK COLUMN 7.

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

248) MARITAL STATUS: CHECK COLUMN 8

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

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT__

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 Rwanda.

For the HIV test, we need a few (more) drops of blood from a finger. Again 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 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 HIV test?

257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN NAME)
PARENT/OTHER RESPONSIBEL ADULT REFUSED 2 (SIGN NAME) (GO TO 267)
SIGN___

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 Rwanda.

For the HIV test, we need a few more drops of blood from a finger. Again 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. 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 whether you have HIV, I can provide you with 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, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED RESPONSE 1 (SIGN NAME)
RESPONDENT REFUSED 2 (SIGN NAME) (GO TO 267)
SIGN__
INTERVIEWER NUMBER___

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

269) BAR CODE LABEL

(PUT THE 1ST BAR CODE LABEL HERE)

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

270) GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.