IDENTIFICATION

PLACE NAME _____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER _____
COMPOUND NUMBER _____
CLUSTER NUMBER _____
REGION _____

URBAN/RURAL:

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL:

HOUSEHOLD SELECTED FOR: MEN'S SURVEY?

ADDITIONAL QUESTIONS ABOUT SEXUAL ACTIVITY SHOULD BE ASKED OF MEN (1) OF WOMEN (2) IN THE INDIVIDUAL SURVEY.

ADDITIONAL QUESTIONS 2

INTERVIEWER VISITS

INTERVIEW 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
INTERVIEWER NAME_____
RESULT___

RESULTS _____

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR 2005
INTERVIEWER CODE _____
RESULT _____

TOTAL NUMBER OF VISITS_____

TOTAL IN THE HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____

RESPONDENT'S LINE NUMBER FOR THE HOUSEHOLD QUESTIONNAIRE_____

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____
KEYED BY_____

HOUSEHOLD SCHEDULE

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

1. LINE NUMBER:

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

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

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

5. RESIDENCE: Does (NAME) usually live here?

6. RESIDENCE: Did (NAME) stay here last night?

7. AGE: How old is (NAME) in completed years?

CHRONIC ILLNESS. IF AGE IS 15-59 YEARS:

7A. Has (NAME) been very sick for at least three months during the past 12 months?
By "very sick" I mean too sick to work or to do his or her normal household activities.

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

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

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

SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:

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

11. IF ALIVE: Does the (NAME'S) biological mother live in the household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER. RECORD '00' IF THE BIOLOGICAL PARENT IS NOT LISTED IN THE HOUSEHOLD TABLE.

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

13. IF ALIVE: Does the (NAME'S) biological father live in the household?
IF YES: What is his name?

RECORD FATHER'S LINE NUMBER. RECORD '00' IF THE BIOLOGICAL PARENT IS NOT LISTED IN THE HOUSEHOLD TABLE.

BIRTH CERTIFICATE. IF 0-4 YEARS:

13A. Does (NAME) have a birth certificate?
IF NO, PROBE: Was (NAME)'s birth recorded by the state?

EDUCATION. IF 5 YEARS OR MORE:

14. Has (NAME) attended school?

15. What is the highest level of education attained by (NAME)?
What is the last grade completed by (NAME) at this level?

EDUCATION. IF 5-24 YEARS OLD:

16. Does (NAME) currently attend school?

17. Has (NAME) attended school during the current school year at any time?

18. During the current school year, which level did (NAME) achieve and in which grade?

19. Did (NAME) attend school at any time during the previous school year?

20. During the previous school year, which level did (NAME) achieve and in which grade?

MARK HERE IF ANOTHER SHEET WAS USED_____

Just to be sure that I have a complete list:
1) Are there other persons such as small children or infants that we have not recorded on the list?

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

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

CHILDREN BETWEEN 3-14 YEARS:

20A. LINE NUMBER FROM COL. (1):

20B. NAME FROM COL. (2):

20C.AGE FROM COL. (7):

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

20E. CARE OF CHILDREN 3-5 YEARS: IF YES, Which one?
RECORD THE APPROPRIATE CODE.

20F. CARE OF CHILDREN 3-5 YEARS: For how many years?
RECORD THE APPROPRIATE CODE.

WORK DURING THE LAST WEEK. IF 5-14 YEARS OLD:

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

20G. Since last (DAY OF THE WEEK), did (NAME) do any kind of work for someone who is not a member of this household last week?
IF YES: Is he/she paid?

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

20I. Since last (DAY OF THE WEEK), did (NAME) help with household work last week?
For example: get groceries, cook, clean, get water, watch children, wash clothes??

20J. IF YES: Since last (DAY OF THE WEEK), about how many hours did he/she spend doing this household work?
IF MORE THAN ONE JOB, TAKE THE SUM OF ALL THE HOURS.

20K. Did (NAME) do other work for the family last week (such as farm work, commerce, business?)?

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

22. How long does it take to go there, get water, and come back?
IF 6 HOURS (360 MINUTES) OR MORE, RECORD '360'.

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

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

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

22D. How long did these interruptions in water availability during the past two weeks last: hours, more than a day, more than a week or the whole time?

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

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

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

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

24B. Do these toilette facilities belong exclusively to the households that use them or are they public or community toilets?

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

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

25. Does your household have:

Electricity?
Radio?
Television?
MMDS/TV5 antenna?
Subscription to CANAL?
Land line telephone?
Cellular telephone?
Washing machine?
Refrigerator?
Gas or electric stove/cooking range?
Improved stove?
Video DVD/CD player?
Air conditioner?
Computer?
Internet in the house?

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

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION

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

28. Is there anyone in your household who owns:

Bicycles?
Scooters or motorcycles?
Personal car?
Commercial cars or trucks?
Carts?
Plows?
Horses?
Cattle?
Camels?
Donkeys?
Sheep/goats?
Boats/fishing nets?
Poultry?

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

29A. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD "7".

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

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

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

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

32B. Since you got the net was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

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

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

32E. Who slept under this net last night?
RECORD THE LINE NUMBER FROM THE HOUSEHOLD TABLE.
RECORD UP TO FIVE PEOPLE PER NET.

32F. RETURN TO THE FIRST COLUMN OF 30 FOR THE NEXT NET/IN A NEW QUESTIONNAIRE; OR IF THERE ARE NO MORE NETS IN THE HOUSEHOLD, GO TO 33.

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

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

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

35A. CHECK THE COVER PAGE:
REGION?

35B. Are the people of the household the owner or the renter of this dwelling/house, or do they occupy it for free?

35C. What kind of document or paper do you have for this dwelling/house?

35D. How did you acquire this dwelling/house?

35E. Is this dwelling/house in your name or in the name of another person?

35F. What type of document or paper do you have for the rental or occupation of this dwelling/house?

35G. Is the document/paper of rental/occupation of this dwelling/house in your name or that of another person?

35H. Do you feel safe from eviction from this dwelling?

35I. Have you ever been evicted from your dwelling during the last 5 years?

35J. Do you own a (another) house in this neighborhood or in another neighbor in Dakar or elsewhere in Senegal?

35K. In your opinion, is your neighborhood safe or not safe?

DECLARATION FOR CONSENT FOR ANEMIA TEST

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

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

May I request now that you (and FIRST AND LAST NAME OF CHILDREN) take this anemia test? However, if you decide to refuse, know that you have this right and that we respect your decision. Now, can you tell me if you accept to take this test?

MEASUREMENT OF WEIGHT, HEIGHT AND HEMOGLOBIN LEVEL

CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF WOMEN 15-49 YEARS, OF MEN 15-59 YEARS AND CHILDREN LESS THAN 6 YEARS.

ALL WOMEN 15-49 AND ALL MEN 15-59:

36. LINE NUMBER FROM COLUMN (8):

37. NAME FROM COLUMN (2):

38. AGE FROM COL. (7):

WEIGHT AND HEIGHT OF WOMEN 15-49:

40. WEIGHT (KILOGRAMS):

41. HEIGHT (METERS):

43. RESULT:

CHILDREN LESS THAN 6:

36. LINE NUMBER FROM COL. (9):

37. NAME FROM COL. (2):

38. AGE FROM COL. (7):

39 What is the birthday of (NAME)?

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

WEIGHT AND HEIGHT OF CHILDREN BORN IN 2000 OR AFTER:

40. WEIGHT (KILOGRAMS):

41. HEIGHT (CENTIMETERS):

42. MEASURED LYING DOWN OR STANDING:

43. RESULT:

MARK IF ANOTHER SHEET WAS USED _____

MEASUREMENT OF HEMOGLOBIN LEVELS OF WOMEN 15-49 YEARS AND MEN 15-59 YEARS:

44. CHECK COLUMN (38):

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

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

47. HEMOGLOBIN LEVEL (G/DL):

48. CURRENTLY PREGNANT?
[ASK ONLY FOR WOMEN. DO NOT ASK FOR MEN]

49. RESULT:

MEASUREMENT OF HEMOGLOBIN LEVEL OF CHILDREN LESS THAN 6 YEARS:

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

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

47. HEMOGLOBIN LEVEL (G/DL):

49. RESULT:

50. CHECK 47 AND 48:
NUMBER OF USUAL RESIDENTS WHOSE HEMOGLOBIN IS BELOW THE CRITICAL THRESHOLD. THE CRITICAL THRESHOLD IS 9G/DL FOR PREGNANT WOMEN AND 7 G/DL FOR CHILDREN, MEN AND WOMEN WHO ARE NOT PREGNANT (OR WHO DON'T KNOW IF THEY ARE PREGNANT)

51. We have detected a low level of hemoglobin in (your blood/ the blood of NAME OF CHILD/CHILDREN). This means that (you/ NAME OF CHILD/CHILDREN) are severely anemic, which is a serious health problem. We wish to inform the doctor of _____about (your condition /the condition of NAME OF CHILD/CHILDREN). This will help you/your child to get the appropriate treatment for your /his/her condition. Do you accept to have this information concerning the hemoglobin level of (your blood/ the blood of NAME OF CHILD/CHILDREN) given to the doctor?

WOMEN 18-49 AND MEN 18-59:

NAME OF THE PERSON(S) WHO IS/ARE BELOW THE CRITICAL THRESHOLD:

ACCEPT THAT THE INFORMATION IS SHARED?

WOMEN AND MEN 15-17 AND CHILDREN:

NAME OF THE PERSON(S) WHO IS/ARE BELOW THE CRITICAL THRESHOLD:

NAME OF PARENT/RESPONSIBLE ADULT:

ACCEPT THAT THE INFORMATION IS SHARED?

INFORMED AND VOLUNTARY CONSENT (HIV TEST)

INFORMED AND VOLUNTARY CONSENT FOR ADULTS 18 YEARS OR MORE:

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

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

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

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

PROCEED TO COLUMN (67) AND CIRCLE THE APPROPRIATE CODE. THEN HAVE IT SIGNED BY THE PERSON RESPONSIBLE OR THE LEGAL REPRESENTATIVE.

INFORMED AND VOLUNTARY CONSENT FOR YOUTH 15-17 YEARS:
FIRST STEP: ASK THE INFORMED CONSENT OF THE PARENT/RESPONSIBLE ADULT.

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

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

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

Now, do you accept that (NAME) take this HIV test?

PROCEED TO COLUMN (66), CIRCLE THE APPROPRIATE CODE AND HAVE IT SIGNED BY THE PERSON RESPONSIBLE OR THE LEGAL REPRESENTATIVE.

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

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

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

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

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

GO TO COLUMN (67), CIRCLE THE APPROPRIATE CODE AND HAVE IT SIGNED BY THE PERSON RESPONSIBLE OR THE LEGAL REPRESENTATIVE.

HIV TEST FOR WOMEN AGED 15-49 AND MEN AGED 15-59

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

61. NAME FROM COL. (2):

62. SEX FROM COL. (4):

63. AGE FROM COL. (7):

64. CHECK AGE FROM COL. (63):

65. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:

66. READ THE CONSENT STATEMENT TO THE PARENT/RESPONSIBLE, CIRCLE THE CODE AND HAVE IT SIGNED:

67. READ THE CONSENT STATEMENT TO THE WOMAN/MAN/YOUTH, CIRCLE THE CODE AND HAVE IT SIGNED:

68. RESULT:

69. LABEL WITH BAR CODE:
PASTE THE LABEL HERE. PASTE THE SECOND ON THE CARBON COPY AND THE THIRD ON THE TRANSFER SHEET FOR THE BLOOD TAKEN.

CHECK HERE IF ANOTHER SHEET WAS USED _____