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DEMOGRAPHIC AND HEALTH SURVEY IN REPUBLIC OF SENEGAL
HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME _____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER _____
CONCESSION NUMBER _____
CLUSTER NUMBER _____
REGION _____
DEPARTMENT _____
HEALTH DISTRICT _____

URBAN OR RURAL:

URBAN 1
RURAL 2

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL:

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME _____
RESULT___

RESULT _____

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

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR 201____
INT. NUMBER _____
RESULT CODE_____

TOTAL NO. OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____
KEYED BY______

INTRODUCTION AND CONSENT:
Hello. My name is _______. I am working with the National Institute of Statistics and Demography. We are conducting a survey about health all over Senegal. 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?

SIGNATURE OF INTERVIEWER_______
DATE_______

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

HOUSEHOLD SCHEDULE

1. LINE NUMBER:

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 THE APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

NAME _____

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

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DOESN'T KNOW

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

MALE 1
FEMALE 2

TICK HERE IF CONTINUATION SHEET USED _____

Just to make sure that I have a complete listing:

2A) 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 else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

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'.

IN YEARS_____

MARITAL STATUS. IF AGE 15 OR OLDER:

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

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

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

ELIGIBILITY:
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 IF THE HOUSEHOLD IS SELECTED FOR THE MEN'S QUESTIONNAIRE.

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

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

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

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

13. Does (NAME)'s natural mother usually live in this household or was she a guest last night? IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER, IF NO, RECORD '00'.

LINE NO. ______

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

YES 1
NO 2 (GO TO 16)
DOESN'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 NO. ______

EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:

16. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

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

LEVEL _____
1 PRIMARY
2 INTERMEDIATE
3 SECONDARY
4 HIGHER
6 PRESCHOOL
8 DOESN'T KNOW
GRADE _____
00 LESS THAN ONE YEAR COMPLETED
98 DOESN'T KNOW

CURRENT/RECENT SCHOOL ATTENDANCE. IF AGE 5-24 YEARS:

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

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

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

LEVEL _____
1 PRIMARY
2 INTERMEDIATE
3 SECONDARY
4 HIGHER
6 PRESCHOOL
8 DOESN'T KNOW
GRADE _____
98 DOESN'T KNOW

PREVIOUS SCHOOL ATTENDANCE, IF AGE 5-24 YEARS:

19A. During the previous school year 2009-2010, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 20G)

19B. During the previous school year, what level and grade was (NAME) attending?

LEVEL _____
1 PRIMARY
2 INTERMEDIATE
3 SECONDARY
4 HIGHER
6 PRESCHOOL
8 DOESN'T KNOW
GRADE _____
98 DOESN'T KNOW

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?

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

20D. CHILDCARE FOR CHILDREN AGE 3-5 YEARS: During this school year, did (NAME) go to childcare outside of school like nursery school, a national childcare program [note: the document uses here the official name of the program, "Case des Tout Petits"], a community center, or other?

YES 1
NO 2 (GO TO 20G)
DOESN'T KNOW 8 (GO TO 20G)

20E. Where did (NAME) go?
RECORD THE APPROPRIATE CODE.

01 NURSERY SCHOOL
02 KINDERGARTEN
03 CASE DE TP [NOTE: THIS IS THE NATIONAL CHILDCARE PROGRAM]
04 PRIMARY SCHOOL
05 DAARA SCHOOL [NOTE: A TYPE OF KORANIC SCHOOL], KORANIC SCHOOL, ARABIC SCHOOL
06 COMMUNITY CENTER
96' DOESN'T KNOW

20F. For how many years?
RECORD THE APPROPRIATE CODE.

1 CURRENT YEAR
2 LAST YEAR
3 YEAR BEFORE
7 OTHER

WORK FOR CHILDREN AGE 5-17 YEARS:

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

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

YES, PAID (CASH, KIND) 1
YES, NOT PAID 2
NO WORK 3 (GO TO 20I)

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

NUMBER OF HOURS _____

20I. Since (DAY OF THE WEEK), did (NAME) do any household chores?
For example: shopping, cooking, cleaning, getting water, taking care of children, washing clothes…?

YES 1
NO 2 (GO TO 20K)

20J. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?
IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.

NUMBER OF HOURS_____

20K. Since (DAY OF THE WEEK), did (NAME) do any (other) work for the family (on the farm, in a shop, in a business)?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

20L. IF YES: Since (DAY OF THE WEEK), approximately how many hours did he/she spend doing this work?
ADD UP ALL THE HOURS.

NUMBER OF HOURS_____

HOUSEHOLD CHARACTERISTIC

101A. What is the occupation status of the dwelling for your household?

OWNER 01
CO-OWNER 02
RENTER TO BUYER 03
RENTER 04
CO-RENTER 05
SUBTENANT 06
LODGED BY EMPLOYER 07
FREE LODGING BY RELATIVE OR FRIEND 08

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED INTO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) _____ 96

103. Where is the water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES____
ON PREMISES 998

104A. Who usually goes to the water source to bring water to your household?

ADULT FEMALE (15 YEARS OR MORE) 1
ADULT MALE (15 YEARS OR MORE) 2
YOUNG GIRL (15 YEARS OR LESS) 3
YOUNG BOY (15 YEARS OR LESS) 4
DOESN'T KNOW 8

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

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

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
DOESN'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 PIT LATRINE 12
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
LATRINE WITH MANUAL FLUSH 22
PIT TOILET WITHOUT FLUSH 23
OTHER IMPROVED SYSTEM 24
TRADITIONAL LATRINE 25
NO FACILITY/BUSH/FIELD 31 (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 use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 _____

10 OR MORE HOUSEHOLDS 95
DOESN'T KNOW 98

110. Does your household have:

Electricity?
A radio?
A television?
A TV5 antenna?
A subscription to Canal?
A non-mobile telephone?
A mobile telephone?
A washing machine?
A refrigerator?
A portable stove/gas or electric stove?
An improved fireplace?
A CD/DVD player?
An air conditioner?
A computer?
Internet at home?

ELECTRICITY?
YES 1
NO 2
A RADIO?
YES 1
NO 2
A TELEVISION?
YES 1
NO 2
A TV5 ANTENNA?
YES 1
NO 2
A SUBSCRIPTION TO CANAL?
YES 1
NO 2
A NON-MOBILE TELEPHONE?
YES 1
NO 2
A MOBILE TELEPHONE?
YES 1
NO 2
A WASHING MACHINE?
YES 1
NO 2
A REFRIGERATOR?
YES 1
NO 2
A PORTABLE STOVE/GAS OR ELECTRIC STOVE?
YES 1
NO 2
AN IMPROVED FIREPLACE?
YES 1
NO 2
A CD/DVD PLAYER?
YES 1
NO 2
AN AIR CONDITIONER?
YES 1
NO 2
A COMPUTER?
YES 1
NO 2
INTERNET AT HOME?
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
WOOD COAL 03
WOOD/STRAW 04
ANIMAL DUNG 05
OTHER (SPECIFY) _____ 06

111A. What type of lighting does your household mainly use?

ELECTRICITY (SENELEC (NAME OF ELECTRIC COMPANY IN SENEGAL)) 01
GENERATOR 02
SOLAR 03
TORCH LAMP 04
GAS LAMP 05
HURRICANE LAMP 06
ARTISANAL OIL LAMP 07
CANDLE 08
WOOD 09
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/LEAVES 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
SHEET METAL 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
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 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?

NUMBER OF ROOMS_____

118. Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A personal car?
A commercial car or truck?
A cart?
A plow?
A canoe or fishing nets?

A BICYCLE?
YES 1
NO 2
A MOTORCYCLE OR MOTOR SCOOTER?
YES 1
NO 2
A PERSONAL CAR?
YES 1
NO 2
A COMMERCIAL CAR OR TRUCK?
YES 1
NO 2
A CART?
YES 1
NO 2
A PLOW?
YES 1
NO 2
A CANOE/OR FISHING NETS?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 121)

120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.

HECTARES_____

95 OF MORE HECTARES 950
DOESN'T KNOW 998

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

YES 1
NO 2 (GO TO 123)

122. How many of the following animals does this household own?
IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'.

Milk cows or bulls?
Camels?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Chickens?

NUMBER OF MILK COWS OR BULLS____
NUMBER OF CAMELS ____
NUMBER OF HORSES, DONKEYS, OR MULES____
NUMBER OF GOATS____
NUMBER OF SHEEP____
NUMBER OF PIGS____
NUMBER OF CHICKENS____

123. Does any member of this household have an account in a bank or in another financial institution (savings and credit union, savings bank)?

YES 1
NO 2
DOESN'T KNOW 8

123A. Does any member of your household participate in a tontine?

YES 1
NO 2
DOESN'T KNOW 8

123B. Does anyone smoke in your household?
Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

123C. In the last 6 months, have you heard any messages about malaria prevention?

YES 1
NO 2 (GO TO 124)
DOESN'T KNOW 8 (GO TO 124)

123D. What was in these messages?

SLEEP UNDER MOSQUITO NET A
EFFECTIVENESS OF ARTEMISININ-COMBINATION THERAPIES (ACT) B
DILIGENCE WITH TREATMENT C
IDENTIFICATION OF MALARIA SYMPTOMS D
DIAGNOSIS OF MALARIA E
SPRAYING IN DWELLING F
METHODS OF PREVENTION G
OTHER (SPECIFY) _____ X
DO NOT RECALL Z

124. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES 1
NO 2 (GO TO 125A)
DOESN'T KNOW 8 (GO TO 125A)

125. Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NON-GOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) _____ X
DOESN'T KNOW Y

125A. Are the windows of your living space equipped with wire netting to keep mosquitoes from entering?

YES 1
NO 2
DOESN'T KNOW 8

125B. Are the doors of your living space equipped with wire netting or curtains to keep mosquitoes from entering?

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2 (GO TO 127D)

127. How many mosquito nets does your household have?
IF 25 OR MORE NETS, RECORD '25'.

NUMBER OF NETS_____

127A. Do you use the mosquito nets outside of the bedrooms: for example, in the yard, under trees?

YES 1
NO 2

127B. Do members of your household always sleep under mosquito nets year round?

YES 1 (GO TO 128)
NO 2
DOESN'T KNOW/DOESN'T REMEMBER 8

127C. Why don't members of your household always sleep under mosquito nets year round?

NOT MANY MOSQUITOES 1 (GO TO 128)
BECAUSE OF THE HEAT 2 (GO TO 128)
DON'T LIKE IT 3 (GO TO 128)
FORGOT 4 (GO TO 128)
OTHER (SPECIFY)_____ 6 (GO TO 128)
DOESN'T KNOW/DOESN'T REMEMBER 8 (GO TO 128)

127D. Why do you not have any mosquito nets in your household?

DOESN'T HAVE THE MEANS A (GO TO 137)
NOT NECESSARY B (GO TO 137)
USES SOMETHING ELSE C (GO TO 137)
NO MOSQUITOES D (GO TO 137)
DOESN'T LIKE IT E (GO TO 137)
DOESN'T KNOW F (GO TO 137)
OTHER (SPECIFY) _____ X (GO TO 137)

[ASK QUESTIONS 128-136 FOR ALL MOSQUITO NETS]

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

OBSERVED 1
NOT OBSERVED 2

128A. OBSERVE OR ASK THE SHAPE OF THE MOSQUITO NET.

RECTANGLE 1
CIRCULAR/CONE-SHAPED 2
OTHER (SPECIFY) _____ 6

128B. OBSERVE OR ASK THE SIZE OF THE MOSQUITO NET.

1 SPACE 1
2 SPACES 2
3 SPACES 3
FOR A BABY 4

129. How many months ago did your household get the mosquito net?

MONTHS AGO____

37 MONTHS OR MORE 95
DOESN'T KNOW/NOT SURE 98

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

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
OLYSET-NET 12 (GO TO 134)
DAWA PLUS 13 (GO TO 134)
ICONLIFE 14 (GO TO 134)
OTHER (SPECIFY) _____ 16 (GO TO 134)
OTHER 'PRETREATED' NET
K-ONET 21 (GO TO 132)
NETTO 22 (GO TO 132)
SENTINELLE 23 (GO TO 132)
INTERCEPTOR 24 (GO TO 132)
OTHER (SPECIFY) ____ 26 (GO TO 132)
OTHER (SPECIFY) ____ 31
DOESN'T KNOW/UNSURE 98

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

YES 1
NO 2
DOESN'T KNOW/NOT SURE 8

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

YES 1
NO 2 (GO TO 134)
DOESN'T KNOW/NOT SURE 8 (GO TO 134)

133. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'. IF MORE THAN 2 YEARS, RECORD THE NUMBER OF MONTHS.

MONTHS AGO_____

MORE THAN 24 MONTHS AGO 95
NOT SURE/DOESN'T KNOW 98

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

YES 1
NO 2 (GO TO 136A)
DOESN'T KNOW 8 (GO TO 136A)

135. Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. RECORD ALL PERSONS WHO SLEPT UNDER EACH MOSQUITO NET LAST NIGHT.

NAME_____
LINE NUMBER_____

136A. In the last 12 months, for how many months did a member of your household sleep under this mosquito net?

MONTHS_____
NOT SURE/DOESN'T KNOW 98

136B. Was this mosquito net made in a factory or was it made by a tailor?

FACTORY MADE 1
TAILOR MADE 2
OTHER (SPECIFY) ____ 6
DOESN'T KNOW 8

136C. CHECK 134:

YES 1 (GO TO 136E)
NO/DOESN'T KNOW 2

136D. Why didn't anyone sleep under this mosquito net last night?
IF SEVERAL REASONS ARE MENTIONED, ASK AND RECORD THE MAIN REASON.

NO MOSQUITOES 1
HEAT 2
RIPPED 3
NO LONGER EFFECTIVE 4
OTHER (SPECIFY) _____ 6
DOESN'T KNOW 8

136E. Where did you get this mosquito net?

HEALTH ESTABLISHMENT 1
PRIVATE PHARMACY 2
OTHER BUSINESS 3
COMMUNITY ORGANIZATION 4
OTHER NON-BUSINESS 5
DISTRIBUTION CAMPAIGN 6
OTHER (SPECIFY) _____ 7
DOESN'T KNOW 8

136F. How was this mosquito net acquired?

PURCHASE WITHOUT COUPON 1
PURCHASE WITH COUPON 2
FREE 3 (GO TO 135H)
OTHER (SPECIFY) _____ 6 (GO TO 135H)
DOESN'T KNOW 8

136G. How much money did you pay to get this mosquito net?
RECORD IN CFA FRANCS.

PRICE_____
DOESN'T KNOW 9998

136H. CHECK 130 AND 132:
MIILDA OR OTHER TYPE OF MOSQUITO NET [NOTE: ACRONYM STANDS FOR A LONG-LASTING MOSQUITO NET WITH INSECTICIDE]
[Note: The original text had the two words as I transcribed them, MIILDA and MILDA, in their respective places. These questions were not on the standard questionnaire. Internet searches show that both terms are related to malaria prevention in French-speaking countries.]

Q130: MILDA (GO TO 136I a)
Q132: CODE '1' (GO TO 136I b)
Q132: CODES '2' OR '8' (GO TO 136I a)

136I-a. Was this mosquito net washed since you acquired it?

YES 1
NO 2 (GO TO 136)
DOESN'T KNOW/NOT SURE 8 (GO TO 136)

136I-b. Was this mosquito net washed since it was last soaked?

YES 1
NO 2 (GO TO 136)
DOESN'T KNOW/NOT SURE 8 (GO TO 136)

136J. How many times was this mosquito net washed in the last 12 months?

NUMBER OF WASHES_____
DOESN'T KNOW/NOT SURE 98

136K. How many months ago was this mosquito net last washed?
IF 12 MONTHS OR MORE, RECORD '12'.

NUMBER OF MONTHS_____
DOESN'T KNOW/NOT SURE 98

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 PLACE FOR HAND WASHING.

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 C

140. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE AND RECORD IN PPM (PARTS PER MILLION).

0 PPM (NO IODINE) 1
LESS THAN 15 PPM 2
15 PPM OR MORE 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED (SPECIFY REASON) ____ 6

140A. In the last three years, has your household been subjected to any traumatic event or shock?

YES 1
NO 2 (GO TO 201)

140B. What was the main traumatic event or shock in this household?

ILLNESS 01
DEATH 02
LOSS OF JOB/UNEMPLOYMENT 03
LOWERING OF WAGES/INCOMING INCOME 04
FLOOD/DROUGHT/LOSS OF HARVEST 05
CONFLICT/INSECURITY/THEFT OF LOSS OF LIVESTOCK 06
FIRE 07
LOSS OF MONEY 08
OTHER (SPECIFY) ____ 96

WEIGHT, HEIGHT, HEMOGLOBIN, AND PARASITEMIA/ANEMIA TESTS 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 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202. LINE NUMBER FROM COLUMN 10 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:

KG _____

NOT PRESENT 99.94
REFUSED 99.95
OTHER 99.96

206. HEIGHT IN CENTIMETERS:

CM_____

NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6

207. MEASURE LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208. CHECK 203:
IS THE 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, 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 NO. ____

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 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.

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

211. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/RESPONSIBLE ADULT REFUSED 2 (SIGN) _____

211A. ASK CONSENT FOR PARASITEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD:

As part of this survey, we are asking children under 6 years old all over the country to take a test to see if they have malaria. Malaria is a serious health problem that is caused by a parasite transmitted from mosquito bites. 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 malaria testing in this survey and give a few drops of blood from a finger (or a heel if the child is less than 6 months old). 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. A portion of the blood drops will be transported to the Laboratory for confirmation. The result will be kept strictly confidential.

Do you have any questions about the malaria test?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria test?

211B. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/RESPONSIBLE ADULT REFUSED 2 (SIGN) _____

[PERFORM EACH TEST FOR EACH CHILD FOR WHOM YOU OBTAINED CONSENT IN 211 AND 211B]

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

G/DL _____

NOT PRESENT 99.4
REFUSED 99.5
OTHER 99.6

212A. RECORD IF THE CHILD WAS TESTED FOR PARASITEMIA PALUDAL:

TESTED 1
NOT PRESENT 2 (GO TO 213)
REFUSED 3 (GO TO 213)
OTHER 6 (GO TO 213)

212B. RECORD THE RESULT CODE OF THE MALARIA TEST:

POSITIVE 1
NEGATIVE 2 (GO TO 212D)
OTHER 6 (GO TO 212D)

212C. READ THE INFORMATION FOR MALARIA TREATMENT AND THE CONSENT OF THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD:

AGREED 1 (SIGN) _____
REFUSED 2
NOT ELIGIBLE 3
OTHER 6

212D. ATTACH 1ST BAR CODE HERE.
ATTACH A BAR CODE ON EACH OF THE 2 STRIPES.
ATTACH ONE ON THE PARASITEMIA PALUDAL TEST (TDR).
ATTACH THE 5TH ON THE SAMPLE TRANSMISSION FORM.

213. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

TREATMENT OF CHILDREN WITH A POSITIVE PARASITEMIA PALUDAL TEST:

IF THE PARASITEMIA PALUDAL TEST IS POSITIVE: The diagnostic test for malaria shows that your child has malaria. We can offer you free medicine. This medicine is called ACT. ACT is very effective and should eliminate the fever and other symptoms in a few days. ACT is also very safe.

However, with all medications, there are side effects, and this medication might have some. The most common side effects are dizziness, fatigue, loss of appetite, palpitations. ACT should not be taken by people who have a serious heart problem or severe malaria (for example, cerebral malaria) or who have problem regulating body salt levels.

ASK IF THE MOTHER IS AWARE OF THE CHILD HAVING ANY OF THESE PROBLEMS. IF YES, DO NOT OFFER THEM ACT. EXPLAIN THE RISKS OF MALARIA AND REFER THE CHILD TO THE CLOSEST HEALTH ESTABLISHMENT.

You don't have to give the medicine to your child. It is your choice. Please tell me if you will take the medicine or not?

TREATMENT WITH ACT (FALCIMON):

WEIGHT (IN KG) -- APPROXIMATE AGE:

LESS THAN 10 KGS -- LESS THAN 1 YEAR:
DAY 1 (ONE DOSE): HALF TABLET ARTESUNATE/HALF TABLET AMODIAQUINE
DAY 2 (ONE DOSE): HALF TABLET ARTESUNATE/HALF TABLET AMODIAQUINE
DAY 3 (ONE DOSE): HALF TABLET ARTESUNATE/HALF TABLET AMODIAQUINE
10-20 KGS -- 1 TO 7 YEARS:
DAY 1 (ONE DOSE): ONE TABLET ARTESUNATE/ONE TABLET AMODIAQUINE
DAY 2 (ONE DOSE): ONE TABLET ARTESUNATE/ONE TABLET AMODIAQUINE
DAY 3 (ONE DOSE): ONE TABLET ARTESUNATE/ONE TABLET AMODIAQUINE

YOU ALSO MUST TELL THE PARENT/ADULT RESPONSIBLE FOR CHILD: If (NAME OF CHILD) has any of the following symptoms, you must immediately take him/her to a health care professional to receive care:

High fever
Convulsions, coma
Rapid breathing or difficulty breathing
Not able to drink or nurse
Gets sicker or doesn't improve in 2 days

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TEST 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.

LINE NUMBER_____
NAME_____

216. WEIGHT IN KILOGRAMS:

KG_____

NOT PRESENT 999.94
REFUSED 999.95
OTHER 999.96

217. HEIGHT IN CENTIMETERS:

CM_____

NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6

218. AGE:
CHECK COLUMN 7.

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

219. MARITAL STATUS:
CHECK COLUMN 8.

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

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

LINE NO. OF PARENT/OTHER RESPONSIBLE ADULT_____

221. ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE 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 member of our survey team.

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

222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

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

223. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than 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) ______ (GO TO 226)

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

YES 1
NO 2
DOESN'T KNOW 8

226. AGE:
CHECK COLUMN 7.

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

227. MARITAL STATUS:
CHECK COLUMN 8.

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

228. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN 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 Senegal

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know 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) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 239)

230. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (country).

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know her HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (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 AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 239)
INTERVIEWER NUMBER _____

232. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 236)

233. MARITAL STATUS:
CHECK COLUMN 8.

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 236)

234. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

235. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 238)

236. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

237. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 239)

238. ADDITIONAL TESTS:
CHECK 235 AND 237: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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 99.4
REFUSED 99.5
OTHER 99.6

241. BAR CODE LABEL.
PUT THE 1ST BAR CODE HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

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

244. LINE NUMBER FROM COLUMN 10.
NAME FROM COLUMN 2.

LINE NUMBER_____
NAME_____

245. WEIGHT IN KILOGRAMS:

KG_____

NOT PRESENT 999.94
REFUSED 999.95
OTHER 999.96

246. HEIGHT IN CENTIMETERS:

CM_____

NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6

247. AGE:
CHECK COLUMN 7.

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

248. MARITAL STATUS:
CHECK COLUMN 8.

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

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT_____

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

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than 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?

251. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 256)

252. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than 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 in the anemia test?

253. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____

254. AGE:
CHECK COLUMN 7.

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

255. MARITAL STATUS:
CHECK COLUMN 8.

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

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

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Senegal.

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

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

257. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 267)

258. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (NAME OF COUNTRY).

For the HIV test, we need a few more drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know your HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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

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

GRANTED 1 (SIGN) ______
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 267)
INTERVIEWER CODE _____

260. AGE:
CHECK COLUMN 247.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 264)

261. MARITAL STATUS:
CHECK COLUMN 248.

CODE '4' (NEVER IN UNION) 1
OTHER 2 (GO TO 264)

262. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

263. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____ (GO TO 266)

264. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

265. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 267)

266. ADDITIONAL TESTS: CHECK 263 AND 265:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

268. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

G/DL_____

NOT PRESENT 99.4
REFUSED 99.5
OTHER 99.6

269. BAR CODE LABEL:
PUT THE 1ST BAR CODE HERE. PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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