Republic of Senegal
Ministry of the Economy and of Finance
Ministry of Health and Social Action

ICF International

Identification

PLACE NAME___________
NAME OF HEAD OF HOUSEHOLD__________
HOUSEHOLD NUMBER_________
PLOT NUMBER_________
CLUSTER NUMBER______
REGION___________

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

INTERVIEWER VISITS

DATE____________

INTERVIEWER'S NAME_____________
RESULT___

RESULT______

FINAL VISIT
DAY
MONTH
YEAR 201__
INTERVIEW NUMBER_________
RESULT_______

NEXT VISIT
DATE________
TIME_________

TOTAL NO. OF VISITS____________

TOTAL PERSONS IN HOUSEHOLD________
TOTAL ELIGIBLE WOMEN_________

LINE NO. OF RESPONDENT TO HOUSEHOLD QUEST____

SUPERVISOR__________
NAME________
DATE_______

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Agency of Statistics and Demography, in collaboration with the Ministry of Health and of Social Action. 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________

HOUSEHOLD SCHEDULE

1) LINE NO.

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

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

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

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)?

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

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

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?

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

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

15) Does (NAME)'s natural father 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.

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

16) Has (NAME) ever attended school?

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

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

18) Did (NAME) attend school at any time during the (2011-2012) school year? (2)

19) During this/that school year, what level and grade (IS/WAS) (NAME) attending?

PREVIOUS SCHOOL ATTENDANCE

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

19b) During the previous school year, what level and grade was (name) attending?

20) BIRTH REGISTRATION IF AGE 0-4 YEARS: Does (NAME) have a birth certificate?

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

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?

2B) In addition, are there any other people who many not be members of your family, such as domestic servants, lodgers or friends who usually live here?

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

CHILDCARE OF CHILDREN AGE 3-5

20D) During this school year, did (NAME) go to a care facility outside of the home, such as nursery school, Case des Tout Petits (national childcare facility), a community center, or other?

20E) What establishment did (name) go to?

20F) FOR HOW MANY YEARS?

WORK OF 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: Should he/she have been paid?

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.

20I) Since (DAY OF THE WEEK), did (NAME) help with any household chores? For example, shopping, cooking, cleaning, getting water, childcare, washing clothes, etc.?

20J) 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 WORK HOURS.

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

20L) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing this work?

ADD TOTAL NUMBER OF HOURS

HOUSEHOLD CHARACTERISTICS

101A) What is the occupational status your household's dwelling?

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

103) Where is the water source located?

104A) Who usually goes to this source to get water for your household?

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

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

106) What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED

107) What kind of toilet facility do members of your household usually use?

108) Do you share this toilet facility with other households?

109) How many households use this toilet facility?

110) Does your household have:

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

111A) What is the main source of lighting for your household?

112) Is the cooking usually done in the house, in a separate building, or outdoors?

113) Do you have a separate room which is used as a kitchen?

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

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

118) Does any member of your household own:

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

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

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

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

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

123a) Does any member of this household have a tontine?

123b) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

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

125) Who sprayed the dwelling?

125A) Were the windows in the rooms in use equipped with wire netting to prevent mosquitoes from entering?

125B) Were the doors in the rooms in use equipped with wire netting to prevent mosquitoes from entering?

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

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

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

127B) Do members of your household sleep under the mosquito nets continuously throughout the year?

127C) Why do members of your household not sleep under the mosquito nets continuously throughout the year?

127D) Why are there no mosquito nets that could be used in your household?

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).

129) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00

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

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

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

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

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

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

135a) Was the net modified after have been obtained?

135b) CHECK 134:

135c) Why did no one sleep under this mosquito net last night?
IF SEVERAL REASONS ARE MENTIONED, ASK AND RECORD THE MAIN ONE.

135d) Where did you get this mosquito net?

135e) How much did you pay for the mosquito net?
RECORD IN CFA FRANCS

135f) CHECK 130 AND 132:
MIILDA OR OTHER TYPE OF MOSQUITO NET
Q. 130: MIILDA: (GO TO 135G a-)
Q. 132: CODE 1: (GO TO 135G b-)
Q. 132: CODES 2 OR 8: (GO TO 135G a-)

135g) a--Has this mosquito net been washed since you obtained it?
b--Has this mosquito net been washed since it was last soaked?

135h) How many times has this mosquito net been washed in the last 12 months?

135i) Have you ever used this mosquito net for any purpose other than for sleeping?

135j) What are these other purposes?

135k) Have you ever tried to fix a hole in this mosquito net?

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

136a) In the last 12 months, have there been any mosquito nets in the household that are no longer there?

136b) How many?

Note (1): You can find one of the following mentions on mosquito nets:
A) Long-lasting insecticide-treated net (LLIN)
1) Permanet: Permanet, www.permanet.com, www.vestergard-frandsen.com;
2) Olysetnet: Olyset Net, Registered Trademark of Sumitomo chemical Co. ltd;
3) Dawa Plus: Dawa, Dawa Plus, Tana Netting Co Ltd By Siamdutch;
4) Iconlife: Iconlife, Insecticide Treated net Syngenta.
5) Interceptor: BASF the Cemical company LLIN

B) other soaked mosquito nets:
1) K-O Net: Siamdutch, Mosquito Netting Co Ltd;
2) Netto: Netto Extra Treated Net;
3) Sentinelle: Sentinelle, Soaked mosquito net

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

138) OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HAND WASHING.

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

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

140A) In the last three years, has there been any event that affected life in your household?

140B) What was the main event for your household?

WEIGHT, HEIGHT, ANEMIA AND MALARIA TESTS FOR CHILDREN AGE 0-5

201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202 IN ORDER ACCORDING TO LINE NUMBER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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

204) CHECK 203:
CHILD BORN IN JANUARY 2007 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

208) CHECK 203:
IS THE CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

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

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

As part of this survey, we are asking children 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 and set up programs to prevent and treat anemia.

We ask that all children born in 2007 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 member 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) to participate in the anemia test?

211) Circle the appropriate code and sign your name.

212) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE 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 a malaria test. Malaria is a serious health problem caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop and set up programs to prevent and treat malaria.

We ask that all children born in 2007 or later take part in malaria 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. (We will use the blood from the anemia 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 member 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) to participate in the malaria test?

213) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

214) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) THAT YOU GOT CONTENT FOR AND CONTINUE WITH THE TESTS.

215) BAR CODE LABEL FOR MALARIA TEST
PUT THE 1ST BAR CODE LABEL HERE

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

216) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA AND MALARIA PAMPHLET.

217) RECORD TDR MALARIA RESULT CODE [TDR=Rapid Diagnostic Test]

218) RECORD TDR MALARIA RESULT CODE HERE AND IN ANEMIA AND MALARIA PAMPHLET.

219) CHECK 216:
HEMOGLOBIN LEVEL

220) REFERENCE DECLARATION FOR SEVERE ANEMIA
The anemia diagnostic test show that (NAME OF CHILD) has severe anemia. Your child is seriously ill and must be taken to a health care establishment immediately.
(GO TO 232)

221) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms:
IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y

222) CHECK 221:
IS A CODE A-H CIRCLED

223) CHECK 216:

224) REFERENCE DECLARATION FOR SERIOUS MALARIA

The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. Your child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. You child is seriously ill and must be taken to a health care establishment immediately.
(GO TO 231)

225) In the last two weeks, has (NAME) taken or is (NAME) taking CTA (CTA IS AN ANTIMALARIAL DRUG, COMBINATION THERAPY) given to him/her by a doctor or health care establishment to treat malaria?
CHECK BY ASKING TO SEE THE TREATMENT

226) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.
You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment for further testing.
(GO TO 231)

227) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.
The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

228) CIRCLE THE APPROPRIATE CODE AND SIGN.

230) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST

Child less than one year old or less than 8 kgs.
25 mg tablet of Artesunate and 67.5 mg of Amodiaquine (Rose striped brochure)

Day 1 (1 tablet) ____________

Day 2 (1 tablet) ____________

Day 3 (1 tablet) ____________

Child age 1-5 years or 8-17 kgs.
50 mg tablet of Artesunate and 135 mg of Amodiaquine (Purple striped brochure)

Day 1 (1 tablet) ____________
Day 2 (1 tablet) ____________
Day 3 (1 tablet) ____________

TELL THE PARENTS/ADULT RESPONSIBLE FOR CHILD: IF (NAME) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you must take him/her to a health professional for treatment immediately.

231) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET

232) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, END THE INTERVIEW.