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CONTINUED DEMOGRAPHIC AND HEALTH SURVEY (EDS-CONTINUED 2012-2013)
HOUSEHOLD QUESTIONNAIRE

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

URBAN 1
RURAL 2

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

DAKAR 1
REGIONAL CAPITAL 2
OTHER CITY 3
RURAL 4

INTERVIEWER 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)

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________

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END

HOUSEHOLD SCHEDULE

1) LINE NO.

__________

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

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

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

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
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)?

IN YEARS______
IF 95 OR MORE, RECORD 95

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

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

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?

YES 1(GO TO 13)
NO 2 (GO TO 14)
DK 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

MOTHER'S LINE NO.____________

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

YES 1(GO TO 15)
NO 2 (GO TO 16)
DK 8 (GO TO 16)

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.

FATHER'S LINE NO.__________

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

16) Has (NAME) ever attended school?

YES 1(GO TO 7)
NO 2 (GO TO 20G)

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 MID-LEVEL
2 SECONDARY
3 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE________
00 LESS THAN 1 YEAR COMPLETED
98 DON'T KNOW

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

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

YES 1
NO 2 (GO TO 19a)

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

LEVEL________
1 PRIMARY
2 MID-LEVEL
2 SECONDARY
3 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE_______
98 DON'T KNOW

PREVIOUS SCHOOL ATTENDANCE

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

YES 1
NO 2 (GO TO 20G)

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

LEVEL______
1 PRIMARY
2 MID-LEVEL
2 SECONDARY
3 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE_____
98 DON'T KNOW

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?

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

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 each in table
NO

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?

YES Add each in 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 each in table
NO

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?

YES 1
NO 2 (GO TO 20G)
DK 8 (GO TO 20G)

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

01 NURSERY SCHOOL (EDUCATIONAL)
02 NURSERY SCHOOL (NON-EDUCATIONAL)
03 PRIMARY SCHOOL
04 DAARA, KORAN, ARAB (RELIGIOUS SCHOOL, ISLAM)
05 COMMUNITY CENTER
96 OTHER

20F) FOR HOW MANY YEARS?

1 CURRENT YEAR ONLY
2 SINCE LAST YEAR
3 SINCE YEAR BEFORE LAST
7 OTHER

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?

1 YES, PAID WORK (CASH, KIND)
2 YES, UNPAID WORK
3 NO WORK (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) help with any household chores? For example, shopping, cooking, cleaning, getting water, childcare, washing clothes, etc.?

YES 1
NO 2 (GO TO 20K)

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.

NUMBER OF HOURS _____

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

YES 1 (NEXT LINE)
NO 2 (NEXT LINE)

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

ADD TOTAL NUMBER OF HOURS

NUMBER OF HOURS ____

HOUSEHOLD CHARACTERISTICS

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

OWNER 01
CO-OWNER 02
RENT-TO-OWN 03
RENTER 04
CO-RENTER 05
SUBTENANT 06
HOUSED BY EMPLOYER 07
HOUSED FREE OF CHARGE 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 BOREHOLD 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/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER/INDUSTRIALIZED BAG 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

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

ADULT WOMAN (15 YEARS OR OLDER) 1
ADULT MAN (15 YEARS OR OLDER) 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
DON'T KNOW 8

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

MINUTES_____________
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 107)
DK 8 (GO TO 107)

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

A BOIL
B ADD BLEACH/CHLORINE
C STRAIN THROUGH A CLOTH
D USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.)
E SOLAR DISINFECTION
F LET IT STAND AND SETTLE
X OTHER (SPECIFY) ______
Z DON'T KNOW Z

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

FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO PIT 12
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH MANUAL FLUSH 22
PIT LATRINE WITHOUT FLUSH 23
OTHER IMPROVED TRADITIONAL LATRINE SYSTEM 24
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
DON'T KNOW 98

110) Does your household have:

ELECTRICITY?
YES 1
NO 2
A RADIO?
YES 1
NO 2
A TELEVISION?
YES 1
NO 2
A MMDS/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 1
LPG 2
WOOD COAL 3
WOOD, STRAW 4
ANIMAL DUNG 5
OTHER (SPECIFY) 6

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

ELECTRICITY (SENELEC [NATIONAL ELECTRIC COMPANY]) 01
GENERATOR 02
SOLAR 03
FLASHLIGHT 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 WAXED WOOD 31
VINYL/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) _____ 96

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS/LEAVES 12
SOD 13
RUDIMENTARY MATERIAL
MAT 21
WOOD 22
PALM/BAMBOO 23
CARDBOARD 24
FINISHED FLOOR
SHEET METAL 31
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
SHINGLES 36
OTHER (SPECIFY)_________ 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
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?

ROOMS _____

118) Does any member of your household own:

A BICYCLE?
YES 1
NO 2
A MOTORCYCLE OR MOTOR SCOOTER?
YES 1
NO 2
A PERSONAL CARE?
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 120)

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
DON'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? __________________
POULTRY? ________________

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…)?

YES 1
NO 2
DK 8

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

YES 1
NO 2
DK 8

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

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

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)
DK 8 (GO TO 125A)

125) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) ________ X
DON'T KNOW Z

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'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 mosquito nets outside of the bedrooms: for example, in the yard, under trees?

YES 1
NO 2

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

YES 1
NO 2
DK/DON'T RECALL (GO TO 128)

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

NOT MANY MOSQUITOES 1 (GO TO 128)
BECAUSE OF THE HEAT 2 (GO TO 128)
DON'T LIKE 3 (GO TO 128)
FORGOT/NEGLIGENCE 4 (GO TO 128)
OTHER (SPECIFY) ____________ 6 (GO TO 128)
DK/DON'T RECALL 8 (GO TO 128)

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

CAN'T AFFORD THEM A (GO TO 136A)
NOT NECESSARY B (GO TO 136A)
USE SOMETHING ELSE C (GO TO 136A)
NO MOSQUITOS D (GO TO 136A)
DON'T LIKE THEM E (GO TO 136A)
OTHER (SPECIFY) __________ X (GO TO 136A)
DON'T KNOW Y (GO TO 136A)

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

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 11 (GO TO 134)
OLYSET-NET 12 (GO TO 134)
DAWA PLUS 13(GO TO 134)
ICONLIFE 14 (GO TO 134)
INTERCEPTOR 15(GO TO 134)
OTHER (SPECIFY) 16 (GO TO 134)
OTHER TREATED MOSQUITO NET
K-ONET 21 (GO TO 132)
NETTO 22 (GO TO 132)
SENTINELLE 23 (GO TO 132)
OTHER (SPECIFY) __________ 26 (GO TO 132)
MADE BY A TAILOR 30
OTHER (SPECIFY) _________ 31
DK BRAND 98

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

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 mosquitoes?

YES 1
NO 2 (GO TO 134)
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.

MONTHS AGO ___________

MORE THAN 24 MONTHS AGO 95
NOT SURE 98

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

YES 1
NO 2 (GO TO 135A)
DK 8 (GO TO 135A)

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.

NAME ____________
LINE NUMBER _____________

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

YES 1
NO 2
DK 8

135b) CHECK 134:

YES 1 (GO TO 135D)
NO/DK 2

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

NO MOSQUITOES 1
HEAT 2
TORN 3
NOT EFFECTIVE 4
OTHER (SPECIFY) _______ 6
DON'T KNOW 8

135d) Where did you get this mosquito net?

HEALTH STRUCTURE 1
PRIVATE PHARMACY 2
OTHER BUSINESS 3
OCB [LOCAL HEALTH NETWORK]/ASSOCIATIONS 4
OTHER NON-COMMERCIAL 5
DISTRIBUTION CAMPAIGN 6
OTHER (SPECIFY) _________ 7
DON'T KNOW 8

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

PRICE ___________
DON'T KNOW 9998

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?

YES 1
NO 2 (GO TO 135I)
DON'T KNOW/UNSURE 8 (GO TO 135I)

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

NUMBER OF WASHES ____________
DK/UNSURE 98

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

YES 1
NO 2 (GO TO 135K)
UNSURE/DK 8 (GO TO 135K)

135j) What are these other purposes?

TO PROTECT HARVEST/PLANTS A
FOR FISHING B
ON MATTRESSES TO PROTECT AGAINST BED BUGS C
CLOTHING D
OTHER (SPECIFY) X

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

YES 1
NO 2
DK/UNSURE 8

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?

YES 1
NO 2 (GO TO 137)
UNSURE/DK 8 (GO TO 137)

136b) How many?

NUMBER____________

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.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 142)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 142)
NOT OBSERVED, OTHER REASON 4 (GO TO 142)

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.

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

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

YES 1
NO 2 (GO TO 201)

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

ILLNESS 01
DEATH 02
LOSS OF EMPLOYMENT/UNEMPLOYED 03
LOWERED REVENUE/REMITTANCE RECEIVED 04
FLOOD/DRAUGHT/LOSS OF HARVEST 05
CONFLICT/INSECURITY/THEFT OR LOSS OF LIVESTOCK 06
FIRE 07
LOSS OF MONEY 08
OTHER (SPECIFY) 96

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

LINE NUMBER ___________
NAME _______________

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?

DAY ___________
MONTH ____________
YEAR ____________

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

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

205) WEIGHT IN KILOGRAMS

KG ____________

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CM _____________

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 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 OR, IF NO MORE CHILDREN, END INTERVIEW)
OLDER 2

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

LINE NUMBER ______________

210) ASK CONSENT FOR ANEMIA TEST 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.

GRANTED 1 (SIGN______________)
REFUSED 2 (SIGN______________)
NOT PRESENT 5
OTHER 6

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.

GRANTED 1 (SIGN____________)
REFUSED 2 (SIGN____________)
NOT PRESENT 5
OTHER 6

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

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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.

G/DL___________

NOT PRESENT 994
REFUSED 995
OTHER 996

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

TESTED 1 (GO TO 219)
NOT PRESENT 2 (GO TO 219)
REFUSED 3 (GO TO 219)
OTHER 6 (GO TO 219)

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

POSITIVE FALCIPARUM 1
POSITIVE ESPECES (OMV) 2
POSITIVE P (F AND OMV) 3
ALL SKIP TO 221
NEGATIVE 4
OTHER 6

219) CHECK 216:
HEMOGLOBIN LEVEL

BELOW 8.0 G/DL SEVERE ANEMIA 1
8.0 G/DL OR HIGHER 2 (GO TO 232)
NOT PRESENT 4 (GO TO 232)
REFUSED 5 (GO TO 232)
OTHER 6 (GO TO 232)

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

EXTREME WEAKNESS? A
HEART PROBLEMS? B
LOSS OF CONSCIOUSNESS? C
RAPID OR DIFFICULTY BREATHING? D
CONVULSIONS? E
ABNORMAL BLEEDING? F
JAUNDICE/YELLOW SKIN? G
DARK URINE? H
NONE OF ABOVE SYMPTOMS Y

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

ONE CODE A-H CIRCLED 1 (GO TO 224)
ONLY CODE Y CIRCLED 2

223) CHECK 216:

HEMOGLOBIN LEVEL UNDER 6.0 G/DL 1
6.0 D/DL OR HIGHER 2 (GO TO 225)
NOT PRESENT 4 (GO TO 225)
REFUSED 5 (GO TO 225)
OTHER 6 (GO TO 225)

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

YES 1
NO 2 (GO TO 227)

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.

DRUG ACCEPTED 1 (SIGNATURE____________)
REFUSED 2 (GO TO 231)
OTHER 6 (GO TO 231)

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

DRUG GIVEN 1
DRUG REFUSED 2
REFERRED FOR SEVERE MALARIA 3
REFERRED BECAUSE CHILD ALREADY TOOK CTA 4
OTHER 6

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.