IDENTIFICATION

PLACE NAME________

NAME OF HEAD OF HOUSEHOLD___________

HOUSEHOLD NUMBER___________

PLOT NUMBER_______

CLUSTER NUMBER_________

REGION________

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE__________
INTERVIEWER'S NAME____________
RESULT*_______

RESULT*

NEXT VISIT______ (FOR INTERVIEWERS 1 AND 2)
DATE_______
TIME______

FINAL VISIT
DAY____________
MONTH___________
YEAR 201__
INT. NUMBER__________
CODE RESULT__________

TOTAL NO. OF VISITS________

TOTAL PERSONS IN HOUSEHOLD__________
TOTAL ELIGIBLE WOMEN___________
TOTAL ELIGIBLE MEN_____________

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE________

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, 2B, 2C TO BE SURE THAT THE LISTING IS COMPLETE.

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

2A) Just to make sure that I have a complete listing:
Are there any other persons such as small children or infants that we have not listed?

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?

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?

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

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

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

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-59

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 (2013-2014) 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 UNDER 5 YEARS (0-59 MONTHS): Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

[##translator note: questions 1-20 repeated for line numbers 11-20 to accommodate larger households]

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?
RECORD APPROPRIATE CODE

20F) For how many years?
RECORD APPROPRIATE CODE

SELECTION TABLE FOR CHILDREN'S WORK

20G) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 5 AND 17 YEARS OLD LIVING IN THIS HOUSEHOLD:

TABLE 1: ELIGIBLE CHILDREN AGE 5-17 FOR QUESTIONS ON CHILDREN'S "WORK"

RECORD EACH CHILD AGE 5-17 FROM THE HOUSEHOLD TABLE IN THE TABLE BELOW, IN THE SAME ORDER AS ON THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS WHO ARE NOT AGE 5-17. RECORD THE LINE NUMBER, NAME, SEX AND AGE OF EACH CHILD, THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 5-17 IN THE RESERVED SPACE. (Q.20M)

20H)RANK NUMBER

20I) LINE NUMBER FROM Q. 1

20J) NAME FROM Q. 2

20K) SEX FROM Q. 4

20L) AGE FROM Q. 7

20M) TOTAL NUMBER OF CHILDREN AGE 5-17

TABLE 2: RANDOM SELECTION FOR QUESTIONS ON "WORK"

USE THIS TABLE TO SELECT ONE CHILDREN AGE 5-17.
a) TAKE THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE OF THE QUESTIONNAIRE.
B) THIS IS THE NUMBER OF THE LINE TO SELECT.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN IN Q.20M.
D) THIS IS THE NUMBER OF THE COLUMN TO SELECT
E) FIND THE SPACE WHERE THE SELECTED LINE AND COLUMN MEET AND CIRCLE THAT NUMBER.
F) THIS IS THE RANK NUMBER OF THE CHILD WHO WILL BE SELECTED FOR "WORK"

EXAMPLE:
THE HOUSEHOLD NUMBER IS 36, SO PICK LINE 6.
THERE ARE 3 ELIGIBLE CHILDREN IN THIS HOUSEHOLD, SELECT COLUMN 3.
THE SPACE AT THE INTERSECTION OF LINE 6 AND COLUMN 3 CONTAINS THE NUMBER 2: THE 2ND ELIGIBLE CHILD LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED. IF THE LINE NUMBER OF 3 ELIGIBLE CHILDREN IS 07, 11, AND 16, THE CHILD SELECTED IS THE 2ND CHILD LISTED, MEANING THE ONE WITH LINE NUMBER 11.

20n) LAST DIGIT IN HOUSEHOLD NUMBER 0-9

TOTAL NUMBER OF ELIGIBLE CHILDREN IN HOUSEHOLD 1-8+

20o) RECORD THE RANK (Q20H), THE LINE NUMBER (Q 20I), THE NAME (Q20J), AND AGE (Q20L) OF THE CHILD SELECTED

WORK OF CHILDREN

20p) Now I would like to talk about all the work that the children of this household can do.

Since last (DAY OF THE WEEK), did (NAME) do any of the following activities, even if only for one hour?

a) Did (NAME) work on his/her own land/farm/garden or help with the household land/farm/garden or take care of animals. For example: grow farm products, harvest them, feed animals, take them to pasture or milk them?

b) Did (name) help with a family business, the business of other relatives with or without payment or work in his/her own business?

c) Did (name) produce, sell goods, artisanal products, cloths, food, or agricultural products?

d) Since last (day of week), did (NAME) engage in any other type of activity in exchange for payment either in case or in kind, even if for only one hour?

IF NO, PROBE:
Please include any type of activity that (NAME) might have done as regular or temporary employment, for his/her own business or as an employer, or as an unpaid family worker to help with household or farm tasks.

20Q) CHECK 20 [A] TO [D]:

20R) Since last (DAY OF WEEK), approximately how many hours in total did (NAME) work doing (this activity/these activities)?
IF LESS THAN ONE HOUR, RECORD 00

20S) Does/Do (this activity/these activities) require carrying heaving loads?

20T) Does/Do (this activity/these activities) require working with dangerous tools (knives, etc) or operating heavy machinery?

20U) How would you describe (NAME)'s work environment?

20V) Since last (DAY OF WEEK), did (NAME) fetch water or firewood for the household?

20W) In total, since last (DAY OF WEEK), how many hours did (NAME) spend fetching water or firewood for the household?
IF LESS THAN ONE HOUR, RECORD 00

20X) Since last (DAY OF WEEK), did (NAME) do any of the following tasks for the household?

20Y) CHECK 20W [A] TO [G]:

20Z) Since last (DAY OF WEEK), about how many hours in total did (NAME) spend doing these activities?
IF LESS THAN ONE HOUR, RECORD 00

PREVALENCE OF CHRONIC ILLNESS AND DANGEROUS PRACTICES

21) I would like to ask you some questions about the health of the members of your household. Does (NAME) suffer from any type of chronic illness?

22) What illness does (NAME) have?
RECORD THE NAME OF THE ILLNESS AND THE CODE.

23) Did a doctor inform (NAME) that he/she has this illness?

24) Does (NAME) receive regular treatment?

25) Does (NAME) have any other chronic illness?

26)What is the second illness that (NAME) has?
RECORD THE NAME OF THE SECOND ILLNESS AND ITS CODE.

27) Did a doctor inform (NAME) that he/she has this second illness?

RISKY BEHAVIOR DURING THE LAST 10 YEARS OR MORE IF 15 YEARS OR OLDER:

28) Does (NAME) smoke cigarettes or any other type of tobacco, or did he/she smoke in the past?

29) Does (NAME) drink alcohol?

DISABILITY MODULE

30) Does (NAME) have any type of physical, mental or other state dating 6 months or more that limit his/her normal daily activities, activities that could be completed by a person of the same age.

IF YES, ASK THE QUESTION: Does this state severely limit the daily activities of his/her life, or does it cause only minor limitations?

31) Does (NAME) have low or weak functioning in any of the following areas:
CIRCLE ALL FUNCTIONS MENTIONED

32) What is the main cause of the incapacity?

33) How old was (NAME) when this current state began?

34) In the last 12 months, did (NAME) receive any treatment or support?
WITH THE EXCEPTION OF Y, CIRCLE ALL CODES MENTIONED

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?

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

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

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 usable mosquito nets 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
ENTER NUMBERS OF MONTHS

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

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.
RECORD THE NUMBER OF MONTHS

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

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 not longer there?

136B) How many?

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

137A) When do members of your household most often wash their hands?

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE WHERE HOUSEHOLD MEMBERS WASH THEIR HANDS.

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 the in your household?

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

WEIGHT, HEIGHT, ANEMIA AND MALARIA TESTING 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 3 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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 date of birth?

204) CHECK 203:
CHILD BORN IN JANUARY 2009 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS
IF LESS THAN 2 YEARS, MEASURE CHILD LYING DOWN, IF NOT, STANDING UP.

207) MEASURED LYING DOWN OR STANDING UP?

208) CHECK 203:
IS 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 TABLE 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 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 and set up programs to prevent and treat anemia.

We ask that all children born in 2009 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 2009 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 TEXTS THAT YOU GOT CONSENT 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 PACKET.

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 shows that (NAME OF CHILD) has severe anemia. You child is seriously ill and needs to 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:
HEMOGLOBIN LEVEL

224) REFERENCE DECLARATION FOR SERIOUS MALARIA

The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. You 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 needs to 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 [##translator note: 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 a nearby 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)

CHILD AGE 1-5 YEARS OR 8-17 KGS: 50 MG TABLET OF ARTESUNATE AND 135 MG OF AMODIAQUINE (PURPLE STRIPED BROCHURE)

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 will bring 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 QUESTIONNAIRES(S); IF THERE ARE NO MORE, END THE INTERVIEW.

[##translator note: questions 202-232 repeated for child 4-6]