IDENTIFICATION

REGION NAME __________
LOCALITY NAME (NEIGHBORHOOD/VILLAGE) ______
NAME OF HEAD OF HOUSEHOLD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER (URBAN=01 TO 25; RURAL=01 TO 30)_____
HOUSEHOLD NUMBER (SEQUENTIAL IN THE CLUSTER)_____
URBAN/RURAL (URBAN=1, RURAL=2)

N'DJAMENA-MOUNDOU/SARH/ABECHE-OTHER CITY-RURAL (N'DJAMENA=1, MOUNDOU/SARH/ABECHE=2, OTHER CITY=3, RURAL=4)

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: HOUSEHOLD WAS SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST?

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY__ __
MONTH__ __
YEAR 201__
INT. NUMBER
CODE RESULT

NEXT VISIT
DATE____
TIME____

TOTAL NO. OF VISITS

*RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NO. OF RESP. TO HOUSEHOLD QUEST.

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, Economic and Demographic Studies (INSEED). We are conducting a survey about health all over Chad. 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

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 HOUSEHOLD HEAD
What is the relationship of (name) to the head of the household?
SEE CODES BELOW.

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.

IF AGE 15 OR OLDER

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

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

10) CHECK COVER PAGE. IF HOUSEHOLD SELECTED FOR MEN'S SURVEY=1 (YES)
CIRCLE LINE NUMBER OF ALL MEN 15-49

11) CHECK COVER PAGE. IF HOUSEHOLD SELECTED FOR MEN'S SURVEY=2 (NO)
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

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.

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

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

IF AGE 5-24 YEARS

Current/recent school attendance

18) Did (NAME) attend school at any time during the (2009-2010) school year? (2)

19) During this/that school year, what level and grade (is/was) (name) attending?
SEE CODES BELOW.

GRADE
PRIMARY:


01=CP1
02=CP2
03=CE1
04=CE2
05=CM1
06=CM2
98=DON'T KNOW


SECONDARY


01=6TH
02=5TH
03=4TH
04=3RD
05=SECOND
06=1ST
07=FINAL
98=DON'T KNOW


SECONDARY TECHNICAL


01=1ST YEAR
02=2ND YEAR
03=3RD YEAR
04=4TH YEAR
05=5TH YEAR
06=6TH YEAR
07=7TH YEAR OR HIGHER
98=DON'T KNOW


SECONDARY PROFESSIONAL


01=6TH OR 1ST YEAR
02=5TH OR 2ND YEAR
03=4TH OR 3RD YEAR
04=3RD OR 4TH YEAR
05=SECOND OR 5TH YEAR
06=1ST OR 6TH YEAR
07=FINAL OR 7TH YEAR
98=DON'T KNOW


HIGHER


01=1ST YEAR
02=2ND YEAR
03=3RD YEAR
04=4TH YEAR
05=5TH YEAR
06=6TH YEAR
07=7TH YEAR OR HIGHER
98=DON'T KNOW


HIGHER PROFESSIONAL


01=1ST YEAR
02=2ND YEAR
03=3RD YEAR
04=4TH YEAR
05=5TH YEAR
06=6TH YEAR OR HIGHER
98=DON'T KNOW

IF AGE 0-4 YEARS

BIRTH REGISTRATION

20) Does (NAME) have a birth certificate?
IF YES: May I see it?

IF NO CERTIFICATE/DON'T KNOW: Has (NAME)'s birth ever been registered with the civil authority?

TICK HERE IF CONTINUATION SHEET USED
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?

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

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

102a) What is the main source of water for things like cooking and hand washing?

103) Where is the water source located?

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?

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 THE 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?

123A) Ask respondent for a teaspoonful of cooking salt.
TEST SALT FOR IODINE.

123B) CHECK THE COVER OF THE QUESTIONNAIRE: HOUSEHOLD SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST?

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?

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

127) How many mosquito nets does your household have?
If 7 or more nets, record 7.

128) ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
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.

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.

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

136A) FILTER
CHECK Q 131 ALL COLUMNS

136b) When you received your soaked mosquito net, did you receive any advice?

136c) What advice/information did you receive?
PROBE: What else?

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 HANDWASHING.

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

4-HANDICAP
(ONLY IN THE HOUSEHOLD NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

201) Now I would like to ask some questions about the health of each person usually living in your household, including small children.

Is there anyone in your household who is missing a body part, for example, a hand, an arm, a foot, or a leg?
IF YES: Can you give me the names of these individuals?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WHO IS MISSING A BODY PART. ASK Q. 203 ABOUT THE 1ST PERSON, THEN THE 2ND PERSON, ETC.
(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

202) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

203) Has (NAME) had this problem since birth, or is it due to an accident, an illness, or another cause?

204) Is there anyone in your household with a deformity of an upper or lower extremity and who cannot walk or has difficulty walking and/or using his/her arms or hands?
IF YES: Could you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH A DEFORMITY. ASK Q. 206 AND 207 FOR THE 1ST PERSON, THEN THE 2ND PERSON, ETC.
(IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

205) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

206) Has (NAME) had this deformity from birth or was it caused by an accident, and illness, or another cause?

207) Does (NAME) only have difficulty using his/her arms or legs, or can (name) not use his/her arms or legs at all?

208) Is anyone in your household blind or nearly blind?
IF YES: Can you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH VISION PROBLEMS. ASK Q 210 AND 211 OF THE 1ST PERSON, THEN THE 2ND, ETC. (IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

209) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

210) Has (NAME) had vision problems since birth, or were the problems caused by an accident, an illness, or another cause?

211) Does (NAME) have trouble seeing or is (NAME) completely blind?

212) Is there anyone in your household who is almost or completely deaf?
IF YES: Can you tell me the name of these people?

RECORD THE NAME AND LINE NUMBER OF EACH PERSON WITH HEARING PROBLEMS. ASK Q. 214 AND 215 OF THE 1ST PERSON, THEN THE 2ND PERSON, ETC. (IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

213) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

214) Did (NAME) have hearing problems since birth or were they caused by an accident, an illness, or another cause?

215) Does (NAME) have difficulty hearing or is (name) completely deaf?

216) Is there anyone in your household that has serious difficulty talking or is mute?
IF YES: Can you tell me the name of these people?

RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK. Q. 218 AND 219 FOR THE FIRST PERSON, THEN THE 2ND, ETC. (IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

217) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

218) Has (NAME) had these problems with talking since birth or were they caused by an accident, an illness, or another cause?

219) Does (NAME) have difficulty talking or is (NAME) completely mute?

220) Is there anyone in your household who is missing certain bodily extremities, such as finger tips, toes, nose, or ears?
IF YES: CAN YOU TELL ME THE NAME OF THESE PEOPLE?

RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK. Q. 222 AND 223 FOR THE FIRST PERSON, THEN THE 2ND, ETC. (IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

221) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

222) Has (NAME) had this problem since birth or was it caused by an accident, an illness, or another cause?

223) Does (NAME) have certain extremities that have no feeling?

224) Does anyone in your household have behavioral problems?
If Yes: Can you tell me the name of these people?

RECORD THE NAME AND NUMBER OF EACH PERSON WITH SPEECH PROBLEMS. ASK. Q. 227 AND 228 FOR THE FIRST PERSON, THEN THE 2ND, ETC. (IF THERE ARE MORE THAN 3 PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE)

225) NAME AND NUMBER FROM LINE COLUMN 1 AND COLUMN 2 OF THE HOUSEHOLD SCHEDULE

226) Has (NAME) had this problem since birth or was it caused by an accident, and illness, or another cause?

227) Are (NAME)'s problems mild or serious?

5-TOBACCO AND ALCOHOL CONSUMPTION
(ONLY FOR HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

228) CHECK COLUMNS 5 AND 7 IN THE HOUSEHOLD SCHEDULE: NUMBER OF PEOPLE AGED 15 OR OLDER WHO USUALLY LIVE IN THE HOUSEHOLD: RECORD THE LINE NUMBER AND NAME OF EACH PERSON AGE 15 OR OLDER IN Q. 229 AND Q. 230.

ASK THE FOLLOWING QUESTIONS FOR EACH PERSON AGE 15 YEAR OR OLDER LIVING IN THE HOUSEHOLD.

Now I would like to ask you some questions about tobacco and alcohol consumption in your household.

229) RECORD THE LINE NUMBER OF EACH PERSON AGE 15 YEARS OR OLDER LIVING IN THE HOUSEHOLD IN THE ORDER OF COLUMN 1 IN THE HOUSEHOLD SCHEDULE.

230) RECORD THE NAME OF EACH PERSON AGE 15 YEARS OR OLDER

231) Does (NAME) currently smoke cigarettes?

232) Approximately how many cigarettes does (NAME) smoke per day?
IF DON'T KNOW, RECORD 98.

233) Does (NAME) currently smoke or use any other form of tobacco?

234) In what form does (NAME) smoke or use tobacco?
RECORD ALL MENTIONED.

235) Does (NAME) drink alcohol, including beer and bilibili?

236) Does (NAME) drink alcohol every day, about once a week, about once a month, or less frequently?

237) Does (NAME) ever get drunk?

(GO TO NEXT LINE OR IF NO MORE PEOPLE, GO TO 238)

6-SELECTION OF A CHILD FOR CHILDREN'S WORK AND DISCIPLINE
(ONLY IN HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY OR THE HIV TEST)

238) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 4 AND 17 YEARS OLD LIVING IN THIS HOUSEHOLD:

TABLE 1: ELIGIBLE CHILDREN AGE 1-17

RECORD EACH CHILD AGE 1-17 FROM THE HOUSEHOLD TABLE IN THE TABLE BELOW, ORDERED BASED ON THEIR LINE NUMBER (Q 1) FROM THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS WHO ARE NOT AGE 1-17. RECORD THE LINE NUMBER, NAME, SEX AND AGE OF EACH CHILD, THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 1-17 IN THE RESERVED SPACE. (Q. 244)

239) RANK NUMBER

240) Line Number From Q. 1

241) NAME FROM Q. 2

242) SEX FROM Q. 4

243) AGE FROM Q. 7

244) TOTAL NUMBER OF CHILDREN AGE 1-17

TABLE 2: RANDOM SELECTION
USE THIS TABLE TO SELECT ONE CHILDREN AGE 1-17, IF THERE IS MORE THAN ONE IN THE HOUSEHOLD.

A) CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE.
B) THIS IS THE LINE NUMBER THAT YOU MUST GO TO IN THE TABLE BELOW.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN IN Q. 244.
D) THIS IS THE COLUMN NUMBER YOU SHOULD USE.
E) FIND THE SPACE WHERE THE LINE AND COLUMN MEET AND CIRCLE THAT NUMBER.
F) THIS IS THE RANK NUMBER OF THE CHILD WHO WILL BE SELECTED (1ST, 2ND, 3RD, ETC) FOR THE CHILDREN'S "WORK" AND "DISCIPLINE" MODELS.

EXAMPLE:
THE HOUSEHOLD NUMBER IS 036, 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.

245) LAST DIGIT IN HOUSEHOLD NUMBER
0-9
TOTAL NUMBER OF ELIGIBLE CHILDREN IN HOUSEHOLD

246) RECORD THE RANK NUMBER (Q. 239), LINE NUMBER (Q. 240), NAME (Q. 241) AND AGE (Q. 243) OF THE CHILD SELECTED.

RANK NUMBER__ __
LINE NUMBER__ __
NAME__________
AGE_________

7-CHILDREN'S WORK
(ONLY FOR HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY AND THE HIV TEST)

247) CHECK 246:

248) Now I would like to ask you some questions on the type of work that children in your household can do.

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

IF NO, PROBE:
PLEASE INCLUDE ANY TYPE OF ACTIVITY THAT (NAME) MIGHT HAVE DONE LIKE REGULAR OR TEMPORARY EMPLOYMENT, FOR HIS OWN BUSINESS OR AS AN EMPLOYER, OR AS AN UNPAID FAMILY WORKER IN THE HOUSEHOLD OR ON THE FARM.

249) CHECK 248 A-D:

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

251) Does this activity/do these activities require carrying heavy loads?

252) Does this activity/do these activities require working with dangerous tools (knives, etc) or big machines?

253) How would you describe (NAME)'s work environment?
a) Is (NAME) exposed to dust, smoke or gas?

b) Is (NAME) exposed to cold, heat, or excessive humidity?

c) Is (NAME) exposed to loud noises or vibrations?

d) Is (NAME) exposed to working at high heights?

e) Is (NAME) exposed to chemical products (pesticides, glues, etc.) or to explosives?

f) Is (NAME) exposed to other things, behaviors, or conditions that are bad for his/her behavior or safety?

254) Since last (DAY OF WEEK OF INTERVIEW), did name fetch water or firewood for the household?

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

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

257) CHECK 256 A-G:

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

8-DISCIPLINE OF CHILDREN
(ONLY FOR HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY OR THE HIV TEST)

259) CHECK 246:

260) RECORD THE NAME OF CHILD SELECTED AND HIS/HER LINE NUMBER ACCORDING TO Q. 246.

261) Adults use certain methods to teach child how to behave well or correctly or to handle behavior problems. I will read you a list of methods that are used and I'd like you to tell me if you or someone else in your household has used one of these methods with (NAME OF CHILD FROM q. 260) in the last month.

262) Do you think that to properly raise and educate a child, you must punish him/her physically?

9-WEIGHT, HEIGHT OF CHILDREN AGE 0-5
(ONLY FOR HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY OR THE HIV TEST)

301) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 302 ACCORDING TO LINE NUMBER ORDER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

302) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

303) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF CHILD'S BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

304) CHECK 303:
CHILD BORN IN JANUARY 2009 OR LATER?

305) WEIGHT IN KILOGRAMS

306) HEIGHT IN CENTIMETERS
IF 2 YEARS OR UNDER, MEASURE THE CHILD LYING DOWN, OTHERWISE STANDING UP.

307) MEASURED LYING DOWN OR STANDING UP?

308) GO BACK TO 303 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, GO TO 309.

9-WEIGHT, HEIGHT FOR WOMEN AGE 15-49
(ONLY IN HOUSEHOLDS NOT SELECTED FOR THE MEN'S SURVEY OR THE HIV TEST)

309) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 310. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES). IF THERE ARE NO MORE WOMEN, END.

310) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

311) WEIGHT IN KILOGRAMS

312) HEIGHT IN CENTIMETERS

313) GO BACK TO 311 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO END HOUSEHOLD QUESTIONNAIRE.

10-SELECTION TABLE FOR WOMEN FOR "DOMESTIC VIOLENCE"

401) CHECK COVER PAGE OF QUESTIONNAIRE: HOUSEHOLD SELECTED FOR MEN'S SURVEY AND HIV TEST?

402) CHECK COLUMN 9 OF THE HOUSEHOLD SCHEDULE: NUMBER OF WOMEN AGE 15-49 IN THE HOUSEHOLD:

TABLE 1: WOMEN BETWEEN 15 AND 49 ELIGIBLE FOR QUESTIONS ON DOMESTIC VIOLENCE
RECORD EACH WOMAN AGED 15-49 YEARS FROM HOUSEHOLD SCHEDULE ONTO TABLE BELOW IN ORDER BASED ON HER LINE NUMBER (Q1) FROM HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER MEMBERS OF THE HOUSEHOLD WHO ARE NOT WOMEN AGE 15-49. RECORD THE NAME, AGE AND LINE NUMBER OF EACH WOMAN. THEN RECORD THE TOTAL NUMBER OF WOMEN AGE 15-49 IN THE BLANK SPACE (Q. 402).

403) TOTAL WOMEN AGE 15-49 IN HOUSEHOLD

TABLE 2: RANDOM SELECTION FOR QUESTIONS ON DOMESTIC VIOLENCE
USE THIS TABLE TO SELECT ONE WOMAN AGE 15-49, IF THERE IS MORE THAN ONE IN THE HOUSEHOLD.

A) CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE.
B) USE THIS FIGURE AS THE LINE NUMBER TO PICK FROM.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN FROM Q. 240393
D) THIS IS THE ONE FROM THE COLUMN TO PICK FROM.
E) FIND THE SPACE THAT CORRESPONDS TO THE INTERSECTION OF THAT LINE AND COLUMN AND CIRCLE THE NUMBER.
F) THIS NUMBER CORRESPONDS TO THE WOMAN WHO WILL BE SELECTED FOR "DOMESTIC VIOLENCE": THE 1ST, 2ND, 3RD WOMAN, ETC.

EXAMPLE:

THE HOUSEHOLD STRUCTURE NUMBER IS 043: SELECT LINE 3
THERE ARE 4 ELIGIBLE WOMEN IN THIS HOUSEHOLD, SELECT COLUMN 4.
THE INTERSECTING SPACE OF LINE 3 AND COLUMN 4 IS 3: THE 3RD ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED.
IF THE LINE NUMBER OF THE 4 ELIGIBLE WOMEN ARE 03, 04, AND 07, THE WOMAN SELECTED IS THE 3RD WOMAN LISTED, MEANING THE ONE WITH LINE NUMBER 07.

[LINE]____________
LAST DIGIT OF STRUCTURE NUMBER __ __
[COLUMN]__________
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD__ __

404) NAME OF WOMAN SELECTED

11-HIV TEST FOR WOMEN AGE 15-49
CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 501. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

501) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

502) AGE: CHECK COLUMN 7

503) MARITAL STATUS: CHECK COLUMN 8

504) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 504 AS RESPONSIBLE FOR NEVER IN UNION WOMEN 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 Chad.

For the HIV test, we 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. 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 the results of (name of adolescent's) test 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 you a voucher for free services for you 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?

506) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

507) 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 Chad.

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 you 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, or you can say no to the test. It is up to you to decide.

Will you take in the HIV test?

508) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.

509) AGE: CHECK Q. 502

510) MARITAL STATUS: CHECK Q. 503

511) Ask for consent for additional testing from parent/other adult identified in 504 as responsible for never in union woman age 15-17.

We ask you to allow the Ministry of Public 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?

512) Circle the appropriate code and sign your name.

513) Ask for consent for additional testing from respondent.
We ask you to allow Ministry of Public 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?

514) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

515) ADDITIONAL TESTS
CHECK 512 AND 514: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

517) 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 WHITE TRANSMITTAL FORM.

518) GO BACK TO 501 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 519.

HIV TEST FOR MEN AGE 15-59
(ONLY FOR HOUSEHOLDS SELECTED FOR THE MEN'S SURVEY AND HIV TEST)

519. CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 520. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

520) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

521) AGE: CHECK COLUMN 7

522) MARITAL STATUS: CHECK COLUMN 8

523) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD 00 IF NOT LISTED
LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT.

524) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 523 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 Chad.

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 his HIV status, I can provide him with 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?

525) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

526) 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 Chad.

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 you 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?

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

528) AGE: CHECK Q. 520

529) MARITAL STATUS: CHECK COLUMN 521

530) Ask for consent for additional testing from parent/other adult identified in 523 as responsible for never in union men age 15-17.

We ask you to allow the Ministry of Public 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?

531) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

532) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow the Ministry of Public 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?

533) Circle the appropriate code and sign your name.

534) ADDITIONAL TESTS

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

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

537) GO BACK TO 520 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT THE HOUSEHOLD:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS

NAME OF SUPERVISOR___________
DATE_____

EDITOR'S OBSERVATIONS

NAME OF EDITOR___________
DATE_____