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REPUBLIC OF CHAD
MINISTRY OF PLANNING AND OF INTERNATIONAL COOPERATION
MINISTRY OF PUBLIC HEALTH, SOCIAL ACTION, AND NATIONAL SOLIDARITY
NATIONAL INSTITUTE OF STATISTICS, ECONOMIC AND DEMOGRAPHIC STUDIES (INSEED)
DEMOGRAPHIC AND HEALTH SURVEY WITH MULTIPLE INDICATORS 2014
HOUSEHOLD QUESTIONNAIRE

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)

URBAN 1
RURAL 2
MILIEU ___

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

RESIDENCE__ __

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

YES 1
NO 2

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:

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)

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

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

____
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= BROTHER-IN-LAW/SISTER-IN-LAW
10= NIECE/NEPHEW
11= CO-SPOUSE
12= OTHER RELATIVE
13=ADOPTED/FOSTER/STEPCHILD
14= NOT RELATED
98= DON'T KNOW

4) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE

5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

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

IN YEARS ____

IF AGE 15 OR OLDER

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

1=MONOGAMOUS MARRIAGE
2=POLYGAMOUS MARRIAGE
3=LIVING TOGETHER
4=DIVORCED/SEPARATED
5=WIDOWED
6=NEVER MARRIED AND NEVER LIVED TOGETHER
___

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?

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

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

____

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

YES 1
NO 2 (GO TO 16)
DON'T KNOW 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.

____

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

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

LEVEL __
GRADE __ __

IF AGE 5-24 YEARS

Current/recent school attendance

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

Yes 1
No 2-Next line

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

LEVEL __
GRADE ____
LEVEL
1=PRIMARY
2=SECONDARY
3=SECONDARY TECHNICAL
4=SECONDARY PROFESSIONAL
5=HIGHER
6=HIGHER PROFESSIONAL
8-DON'T KNOW
00=LESS THAN ONE YEAR COMPLETED

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?

HAS CERTIFICATE SEEN 1
HAS CERTIFICATE NOT SEEN 2
NO CERTIFICATE 3
DON’T KNOW IF HE/SHE HAS CERTIFICATE 4
NO CERTIFICATE OR DON’T KNOW, BUT YES, REGISTERED 5
NO CERTIFICATE OR DON’T KNOW, AND NO, NOT REGISTERED 6
DON’T KNOW IF HAS CERTIFICATE AND DON’T KNOW IF REGISTERED 7

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?

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

101) 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

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 TAP 13 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 103)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK/BARREL 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) ______ 96 (GO TO 103)

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

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

103) Where is the water source located?

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

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

MINUTES __ __ __
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)
DON'T KNOW (GO TO 107)

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

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

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO SEPTIC TANK 11
FLUSH TO PIT LATRINE 12
FLUSH TO SOMEWHERE ELSE 13
FLUSH, DON'T KNOW WHERE 14
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (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?

NUMBER 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 CD/DVD/tape player?
YES 1
NO 2
A mobile telephone?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A stove?
YES 1
NO 2
Chairs?
YES 1
NO 2
Beds?
YES 1
NO 2
Lamps?
YES 1
NO 2
Grain mill?
YES 1
NO 2
Fan?
YES 1
NO 2
Sewing machine?
YES 1
NO 2
Rickshaw?
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
SAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) ________ 96

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

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFY) ________ 6 (GO TO 114)

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

YES 1
NO 2

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 33
CARPET 34
OTHER (SPECIFY) ________ 96

115) MAIN MATERIAL OF THE ROOF
RECORD OBSERVATION

NATURAL MATERIAL
NO ROOF 11
THATCH/PALMS LEAVES 12
SOD 13
RUDIMENTARY MATERIAL
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
SHEET METAL 31
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
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?

NUMBER OF ROOMS_____

118) Does any member of your household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2

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

YES 1
NO 2 (SKIP TO 121)

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

HECTARES __ __
95 OF MORE HECTARES 950
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?
____
Horses, donkeys, or mules?
____
Goats?
____
Sheep?
___
Chickens/fowl/duck/pigeon?
____
Pigs
____
Camels
____
Rabbits
___

123) Does any member of this household have a bank account?

YES 1
NO 2

123A) 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

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

YES (GO TO 401)
NO (CONTINUE)

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 126)
DON'T KNOW (GO TO 126)

125) Who sprayed the dwelling?

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

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

YES 1
NO 2 (GO TO 137)

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

NUMBER OF NETS___

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

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11
OLYSET-NET 12
NETPROTECT 13
DURANET 14
INTERCEPTOR 15
OTHER (SPECIFY) 16
(ALL SKIP TO 134)
OTHER BRAND 96
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 1354)

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

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 136)
DON'T KNOW 8 (GO TO 136)

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME_____
LINE NUMBER_____

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

136A) FILTER
CHECK Q 131 ALL COLUMNS

AT LEAST ONE YES-CODE 1 CIRCLED OR IS Q.131 NOT ASKED (CONTINUE)
NOT A SINGLE YES (GOTO 137)

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

YES 1
NO 2 (GO TO 137)
DON'T KNOW 8 (GO TO 137)

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

NEED TO INSTALL AND USE SOAKED MOSQUITO NET A
HOW TO INSTALL SOAKED MOSQUITO NET B
HOW TO WASH SOAKED MOSQUITO NET C
WHERE TO RE-SOAK SOAKED MOSQUITO NET D
WHEN TO SOAKED MOSQUITO NET E
OTHER (SPECIFY) ________ X

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 201)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 201)
NOT OBSERVED, OTHER REASON 4 (GO TO 201)

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

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

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?

YES 1
NO 2-SKIP TO 204

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

NAME_____
LINE NUMBER____

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 07
DON'T KNOW 98

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?

YES 1
NO 2 (GO TO 208)

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

NAME_____
LINE NUMBER_____

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

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

PARTIAL HANDICAP 1
TOTAL HANDICAP 2

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

YES 1
NO 2 (GO TO 212)

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

NAME________
LINE NUMBER_______

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

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

PARTIAL VISION LOSS 1
BLIND 2

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

YES 1
NO 2 (GO TO 216)

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

NAME____
LINE NUMBER______

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

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

PARTIAL HEARING LOSS 1
DEAF 2

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?

YES 1
NO 2 (GO TO 220)

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

NAME______
LINE NUMBER______

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

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

PARTIAL SPEAKING LOSE 1
MUTE 2

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?

YES 1
NO 2 (GO TO 224)

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

NAME_________
LINE NUMBER______

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 228)

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

NAME_______
LINE NUMBER______

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

FROM BIRTH 01
ACCIDENT 02
INCORRECTLY DONE CARE/INJECTIONS 03
ILLNESS 04
OLD AGE 05
WITCHCRAFT 06
OTHER 96
DON'T KNOW 98

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

MILD 1
SERIOUS 2
DON'T KNOW 8

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

(NAME)___________

231) Does (NAME) currently smoke cigarettes?

YES 1
NO 2 (GO TO 233)
DON'T KNOW 8 (GO TO 233)

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?

YES 1
NO 2 (GO TO 235)
DON'T KNOW 8 (GO TO 235)

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

PIPE A
CIGAR B
CHEW C
SNORTING D
OTHER E
DON'T KNOW Z

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

YES 1
NO 2 (GO TO NEXT LINE)
DON'T KNOW 8 (GO TO NEXT LINE)

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

ONCE/DAY 1
ONCE/WEEK 2
ONCE/MONTH 3
LESS FREQUENTLY 4
DON'T KNOW 8

237) Does (NAME) ever get drunk?

YES 1
NO 2
DON'T KNOW 8

(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:

TWO OR MORE (CONTINUE)
ONLY ONE (GO TO 246)
NONE (GO TO 301)

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

MALE 1
FEMALE 2

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:

CHILD AGE 5-17: ASK THE FOLLOWING QUESTIONS TO THE PERSON RESPONSIBLE FOR THE CHILD
CHILD AGE 1-4 (GO TO 259)

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?

a) Did (NAME) work on his/her own land/farm/garden or help on one of a household member, or take care of animals. For example: help grow farm produce, harvest, feed animal, take them to pasture or bring them back?
YES 1
NO 2
b) Did (NAME) help in a relative's family business, without with payment or worked in his or her own business?
YES 1
NO 2
c) Did (NAME) produce or sell items, artisanal products, clothes, food, or agricultural products?
YES 1
NO 2
d) Did (NAME) do any kind of activity in exchange for payment in cash or in kind, even for only one hour?
YES 1
NO 2

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:

AT LEAST ONE YES (CONTINUE)
NOT A SINGLE YES (GO TO 254)

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

NUMBER OF HOURS __ __

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1 (GO TO 254)
NO 2

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

YES 1
NO 2

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.

NUMBER OF HOURS __ __

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

a) Make purchases for the household?
YES 1
NO 2
b) Fix any type of equipment for the household?
YES 1
NO 2
c) Cook or clean utensils for the household?
YES 1
NO 2
d) Wash clothing?
YES 1
NO 2
e) Take care of children?
YES 1
NO 2
f) Take care of elderly or sick people?
YES 1
NO 2
g) Other tasks for the household?
YES 1
NO 2

257) CHECK 256 A-G:

AT LEAST ONE YES (CONTINUE)
NOT A SINGLE YES (GO TO 259)

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.

NUMBER OF HOURS __ __

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

259) CHECK 246:

CHILDREN AGE 1-14 (CONTINUE)
CHILDREN AGE 15-17 (GO TO 309)

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

NAME OF CHILD_________
LINE NUMBER OF CHILD __ __

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.

a) Revoke privileges, not allow (NAME) to do something that he/she likes or now allow him/her to leave the house.
YES 1
NO 2
b) Explain to (NAME) why his/her behavior is not acceptable.
YES 1
NO 2
c) Shake him/her.
YES 1
NO 2
d) Yell or scream at him/her.
YES 1
NO 2
e) Give him/her something else to do.
YES 1
NO 2
f) Hit or spank him/her on his/her buttocks with hands.
YES 1
NO 2
g) Hit him/her on his/her buttocks or elsewhere on his/her body with something like a belt, a whip, a stick, or another hard object.
YES 1
NO 2
h) Call him/her an idiot, lazy or a similar word.
YES 1
NO 2
i) Slap or hit him/her on the face, head, or ears.
YES 1
NO 2
j) Slap or hit him/her on the hands, arms or legs.
YES 1
NO 2
k) Beat him/her, that is, hitting as hard as possible without stopping.
YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW/NO OPINION 8

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

LINE NUMBER__ __
NAME_________

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?

DAY __ __
MONTH __ __
YEAR __ __ __ __

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

YES 1
NO 2 (GO TO 303 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 310)

305) WEIGHT IN KILOGRAMS

KG. __ __. __ __
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

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

CM __ __ __.__
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

307) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

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

LINE NUMBER __ __
NAME__________

311) WEIGHT IN KILOGRAMS

KG __ __ __.__ __
ABSENT 9994
REFUSED 9995
OTHER 9996

312) HEIGHT IN CENTIMETERS

CM __ __ __.__
ABSENT 9994
REFUSED 9995
OTHER 9996

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?

YES
NO (END OF HOUSEHOLD QUESTIONNAIRE)

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

ONE ELIGIBLE WOMAN (GO TO 404)
TWO OR MORE ELIGIBLE WOMEN (GO TO TABLE 1)
NO ELIGIBLE WOMEN (GO TO 519)

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).

RANK NUMBER_____
1ST, 2ND, 3RD [ETC]____
NAME OF WOMAN FROM Q. 2_______________
AGE FROM Q 7_____
LINE NUMBER_____

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

LINE NUMBER OF WOMAN SELECTED FORM HOUSEHOLD SCHEDULE_______
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

LINE NUMBER_______
NAME__________

502) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 507)

503) MARITAL STATUS: CHECK COLUMN 8

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 507)

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.

GRANTED 1-SIGN
REFUSED BY PARENT/OTHER RESPONSIBLE ADULT 2-SIGN
(IF REFUSED, GO TO 517)

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.

GRANTED 1-SIGN
RESPONDENT REFUSED 2-SIGN
(IF REFUSED, GO TO 517)

509) AGE: CHECK Q. 502

15-17 YEARS 1
18-49 YEARS 2-SKIP TO 513

510) MARITAL STATUS: CHECK Q. 503

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 513)

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.

GRANTED 1-SIGN
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2-SIGN
(IF REFUSED, GO TO 515)

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.

GRANTED 1-SIGN
RESPONDENT REFUSED 2-SIGN
(IF REFUSED-GO TO 516)

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.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

LINE NUMBER________
NAME____

521) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-59 YEARS 2 (GO TO 526)

522) MARITAL STATUS: CHECK COLUMN 8

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 526)

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.

GRANTED 1-SIGN
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2-SIGN
(IF REFUSED, GO TO 536)

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.

GRANTED 1-SIGN
RESPONDENT REFUSED 2-SIGN
(IF REFUSED, GO TO 536)

528) AGE: CHECK Q. 520

15-17 YEARS 1
18-59 YEARS 2-GO TO 532

529) MARITAL STATUS: CHECK COLUMN 521

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 532)

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.

GRANTED 1-SIGN
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2-SIGN
(IF REFUSED, GO TO 534)

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.

GRANTED 1-SIGN
RESPONDENT REFUSED 2-SIGN
(IF REFUSED, GO TO 535)

534) ADDITIONAL TESTS

CHECK 531 AND 533: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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.

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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_____