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DEMOGRAPHIC AND HEALTH SURVEYS - TANZANIA 2010 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

REGION

DISTRICT

WARD

ENUMERATION AREA

NAME OF HOUSEHOLD HEAD

TDHS NUMBER

HOUSEHOLD NUMBER

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE

LARGE CITY=1
SMALL CITY=2
TOWN=3
COUNTRYSIDE=4

LARGE CITIES ARE: DAR ES SALAAM, MWANZA, MBEYA AND TANGA. SMALL CITIES ARE: MOROGORO, DODOMA, MOSHI, IRINGA, SHINYANGA, SINGIDA, SONGEA, MTWARA, TABORA, MUSOMA, SUMBAWANGA, BUKOBA, KIGOMA NA MJINI MAGHARIBI. MIJI MINGINE NI MIJI MIDOGO

HOUSEHOLD SELECTED FOR MEN'S SURVEY AND SALT TESTING

YES=1
NO=2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER NAME
RESULT*

RESULT

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT IN HOUSEHOLD AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _________

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE
TIME

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN 15-49

TOTAL ELIGIBLE MEN 15-49

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME

FIELD EDITOR
NAME

OFFICE EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is ______. I am working with National Bureau of Statistics. We are conducting a survey about health all over Tanzania. The information we collect will help the government to plan health services.
Your household was selected for the survey. The survey usually takes about 30 to 60 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.
Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: __________

DATE: ___________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

(1) LINE NO.

LINE NUMBER____

(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 5-19 FOR EACH PERSON.

NAME___

(3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

01 = HEAD
02 = WIFE OR HUSBAND
03 = SON OR DAUGHTER
04 = SON-IN-LAW OR DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = CO-WIFE
10 = OTHER RELATIVE
11 = ADOPTED/FOSTER/STEPCHILD
12 = NOT RELATED
98 = DON'T KNOW

(4) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

(5) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

(6) RESIDENCE: Did (NAME) stay here last night?

YES 1
NO 2

(7) AGE: How old is (NAME)?
IF 95 OR MORE, WRITE '95'

IN YEARS _______

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

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

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

(10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

(11) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 5

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 TO TABLE)
NO

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

YES (ADD TO 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 TO TABLE)
NO

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS

(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'.

LINE NUMBER_____________

(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 usually 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'.

LINE NUMBER_____________

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

(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? SEE CODES BELOW.

LEVEL
00=PREPRIMARY
01 = PRIMARY
02=POST PRIMARY TRAINING
03= SECONDARY O-LEVEL
04= SECONDARY A-LEVEL
05=POST-SECONDARY TRAINING 'O' LEVEL
06=POST-SECONDARY TRAINING'A' LEVEL
07=UNIVERSITY
98= DON'T KNOW
GRADE
00=LESS THAN 1 YEAR COMPLETED
98 = DON'T KNOW

(18) CURRENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: Is (NAME) currently attending school?

YES 1
NO 2 (NEXT LINE)

(19) BIRTH REGISTRATION IF 0-4 YEARS: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME'S) birth ever been registered with the civil authority?

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

HOUSEHOLD CHARACTERISTICS

101. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11
PIPED INTO YARD/PLOT 12
PUBLIC TAP 13
NEIGHBOUR'S TAP 14 (GO TO 101B)
WATER FROM OPEN WELL
OPEN WELL IN DWELLING 21 (GO TO 101B)
OPEN WELL IN YARD/PLOT 22 (GO TO 101B)
OPEN PUBLIC WELL 23 (GO TO 101B)
NEIGHBOUR'S OPEN WELL 24 (GO TO 101B)
WATER FROM COVERED WELL OR BOREHOLE
PROTECTED WELL IN DWELLING 31 (GO TO 101B)
PROTECTED WELL IN YARD/PLOT 32 (GO TO 101B)
PROTECTED PUBLIC WELL 33 (GO TO 101B)
NEIGHBOUR'S BOREHOLE 34 (GO TO 101B)
SURFACE WATER
SPRING 41 (GO TO 101B)
RIVER/STREAM 42 (GO TO 101B)
POND/LAKE 43 (GO TO 101B)
DAM 44 (GO TO 101B)
RAINWATER 51 (GO TO 101B)
TANKER TRUCK 61 (GO TO 101B)
WATER VENDOR 71 (GO TO 101B)
BOTTLED WATER 81 (GO TO 101B)
OTHER (SPECIFY) ________________________ 96 (GO TO 101B)

101A. Who is providing water at your main source?

AUTHORITY 1
CBO/NGO 2
PRIVATE OPERATOR 3
DON'T KNOW 8

101B. How long does it take you to go there, get water, and come back including waiting time?

MINUTES ________
ON PREMISES 996

101C. Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 102)
DON'T KNOW 8 (GO TO 102)

101D. 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
OTHER (SPECIFY) ___________ X
DON'T KNOW Z

102. What kind of toilet facility do members of your household usually use?

FLUSH/ POUR FLUSH TO PIPED
SEWER SYSTEM 11
FLUSH/ POUR FLUSH TO PIPED SEPTIC TANK 12
FLUSH/ POUR FLUSH TO PIT LATRINE 13
FLUSH/ POUR FLUSH TO ELSEWHERE 14
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE (VIP) 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET/ECOSAN 31
BUCKET 41
NO FACILITY/BUSH/FIELD 51 (GO TO 104)
OTHER (SPECIFY) ___________________ 96

103. Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 104)

103A. How many households share this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 _________

10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

104. Does your household have:

Electricity?
A paraffin lamp?
A radio?
A television?
A mobile telephone?
A non-mobile telephone (land line)?
An iron (charcoal or electric)?
A refrigerator?

ELECTRICITY
YES 1
NO 2
PARAFFIN LAMP
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
IRON
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

105. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
SOLAR 02
GAS 03
PARAFFIN-HURRICANE LAMP 04
PARAFFIN-PRESSURE LAMP 05
PARAFFIN-WICK LAMP 06
FIREWOOD 07
CANDLES 08
OTHER (SPECIFY) _____________________ 96

106. What is the main source of energy for lighting in the household?

ELECTRICITY 01
BOTTLED GAS 02
PARAFFIN / KEROSENE 03
CHARCOAL 04
FIREWOOD 05
CROP RESIDUALS, STRAW, GRASS 06
ANIMAL DUNG 07
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY) _______________ 96

107. MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION.
MARK ONLY ONE.

EARTH, SAND, DUNG 11
WOOD PLANKS, BAMBOO, PALM 21
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES, TERRAZZO 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) ________________________ 96

108. WALL MATERIAL
RECORD OBSERVATION.
MARK ONLY ONE.

GRASS 01
POLES AND MUD 02
SUN-DRIED BRICKS 03
BAKED BRICKS 04
WOOD, TIMBER 05
CEMENT BLOCKS 06
STONES 07
OTHER (SPECIFY) _____________________ 96

109. ROOFING MATERIAL
RECORD OBSERVATION.
MARK ONLY ONE.

GRASS / THATCH / MUD 01
IRON SHEETS 02
TILES . 03
CONCRETE 04
ASBESTOS 05
OTHER (SPECIFY) _____________________ 96

110. How many rooms in your household are used for sleeping?
(INCLUDING ROOMS OUTSIDE THE MAIN DWELLING)

ROOMS _______

111. Does any member of your household own:

A watch?
A bicycle?
A motorcycle or motor scooter?
A car or truck?
A bank account?

WATCH
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BANK ACCOUNT
YES 1
NO 2

112. How many acres of land for farming or grazing does this household own?
(PUT '0000.0' IF NONE AND 9999.8 IF DOESN'T KNOW)

ACRES FOR FARMING ______.___
ACRES FOR GRAZING ______.___

113. Does the household use land for farming or grazing that it doesn't own?
IF YES: Is it rented, sharecropped, private land provided free, or open access/communal/other?

YES, RENTED 1
YES, SHARECROPPED 2
YES, PRIVATE LAND PROVIDED FREE 3
YES, OPEN ACCESS/COMMUNAL 4
NO 5 (GO TO 115)

114. How many acres of land are used?
(PUT '0000.0' IF NONE AND 9999.8 IF DOESN'T KNOW)

ACRES FOR FARMING ______.___
ACRES FOR GRAZING ______.___

115. How far is it to the nearest market place?
(WRITE '00' IF LESS THAN ONE KILOMETRE)

KILOMETRES _________

116. Now I would like to ask you about the food your household eats?
How many meals does your household usually have per day?

MEALS ___________

117. In the past week, on how many days did the household eat meat?

DAYS __________

118. In the past week, on how many days did the household eat fish?

DAYS __________

119. How often in the last year did you have problems in satisfying the food needs of the household?

NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5

120. How far is it to the nearest health facility?
(WRITE '00' IF LESS THAN ONE KILOMETRE)
IF MORE THAN 95 KM, WRITE 95.

KILOMETRES ________

121. If you were to go to (NAME OF HOSPITAL, HEALTH CENTRE, or HEALTH POST), how would you go there?

CAR/MOTORCYCLE 1
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
BICYCLE 5
OTHER 6

122. Did anyone in the household prepare ugali with maize flour in the past 7 days?

YES 1
NO 2 (GO TO 126)

123. Where did you get the maize flour?

GROUND OWN MAIZE AT HOME 1 (GO TO 126)
GROUND AT MAIZE MILL 2 (GO TO 126)
BOUGHT FLOUR 3
OTHER (SPECIFY) ________ 6 (GO TO 126)

124. Where did you buy the maize flour?

SHOP 1
MARKET 2
AT HAMMERMILL 3
OTHER (SPECIFY) ________ 6

125. What brand did you buy?

SEMBA 1
DONA 2
NO BRAND SHOWN 3
OTHER (SPECIFY) ________6
DON'T KNOW 8

126. Did your household use oil to cook with in the past 7 days?

YES 1
NO 2

127. What kind of oil was it?

SIMSIM/SESAME 01
GROUNT NUT 02
SUNFLOWER 03
COCONUT 04
RED PALM 05
COTTONSEED 06
COW FAT 07
GHEE 08
OTHER FAT (SPECIFY) _______96

128. Where did you get the oil?

PROCESSED SELF AT HOME 1 (GO TO 130)
LOCAL MILL 2(GO TO 130)
BOUGHT 3
OTHER (SPECIFY) __________ 6(GO TO 130)

129. What brand did you buy?

NO BRAND 1
BRAND (SPECIFY) ________ 6
DON'T KNOW 8

130. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 141)

131. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS _________

132. ASK RESPONDENT TO SHOW YOU THE NET(S).
IF MORE THAN 6 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

133. How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, WRITE '00'.

MONTHS AGO _______

37 OR MORE MONTHS AGO 95
NOT SURE 98

134. OBSERVE BRAND OR TYPE OF MOSQUITO NET.
FEEL TEXTURE OF NET IF STIFF/ROUGH CIRCLE 'OLYSET'

'PERMANENT' NET OLYSET 11 (GO TO 138)
OTHER/DON'T KNOW BRAND 12

135. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?

YES 1
NO 2 (GO TO 138)
NOT SURE 8 (GO TO 138)

136. Who treated the net?

SELF/HOUSEHOLD MEMBER 1
CAMPAIGN 2
DON'T KNOW 8

137. How many months ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS AGO _________

25 OR MORE MONTHS AGO 95
NOT SURE 98

138. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 140)
NOT SURE 8 (GO TO 140)

139. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

NAME _________
LINE NUMBER ________

140. GO BACK TO 132 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 141.

141. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
BELOW 15 PPM 2
15 PPM AND ABOVE 3
NO SALT IN HH 4
SALT NOT TESTED (SPECIFY REASON) __________ 6

142. CHECK COVER OF HOUSEHOLD QUESTIONNAIRE. IF HOUSEHOLD SELECTED FOR ADDITIONAL SALT TESTING ASK FOR ADDITIONAL FULL TABLESPOON OF SALT. PLACE SALT IN CONTAINER.
PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S CONTAINER OF SALT AND THE 3RD ON THE TRANSMITTAL FORM.

SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE

200. ONLY ONE WOMAN PER HOUSEHOLD SHOULD BE SELECTED FOR DV MODULE. USE THE TABLE BELOW TO SELECT ONE WOMAN TO BE INTERVIEWED WITH DV MODULE IN THIS HH.

NAME OF SELECTED WOMAN____________________________________
HH LINE NUMBER _______

GO TO COL. 9 IN THE HH SCHEDULE AND WRITE 'DV' NEXT TO THE LINE NUMBER OF THE WOMAN SELECTED.

HOW TO USE THE TABLE FOR SELECTION OF RESPONDENTS FOR DV

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE.
THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE FEMALES (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN YOU SHOULD GO TO.
THE CELL WHERE THE ROW AND THE COLUMN MEET IS THE NUMBER OF THE SELECTED WOMAN FOR THE DOMESTIC VIOLENCE MODULE IN THE HOUSEHOLD SCHEDULE.
FOR EXAMPLE, THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 (LINE NUMBERS 02, 04, AND 05). IF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '216', THE LAST DIGIT IS "6", THEREFORE GO TO ROW '6'. THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD, THEREFORE GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER WHERE THE ROW AND COLUMN MEET ('2') AND CIRCLE THE BOX. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER "04" IN OUR EXAMPLE). WRITE HER LINE NUMBER ABOVE IN THE BOXES INDICATED.
TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE
LAST DIGIT OF THE HOUSEHOLD Q-RE SERIAL NUMBER
TOTAL NUMBER OF ELIGIBLE WOMEN 15-49 IN THE HOUSEHOLD

WEIGHT, HEIGHT, HEMOGLOBIN, VITAMIN A AND IRON FOR CHILDREN 0-5 YEARS

501. CHECK COLUMN 11. RECORD THE LINE NUMBER, NAME AND AGE FOR ALL ELIGIBLE CHILDREN LESS THAN 5 YEARS OF AGE IN QUESTIONS 502-503. IF THERE ARE MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 513 AND FOR THE VITAMIN A TEST PROCEDURE IN 517 FOR EACH ELIGIBLE CHILD.
IF NO ELIGIBLE CHILDREN, TICK HERE AND SKIP TO Q. 601

502. LINE NUMBER (COLUMN 11)
NAME (COLUMN 2)

LINE NUMBER _______
NAME ________

503. What is (NAME'S) birth date?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HIST ORY AND ASK DAY OF BIRTH; IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH AND YEAR OF BIRTH

DAY ______
MONTH ______
YEAR ______

504. CHECK 503:
CHILD BORN IN JANUARY 2005 OR LATER?

YES 1
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 601)

505. WEIGHT IN KILOGRAMS

KG ____.__

NOT PRESENT 994
REFUSED 995
OTHER 996

506. HEIGHT IN CENTIMETERS

CM ___.__

NOT PRESENT 9994
RESFUED 9995
OTHER 9996

507. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

509. CHECK 503:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 601)
OLDER 2

510. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONS IBLE FOR CHILD (COLUMN 1 HH SCHEDULE). RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ______

510A. READ ALL CONSENT STATEMENTS. PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT WAS GIVEN.

CONSENT STATEMENT FOR ANEMIA TEST FOR CHILDREN
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 programs to prevent and treat anemia.
We request that all children born in 2005 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger.
The equipment used in taking 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 told to you right away. The result will be kept confidential and will not be shared with anyone other than members 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(S) OF CHILD(REN)) to participate in the anemia test?

512. READ ANEMIATEST CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD.
CIRCLE CODE AND SIGN.

GRANTED 1 (SIGN) _______
REFUSED 2 (SIGN) ________

513. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ______

NOT PRESENT 994
REFUSED 995
OTHER 996

515. READ VITAMIN A AND IRON CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

GRANTED 1 (SIGN) _______
REFUSED 2 (SIGN) ________

CONSENT STATEMENT FOR VITAMIN A, IRON DEFICIENCY AND INFECTION TEST FOR CHILDREN
As part of the survey we also are asking people all over the country to take a test for vitamin A and iron deficiency and infection. Vitamin A and iron deficiency are health problems that can result from poor nutrition.
Low Vitamin A can lead to blindness and low resistence to infection and low iron can slow how well children grow and develop.
This survey will help the government to develop programs to prevent and treat iron and Viatmin A deficiency.
For these tests, we need a few (more) drops of blood from a finger.
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 test results are for your child.
The test will be done at the Tanzanian Food and Nutrition Center Laboratory.
The result will be kept strictly confidential and will not be shared with anyone other than members 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(S) OF CHILD(REN)) to take the vitamin A deficiency test?

516. BAR CODE LABEL
VITAMIN A AND IRON
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.

517. OUTCOME OF BLOOD VITAMIN A AND IRON TEST PROCEDURE

BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6

518. GO BACK TO 502 IN NEXT COLUMN IN THIS QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 601.

TICK HERE IF CONTINUED IN ANOTHER QUESTIONNAIRE.

WEIGHT, HEIGHT, HEMOGLOBIN, VITAMIN A. IRON AND URINARY IODINE FOR WOMEN AGE 15-49

601. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 602. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 610 AND FOR THE VITAMIN A TEST PROCEDURE IN 616 FOR EACH ELIGIBLE WOMAN.

IF NO ELIGIBLE WOMEN, TICK HERE

602. LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

LINE NUMBER ________
NAME ________

603. WEIGHT IN KILOGRAMS

KG _____.__

NOT PRESENT 99994
REFUSED 99995
OTHER .99996

604. HEIGHT IN CENTIMETERS

CM _____.___

NOT PRESENT 9994
REFUSED 9995
OTHER .9996

606. AGE:
CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 609)

607. MARITAL STATUS:
CHECK COLUMN 8.

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 609)

608. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONS IBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT _____

608A. READ CONSENT STATEMENTS AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED.

609. READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 608 BEFORE ASKING RESPOND ENT'S CONSENT.

GRANTED 1(SIGN) _______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _______ (GO TO 610)
RESPONDENT REFUSED 3 (SIGN) _______ (GO TO 610)

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 609 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE Q.608) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 609 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of this survey, we are asking people all over the country to give blood for 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 programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used in taking 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 told to you right away.
The result will be kept strictly confidential and will not be shared with anyone other than members 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 ADOLESCENT to) take the anemia test?

610. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ______

NOT PRESENT 994
REFUSED 995
OTHER 996

613. PREGNANCY STATUS:
CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

614. READ THE VITAMIN A AND IRON CONSENT STATEMENT.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 608 BEFORE ASKING RESPONDENT'S CONSENT.

GRANTED 1(SIGN) _______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _______ (GO TO 616)
RESPONDENT REFUSED 3 (SIGN) _______ (GO TO 616)

CONSENT STATEMENT FOR VITAMIN A AND IRON DEFICIENCY TESTS
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 614 IF RESPONDENT CONSENTS TO THE VITAMIN A AND IRON TESTS AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 608) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 614 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of the survey we also are asking people all over the country to give blood for a vitamin A and iron deficiency test. Low Iron and vitamin A are health problems that can result from poor nutrition. Low Vitamin A can lead to blindess and lower resistence to infections and low iron cause low energy and tiredness in women.
This survey will help the government to develop programs to prevent and treat vitamin A and iron deficiency.
For the tests, we need a few more drops of blood from a finger after the blood for anemia has been collected.
Again the equipment used in taking the blood is clean and completely safe.
It has never been used before and will be thrown away after each test.
The test will be done at the Tanzanian Food and Nutrition Center Laboratory.
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 test results are for you/(NAME OF ADOLESCENT).
The result will be kept strictly confidential and will not be shared with anyone other than members 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 ADOLESCENT to) take the test?

615. BAR CODE LABEL
VITAMIN A
AND IRON
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.

616. OUTCOME OF VITAMIN A AND IRON TESTS PROCEDURE

BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6

617. READ THE URINARY IODINE CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 608 BEFORE ASKING RESPONDENT'S CONSENT.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________ (GO TO 620)
REFUSED 3 (SIGN) ________ (GO TO 620)

CONSENT STATEMENT FOR URINARY IODINE TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 617 IF RESPONDENT CONSENTS TO THE URINARY IODINE TEST AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 608) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 617 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of the survey we also are asking women all over the country to take a test for iodine deficiency. Iodine deficiency is a health proble that can result poor nutrition.
This survey will help the government to develop programs to prevent and treat iodine deficiency.
For the iodine test, we need a small amount of your urine. The urine will be tested at the Tanzanian Food and Nutrition Laboratory
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 test results are for you/(NAME OF ADOLESCENT).
The result will be kept strictly confidential and will not be shared with anyone other than members 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 ADOLESCENT to) take the iodine deficiency test?

618. BAR CODE
URINARY IODINE

PUT THE 1ST BAR CODE LABEL
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S COLLECTION CUP AND THE THIRD LABEL ON THE COLLECTION TUBE AND THE FOURTH LABEL ON THE TRANSMITTAL FORM.

619. OUTCOME OF URINARY IODINE TEST PROCEDURE

URINE GIVEN 1
NOT PRESENT 2
TEST REFUSED 3
OTHER 6

620. GO BACK TO 603 IN THE NEXT COLUMN IN THE QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, END INTERVIEW.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
______________________________________

COMMENTS ON SPECIFIC QUESTIONS:
______________________________________

ANY OTHER COMMENTS:
______________________________________

SUPERVISOR'S OBSERVATIONS
______________________________________

NAME OF THE SUPERVISOR: __________
DATE: __________