UGANDA BUREAU OF STATISTICS

IDENTIFICATION

REGION

DISTRICT

COUNTY

SUBCOUNTY/TOWN

PARISH/LC2 NAME

EA NAME

UDHS NUMBER

NAME OF HEAD OF HOUSEHOLD

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MALE SURVEY, HEIGHT, WEIGHT, ANEMIA, VITAMIN A

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE

HOUSEHOLD SELECTED FOR UNHS III (IF YES RECORD HH CODE)

INTERVIEWER VISITS

FIRST VISIT

DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

SECOND VISIT

DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

THIRD VISIT

DATE
INTERVIEWER NAME
RESULT

FINAL VISIT

DAY
MONTH
YEAR
INTERVIEWER NUMBER
RESULT

TOTAL NUMBER OF VISITS

RESULT CODES

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGABLE WOMEN

TOTAL ELIGABLE MEN

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF THE QUESTIONAIRE

LANGUAGE USED IN THE INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANLATOR USED

SUPERVISOR

NAME
DATE

FIELD EDITOR

NAME
DATE

OFFICE EDITOR

KEYED BY

Introduction and Consent

Hello. My name is _______________________________________ and I am working with UGANDA BUREAU OF STATISTICS. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes 30 to 45 minutes to complete.

As part of the survey we would first like to ask some questions about your household. All of the
answers you give will be confidential. If we should come to any question you don't want to answer, just let me know and I will go on to the next question.

At this time, do you want to ask me anything about the survey?

May I begin the interview now?

SIGNATURE OF THE INTERVIEWER ________

DATE ________

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

HOUSEHOLD SCHEDULE

1) 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 5-39 FOR EACH PERSON.

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

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

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

3) RELATIONSHIP TO HEAD OF HOUSEHOLD

What is the relationship of (NAME) to the head of the household?

4) SEX

Is (NAME) male or female?

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) How old is (NAME)?

IF AGE 15 OR OLDER

8) MARITAL STATUS

What is (NAME'S) current marital status?

ELIGIBILITY

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

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF AGE 18-59 YEARS

12) SICK PERSON

Has (NAME) been very sick for at least 3 months during the past 12 months, that is (NAME) was too sick to work or do normal activities?

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

13) Is (NAME'S) natural mother alive?

14) IF ALIVE: Does (NAME'S) natural mother 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

15) IF MOTHER NOT LISTED IN HOUSEHOLD

Has (NAME'S) mother been very sick for at least 3 months during the past 12 months, that is she was too sick to work or do normal activities.

16) Is (NAME'S) natural father alive?

17) IF ALIVE: 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

18) IF FATHER NOT LISTED IN HOUSEHOLD

Has (NAME'S) father been very sick for at least 3 months during the past 12 months, that is he was too sick to work or do normal activities?

19) MOTHER AND/OR FATHER DEAD/SICK

CIRCLE LINE NUMBER IF CHILD'S MOTHER AND/OR FATHER HAS DIED (QUESTION 13 OR 16 = NO) OR BEEN SICK (QUESTION 15 OR 18 = YES)

20) BOTH PARENTS ALIVE

IF YES TO QUESTION 13 AND 16 (BOTH ALIVE), CIRCLE '1.' FOR ALL OTHER CASES, CIRCLE '2.'

BROTHERS AND SISTERS

21) Does (NAME) have any brothers or sister under age 18 who have the same mother and the same father?

22) Do any of these brothers and sisters under age 18 not live in this household?

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

23) Has (NAME) ever attended school?

24) What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?

IF AGE 5-24 YEARS

CURRENT SCHOOL ATTENDANCE

24A) At what age did (NAME) first attend primary school?

25) Did (NAME) attend school at any time during the 2006 school year?

26) During the school year, what level and grade is/was (NAME) attending?

ABSENTISM

26A) How many days was (NAME'S) school open last week?

26B) How many days did (NAME) attend school last week?

26C) What was the main reason for (NAME) being absent at school?

RECENT SCHOOL ATTENDANCE

27) Did (NAME) attend school at any time during the previous school year, that is, 2005?

28) During that school year, what level and grade did (NAME) attend?

28A) IF STUDENT IS IN PRIMARY OR SECONDARY SCHOOL IN 2006: Did (NAME) change schools between the 2005 school year and the 2006 school year?

IF AGE 5-17 YEARS

BASIC MATERIAL NEEDS

29) Does (NAME) have a blanket?

30) Does (NAME) have a pair of shoes?

31) Does (NAME) have at least two sets of clothes?

COMPLETE COLUMNS 32-37 FOR ALL HH MEMBERS AGED 5 OR OLDER

DISABILITY

32) Does (NAME) have difficulty seeing, even if he/she is wearing glasses?

33) Does (NAME) have difficulty hearing, even if he/she is using a hearing aid?

34) Does (NAME) have difficulty walking or climbing steps?

35) Does (NAME) have difficulty remembering or concentrating?

36) Does (NAME) have difficulty (with self-care such as) washing all over or dressing, feeding, toileting, etc..?

37) Does (NAME) have difficulty communicating (for example understanding others or others understanding him/her) because of a physical, mental or emotional health condition?

38) 0-14 YEARS

DEWORMING

Has (NAME) been dewormed in the last 6 months?

39) 0-17 YEARS

BIRTH REGISTRATION

Does (NAME) have a birth certificate?

(IF YES, ASK RESPONDENT TO SHOW THE CERTIFICATE)

IF NO, PROBE: Has (NAME) ever been registered for purpose of being given a birth certificate (by LC1 officials)?

TABLE FOR SELECTION OF RESPONDENT FOR THE DOMESTIC VIOLENCE QUESTIONS

CHECK COVER PAGE TO SEE IF HOUSEHOLD IS SELECTED FOR DOMESTIC VIOLENCE SECTION

INSTRUCTIONS

Look at the last digit of the questionnaire number on the cover page. This is the row number you should circle if the household is selected for a female respondent, check the total number of eligible women on the cover sheet of the household questionnaire. This is the column number you should circle. If the household is selected for a male respondent, check the total number of eligible men on the cover sheet of the household questionnaire and circle the number that appears in the box. This is the number of the eligible woman/man who will be asked the domestic violence questions. Then, go to column 9 in the household schedule if the household is selected for a female respondent or 10 if the household is selected for a male respondent, and put a * next to the household line number of the selected eligible woman/man and record this household line in the two boxes at the bottom of this table.

For example, if the household questionnaire number is '3716,' go to row 6 and circle the row number( '6'). If the household is selected for a female respondent to the DV section and there are three eligible women in the household, go to column 3 and circle the column number ('3'). Draw lines from row 6 and column 3 and find the box where the two meet, and circle the number in it ('2'). This means you have to select the second eligible woman. Suppose the household line numbers of the three eligible women are 02, 03, and 07; then the eligible woman for the domestic violence questions is the second eligible woman, i.e., the woman with household line number 03. Put a * next to this woman's line number in column 9 of the household schedule and also enter the two digit line number in the two boxes at the bottom of this table.

HEADER FOR LEFT HAND COLUMN OF TABLE: LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW) [VALUES 0 to 9 going down that column].

TOP ROW OF TABLE: TOTAL NUMBER OF ELIGIBLE WOMAN IN HOUSEHOLD (COLUMN) [Values of 1, 2, 3, 4, 5, 6, 7, 8 fill up each column of table].

HOUSEHOLD CHARACTERISTICS

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

102) What is the main source of water used by your household for other purposes such as cooking and hand washing?

104) How long does it usually take to travel to the source of water which you use for cooking, washing, and so forth?

104A) After arriving at the water source, how long is the waiting time to get water?

104B) How long does it take to travel home from the water source?

105) Who usually goes to this source to fetch water for your household?

(RECORD LINE NUMBER FROM HOUSEHOLD SCHEDULE)

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

107) What do you usually do to make the water safer to drink? Anything else?

RECORD ALL MENTIONED.

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

109) Do you share this toilet facility with other households?

110) How many households use this toilet facility?

111) Does your household have:

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

113) In this household, is food cooked on an open fire or a stove?

114) Is the cooking done under a chimney?

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

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

117) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

118) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

119) MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

120) How many rooms in this household are used for sleeping?

121) Does any member of this household own a:

122) Does any member of this family own any agricultural land?

123) How many acres of agricultural land do members of this household own?

125) How many of the following animals/birds does this household own?

IF NONE, ENTER 00
IF MORE THAN 95, ENTER 95
IF UNKNOWN, ENTER 98

125A) Were there any cases of measles in this household in the last 3 months?

126A) At any one time in the last 12 months, has anyone sprayed the interior walls of your dwelling unit with insecticide?

126B) How many months ago was the house last sprayed?

IF LESS THAN ONE MONTH RECORD 00

127) Does your household have any mosquito nets?

128) How many mosquito nets does your household have?

IF 7 OR MORE NETS RECORD 7.

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

May I have a look at (all) the net(s) to establish the brand?

IF MORE THAN 3 NETS USE ADDITIONAL QUESTIONNAIRE(S).

130) How many months ago did your household obtain the mosquito net?

IF LESS THAN ONE MONTH RECORD 00.

130A) From where did you get the mosquito net?

131) OBSERVE THE BRAND/TYPE OF MOSQUITO NET.

IF NOT OBSERVED ASK: What brand is this net?

133) Since you got the mosquito net, was it ever soaked or dipped in an insecticide to kill or repel mosquitos?

134) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH, RECORD 00.

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

136) Who slept under this mosquito net last night?

RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

137) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138.

138) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.

TEST SALT FOR IODINE.

RECORD PPM (PARTS PER MILLION)

PERSONS WHO HAVE DIED

301) Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has any usual member of your household died in the last 12 months?

302) How many household members died in the last 12 months?

303) ASK 304-306 AS APPROPRIATE FOR EACH PERSON WHO DIED. IF THERE WERE MORE THAN 6 DEATHS, USE ADDITIONAL QUESTIONNAIRE(S).

304) What was the name of the person who died (most recently/before him/her)?

305) Was (NAME) male or female?

306) How old was (NAME) when (he/she) died?

307) GO BACK TO 304 FOR NEXT DEATH; OR, IF NO MORE DEATHS, GO TO 401.

SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

401) CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE: ANY CHILD AGE 0-17?

402) CHECK COLUMN 12 IN THE HOUSEHOLD SCHEDULE: ANY ADULT AGE 18-59 WHO IS VERY SICK?

403) CHECK 306 IN THE PREVIOUS SECTION: ANY ADULT AGE 18-59 WHO DIED IN PAST 12 MONTHS?

404) CHECK COLUMN 19 IN THE HOUSEHOLD SCHEDULE: ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND IS VERY SICK?

405) RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AGE 0-17 FOR ALL CHILDREN WHO ARE IDENTIFIED IN COLUMN 19 AS HAVING A MOTHER AND/OR FATHER WHO HAS DIED OR HAS BEEN VERY SICK.

406) NAME FROM COLUMN 2, LINE NUMBER FROM COLUMN 1, AND AGE FROM COLUMN 7

407) I would like to ask you about any formal, organized help or support for children that your household may have received for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

408) Now I would like to ask you about the support your household received for (NAME). In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

409) In the last 12 months, has your household received any emotional or psychosocial support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home and for which you did not have to pay?

410) Did your household receive any of this emotional or psychosocial support in the past 3 months?

411) In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

412) Did your household receive any of this material support in the past 3 months?

413) In the last 12 months, has your household received any social support for (NAME) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

414) Did your household receive any of this social support in the past 3 months?

415) CHECK 406: AGE OF CHILD

416) In the last 12 months, has your household received any support for (NAME'S) schooling, such as allowance, free admission, books or supplies, for which you did not have to pay?

417) GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.

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

501) CHECK COLUMN 11. RECORD THE LINE NUMBER, NAME AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS 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 513B FOR EACH ELIGIBLE WOMAN.

IF NO ELIGIBLE CHILDREN, TICK HERE AND SKIP TO Q. 515.

502) LINE NUMBER (COLUMN 11)

NAME (COLUMN 2)

503) What is (NAME'S) birth date?

IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH, AND YEAR.

504) CHECK 503: CHILD BORN IN JANUARY 2001 OR LATER?

505) WEIGHT IN KILOGRAMS

506) HEIGHT IN CENTIMETERS

507) MEASURED LYING DOWN OR STANDING UP?

508) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

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

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

511) READ ANEMIA TEST CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

511A) READ VITAMIN A TEST CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

511B) CHECK 511 AND 511A AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 513 AND FOR THE VITAMIN A TEST PROCEDURE IN 513B FOR EACH ELIGIBLE CHILD EVEN IF THE CHILD WAS NOT PRESENT, PARENT/ADULT REFUSED, OR CHILD COULD NOT BE TESTED FOR SOME OTHER REASON.

512) RECORD HEMOGLOBIN LEVEL HERE AND IN PAMPHLET

513) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

513A) BAR CODE LABEL

PUT FIRST BAR CODE LABEL HERE.

PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

513B) OUTCOME OF VITAMIN A TEST PROCEDURE

513C) CHECK 513B: OUTCOME OF VITAMIN A TEST

513D) READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

513E) ADDITIONAL TESTS

CHECK 513D: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

514) GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

TICK HERE IF CONTINUED IN ANOTHER QUESTIONNAIRE.

WEIGHT, HEIGHT, HEMOGLOBIN AND VITAMIN A FOR WOMEN AGE 15-49

515) CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 516.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 528 AND FOR THE VITAMIN A TEST PROCEDURE IN 530 FOR EACH ELIGIBLE WOMAN.

IF NO ELIGIBLE WOMEN, TICK HERE AND SKIP TO QUESTION 531.

516) LINE NUMBER (COLUMN 9)

NAME (COLUMN 2)

517) WEIGHT IN KILOGRAMS

518) HEIGHT IN CENTIMETERS

519) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

520) AGE: CHECK COLUMN 7

521) MARITAL STATUS: CHECK COLUMN 8.

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

523) READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMAN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

IF REFUSED, GO TO 525.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 523 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 QUESTION 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT.

CIRCLE CODE '2' IN 523 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 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. 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 confidential. 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?

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

525) READ THE VITAMIN A TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

526) CHECK 523 AND 525 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 528 AND FOR THE VITAMIN A TEST PROCEDURE IN 530 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

527) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET (9).

528) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

529) BAR CODE LABEL

PUT FIRST BAR CODE LABEL HERE

PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.

530) OUTCOME OF VITAMIN A TEST PROCEDURE

CONSENT STATEMENT FOR VITAMIN A DEFICIENCY TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 525 IF RESPONDENT CONSENTS TO THE VITAMIN A 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 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT.

CIRCLE CODE '2' IN 525 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 take a test for vitamin A deficiency. Vitamin A deficiency is a health problem that can result poor nutrition. This survey will help the government to develop programs to prevent and treat vitamin A deficiency.

For the vitamin A test, we need a few more drops of blood from a finger. 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. 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 either.
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 vitamin A deficiency test?

530A) CHECK 530: OUTCOME OF VITAMIN A TEST

530B) READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

530C) ADDITIONAL TESTS

CHECK 530B: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 530B IF RESPONDENT CONSENTS TO THE ADDITIONAL 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 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 530A IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR MEN AGE 15-54

531) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 532. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 543 FOR EACH ELIGIBLE MAN.

IF NO ELIGIBLE , TICK HERE.

532) LINE NUMBER (COLUMN 10)

NAME (COLUMN 2)

533) WEIGHT IN KILOGRAMS

534) HEIGHT IN CENTIMETERS

535) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

536) AGE: CHECK COLUMN 7.

537) MARITAL STATUS: CHECK COLUMN 8.

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

539) READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 539 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 539 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 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.

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 confidential.

Do you have any questions?

You can say yes or you can say no. It is up to you to decide.

Will you (allow NAME OF ADOLESCENT to) take the anemia test?

541) CHECK 539 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE ANEMIA TEST IF CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST.

A FINAL OUTCOME OF THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 543 FOR EACH ELIGIBLE MAN EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

542) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET (9).

543) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT