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UGANDA BUREAU OF STATISTICS
2011 UGANDA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE-ENGLISH


IDENTIFICATION

DISTRICT

RESIDENCE STATUS

RURAL 3
URBAN 1

COUNTY

SUBCOUNTY/TOWN

PARISH/LC1 NAME

EA NAME

NAME OF HOUSEHOLD HEAD

HOUSEHOLD NUMBER

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

YES 1
NO 2

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE

NO 0
FEMALE 1
MALE 2

HOUSEHOLD SELECTED FOR UNHS IV

YES 1
NO 0
IF YES RECORD HH CODE


INTERVIEWER VISITS

FIRST VISIT

DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT

DATE
TIME

SECOND VISIT

DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT

DATE
TIME

THIRD VISIT

DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT

DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NUMBER __ __ __
RESULT __

TOTAL NUMBER OF VISITS __

*RESULT CODES:

1 COMPLETED
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 RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __ __

LANGUAGE OF THE QUESTIONNAIRE __ __

LANGUAGE USED IN THE INTERVIEW __ __

NATIVE LANGUAGE OF RESPONDENT __ __

TRANSLATOR USED

NOT AT ALL 1
SOMETIMES 2
ALL THE TIME 3

LANGUAGE USED:

01 ATESO
02 LUGANDA
03 LUGBARA
04 LUO
05 RUNYANKOLE-RUKIGA
06 RUNYORO-RUTORO
07 NGAKARAMOJONG
08 ENGLISH
96 OTHER (SPECIFY) ___________

SUPERVISOR

NAME ___________ __ __ __

FIELD EDITOR
NAME ___________ __ __ __

OFFICE EDITOR __ __

KEYED BY __ __


INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ I am working with Uganda Bureau of Statistics. We are conducting a survey about health all over UGANDA. 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 30 to 45 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?

YES ___
NO ___

May I begin the interview now?

YES ___
NO ___

SIGNATURE OF INTERVIEWER: ____________________
DATE: __________

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

START TIME

HOUR __ __
MINUTES __ __


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 5-29 FOR EACH PERSON.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD

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

SEE CODES BELOW

__ __

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'

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 NEVER- MARRIED AND NEVER LIVED TOGETHER

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

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 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 __

CODES FOR Q 3: RELATIONSHIP TO HEAD OF 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 NIECE/NEPHEW BY BLOOD
10 NIECE/NEPHEW BY MARRIAGE
11 CO-WIFE
12 OTHER RELATIVE
13 ADOPTED/FOSTER/STEPCHILD
14 NOT RELATED
98 DON'T KNOW
00 MOTHER NOT LISTED

[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 (NAMES)'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 3 YEARS OR OLDER]

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20)

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 __
GRADE __ __

[IF AGE 3-24 YEARS]

CURRENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the 2011 school year?

YES 1
NO 2 (GO TO 20)

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

SEE CODES BELOW.

LEVEL __
GRADE __ __

[0-4 YEARS]

BIRTH REGISTRATION

20) Does (NAME) have a birth certificate?

IF YES, ASK RESPONDENT TO SHOW CERTIFICATE.

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

1 HAS CERTIFICATE SEEN
2 HAS CERTIFICATE NOT SEEN
3 REGISTERED
4 NOT REGISTERED
8 DON'T KNOW

[IF AGE 5-17 YEARS]

BASIC MATERIAL NEEDS

21) Does (NAME) have a blanket?

YES 1
NO 2

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

YES 1
NO 2

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

YES 1
NO 2

CODES FOR Qs 17 AND 19: EDUCATION

LEVEL

0 PRESCHOOL
1 PRIMARY
2 'O' LEVEL
3 'A' LEVEL
4 TERTIARY
5 UNIVERSITY
6 FAL
8 DON'T KNOW

GRADE

00 LESS THAN 1 YEAR COMPLETED (USE '00' FOR Q 17 ONLY THIS CODE IS NOT ALLOWED FOR Q 19)
98 DON'T KNOW

[COMPLETE COLUMNS 24-29 FOR ALL HH MEMBERS AGED 5 OR OLDER]

DIFFICULTIES

24) Because of a physical, mental or, emotional health condition, does (NAME) have difficulty seeing even if he/she is wearing glasses?

1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW
1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW

25) Because of a physical, mental or, emotional health condition, does (NAME) have difficulty hearing even if he/she is using a hearing aid?

1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW

26) Because of a physical, mental or, emotional health condition, does (NAME) have difficulty walking or climbing steps?

1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW

27) Because of a physical, mental or, emotional health condition, does (NAME) have difficulty remembering or concentrating?

1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW

28) Because of a physical, mental or, emotional health condition does (NAME) have difficulty with self care such as washing all over, dressing, feeding, toileting?

1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW

29) Because of a physical, mental or, emotional health condition does (NAME) have difficulty
communicating for example understanding others or being understood by others?

1 NO - NO DIFFICULTY
2 YES -- SOME DIFFICULTY
3 YES -- A LOT OF DIFFICULTY
4 CANNOT DO AT ALL
8 DON'T KNOW


TABLE FOR SELECTION OF RESPONDENT FOR THE VIOLENCE QUESTIONS

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

HOUSEHOLD IS SELECTED FOR DV ___
HOUSEHOLD IS NOT SELECTED FOR DV ___ (GO TO 101)

INSTRUCTIONS

LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE IF THE HH 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 HH IS SELECTED FOR A MALE RESPONDENT, CHECK THE TOTAL NUMBER OF ELIGIBLE MEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE AND CIRCLE THIS COLUMN NUMBER. FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE ELIGIBLE WOMAN/MAN WHO WILL BE ASKED THE VIOLENCE QUESTIONS.

THEN, GO TO COLUMN (9) IN THE HOUSEHOLD SCHEDULE IF THE HH IS SELECTED FOR FEMALE RESPONDENT OR COLUMN (10) IF THE HH 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 NUMBER 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 HH 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.

[Lefthand column of table] LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW).
Numbers 0 through 9 follow.

[Top row of table] TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)
Rows of numbers 1 through 8, 1 number in each column, follows.

HOUSEHOLD LINE NUMBER OF PERSON SELECTED FOR VIOLENCE MODULE __ __

HOUSEHOLD CHARACTERISTICS

101) Sometimes people smoke inside our houses for example our family members, our neighbors or even our friends. 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 TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
WATER FROM OPEN WELL/SPRING
OPEN WELL/SPRING IN YARD/PLOT 21
OPEN PUBLIC WELL/SPRING 22
WATER FROM PROTECTED WELL/SPRING
PROTECTED WELL/SPRING IN YARD/PLOT 31
PROTECTED PUBLIC WELL/SPRING 32
WATER FROM BOREHOLE
BOREHOLE IN YARD/PLOT 41
PUBLIC BOREHOLE 42
SURFACE WATER (RIVER/DAM ETC)
RIVER/STREAM 51
POND/LAKE 52
DAM 53
RAIN WATER 61 (GO TO 105)
TANKER TRUCK 71 (GO TO 105)
VENDOR 72 (GO TO 105)
BOTTLED WATER 91 (GO TO 105)
OTHER (SPECIFY) ____________ 96

103) Where is that 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 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 8 ( GO TO 107)

106) What do you usually do to make the water safer to drink?

Anything else?
RECORD ALL MENTIONED

BOIL A
ADD WATER GUARD B
ADD BLEACH/CHLORINE C
STRAIN THROUGH A CLOTH D
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC) E
SOLAR DISINFECTION F
LET IT STAND AND SETTLE 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 01
VIP LATRINE 02
COVERED PIT LATRINE NO SLAB 03
COVERED PIT LATRINE W/ SLAB 04
UNCOVERED PIT LATRINE NO SLAB 05
UNCOVERED PIT LATRINE W/ SLAB 06
COMPOSTING TOILET 07
NO FACILITY/BUSH/FIELD 08 (GO TO 110)
ECOSAN 09
OTHER (SPECIFY) __________ 96

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

YES 1
NO 2 (GO TO 109A)

109) How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 __ __
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

109A) Does this toilet have any facility for washing hands after use?

YES 1
NO 2

110) Does your household have:

a) Electricity?
YES 1
NO 2
b) A radio?
YES 1
NO 2
c) A cassette player?
YES 1
NO 2
d) A television?
YES 1
NO 2
e) A mobile phone?
YES 1
NO 2
f) A fixed phone?
YES 1
NO 2
g) A refrigerator?
YES 1
NO 2
h) A table?
YES 1
NO 2
i) A chair?
YES 1
NO 2
j) A sofa set?
YES 1
NO 2
k) A bed?
YES 1
NO 2
l) A cupboard?
YES 1
NO 2
m) A clock?
YES 1
NO 2

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

ELECTRICITY 01
LPG/NATURAL GAS 02
BIOGAS 04
KEROSENE/PARAFFIN 05
CHARCOAL 07
FIREWOOD 08
STRAW/SHRUBS/GRASS 09
ANIMAL DUNG 10
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
EARTH AND DUNG 12
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
MOSAIC OR TILES 33
BRICKS 34
CEMENT 35
STONES 36
OTHER (SPECIFY) __________ 96

115) MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
THATCHED 11
MUD 12
FINISHED ROOFING
WOOD/PLANKS 21
IRON SHEETS 22
ASBESTOS 23
TILES 24
TIN 25
CEMENT 26
OTHER (SPECIFY) ___________ 96

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

NATURAL WALLS
THATCHED/STRAW 11
RUDIMENTARY WALLS
MUD AND POLES 21
UN-BURNT BRICKS 22
UN-BURNT BRICKS WITH PLASTER 23
BURNT BRICKS WITH MUD 24
FINISHED WALLS
CEMENT BLOCKS 31
STONE 32
TIMBER 33
BURNT BRICKS WITH CEMENT 34
OTHER (SPECIFY) ___________ 96

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

ROOMS __ __

118) Does any member of this household own:

a) A watch?
YES 1
NO 2
b) A bicycle?
YES 1
NO 2
c) A motorcycle or motor scooter?
YES 1
NO 2
d) An animal-drawn cart?
YES 1
NO 2
e) A car or truck?
YES 1
NO 2
f) A boat with a motor?
YES 1
NO 2
g) A boat without a motor?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 121)

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

ACRES __ __ . __
95 OR MORE ACRES 950
DON'T KNOW 998

121) Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 124)

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'

LOCAL CATTLE __ __
EXOTIC/CROSS CATTLE __ __
HORSES/DONKEYS/MULES __ __
GOATS __ __
SHEEP __ __
PIGS __ __
CHICKENS __ __

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 8 (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 Y

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 THE BRAND/TYPE OF MOSQUITO NET.

IF NOT OBSERVED ASK: What brand is this net?

IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT

'LONGLASTING' NET
PERMANET 11 (GO TO 134)
DURANET 12 (GO TO 134)
INTERCEPTOR 13 (GO TO 134)
NETPROTECT 14 (GO TO 134)
OLYSET 15 (GO TO 134)
DAWANET 16 (GO TO 134)
ICONLIFE 17 (GO TO 134)
FACTORY NET WITH INSECTICIDE KIT
KO NET 21
KOOPER NET 22
ICONET 23
SAFI NET 24
FACTORY NET WITH NO INSECTICIDE
B52 31
BAMBOO HUT 32
CENTURY 33
LUCKY NET 34
VICTORIA 35
HOMEMADE NET 41
OTHER (SPECIFY) ______________ 96
DON'T KNOW BRAND 98

132) Since you got the mosquito 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 134)

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

IF LESS THAN ONE MONTH AGO, RECORD '00'

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)
NOT SURE 8 (GO TO 136)

135) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM THEHOUSEHOLD SCHEDULE

NAME_____________
LINE NO. __ __

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

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 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON (GO TO 140)

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

140) 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


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

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER __ __
NAME ___________________

203) IF MOTHER INTERVIEWED, COPY MONTH ANDYEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY;

IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

DAY __ __
MONTH __ __
YEAR __ __ __ __

204) CHECK 203: CHILD BORN IN JANUARY 2006 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 216)

205) WEIGHT IN KILOGRAMS

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

206) HEIGHT IN CENTIMETERS

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

207) MEASURED LYING DOWN
OR STANDING?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203: 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 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 216)
OLDER 2

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE).

RECORD '00' IF NOT LISTED

LINE NUMBER __ __

210) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2006 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than 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 CHILD) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
(SIGN) _________________
REFUSED 2
(SIGN) _________________

211A) ASK CONSENT FOR VITAMIN A TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

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 from 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 CHILD) to take the vitamin A deficiency test?

211B) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

GRANTED 1
(SIGN) __________________
REFUSED 2
(SIGN) __________________

211C) CIRCLE THE APPROPRIATE CODE

DON'T TAKE DBS IFRESPONDENT DOES NOT AGREE FOR VITAMIN A

AGREED TO ANEAMIA AND VITAMIN A TEST 1
AGREED TO ANEAMIA ONLY 2 (GO TO 212 THEN SKIP 213 AND GO TO 215)
AGREED TO VITAMIN A ONLY 3 (GO TO 213)
AGREED TO NEITHER 4 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 216)

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

G/DL __ __ . __
NOT PRESENT 994
REFUSED 995
OTHER 996

213) BAR CODE LABEL FOR VITAMIN A TEST

[PUT THE 1ST BAR CODE LABEL HERE]
BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

215) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 216.


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

216) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 217.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONALQUESTIONNAIRE(S).

217) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER __ __
NAME ______________

218) WEIGHT IN KILOGRAMS

KG __ __ __. __ __
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

219) HEIGHT IN CENTIMETERS

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

220) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 225)

221) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 225)

222) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT

RECORD '00' IF NOT LISTED

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT __ __

223) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 222 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17

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 to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) 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 for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

224) CIRCLE THE APPROPRIATE CODE ANDSIGN YOUR NAME

GRANTED 1
(SIGN) _________________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN) _________________
(IF REFUSED, GO TO 228)

225) ASK CONSENT FOR ANEAMIA TEST FROM RESPONDENT

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 to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than 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 take the anemia test?

226) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
(SIGN) _______________
RESPONDENT REFUSED 2
(SIGN) _______________
(IF REFUSED, GO TO 227A)

227) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:

Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

227A) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 230)

227B) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 230)

228) ASK FOR CONSENT FROM PARENT/ OTHER ADULT IDENTIFIED IN 222 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 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?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
(SIGN) ____________________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN) ____________________
(IF REFUSED, GO TO 237)

230) ASK CONSENT FOR VITAMIN A TESTING FROM RESPONDENT
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 take the vitamin A deficiency test?

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

GRANTED 1
(SIGN) _________________
RESPONDENT REFUSED 2
(SIGN) _________________
__ __ __

(IF REFUSED, GO TO 237)

231A) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 230)

231B) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2
(GO TO 230)

232 ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 222 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests 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 later use, (NAME OF ADOLESCENT) can still participate in the vitamin A testing in this survey.

Will you allow us to keep the blood sample stored for later testing or research?

233) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
(SIGN) _______________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN) _______________
(IF REFUSED, GO TO 236)

234) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT).

Will you allow us to keep the blood sample stored for later testing or research?

235) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
(SIGN) ________________
RESPONDENT REFUSED 2
(SIGN) ________________
(IF REFUSED, GO TO 237)

236) ADDITIONAL TESTS

CHECK 233 AND 235:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

238) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPLET

G/DL __ __ . __
NOT PRESENT 994
REFUSED 995
OTHER 996

239) BAR CODE LABEL FOR VITAMIN A TEST

[PUT THE 1ST BAR CODE LABEL HERE]
BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM

240) GO BACK TO 217 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 241.


WEIGHT AND HEIGHT MEASUREMENT FOR MEN AGE 15-54

241) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 242.
IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

242) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

LINE NUMBER __ __
NAME _________________

243) WEIGHT IN KILOGRAMS

KG __ __ __ . __ __
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

244) HEIGHT IN CENTIMETERS

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

245) GO BACK TO 242 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

END TIME

HOUR __ __
MINUTES __ __