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HOUSEHOLD QUESTIONNAIRE

REPUBLIC OF YEMEN
MINISTRY OF PUBLIC HEALTH AND POPULATION
CENTRAL STATISTICAL ORGANIZATION
NATIONAL HEALTH AND DEMOGRAPHIC SURVEY 2013

IDENTIFICATION

GOVERNORATE____

DIRECTORATE NAME____

SUB-DIRECTORATE NAME____

URBAN OR RURAL:

URBAN 1
RURAL 2

SECTOR NUMBER____

SECTION NUMBER____

CLUSTER NUMBER____

HOUSEHOLD NUMBER____

HOUSEHOLD CLUSTER NUMBER____

NAME OF HOUSEHOLD HEAD____

IS THIS HOUSEHOLD SELECTED FOR ANEMIA TESTING?

YES 1
NO 2

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
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 EVER MARRIED WOMEN IN AGE 15-49____
TOTAL ELIGIBLE NEVER MARRIED WOMEN IN AGE 15-49____
TOTAL CHILDREN 0-5____
LINE NUMBER OF RESPONDENT IN HH____

FIELD EDITOR
NAME
SIGNATURE
DATE
CODE

SUPERVISOR
NAME
SIGNATURE
DATE
CODE

OFFICE EDITOR
NAME
SIGNATURE
DATE
CODE

KEYER
NAME
SIGNATURE
DATE
CODE

INTRODUCTION AND CONSENT

INFORMED CONSENT
Hello. My name is (INTERVIEWER'S NAME). I am working on the National Health and Demographic Survey which is implemented (by the Ministry of Public Health and Population and the Central Statistical Organization). We are conducting a survey about health all over Yemen. The information we collect will help the government to plan health services. Your household was selected for the survey. All of the answers you give will be confidential under Article (5) of the Statistics Law No. (28) for the year 1995 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 (CONTINUE)
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 NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK QUESTIONS IN COLUMNS 5-35 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?

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

3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

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 OTHER RELATIVE
10 ADOPTED/FOSTER/CHILD
11 STEPCHILD
12 NOT RELATED
98 DON'T KNOW

4) SEX
Is (NAME) male or female?

MALE
FEMALE

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'.
IF LESS THAN 1 YEAR RECORD '00'.

AGE IN YEARS___

IF AGE 10 OR OLDER

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

MARRIED 1
DIVORCED 2
WIDOWED 3
NEVER MARRIED 4

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

9A) CIRCLE LINE NUMBER OF ALL NEVER MARRIED WOMEN AGE 15-49

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

IF 6 YEARS OR MORE

11A) EMPLOYMENT STATUS

Was (NAME) working most of the time last month?

WORKING 1
NOT WORKING/USED TO WORK 2
NOT WORKING/ NEVER WORKED 3
STUDENT 4
HOUSEWIFE 5
SELF 6
RETIRED 7
HANDICAPPED 8
OTHER (SPECIFY)____ 96

IF 15 YEARS OR MORE

11B) EMPLOYMENT STATUS

ONLY IF THE ANSWER IS 01. 02 OR 07 TO Q. 11A, ASK:

What was/is your main occupation?

OCCUPATION____
CODE____

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: RECORD MOTHER'S LINE NUMBER.
IF NO, '00'.

LINE NUMBER____

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

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

15) Does (NAME)'s natural father usually live in this household or was he a guest last night?

IF YES: RECORD FATHER'S LINE NUMBER.
IF NO, '00'.

LINE NUMBER____

IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 21)
DON'T KNOW 8 (GO TO 21)

17) What is the highest level of school (NAME) has attended?

What is the highest grade (NAME) completed at that level?

SEE CODES BELOW.

CODES FOR Qs. 17 AND 19: EDUCATION

LEVEL

PRE-PRIMARY 0
PRIMARY 1
FUNDAMENTAL (PREPARATORY, UNIFIED) 2
DIPLOMA BEFORE SECONDARY 3
SECONDARY 4
DIPLOMA AFTER SECONDARY 5
UNIVERSITY/HIGHER 6
DON'T KNOW 8

GRADE

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

IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the current school year (2014-2014)?

YES 1
NO 2 (GO TO 21)
DON'T KNOW 8 (GO TO 21)

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

SEE CODES BELOW.

CODES FOR Qs. 17 AND 19: EDUCATION

LEVEL

PRE-PRIMARY 0
PRIMARY 1
FUNDAMENTAL (PREPARATORY, UNIFIED) 2
DIPLOMA BEFORE SECONDARY 3
SECONDARY 4
DIPLOMA AFTER SECONDARY 5
UNIVERSITY/HIGHER 6
DON'T KNOW 8

GRADE

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

IF AGE 0-4 YEARS

20) BIRTH REGISTRATION

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

PREVALENCE OF CHRONIC DISEASES AND SOME HARMFUL PRACTICES

SPREAD OF CHRONIC DISEASES

21) I would like to ask you some questions about the health of all family members. Does (NAME) suffer from any chronic disease?

YES 1
NO 2 (GO TO 28)

22) What is the disease suffered by (NAME)?
RECORD THE NAME OF THE DISEASE AND THE CODE

DISEASE ____
CODE ____

23) Does any physician inform (NAME) that (s)he suffers from this disease?

YES 1
NO 2

24) Does (NAME) get treatment regularly?

YES 1
NO 2

25) Does (NAME) suffer from any other chronic disease?

YES 1
NO 2 (GO TO 28)

26) What is the second disease suffered by (NAME)?

RECORD THE NAME OF THE SECOND DISEASE AND THE CODE

DISEASE ____
CODE____

27) Does any physician inform (NAME) that (s)he suffers from this second disease?

YES 1
NO 2

27A) Does (NAME) take treatment regularly?

YES 1
NO 2

IF 10 YEARS OR PLUS SOCIAL HABITS

28) Does (NAME) smoke cigarettes, or any other kind of tobacco, or was smoking in the past?

YES CURRENTLY 1
YES BEFORE 2
SOMETIMES 3
NEVER 4
DON'T KNOW 8

29) Does (NAME) currently chew al-Qat?

YES DAILY 1
YES WEEKLY 2
SOMETIMES 3
YES BEFORE 4
NEVER 5
DON'T KNOW 6

30) Does (NAME) use orange snuff, or was using snuff in the past?

YES CURRENTLY 1
YES BEFORE 2
SOMETIMES 3
NEVER 4
DON'T KNOW 8

DISABILITY

31) Has (NAME) suffered from any physical or mental conditions in the past 6 months or more that would limit from exercising or performing normal daily activities as other people of the same age?

IF 'YES' PROBE BY ASKING: Does this state severely or moderately limit exercising or daily activities?

YES, SEVERELY 1
YES, FAIRLY 2
NO 3
DON'T KNOW 8

32) Does (NAME) face limitations of any of the following:

CIRCLE ALL MENTIONED

SIGHT? 1
HEARING? 2
COMPREHENSION AND COMMUNICATION? 3
MOBILITY? 4
SELF-CARE? 5
DEALING WITH PEOPLE? 6

33) What is the main reason for (NAME)'s disability?

CONGENITAL 1
CONDITIONS RELATED TO CHILDBIRTH 2
CONTAGIOUS 3
OTHER DISEASE 4
PHYSICAL AND PSYCH. ABUSE 5
AGING 6
INJURY/ACCIDENT 7
ENVY/MAGIC 8
OTHER 96
DON'T KNOW 98

34) How old was (NAME) when this condition started?

AGE ____
AT BIRTH 95
DON'T KNOW 98

35) During the last 12 months did (NAME) receive any care or support?

WITH THE EXCEPTION OF 'Y' CIRCLE ALL MENTIONED, IF YES CIRCLE TYPE OF CARE OR SUPPORT

MEDICAL CARE A
WELFARE B
FINANCIAL SUPPORT C
NUTRITIONAL SUPPORT D
NO CARE/SUPPORT Y

INJURIES, ACCIDENT AND HEALTH SERVICES IN THE TWO YEARS PRECEDING THE SURVEY

41) Have you and/or any member of your household been injured or had an accident in the two years preceding the survey?

YES 1
NO 2 (GO TO MODULE 5)

41A) FOR HOUSEHOLD MEMBERS WITH INJURIES

NUMBER OF HH WITH INJURIES____

42) Who are the members of your household injured in the two years preceding the survey? Please provide their names.

NAME____

43) What injury or accident did you or any member of your household have?

CIRCLE INJURY OR ACCIDENT CODE AS SHOWN BELOW.

CODE Q. 43:

TRAFFIC ACCIDENT A
FALL B
BLOW/BY A PERSON OR OBJECT C
STABBED D
GUNSHOT E
BURNS (FIRE, THERMAL FLAMES) F
DROWNING G
POISONING H
ELECTRIC SHOCK I
OTHER (SPECIFY) ____ X
CODE____

44) IF (NAME) IS DEAD, ASK: What is the injury or the accident that caused the death?
IF (NAME) IS NOT DEAD, GO TO NEXT LINE OR Q. 45

INJURY/ACCIDENT/(SPECIFY) ____
CODE____

45) Did a member of your household go to any health facility for treatment in the two years preceding the survey?

YES 1
NO 2 (GO TO 51)
DON'T KNOW 8 (GO TO 51)

46) Where did (s)he receive the health services last time?

PUBLIC HEALTH FACILITY 1
PRIVATE HEALTH FACILITY 2
MILITARY/POLICE HEALTH FACILITY 3
NGOs 4
FREE MEDICAL CAMPS 5
OTHER (SPECIFY)____ 6

47) Did you have to pay a fee for the service?

YES 1
NO 2 (GO TO 49)
DON'T KNOW 8 (GO TO 49)

48) Who paid for the fees?

THE PERSON HIMSELF 01
EMPLOYER 02
FAMILY MEMBER 03
HEALTH INSURANCE 04
PHILANTHROPIST 05
OTHER (SPECIFY)____ 96
DON'T KNOW 98

49) Were the following health services were provided:

Medical examination?
YES 1
NO 2
DON'T KNOW 8
Laboratory work?
YES 1
NO 2
DON'T KNOW 8
Radiology?
YES 1
NO 2
DON'T KNOW 8
Operations?
YES 1
NO 2
DON'T KNOW 8
Hospital stay?
YES 1
NO 2
DON'T KNOW 8
Medicine?
YES 1
NO 2
DON'T KNOW 8
Physiotherapy?
YES 1
NO 2
DON'T KNOW 8

5. MODULE ON CONTROLLING CHILDREN'S BEHAVIOR

TABLE 1: FOR CHILDREN AGE 2-14 YEARS
RECORD IN THE FOLLOWING TABLE IN ORDER THE LINE NUMBER IN THE FIRST COLUMN AND DON'T TAKE INTO ACCOUNT INDIVIDUALS OUTSIDE THE AGE GROUP 2-14 YEARS. ENTER THE CHILDREN'S LINE NUMBERS, THE NAME, SEX AND AGE OF CHILDREN, AND IN Q. 56, ENTER THE TOTAL OF CHILDREN AGED 2-14 YEARS.

51) LINE NUMBER____

52) LINE NUMBER FROM THE HOUSEHOLD SCHEDULE, COL. 1

LINE NUMBER____

53) CHILDREN'S NAMES FROM THE HOUSEHOLD SCHEDULE, COL.2

NAME____

54) SEX FROM THE HOUSEHOLD SCHEDULE, COL. 4

MALE 1
FEMALE 2

55) AGE FROM THE HOUSEHOLD SCHEDULE, COL. 7

AGE____

56) RECORD THE TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS

NUMBER OF CHILDREN____

CHECK Q. 56, IF ONLY ONE CHILD AGE 2-14, SKIP TABLE 2, AND GO TO Q. 58. ENTER THE LINE NO. FROM TABLE 1 Q. 51 AND CONTINUE

TABLE 2: RANDOM SELECTION OF THE CHILD FOR THE QUESTIONS ON CHILDREN BEHAVIOR
USE THIS TABLE TO SELECT A CHILD IN THE AGED GROUP 2-14 YEARS, IF THERE IS MORE THAN ONE CHILD IN THAT CATEGORY IN THE HOUSEHOLD. CHECK THE HOUSEHOLD NUMBER OF THE COVER PAGE AND THE FIRST DIGIT OF THE HOUSEHOLD NUMBER IS THE ROW NUMBER AND THE TOTAL NUMBER OF CHILDREN 2-14 YEARS RECORDED IN Q. 56 IS THE COLUMN NUMBER. THE NUMBER IN THE BOX WHICH MEETS THE SELECTED ROW AND COLUMN IS THE ORDINAL NUMBER OF THE CHILD THAT WILL BE SELECTED TO THE QUESTIONS ON CHILDREN'S BEHAVIOR. ENTER THIS NUMBER IN Q. 58, AND IN Q. 59, RECORD THE LINE NUMBER AND THE NAME OF THE SELECTED CHILD AS INDICATED IN Qs. 52 AND 53. THEN LOOK FOR THE MOTHER/CARETAKER OF THE CHILD AND ASK HER THE QUESTIONS STARTING WITH Q. 61.

57) FIRST DIGITAL NO. FROM HH NO. IN COVER PAGE

TOTAL NUMBER OF CHILDREN 2-14 YEARS (Q. 56)

58) ENTER THE NUMBER OF THE SELECTED CHILD IN THE BOX

NUMBER OF SELECTED CHILD____

IDENTIFY THE ELIGIBLE CHILDREN AGED 2-14 YEARS USING THE TABLES IN THE PREVIOUS PAGE ACCORDING TO THE INSTRUCTIONS. ASK TO INTERVIEW THE MOTHER/CARETAKER OF THE SELECTED CHILD IDENTIFIED BY THE MOTHER'S/CARETAKER'S LINE NUMBER IN 58.

59) REFER TO Qs. 52 AND 53 AND ENTER THE NAME AND THE LINE NUMBER OF THE SELECTED CHILD BASED ON THE ORDINAL NUMBER OF Q. 58
RECORD MOTHER/CARETAKER'S LINE NUMBER WHO WILL ANSWER THE FOLLOWING QUESTIONS

NAME____
CHILD LINE NUMBER____
MOTHER/CARETAKER'S LINE NO.____

60) Many parents use some of these ways to teach their children proper behavior or to deal with behavioral problems. I will tell you some of the ways that are used and I would like you to tell me if you or anyone in the household used this method with (NAME) during last month:

61) Taking away a privilege from (NAME), taking away something (s)he wants or loves, or not letting him/her leave the house

YES 1
NO 2

62) Explain to the child why his/her behavior is wrong

YES 1
NO 2

63) Hitting the child on the shoulder or spanking on the rear

YES 1
NO 2

64) Hitting on the rear or on any other place of the child's body using something such as a belt, a hair brush, a stick, or something solid

YES 1
NO 2

65) Hitting the child in the face or hitting the child's head or ear

YES 1
NO 2

66) Hitting the child's hand, arm, or leg

YES 1
NO 2

67) Punishing the child by using a tool, and then continuing to hit the child very hard
PROBE FOR MORE INFORMATION, IF NECESSARY

YES 1
NO 2

68) Do you think that a child must be punished physically in order to be raised in an appropriate way?

YES 1
NO 2
DON'T KNOW/NO OPINION

6. HOUSEHOLD CHARACTERISTICS

100) What type of dwelling unit does your household live in?

INDEPENDENT HOUSE/ROOM 01
VILLA 02
APARTMENT IN BUILDING 03
TENT 04
HUT 05
TEMPORARY SHELTER 06
OTHER (SPECIFY)____ 96

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

PIPED GOVERNMENT NETWORK 01
PIPED LOCAL NETWORK 02
TUBE WELL OR BOREHOLE 03
REGULAR WELL 04
WATER FROM SPRING 05
SURFACE WATER/PROTECTED 06
SURFACE WATER/UNPROTECTED 07
TANKER TRUCK 08
RAIN WATER COLLECTION 09
BOTTLED WATER 10
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 (SPECIFY)____ 6

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? RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER D
TREATED AT SOURCE E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ____ X

107) Is there a special room or closed space used as a toilet facility inside or outside the dwelling?

YES IN DWELLING 1 (GO TO 108)
YES OUTSIDE DWELLING 2 (GO TO 108)
NO TOILET FACILITY IN DWELLING 3

107A) Where do you go or what do you use when you need to go to the toilet?

IN OPEN AIR 1 (GO TO 109)
PUBLIC TOILET 2 (GO TO 109)
OTHER (SPECIFY) ____ 6

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

YES SHARED 1
NO, NOT SHARED 2

108A) What type of toilet?

FLUSH TO PIPED SEWER SYSTEM 1
FLUSH TO SEPTIC TANK 2
BUCKET 3
PIT 4
LATRINE 5
OTHER (SPECIFY)____ 6

109) Is there a special room used for cooking inside or outside the dwelling?

YES INSIDE THE DWELLING 1
YES OUTSIDE THE DWELLING 2
NO KITCHEN 3

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

ELECTRICITY 01
BIOGAS 02
KEROSENE 03
CHARCOAL 04
WOOD 05
ANIMAL DUNG 06
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY)____ 96

111) What is the main source of light?

PUBLIC ELECTRIC NETWORK 01
COOP. ELECTRIC NETWORK 02
PRIVATE ELECTRIC NETWORK 03
SPECIAL GENERATOR 04
SOLAR ENERGY 05
GAZ (KEROSENE) 06
OTHER (SPECIFY)____ 96
NO LIGHTING 97

112) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

CEMENT 01
PLAIN TILE 02
PLASTER 03
DIRT/CLAY 04
STONE 05
MARBLE 06
OTHER (SPECIFY)____ 96

113) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

CONCRETE ROOF/CEMENT 01
WOOD AND CEMENT 02
WOOD AND DIRT 03
WOOD 04
METAL PLATES (ZINC) 05
STRAW/CANE 06
CANE AND MUD 07
METAL PLATES AND MUD 08
OTHER (SPECIFY)____ 96

114) MAIN MATERIAL OF THE EXTERIOR WALLS

CARVED STONE 01
PLAIN STONE 02
CEMENT BLOCKS 03
LOCAL ADOBE 04
COVERED ADOBE 05
DIRT 06
STRAW/CANE 07
CLOTH/WOOL 08
OTHER (SPECIFY)____ 96

115) How many rooms in this household are used by the family?

ROOMS ____

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

ROOMS ____

117) Does any member of your household own:

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
A radio?
YES 1
NO 2
A TV?
YES 1
NO 2
A cell phone?
YES 1
NO 2
A fixed phone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A washer?
YES 1
NO 2
An air conditioner?
YES 1
NO 2
A fan?
YES 1
NO 2
A generator?
YES 1
NO 2
A water heater?
YES 1
NO 2

118) Does any member of this household own any:

Agricultural land?
YES 1
NO 2
Real estate?
YES 1
NO 2
Commercial or industrial property?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 137)

122) How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'
IF DON'T KNOW, ENTER '98'.

Cows?
NUMBER OF COWS____
Horses, donkeys, or mules?
NUMBER OF HORSES____
Camels?
NUMBER OF CAMELS____
Goats?
NUMBER OF GOATS____
Sheep?
NUMBER OF SHEEP____
Chickens?
NUMBER OF CHICKENS____

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 (SPECIFY)____ 6 (GO TO 140)

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

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 Y

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

140A) In the last four weeks, were there cases where you did not have any kind of food to eat because of the lack of resources?

RARELY 1
SOMETIMES 2
OFTEN 3
NEVER 4

140B) In the last four weeks, were there cases where you or a family member went to bed hungry because there was not enough food?

RARELY 1
SOMETIMES 2
OFTEN 3
NEVER 4

140C) In the last four weeks, were there cases where you or anyone from your family spent the whole day without eating because there was not enough food?

RARELY 1
SOMETIMES 2
OFTEN 3
NEVER 4

7 - WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

201) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS. IN QUESTION 202. IF MORE THAN THREE CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 10, NAME FROM COLUMN 2

LINE NUMBER____
NAME____

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR 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 2008 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)

205) WEIGHT IN KILOGRAMS

KILOGRAMS____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CENTIMETERS____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

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 214)
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 all children born in 2008 or later to 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)____

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

G/DL____
NOT PRESENT 994
REFUSED 995
OTHER 996

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 214.

214) CHECK COLUMN 9 AND 9A IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) LINE NUMBER FROM COLUMN 9, 9A NAME FROM COLUMN 2

LINE NUMBER ____
NAME ____

216) WEIGHT IN KILOGRAMS

KILOGRAMS____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

217) HEIGHT IN CENTIMETERS

CENTIMETERS____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

217A) MID-UPPER ARM CIRCUMFERENCE IN CENTIMETERS

CENTIMETERS____
NOT PRESENT 994
REFUSED 995
OTHER 996

217B) CHECK COVER PAGE: IS THIS HOUSEHOLD SELECTED FOR ANEMIA TESTING?

YES (CONTINUE)
NO (GO TO 228)

218) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 223)

219) MARITAL STATUS: CHECK COLUMN 8.

NEVER MARRIED 1
MARRIED OR EVER MARRIED 2 (GO TO 223)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT ____

221) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 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, or you can say no. It is up to you to decide.

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

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)____ (GO TO 227)
REFUSED 2 (SIGN)____ (GO TO 228)

223) ASK CONSENT FOR ANEMIA 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 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 take the anemia test?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)____
REFUSED 2 (SIGN)____ (GO TO 228)

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

YES 1
NO 2
SINGLE WOMEN 3
DON'T KNOW 8

226) CHECK 224 AND PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

227) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ____
NOT PRESENT 994
REFUSED 995
OTHER 996

228) GO BACK TO 215 IN NEXT COLUMN OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END THE HOUSEHOLD 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 SUPERVISOR: ____

DATE: ____

EDITOR'S OBSERVATIONS: ____

NAME OF EDITOR: ____

DATE: ____