IDENTIFICATION

LOCALITY NAME _________________

NAME OF HOUSEHOLD HEAD __________________

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

PROVINCE ___

URBAN/RURAL___

LUSAKA/OTHER CITY/ TOWN/ VILLAGE___

LINE NUMBER OF WOMAN SELECTED FOR Qs. 720A-720L ___

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

HOUSEHOLD SELECTED FOR SUGAR SAMPLE?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT____

RESULT* ______________

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ___
RESULT ____

TOTAL NUMBER OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN __

TOTAL ELIGIBLE MEN __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTION __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR

KEYED BY

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

(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.

(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?

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

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

(7) AGE: How old is (NAME)?

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

(9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6.

(9A) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

(9B) CIRCLE LINE NO. OF WOMAN SELECTED FOR Qs. 720A-720L.

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD**

(10) Is (NAME)'s natural mother alive?

(11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

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

(13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.

(14) EDUCATION IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

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

(16) IF AGE 5-24 YEARS: Is (NAME) currently attending school/Did (NAME) attend school in 2001?

(17) During the current school year/year 2001, did (NAME) attend school at any time?

(18) During the current school year/year 2001, what level and grade [is/was] (NAME) attending?

(19) During the previous school year/year 2000, did (NAME) attend school at any time?

(20) During that school year/year 2000, what level and grade did (NAME) attend?

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

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

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

TICK HERE IF CONTINUATION SHEET USED. __

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

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

23. How do you store drinking water?

24. Do you usually boil your drinking water?

25. Have you ever seen or heard of a product called Clorin - a liquid that is sold in a bottle and can be used to make water safe to drink?

26. Where have you seen or heard messages about Clorin?
CIRCLE ALL MENTIONED.

27. Is your household water currently treated with Clorin from a bottle or packet?

29. What kind of toilet facilities does your household have?

30. Do you share these facilities with other households?

31. Does your household have:

32. What is the main source of energy used for cooking?

33. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

34. Does any member of your household own:

35. Does your household own any mosquito nets that can be used to protect against mosquitoes while sleeping?

36. How many mosquito nets does your household own?

ASK THE FOLLOWING QUESTIONS FOR EACH NET.
37. How long ago did your household obtain the mosquito net?

38. Was the mosquito net treated with insecticide to repel mosquitoes or bugs when you obtained it?

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

40. Who slept under this mosquito net last night?
RECORD RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

41. GO BACK TO 37 IN NEXT COLUMN; OR, IF NO MORE NETS, GO TO 42.

42. Do you have sugar in your house now?

43. ASK RESPONDENT TO BRING THE PACKAGE OF SUGAR.
RECORD TYPE OF SUGAR PACKAGE. IF HOUSEHOLD IS SELECTED FOR SUGAR SAMPLE, COLLECT SUGAR AS INSTRUCTED.

44. Approximately how much sugar does this household usually consume in one week?

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

46. These days, would you say that this household usually has enough food to eat, sometimes has enough food to eat, seldom has enough food to eat, or never has enough food to eat?

47. In the last 12 months, have you or any member of this household been denied care from a health facility because you couldn't pay?

48. In the last 12 months, have you or any member of this household been prescribed medicine that you didn't obtain because you couldn't pay?

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

Take the last digit of the sequential questionnaire number. This is the number of the row you should go to. See the total number of eligible women on the cover sheet of the household questionnaire. This is the number of the column you should go to. Find the box where the row and the column meet. Circle the number that appears in the box. This is the number of the woman who will be asked the domestic violence questions. Then, go to Column 9(B) in the household schedule and circle the corresponding line number of the eligible woman (e.g. if the number in the box is '2' and there are three women in the household whose line numbers are '02', '03', and '07, the line number of the eligible woman for domestic violence questions is '03').

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN HOUSEHOLD (COLUMN)
1 2 3 4 5 6 7 8
0 1 2 2 4 3 6 5 4
1 1 1 3 1 4 1 6 5
2 1 2 1 2 5 2 7 6
3 1 1 2 3 1 3 1 7
4 1 2 3 4 2 4 2 8
5 1 1 1 1 3 5 3 1
6 1 2 2 2 4 6 4 2
7 1 1 3 3 5 1 5 3
8 1 2 1 4 1 2 6 4
9 1 1 2 1 2 3 7 5

WEIGHT AND HEIGHT MEASUREMENT

CHECK COLUMNS (8) AND (9A): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

(49) LINE NO. FROM COL. (8)

(50) NAME FROM COL. (2)

(51) AGE FROM COL. (7)

(52) What is (NAME'S) date of birth?

(53) WEIGHT (KILOGRAMS)

(54) HEIGHT (CENTIMETRES)

(55) MEASURED LYING DOWN OR STANDING UP

(56) RESULT

TICK HERE IF CONTINUATION SHEET USED __

There will be an education survey done at a later point in time. Your household may or may not be asked to participate in this survey. If your household is included in the survey, someone will return to your house and ask additional questions about education.

INFORMED CONSENT FOR SYPHILIS AND HIV TESTS
SYPHILIS TESTING

Hello, my name is (YOUR NAME) and I am from the Ministry of Health. As my colleague has informed you already, we are doing a health survey. In this survey, we are studying syphilis among women 15-49 of age and men 15-59 of age in Zambia. Syphilis can cause serious problems if it is not treated. The results from this survey will help the government to develop programs to prevent and treat syphilis.

We encourage you to participate in this test by giving a small amount of blood from your arm. For this test we use sterile instruments that are clean and completely without risk. The blood will be analyzed this evening and I will be back tomorrow to give you the results if you tell me when you will be here. If the test results show that you have syphilis, we would provide free treatment for you and your partner(s) at home or at the nearest health center. No one will know the results of your test except you and me.

At this moment, do you have any questions?

Now, will you tell me if you accept to participate in the syphilis test? GO BACK TO COLUMN (62). CIRCLE THE APPROPRIATE CODE AND SIGN.

IF RESPONDENT IS AGE 15-17, ASK PARENT/GUARDIAN: Now, will you tell me if you accept for (NAME OF YOUTH) to participate in the syphilis test? GO TO COLUMN (62). CIRCLE THE APPROPRIATE CODE AND SIGN. THEN READ THE CONSENT FORM TO YOUTH.

IF CONSENTED, TAKE BLOOD. THEN ASK: If the test shows that you have syphilis and we can't find you for treatment at home, we would like to give that information to the health authorities so that they can follow up. Do you agree that we can give your name and the location of this house to the health authorities if the test shows that you need treatment? CIRCLE CODE FOR 'YES' OR 'NO' IN COLUMN (63).

HIV TESTING

CHECK SYPHILIS CONSENT STATEMENT:

CONSENTED ___
We are also studying HIV among women and men in our survey. HIV is a serious health problem. As you may know, HIV is the virus that causes AIDS, which is usually fatal. This survey will assist the government to develop programs for preventing HIV and AIDS.

We request that you participate in the HIV testing part of this survey by authorizing us to use a few drops of the blood that we have already collected for the syphilis test.

To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your HIV test and no one will be able to trace the test back to you. However, if you want to know your HIV status you will be referred to the nearest health facility which will offer you free testing and counseling.

At this moment, do you have any questions?

Now, will you tell me if you accept to participate in the HIV test? GO BACK TO COLUMN (64). CIRCLE THE APPROPRIATE CODE AND SIGN.

IF RESPONDENT IS AGE 15-17, ASK PARENT/GUARDIAN: Now, will you tell me if you accept for (NAME OF YOUTH) to participate in the HIV test? GO BACK TO COLUMN (64). CIRCLE THE APPROPRIATE CODE AND SIGN. THEN READ CONSENT FORM TO YOUTH.

NOT CONSENTED ___
We are also studying HIV among women and men in our survey. HIV is a serious health problem. As you may know, HIV is the virus that causes AIDS, which is usually fatal. This survey will assist the government to develop programs for preventing HIV and AIDS.

We ask that you participate in this test by giving a few drops of blood from your finger. For this test we use sterile instruments that are clean and completely without risk. Blood will be tested later in the laboratory.

To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your HIV test and no one will be able to trace the test back to you. However, if you want to know your HIV status you will be referred to the nearest health facility which will offer you free testing and counseling.

At this moment, do you have any questions?

Now, will you tell me if you accept to participate in the HIV test? GO BACK TO COLUMN (64). CIRCLE THE APPROPRIATE CODE AND SIGN.

IF RESPONDENT IS AGE 15-17, ASK PARENT/GUARDIAN: Now, will you tell me if you accept for (NAME OF YOUTH) to participate in the HIV test? GO BACK TO COLUMN (64). CIRCLE THE APPROPRIATE CODE AND SIGN. THEN READ CONSENT FORM TO YOUTH.

NOTE FOR THE NURSE/COUNSELOR:

THE RESPONDENT HAS THE RIGHT TO REFUSE HIV/SYPHILIS TEST(S), AND THEREFORE SHOULD NOT BE FORCED.

SYPHILIS AND HIV TESTING

CHECK COLUMNS (8) AND (9A): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND MEN AGE 15-59.

(57) LINE NO. FROM COL.(8)

(58) NAME FROM COL.(2)

(59) AGE FROM COL.(7)

(60) CHECK COLUMN 59 (AGE)

(61) LINE NO. OF PARENT OR OTHER ADULT RESPONSIBLE FOR THE CARE OF THIS PERSON

(62) READ THE SYPHILIS CONSENT STATEMENT TO THE WOMAN/MAN OR RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN). 15-17 YEAR OLD RESPONDENTS MUST CONSENT AS WELL AS THE GUARDIAN.

(63) AGREES RESULT BE GIVEN TO HEALTH AUTHORITIES

(64) READ THE HIV CONSENT STATEMENT TO THE WOMAN/MAN OR RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN). 15-17 YEAR OLD RESPONDENTS MUST CONSENT AS WELL AS THE GUARDIAN.

(65) SAMPLE COLLECTED?

TICK HERE IF CONTINUATION SHEET USED ___