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ZIMBABWE 2005 DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE

CENTRAL STATISTICAL OFFICE

IDENTIFICATION

PROVINCE __________

DISTRICT __________

NAME OF HOUSEHOLD HEAD __________

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

LARGE CITY/SMALL CITY/TOWN/RURAL

HARARE 1
SMALL CITY 2
TOWN 3
RURAL 4

INTERVIEWER VISITS

FIRST VISIT

DATE _____
INTERVIEWER'S NAME __________
RESULT __________

SECOND VISIT

DATE _____
INTERVIEWER'S NAME __________
RESULT __________

THIRD VISIT

DATE _____
INTERVIEWER'S NAME __________
RESULT __________

FINAL VISIT

DAY ___
MONTH __________
YEAR _____
ID NUMBER ___
RESULT __________

NEXT VISIT

DATE _____
TIME _____

TOTAL NUMBER OF VISITS ___

RESULT__
*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 NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

LANGUAGE OF QUESTIONNAIRE:

SHONA 1
NDEBELE 2
ENGLISH 3
OTHER 4

LANGUAGE USED FOR INTERVIEW:

SHONA A
NDEBELE B
ENGLISH C
OTHER D

TRANSLATOR USED:

YES 1
NO 2

SUPERVISOR

NAME __________
DATE _____

FIELD EDITOR

NAME __________
DATE _____

OFFICE EDITOR ___

KEYED BY ___

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 NAMES, RELATIONSHIPS, AND SEX ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-35 FOR EACH MEMBER OF THE HOUSEHOLD.

NAME(S) __________

3) RELATIONSHIP TO HEAD OF HOUSEHOLD

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

SEE CODES BELOW

CODES FOR QUESTION 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 OTHER RELATIVE
12 ADOPTED/FOSTER/STEPCHILD
13 NOT RELATED
98 DON'T KNOW

4) SEX

Is (NAME) male or female?

MALE 1
FEMALE 2

5) RESIDENCE

Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE

How old is (NAME)?

IN YEARS ___

8) IF AGE 15 OR OLDER: MARITAL STATUS

What is (NAME'S) current marital status?

SEE CODES BELOW

CODES FOR QUESTION 8

1 MARRIED
2 LIVING WITH PARTNER
3 DIVORCED
4 SEPARATED
5 WIDOWED
6 NEVER MARRIED/NEVER LIVED WITH PARTNER

9) ELIGIBILITY

LINE NUMBER OF ALL WOMEN AGE 15-49

LINE NUMBER ___

10) LINE NUMBER OF WOMEN SELECTED FOR DOMESTIC VIOLENCE MODULE USING QUESTION 38

LINE NUMBER ___

11) LINE NUMBER OF ALL MEN AGE 15-54

LINE NUMBER ___

12) LINE NUMBER OF ALL CHILDREN AGE 0-5

LINE NUMBER ___

13) SICK PERSON: IF AGE 18-59

Has (NAME) been very sick for at least 3 months during the past 12 months? By very sick I mean (NAME) was too sick to work or do normal activities around the house for at least 3 months during the past 12 months?

YES 1
NO 2
DK 8

PARENTAL SURVIVORSHIP, RESIDENCE, AND HEALTH STATUS: FOR PERSONS AGE 0-17 YEARS

14.Is (NAME)'s biological mother alive?

YES 1
NO 2 (SKIP TO 17)
DK 8 (SKIP TO 17)

15) IF ALIVE

Does (NAME)'s biological mother live in this household?

IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

RECORD '00' IF NOT LISTED IN SCHEDULE LISTED

YES 1
NAME __________
LINE NUMBER ___
NO 2

16) FOR MOTHERS NOT IN HOUSEHOLD ASK:

Has (NAME)'s biological mother been very sick for at least 3 months during the past 12 months, that is, too sick to work or do normal activities around the house for at least 3 months during the past 12 months?

YES 1
NO 2
DK 8

17) Is (NAME)'s biological father alive?

YES 1
NO 2 (SKIP TO 20)
DK 8 (SKIP TO 20)

18) IF ALIVE

Does (NAME)'s biological father live in this household?

IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

RECORD '00' IF NOT LISTED IN SCHEDULE

YES 1
NAME __________
LINE NUMBER ___
NO 2

19) FOR FATHERS NOT IN HOUSEHOLD ASK:

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

YES 1
NO 2
DK 8

20) CHECK QUESTIONS 13-19
RECORD LINE NUMBER FOR ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED (QUESTION 14 AND QUESTION 17) OR IS VERY SICK (QUESTION 16 AND QUESTION 19)

21) CHECK QUESTION 14 AND QUESTION 17

IF BOTH YES (BOTH ALIVE) CIRCLE '1'

IF ELSE, CIRCLE '2'

YES 1 (SKIP TO 26)
NO 2

22) NATURAL BROTHERS AND SISTERS AGE 0-17 YEARS: FOR PERSONS AGE 0-17 YEARS

Does (NAME) have any natural brothers under the age of 18? (By natural brothers, I mean brothers who have the same biological mother and the same father)

YES 1
NO 2 (SKIP TO 24)
DK 8 (SKIP TO 24)

23) Do all of (NAME)'s natural brothers under the age of 18 live in this household?

YES 1
NO 2

24) Does (NAME) have any natural sisters under the age of 18? (By natural sisters I mean sisters who have the same biological mother and the same father)

YES 1
NO 2 (SKIP TO 26)
DK 8 (SKIP TO 26)

25) Do all of (NAME)'s natural sisters under the age of 18 live in this household?

YES 1
NO 2

EDUCATION: IF AGE 3 YEARS OR OLDER

26) Has (NAME) ever attended school?

YES 1
NO 2 (SKIP TO 32)

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

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

SEE CODES BELOW.

LEVEL ___
GRADE ___

IF AGE 3-24 YEARS

28) Did (NAME) attend school at any time during the current 2005 school year?

YES 1
NO 2 (SKIP TO 30)

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

LEVEL ___
GRADE ___

30) Did (NAME) attend school at any time during the previous school year, that is, in 2004?

YES 1
NO 2 (SKIP TO 32)

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

LEVEL ___
GRADE ___

CODES FOR QUESTIONS 27, 29 AND 31
EDUCATION LEVEL:

0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW

EDUCATION GRADE:

00 LESS THAN 1 YEAR COMPLETED (NOT ALLOWED FOR QUESTIONS 29 AND 31)
98 DON'T KNOW

BASIC MATERIAL NEEDS: IF AGE 3-17 YEARS

32) Is there something that (NAME) can use to cover (himself/herself) when (he/she) is sleeping?

YES 1
NO 2
DK 8

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

YES 1
NO 2
DK 8

34) Does (NAME) have at least two sets of clothing?

YES 1
NO 2
DK 8

35) BIRTH REGISTRATION: IF AGE 0-4

Does (NAME) have a birth certificate? IF NO, PROBE:
Has (NAME)'s birth ever been registered with the civil authority?

HAS CERTIFICATE 1
REGISTERED, NO CERTIFICATE 2
BIRTH NOT REGISTERED 3
DON'T KNOW 8

TICK HERE IF ADDITIONAL QUESTIONNAIRE USED ___

PROBE TO IDENTIFY ADDITIONAL HOUSEHOLD RESIDENTS
.

Just to make sure that I have a complete household listing:

2A) Are there any other persons such as small children or infants that we have not listed?

YES ___ ENTER EACH IN TABLE
NO ___

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

YES ___ ENTER EACH IN TABLE
NO ___

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

YES ___ ENTER EACH IN TABLE
NO

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

38) LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK 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 AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS NUMBER IS USED TO IDENTIFY WHETHER THE FIRST ('1'), SECOND ('2'), THIRD ('3'), ETC. ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
CIRCLE THE LINE NUMBER FOR THIS WOMAN IN COLUMN 10.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.
FIND THE BOX WHERE ROW '6' AND COLUMN '3' MEET. THE NUMBER IN THAT BOX ('2') INDICATES THAT THE SECOND ELIGIBLE WOMAN IN THE HOUSEHOLD LISTING SHOULD BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07'. THE WOMAN TO BE ASKED THE DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE WOMAN ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)

NUMBER ___

TOTAL NUMBER OF ELIGIBLE WOMAN IN HOUSEHOLD (COLUMN)

NUMBER ___

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

PIPED WATER
PIPED INTO DWELLING 11 (SKIP TO 106)
PIPED INTO TAP IN YARD/PLOT 12 (SKIP TO 106)
PUBLIC TAP 13 (SKIP TO 103)
TUBE WELL OR BOREHOLE 21 (SKIP TO 103)
DUG WELL
PROTECTED DUG WELL 31 (SKIP TO 103)
UNPROTECTED DUG WELL 32 (SKIP TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
RAIN WATER 51 (SKIP TO 106)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK 71 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) __________ 96 (SKIP TO 103)

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

PIPED WATER
PIPED INTO DWELLING 11 (SKIP TO 106)
PIPED INTO TAP IN YARD/PLOT 12 (SKIP TO 106)
PUBLIC TAP 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED DUG WELL 31
UNPROTECTED DUG WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAIN WATER 51 (SKIP TO 106)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) __________ 96

103) Where is the water source located?

IN OWN DWELLING 1 (SKIP TO 106)
IN OWN YARD/PLOT 2 (SKIP TO 106)
ELSEWHERE 3

104) How long does it take to go there, get water, and come back?

MINUTES ___
DON'T KNOW 998

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

ADULT WOMAN 1
ADULT MAN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) __________ 6

106) Do you treat your water to make it more safe to drink?

YES 1
NO 2 (SKIP TO 108)
DK 8 (SKIP TO 108)

107) What do you usually do to the water to make it more safe to drink?
Anything else?
RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) __________ X
DON'T KNOW Z

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

FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH OTHER 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE (VIP)/BLAIR TOILET 21
NON-VIP PIT LATRINE WITH SLAB 22
NON-VIP PIT LATRINE WITHOUT SLAB 23
COMPOSTING TOILET/ARBO LOO 31
BUCKET TOILET 41
NO FACILITY/BUSH/FIELD 51 (SKIP TO 111)
OTHER (SPECIFY) __________ 96

109) Do you share this facility with other households?

YES 1
NO 2 (SKIP TO 111)

110) Including this household, how many households use this toilet facility?

NUMBER OF HOUSEHOLDS IF LESS THAN 10 ___
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

111) Does your dwelling unit/household have:

ELECTRICITY

YES 1
NO 2

RADIO

YES 1
NO 2

TELEVISION

YES 1
NO 2

MOBILE TELEPHONE

YES 1
NO 2

NON-MOBILE TELEPHONE

YES 1
NO 2

REFRIGERATOR

YES 1
NO 2

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

ELECTRICITY 01 (SKIP TO 114)
LIQUID PROPANE GAS 02 (SKIP TO 114)
NATURAL GAS 03 (SKIP TO 114)
BIOGAS 04 (SKIP TO 114)
PARAFFIN/KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
MAIZE/OTHER CROP WASTE 10
ANIMAL DUNG 11
DO NOT COOK 12 (SKIP TO 116)
OTHER (SPECIFY) __________ 96

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

OPEN FIRE OR STOVE WITHOUT CHIMNEY/HOOD 1
OPEN FIRE OR STOVE WITH CHIMNEY/HOOD 2
CLOSED STOVE WITH CHIMNEY 3
OTHER (SPECIFY) __________ 6

114) Is the cooking usually done in the same building where people sleep, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (SKIP TO 116)
OUTDOORS 3 (SKIP TO 116)
OTHER (SPECIFY) __________ 6 (SKIP TO 116)

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

YES 1
NO 2

116) TYPE OF DWELLING UNIT
RECORD OBSERVATION.

TRADITIONAL 01
MIXED 02
DETACHED 03
SEMI-DETACHED 04
FLAT/TOWNHOME 05
SHACK 06
OTHER (SPECIFY) __________ 96

117) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND/DUNG 11
RUDIMENTARY FLOOR
WOOD PLANKS
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) __________ 96

118) MAIN MATERIAL OF THE ROOF
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
WOOD PLANKS 23
FINISHED ROOFING
METAL 31
WOOD 32
ASBESTOS 33
TILES 34
CEMENT 35
OTHER (SPECIFY) __________ 96

119) MAIN MATERIAL OF THE WALLS
RECORD OBSERVATION.

NATURAL WALLS
CANE/TRUNKS 11
MUD 12
RUDIMENTARY WALLS
STONE WITH MUD 22
PLYWOOD 23
CARTON 24
REUSED WOOD 25
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS 35
OTHER (SPECIFY) __________ 96

120) TYPE OF WINDOWS
RECORD OBSERVATION.

ANY WINDOWS
YES 1
NO 2
WINDOWS WITH GLASS
YES 1
NO 2
WINDOWS WITH SCREENS
YES 1
NO 2
WINDOWS WITH CURTAINS/SHUTTERS
YES 1
NO 2

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

ROOMS ___

122) Does any member of this household own:

A watch?
YES 1
NO 2
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 wheelbarrow?
YES 1
NO 2

123) Do any members of this household have access to use land for agricultural purposes?

YES 1
NO 2 (SKIP TO 125)

124) How many acres of land are used by household members for agricultural purposes?
IF MORE THAN 97, ENTER '97'.
IF UNKNOWN, ENTER '98'.

ACRES ___

125) Does this household own any livestock, herds, or farm animals?

YES 1
NO 2 (SKIP TO 127)

126) How many of the following animals does this household have?
IF NONE, ENTER '00'.
IF MORE THAN 97, ENTER '97'.
IF UNKNOWN, ENTER '98'.

CATTLE ___
HORSES/DONKEYS/MULES ___
GOATS ___
SHEEP ___
CHICKENS OR OTHER POULTRY ___
PIGS ___

127) Does any member of this household have a bank account?

YES 1
NO 2

128) During the past 12 months, has anyone sprayed the interior walls of your dwelling against mosquitoes?
IF NOT SPRAYED, RECORD 95.
IF YES: How many months ago was the house sprayed?
RECORD '00' IF LESS THAN ONE MONTH.

MONTHS AGO ___
NOT SPRAYED 95 (SKIP TO 130)

129) Who sprayed the house?

GOVERNMENT PROGRAM 1
PRIVATE COMPANY 2
HOUSEHOLD MEMBER 3
OTHER (SPECIFY) __________ 6
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 201)

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

NUMBER OF NETS ___

132) ASK THE RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

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

MONTHS AGO ___
MORE THAN 37 MONTHS AGO 96
NOT SURE 98

134) What type of mosquito net do you have?

'PERMANET/LONG-LASTING' NET 11 (SKIP TO 138)
'ORDINARY' NET 21
OTHER (SPECIFY) __________ 31
NOT SURE 98

135) When you got the net, was it treated with an insecticide to kill or repel mosquitos?

YES 1
NO 2
NOT SURE 8

136) Since you got the mosquito net, was it ever soaked or dipped in a liquid or chemical to repel mosquitos?

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

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

MONTHS AGO ___
MORE THAN 37 MONTHS AGO 96
NOT SURE 98

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

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

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

NAME __________
LINE NUMBER ___

140) GO BACK TO 132 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 201.

SECTION 2: SUPPORT FOR SICK PEOPLE

201) CHECK QUESTION 36 IN HOUSEHOLD SCHEDULE AND RECORD NUMBER OF CHRONICALLY SICK HOUSEHOLD MEMBERS AGE 18-59.

NUMBER ___
AT LEAST ONE (SKIP TO 202)
NONE (SKIP TO 301)

202) ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-59, BEGINNING WITH THE FIRST SICK PERSON LISTED IN THE HOUSEHOLD SCHEDULE. ASK THE QUESTIONS ABOUT ALL OF THESE PEOPLE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

203) LINE NUMBER AND NAME FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE

1ST SICK PERSON
NAME __________
LINE NUMBER ___

204) You told me that in your household, (NAME OF EACH SICK PERSON IN 203) has(have) been very sick for at least three of the past 12 months. I would like to ask you about any formal, organized help or support that your household may have received for [that/each of those] person(s) 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.

205) Now I would like to ask you about the support you 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?

YES 1
NO 2 (SKIP TO 207)
DK 8 (SKIP TO 207)

206) Did your household receive any of this support at least once a month while (NAME) was sick?

YES 1
NO 2
DK 8

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

YES 1
NO 2 (SKIP TO 209)
DK 8 (SKIP TO 209)

208) Did your household receive any of this support in the past 30 days?

YES 1
NO 2
DK 8

209) 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?

YES 1
NO 2 (SKIP TO 211)
DK 8 (SKIP TO 211)

210) Did your household receive any of this support in the past 30 days?

YES 1
NO 2
DK 8

211) 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?

YES 1
NO 2 (SKIP TO 213)
DK 8 (SKIP TO 213)

212) Did your household receive any of this support in the past 30 days?

YES 1
NO 2
DK 8

213) Now I would like to ask about health problems (NAME) may have recently had. In the last 30 days, has (NAME) had severe pain, mild pain, or no pain at all?

SEVERE 1
MILD 2
NOT AT ALL 3 (SKIP TO 215)

214) When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

215) In the last 30 days, did (NAME) suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Was this problem (were any of these problems) ever severe?

YES, SEVERE 1
YES, NEVER SEVERE 2
NO 3 (SKIP TO 217)

216) Was (NAME) able to reduce or stop the (nausea/coughing/diarrhea/constipation) most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

217) GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE SICK PEOPLE, GO TO 301.

SECTION 3: SUPPORT FOR 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?

YES 1
NO 2 (SKIP TO 401)
DK 8 (SKIP TO 401)

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

NUMBER OF PERSONS ___

303) ASK 304-322 FOR ONE PERSON AT A TIME. IF MORE THAN 3 PEOPLE HAVE DIED, USE ADDITIONAL QUESTIONNAIRE.

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

NAME 1ST DEATH __________

305) Was (NAME) male or female?

MALE 1
FEMALE 2

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

AGE ___

307) Was (NAME) very sick for at least three of the 12 months before (he/she) died? By very sick, I mean that (NAME) was too sick to work or do normal activities around the house for at least three months.

YES 1
NO 2 (SKIP TO 322)
DK 8 (SKIP TO 322)

308) CHECK 306: AGE OF PERSON AT DEATH

YOUNGER THAN 18 OR OLDER THAN 60 (SKIP TO 322)
18-59 (go to 309)

309) I would like to ask you about any formal, organized help or support that your household may have received for [NAME] before (he/she) died, 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.

310) In the last 12 months, did your household receive any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

YES 1
NO 2 (SKIP TO 312)
DK 8 (SKIP TO 312)

311) Did your household receive any of this support at least once a month while (NAME) was sick?

YES 1
NO 2
DK 8

312) In the last 12 months, did your household receive any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did not have to pay?

YES 1
NO 2 (SKIP TO 314)
DK 8 (SKIP TO 314)

313) Did your household receive any of this support in the last 30 days before (NAME)'s death?

YES 1
NO 2
DK 8

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

YES 1
NO 2 (SKIP TO 316)
DK 8 (SKIP TO 316)

315) Did your household receive any of this support in the last 30 days before (NAME)'s death?

YES 1
NO 2
DK 8

316) In the last 12 months, did your household receive 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?

YES 1
NO 2 (SKIP TO 318)
DK 8 (SKI TO 318)

317) Did your household receive any of this support in the last 30 days before (NAME)'s death?

YES 1
NO 2
DK 8

318) Now I would like to ask about health problems (NAME) may have recently had. In the 30 days before (NAME) died, did he/she have severe pain, mild pain, or no pain at all.

SEVERE 1
MILD 2
NOT AT ALL 3 (SKIP TO 320)

319) When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

320) In the 30 days before (NAME) died, did he/she suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Was this problem (were any of these problems) ever severe?

YES, SEVERE 1
YES, NEVER SEVERE 2
NO 3 (SKIP TO 322)

321) Was (NAME) able to reduce or stop the (nausea/coughing/diarrhea/constipation) most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

322) GO BACK TO 304 IN NEXT COLUMN; OR, IF NO MORE PEOPLE HAVE DIED, GO TO 401.

SECTION 4: SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

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

AT LEAST ONE CHILD AGE 0-17 (SKIP TO 402)
NO CHILD AGE 0-17 (END)

402) CHECK QUESTION 36 IN HOUSEHOLD QUESTIONNAIRE: ANY VERY SICK ADULTS 18-59?

NO SICK ADULT AGE 18-59 (SKIP TO 403)
AT LEAST ONE SICK ADULT AGE 18-59 (GO TO QUESTION 405 AND LIST ALL CHILDREN AGE 0-17 IN HOUSEHOLD)

403) CHECK 306 IN SECTION 3: ANY ADULT AGE 18-59 WHO DIED IN PAST 12 MONTHS?

NO ADULT AGE 18-59 IN 306 (SKIP TO 404)
AT LEAST ONE ADULT 18-59 IN 306 (GO TO QUESTION 405 ADN LIST ALL CHILDREN AGE 0-17 IN HOUSEHOLD)

404) CHECK QUESTION 37 IN HOUSEHOLD SCHEDULE: ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LIVING IN THE HOUSEHOLD AND IS SICK?

AT LEAST ONE CHILD WHOSE MOTHER AND/OR FATHER WHO HAS DIED OR IS SICK (GO TO 405 AND LIST ALL CHILDREN WHOSE LINE NUMBERS ARE RECORDED IN COLUMN 20)
NO CHILD WITH MOTHER OR FATHER WHO HAS DIED OR IS VERY SICK (SKIP TO 501)

405) RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AS APPRORIATE BEGINNING WITH THE FIRST CHILD AND CONTINUING IN THE ORDER IN WHICH THE CHILDREN ARE LISTED IN THE SCHEDULE OR IN COLUMN 20. IF MORE THAN 8 CHILDREN USE AN ADDITIONAL QUESTIONNAIRE.

1ST CHILD
NAME __________
LINE NUMBER ___
AGE ___

406) I would like to ask you about any formal, organized help or support that your household may have received for (NAME OF EACH CHILD IN 405) and 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.

ASK THE CARE AND SUPPORT QUESTIONS FOR EACH CHILD LISTED IN QUESTION 405, BEGINNING WITH THE CHILD LISTED IN THE FIRST COLUMN.

407) 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?

YES 1
NO 2
DK 8

408) In the last 12 months, has your household received any emotional or psychological 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?

YES 1
NO 2 (SKIP TO 410)
DK 8 (SKIP TO 410)

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

YES 1
NO 2
DK 8

410) 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?

YES 1
NO 2 (SKIP TO 412)
DK 8 (SKIP TO 412)

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

YES 1
NO 2
DK 8

412) 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?

YES 1
NO 2 (SKIP TO 414)
DK 8 (SKIP TO 414)

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

YES 1
NO 2
DK 8

414) CHECK 405: AGE OF CHILD

AGE 0-4 (SKIP TO 416)
AGE 5-17 (SKIP TO 415)

415) 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?

YES 1
NO 2
DK 8

416) GO BACK TO 407 IN NEXT COLUMN IN THIS QUESTIONNAIRE, OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); OR, IF NO MORE CHILDREN, CONTINUE WITH INDIVIDUAL INTERVIEW WITH ELIGIBLE RESPONDENT.

SECTION 5: WEIGHT AND HEIGHT MEASUREMENT - ALL CHILDREN UNDER AGE 5 HEMOGLOBIN MEASUREMENT - CHILDREN 6-60 MONTHS

CHECK COLUMN (12): RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN AGE 0-60 MONTHS.

FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COMPARE MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

BEFORE CONDUCTING ANEMIA TESTING, OBTAIN CONSENT FROM PARENT, GUARDIAN, OR OTHER RESPONSIBLE ADULT.

501) CHILDREN UNDER AGE 5: LINE NUMBER FROM COLUMN (12)

LINE NUMBER ___

502) NAME FROM COLUMN (2)

NAME __________

503) AGE FROM COLUMN (7)

AGE ___

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

DAY ___
MONTH __________
YEAR _____

505) WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 2000 OR LATER: WEIGHT (KILOGRAMS)

WEIGHT ___

506) HEIGHT (CENTIMETERS)

HEIGHT ___

507) MEASURED LYING DOWN OR STANDING UP

LYING 1
STANDING 2

508) RESULT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 4

TICK HERE IF CONTINUATION SHEET USED ___

CONSENT STATEMENT

As part of this survey, we are trying to find out more about anaemia, that is, low blood levels, in men, women, and children.

To know more about this problem in Zimbabwe, we are asking in this survey that young children all over the country take a test for low blood levels. We would like (NAME OF CHILD(REN) BORN IN 2000 OR LATER, AND AT LEAST 6 MONTHS OF AGE) to take part in this test by giving a few drops of blood from his (her) finger or heel.

The test uses clean and completely safe equipment that is used only once and then thrown away. The blood will be tested with new equipment. The result(s) for (NAME OF CHILD[REN]) will be given to you right after the test is done.

We will not tell anyone else the results of the test.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of anaemia.

Do you agree that (NAME) may give blood for the anaemia test?
CIRCLE CODE AND SIGN.

509) HEMOGLOBIN MEASUREMENT OF CHILDREN 6-60 MONTHS: RECORD NAME OF PARENT/RESPONSIBLE ADULT

NAME __________

510) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

LINE NUMBER ___

511) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT.
CIRCLE CODE (AND SIGN)

GRANTED 1 SIGN __________
REFUSED 2 (SKIP TO NEXT LINE)

512) HEMOGLOBIN LEVEL (G/DL)

G/DL ___

513) RESULT

MEASURED 1
REFUSED 2
NOT PRESENT 3
OTHER 6

514) CHECK 512: NUMBER OF CHILDREN WITH HEMOGLOBIN LEVEL BELOW 7 G/DL.

ONE OR MORE ___ (GIVE EACH PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH 515 FOR ANY CHILD WITH A LEVEL BELOW 7 G/DL)
NONE ___ (GIVE EACH PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH HOUSEHOLD INTERVIEW)

515) We detected a low level of hemoglobin in the blood of (NAME OF CHILD(REN)). This indicates that (NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the clinic at __________ about the condition of (NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in the blood of (NAME OF CHILD(REN)) may be given to the clinic?

NAME OF CHILD WITH HEMOGLOBIN BELOW THE CUT OFF POINT __________
NAME OF PARENT/RESPONSIBLE ADULT __________
AGREES TO REFERRAL?
YES 1
NO 2

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:

__________

COMMENTS ON SPECIFIC QUESTIONS:

__________

ANY OTHER COMMENTS:

__________

SUPERVISOR'S OBSERVATIONS

NAME OF THE SUPERVISOR: __________

DATE: _____