PLACE NAME__
NAME OF HOUSEHOLD HEAD__
CLUSTER NUMBER___
HOUSEHOLD NUMBER______
REGION__
RURAL 2
LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER NAME___
RESULTS
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) __________
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE__
TIME__
FINAL VISIT
DAY__
MONTH__
YEAR __
NAME__
RESULT__
TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___
FIELD EDITOR
NAME__
DATE__
OFFICE EDITOR__
KEYED BY___
Now we would like some information about the people who usually live in your household or who are staying with you now.
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.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
NOT RELATED 12
DON'T KNOW 98
4) SEX: Is (NAME) male or female?
FEMALE 2
5) RESIDENCE: Does (NAME) usually live here?
NO 2
6) RESIDENCE: Did (NAME) stay here last night?
NO 2
8) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD:
(THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.)
10) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
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?
NO 2
DON'T KNOW 8
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.
EDUCATION IF AGE 5 YEARS OR OLDER:
14) Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE)
15) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
16) Is (NAME) currently attending school?
NO 2
17) During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 19)
18) During the current school year, what level and grade [is/was] (NAME) attending?
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
19) During the previous school year, did (NAME) attend school at any time?
NO 2 (GO TO NEXT HOUSEHOLD MEMBER)
20) During that school year, what level and grade did (NAME) attend?
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
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?
NO
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?
NO
3. Are there any guests or temporary visitors staying here, or anyone who stayed here last night, who have not been listed?
NO
21) What is the main source of drinking water for members of your household?
PULED INTO YARD/PLOT 12 (GO TO 23)
PUBLIC TAP 13
OPEN WELL IN YARD/PLOT 22 (GO TO 23)
OPEN PUBLIC WELL 23
PROTECTED WELL IN YARD/PLOT 32 (GO TO 23)
PROTECTED PUBLIC WELL 33
RIVER/STREAM 42
POND/LAKE 43
DAM 44
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY) _____ 96
22) How long does it take you to go there, get water, and come back?
ON PREMISES 996
23) What kind of toilet facilities does your household have?
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) _____ 96
24) Do you share these facilities with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26) What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, LIGNITE 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) ______ 96
27) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
28) Does any member of your household own:
NO 2
NO 2
NO 2
29) Does your household have any bednets that can be used while sleeping?
NO 2 (GO TO 33)
30) CHECK COLUMNS (6) AND (7):
NUMBER OF CHILDREN UNDER AGE 5 WHO SLEPT IN THE HOUSEHOLD LAST NIGHT.
ONE (GO TO 31)
TWO OR MORE (GO TO 32)
31) Did (NAME) sleep under a bednet last night?
NO 2 (GO TO 33)
32) Did all, some or none of the children under age 5 who slept in the household last night sleep under a bednet?
SOME CHILDREN 2
NONE 3
33) Where do you usually wash your hands?
SOMEWHERE ELSE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)
34) ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.
NO 2
NO 2
NO 2
35) ASK RESPONDENT FOR A TEASPOON OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).
7 PPM 2
15 PPM 3
30 PPM 4
NO SALT IN HOUSEHOLD 5
SALT NOT TESTED (SPECIFY REASON) _______ 6
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT
CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
36) LINE NUMBER FROM COLUMN 8 FOR WOMEN 15-49/COLUMN 9 FOR CHILDREN UNDER AGE 6
39) What is (NAME)'s date of birth?
[FOR CHILDREN UNDER AGE 6 ONLY]
MONTH____
YEAR____
42) MEASURED LYING DOWN OR STANDING UP
[FOR CHILDREN BORN IN 1995 OR LATER ONLY]
STANDING 2
NOT PRESENT 2
REFUSED 3
OTHER 6
HEMOGLOBIN MEASUREMENT OF WOMEN 15-49 AND CHILDREN BORN IN 1995 OR LATER
44) CHECK COLUMN (38):
[ONLY FOR WOMEN 15-49]
AGE 18-49 YEARS 2 (GO TO 46)
45) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.
46) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT.
CIRCLE CODE (AND SIGN).
CONSENT STATEMENT:
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1995* or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
*For fieldwork beginning in 2001, 2002, or 2003, the year should be 1996, 1997, or 1998 respectively.
REFUSED 2 (GO TO NEXT LINE)
48) CURRENTLY PREGNANT?
[ONLY FOR WOMEN 15-49]
NO/DON'T KNOW 2
NOT PRESENT 2
REFUSED 3
OTHER 6
50) CHECK 47 AND 48:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*
(*The cutoff point is 9 g/dl for pregnant women and 7 g/dl for children and women who are not pregnant (or who don't know if they are pregnant))
NONE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND END HOUSEHOLD INTERVIEW)
51) We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the doctor at ______ about (your condition/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 (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?
NAME OF PERSON WITH HEMOGLOBIN BELOW THE CUTOFF POINT:
NAME OF PARENT/RESPONSIBLE ADULT:
[ONLY FOR WOMEN AGE 15-17 AND CHILDREN]
AGREES TO REFERRAL?
NO 2