[NAME OF COUNTRY]

[NAME OF ORGANIZATION]

IDENTIFICATION (1)

PLACE NAME

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

REGION

LARGE CITY/SMALL CITY/TOWN/RURAL (2)

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

TOTAL NUMBER OF VISITS

*RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _______
TOTAL ELIGIBLE MEN ________
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __________

COUNTRY-SPECIFIC INFORMATION:
LANGUAGE OF QUESTIONNAIRE
LANGUAGE OF INTERVIEW, NATIVE
LANGUAGE OF RESPONDENT
WHETHER TRANSLATOR USED

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR

KEYED BY

Introduction and Consent

Hello. My name is _______________________________________ and I am working with (NAME OF ORGANIZATION). We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes between 10 and 15 minutes to complete. As part of the survey we would first like to ask some questions about your household. Whatever information you provide will be kept strictly confidential, and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, and if we should come to 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. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ________
Date: _______

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

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 5-32 FOR EACH PERSON.

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

4) SEX
Is (NAME) male or female?

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE
How old is (NAME)?

IF AGE 15 OR OLDER

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

ELIGIBILITY

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

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

11) CIRCLE LINE NUMBER OF ALL CHILDREN 0-5

Just to make sure that I have a complete listing:

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

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?

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

IF AGE 18-59 YEARS

12) SICK PERSON
Has (NAME) been very sick for at least 3 months during the past 12 months, that is (NAME) was too sick to work or do normal activities?

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

13) IS (NAME)'s natural mother alive?

14) 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'.

15) IF MOTHER NOT LISTED IN HOUSEHOLD
Has (NAME)'s mother been very sick for at least 3 months during the past 12 months, that is she was too sick to work or do normal activities?

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

17) Does (NAME)'s natural father usually 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'.

18) IF FATHER NOT LISTED IN HOUSEHOLD
Has (NAME)'s father been very sick for at least 3 months during the past 12 months, that is he was too sick to work or do normal activities?

19) MOTHER AND/OR FATHER DEAD/SICK
CIRCLE LINE NUMBER IF CHILD'S MOTHER AND/OR FATHER HAS DIED (Q. 13 OR 16 = NO) OR BEEN SICK (Q. 15 OR 18 = YES).

20) BOTH PARENTS ALIVE
IF YES TO Q.13 AND Q.16 (BOTH ALIVE), CIRCLE '1'. FOR ALL OTHER CASES, CIRCLE '2'.

Question 12, Question 15, and Questions 18-20 relate to the situation of orphans and vulnerable children and are part of the HIV/AIDS module. They should be included only in countries where HIV prevalence is higher than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents have died).

IF AGE 0-17 YEARS

BROTHERS AND SISTERS

21) Does (NAME) have any brothers or sisters under age 18 who have the same mother and the same father?

22. Do any of these brothers and sisters under age 18 not live in this household?

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

23) Has (NAME) ever attended school?

24. 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.

IF AGE 5-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

25. Did (NAME) attend school at any time during the (2006-2007)(3) school year?

26. During this/that school year, what level and grade [is/was] NAME attending? SEE CODES BELOW.

27. Did (NAME) attend school at any time during the previous school year, that is (2005-2006) (3)?

28. During that school year, what level and grade did (NAME) attend? SEE CODES BELOW.

Questions 21 and 22 relate to situation of orphans and vulnerable children and are part of the HIV/AIDS module. They should be included only in countries where HIV prevalence is higher than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents have died).

CODES FOR Qs. 24, 26, AND 28: EDUCATION
LEVEL

GRADE

IF AGE 5-17 YEARS

BASIC MATERIAL NEEDS

29) Does (NAME) have a blanket?

30. Does (NAME) have a pair of shoes?

31) Does (NAME) have at least 2 sets of clothes?

IF AGE 0-4 YEARS

BIRTH REGISTRATION

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

Questions 29-31 relate to the situation of orphans and vulnerable children and are part of the HIV/AIDS module. They should be included only in countries where HIV prevalence is higher than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents have died).

HOUSEHOLD CHARACTERISTICS

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

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

103) Where is that water source located?

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

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

106) Do you do anything to the water to make it safer to drink?

107) What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED

108) What kind of toilet facility do members of your household usually use? (4)

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

110) How many households use this toilet facility?

111) Does your household have: (5)

.

[ADD ADDITIONAL ITEMS. SEE FOOTNOTE 5.]

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

113) In this household, is food cooked on an open fire, an open stove or a closed stove?

114) Does this (fire/stove) have a chimney, a hood, or neither of these?

115) Is the cooking usually done in the house, in a separate building, or outdoors?

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

117) MAIN MATERIAL OF THE FLOOR. (4) RECORD OBSERVATION.

118) MAIN MATERIAL OF THE ROOF. (4) RECORD OBSERVATION.

119) MAIN MATERIAL OF THE EXTERIOR WALLS. (4) RECORD OBSERVATION.

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

121) Does any member of this household own:

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

123) How many hectares of agricultural land do members of this household own?

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

125) How many of the following animals does this household own? (6)
IF NONE, ENTER '00'.
IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.

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

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

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

Text Box: Questions 127-137 are part of the malaria module and should be omitted in countries that do not adopt the module. The malaria module should be used in all malaria endemic countries.

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

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

131) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

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

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

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

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

136 Who slept under this mosquito net last night?

RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

137 GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138.

138 ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE. (7)
RECORD PPM (PARTS PER MILLION)

SUPPORT FOR SICK PEOPLE

Questions 201-211 should only be included in countries with HIV prevalence greater than 5 percent.

201 CHECK QUESTIONS 7 AND 12 IN THE HOUSEHOLD SCHEDULE:

202 ENTER IN QUESTION 203 THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-59, BEGINNING WITH THE FIRSTSICK PERSON LISTED IN QUESTION 12 IN THE HOUSEHOLD SCHEDULE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

READ THE INTRODUCTION THAT FOLLOWS. THEN ASK QUESTIONS 204-215 AS APPROPRIATE FOR EACH OF THE PERSONS AGE 18-59 REPORTED AS HAVING BEEN VERY SICK.

You told me that in your household one (some) of the members of your household has(ve) been very sick for at least three of the past 12 months. We are interested in learning about the care and support that may have been received for [that/each of those persons].

First I would like to ask you about any formal, organized help or support that your household may have been given 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.

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

204 Now I would like to ask you about any 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?

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

206 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?

207 Did your household receive of this any emotional or psychological support in the past 30 days?

208 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?

209Did your household receive any of this material support in the past 30 days?

210 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?

211Did your household receive any of this social support in the past 30 days?

Questions 212-215 are used to assess aspects of the President's Emergency Plan for AIDS Relief and can be deleted in the countries that are not targeted for special initiatives under the Plan.

212 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?

213When (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?

214 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?

215 Was (NAME) able to reduce or stop this (these) problem(s) most of the time, some of the time, or not at all?

216 GO BACK TO 204 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE SICK PEOPLE, GO TO 301.

SUPPORT FOR PERSONS WHO HAVE DIED

Questions 301-306 relate to the situation of orphans and vulnerable children and are part of the HIV/AIDS module. They should be included only in countries where HIV prevalence is higher than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents 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?

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

303 ASK 304-322 AS APPROPRIATE FOR EACH PERSON WHO DIED. IF THERE WERE MORE THAN 3 DEATHS, USE ADDITIONAL QUESTIONNAIRE(S).

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

305 Was (NAME) male or female?

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

Questions 307-317 should only be included in countries with HIV prevalence greater than 5 percent.

307 CHECK 306: AGE OF PERSON AT DEATH

308 Was (NAME) very sick for at least three of the 12 months before (he/she) died, that is (NAME) was too sick to work or do normal activities?

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 supplies for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

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

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?

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

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?

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

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?

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

Questions 318-321 are used to assess aspects of the President's Emergency Plan for AIDS Relief and can be deleted in the countries that are not targeted for special initiatives under the Plan.

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

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?

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) severe?

321 Was (NAME) able to reduce or stop this (these) problem(s) most of the time, some of the time, or not at all?

322 GO BACK TO 304 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE DEATHS, GO TO 401.

SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

Questions 401-417 relate to the situation of orphans and vulnerable children and are part of the HIV/AIDS module. They should be included only in countries where HIV prevalence is higher than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents have died).

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

402 CHECK COLUMN 12 IN THE HOUSEHOLD SCHEDULE: ANY SICK ADULT AGE 18-59 WHO IS VERY SICK?

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

404 CHECK COLUMN 19 IN THE HOUSEHOLD SCHEDULE: ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND IS VERY SICK?

405 RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AGE 0-17 FOR ALL CHILDREN WHO ARE IDENTIFIED IN COLUMN 19 AS HAVING A MOTHER AND/OR FATHER WHO HAS DIED OR HAS BEEN VERY SICK.

406 NAME FROM COLUMN 2
LINE NUMBER FROM COLUMN 1
AGE FROM COLUMN 7

407 I would like to ask you about any formal, organized help or support for children that your household may have received 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.

408 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?

409 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?

410 Did your household receive any of this emotional or psychological support in the past 3 months?

411In 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?

412 Did your household receive any of this material support in the past 3 months?

413 In the last 12 months, has your household received any material support for (NAME), such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

414 Did your household receive any of this social support in the past 3 months?

415 CHECK 406:
AGE OF CHILD

416 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?

417 GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.

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

501 CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502.
IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 508 AND FOR THE ANEMIA PROCEDURE IN 513.

502 LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

503 IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

504 CHECK 503:
CHILD BORN IN JANUARY 2001(8) OR LATER?

505 WEIGHT IN KILOGRAMS

506 HEIGHT IN CENTIMETERS

507 MEASURED LYING DOWN OR STANDING UP?

508 RESULT OF WEIGHT AND HEIGHT MEASUREMENT

509 CHECK 503:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

510 LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1) RECORD '00' IF NOT LISTED.

511 READ CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

512 RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET (9).

513 RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

514 GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

CONSENT STATEMENT FOR ANEMIA FOR CHILDREN

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 request that all children born in 2001 (8) or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. 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.

The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept strictly confidentialand 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(S) OF CHILD (REN) to participate in the anemia test?

515 CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 516.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 519, FOR THE ANEMIA TEST PROCEDURE IN 528, AND FOR THE HIV TEST PROCEDURE IN 530.

516 LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

517 WEIGHT IN KILOGRAMS

518 HEIGHT IN CENTIMETERS

519 RESULT OF WEIGHT AND HEIGHT MEASUREMENT

520 AGE: CHECK COLUMN 7.

521 MARITAL STATUS: CHECK COLUMN 8.

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

523 READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 523 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT

(SEE QUESTION 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 523 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 in taking 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 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 ADOLESCENT to) take the anemia test?

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

Questions 525, Questions 529-530 and the HIV test consent statement should be omitted in countries in which HIV testing is not a component of the survey.

525 READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

526 CHECK 523 AND 525 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 528 AND FOR THE HIV TEST PROCEDURE IN 530 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

527 RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET (9).

528 RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.

529 BAR CODE LABEL
PUT THE 1ST BAR CODE LABEL HERE.

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

530 OUTCOME OF HIV TEST PROCEDURE

CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 525 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 525 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (COUNTRY).

For the HIV 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 (your/NAME OF ADOLESCENT's) test results either.

If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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 HIV test?

530A CHECK 530: OUTCOME OF HIV TEST

530B READ THE CONSENT STATEMENT. FOR NEVER-IN-UNION WOMENAGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

530C ADDITIONAL TESTS
CHECK 530B:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

530D GO BACK TO 517 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, GO TO 531.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 530B IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 530B IF THE PARENT (OTHER ADULT) REFUSES.CIRCLE CODE '1' IN 530B IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow [SURVEY IMPLEMENTING ORGANIZATION/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 (you/NAME OF ADOLESCENT). You do not have to agree.

If you do not want the blood sample stored for later use, (you/NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for later testing or research?

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-49

531 CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 532.
IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 535, FOR THE ANEMIA TEST PROCEDURE IN 543, AND FOR THE HIV TEST PROCEDURE IN 545.

532 LINE NUMBER (COLUMN 10)
NAME (COLUMN 2)

533 WEIGHT IN KILOGRAMS

534 HEIGHT IN CENTIMETERS

535 RESULT OF WEIGHT AND HEIGHT MEASUREMENT

536 AGE: CHECK COLUMN 7.

537 MARITAL STATUS: CHECK COLUMN 8

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

539 READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION MENAGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 539 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 539 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 in taking 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 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 ADOLESCENT to) take the anemia test?

Questions 540, Questions 544-545, and the HIV test consent statement should be omitted in countries in which HIV testing is not a component of the survey.

540 READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION MENAGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

541 CHECK 539 AND 540 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME OF THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 543 AND FOR THE HIV TEST PROCEDURE IN 545 FOR EACH ELIGIBLE MAN EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

542 RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET (9).

543 RECORD RESULT CODE OF HOMEGLOBAL MEASUREMENT.

544 BAR CODE LABEL
PUT THE 1ST BAR CODE LABEL HERE.

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

545 OUTCOME OF HIV TEST PROCEDURE

CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 540 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 540 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (COUNTRY).

For the HIV 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 (your/NAME OF ADOLESCENT's) test results either.

If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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 HIV test?

545A CHECK 545: OUTCOME OF HIV TEST

545B READ THE CONSENT STATEMENT. FOR NEVER-IN-UNION MENAGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

545C ADDITIONAL TESTS
CHECK 545B:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

545D GO BACK TO 533 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE MEN, END INTERVIEW.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 545B IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 545B IF THE PARENT (OTHER ADULT) REFUSES. CIRCLE CODE '1' IN 545B ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow [SURVEY IMPLEMENTING ORGANIZATION/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 (you/NAME OF ADOLESCENT). You do not have to agree.

If you do not want the blood sample stored for later use, (you/NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for later testing or research?

FOOTNOTES

1 This section should be adapted for country-specific survey design.

2 The following guidelines should be used to categorize urban sample points: "Large cities" are national capitals and places with over 1 million population; "small cities" are places with between 50,000 and 1 million population; the remaining urban sample points are "towns."

3 In Q. 25, the year should refer to the school year that is in session at the time the survey begins. If the survey begins between two school years, then the year should refer to the school year that just ended. In Q. 27, the year should be the school year prior to the year mentioned in Q. 25.

4 Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.

5 Each country should add to the list at least five items of furniture (such as a table, a chair, a sofa, a bed, an armoire, or a cupboard or cabinet). In addition, each country should add at least four additional household appliances so that the list includes at least three items that even a poor household may have, at least three items that a middle income household may have, and at least three items that a high income household may have. Some possible additions are clock, water pump, grain grinder, fan, blender, water heater, electric generator, washing machine, microwave oven, computer, VCR or DVD player, cassette or CD player, camera, air conditioner or cooler, color TV, sewing machine.

6 Add other country-specific animals, such as oxen, water buffalo, camels, llamas, alpacas, pigs, ducks, geese, or elephants.

7 There are many different kinds of iodine testing kits available. The proper test kit should be selected in each country depending on the type of iodine additive used in the country (potassium iodate or potassium iodide). If both of these additives are used in a country, then both types of test kits should be ordered. The test kits should have standard gradations at 0, below 15 PPM, and 15 PPM AND ABOVE so that the percentage of households using adequately iodized salt can be calculated according to the UNICEF standard cutoff point of 15 PPM.

8 For fieldwork beginning in 2007, 2008 or 2009, the year should be 2002, 2003 or 2004, respectively.

9 In countries where some enumeration areas are higher than 1,000 meters, altitude information should be collected on a separate form for each enumeration area higher than 1,000 meters so that the anemia estimates can be adjusted appropriately.