MODEL HOUSEHOLD QUESTIONNAIRE
[NAME OF COUNTRY]
[NAME OF ORGANIZATION]
PLACE NAME ____
NAME OF HOUSEHOLD HEAD ____
CLUSTER NUMBER ____
HOUSEHOLD NUMBER ____
INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE ____
NAME ____
RESULT ____
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ____ 9
NEXT VISIT
DATE ____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT ____
TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____
FIELD EDITOR
NAME ____
OFFICE EDITOR ____
KEYED BY ____
[NOTE: Questions with blue highlighting in the question number column are HIV related questions that may be deleted in some circumstances (see footnotes). Questions with pink highlighting in the questions number column are malaria related questions that may be deleted in some circumstances (see footnotes). ]
INTRODUCTION AND CONSENT:
Hello. My name is ______. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over (NAME OF COUNTRY). The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential 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.
In case you need more information about the survey, you may contact the person listed on this card.
GIVE CARD WITH CONTACT INFORMATION.
Do you have any questions?
May I begin with the interview?
SIGNATURE OF INTERVIEWER _____ DATE ____
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END OF INTERVIEW)
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 5-20 (QUESTIONS 5-20) FOR EACH PERSON.
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 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
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
7. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'.
MARITAL STATUS. IF AGE 15 OR OLDER:
8. What is (NAME)'s current marital status?
DIVORCED OR SEPARATED 2
WIDOWED 3
NEVER-MARRIED AND NEVER LIVED TOGETHER 4
ELIGIBILITY:
9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
ELIGIBILITY:
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-49
ELIGIBILITY:
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
TICK HERE IF CONTINUATION SHEET USED ____
Just to make sure that I have a complete listing:
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?
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?
NO
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS. IF AGE 0-17 YEARS:
12. Is (NAME)'s natural mother alive?
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: What is her name?
RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.
14. Is (NAME)'s natural father alive?
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)
15. 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'.
IF EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:
16. Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE)
17. What is the highest grade (NAME) completed at that level?
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8
DON'T KNOW 98
CURRENT/RECENT SCHOOL ATTENDANCE. IF AGE 5-24 YEARS:
18. Did (NAME) attend school at any time during the (2009-2010) (2) school year?
NO 2 (GO TO NEXT LINE)
19. During this/that school year, what level and grade is/was (NAME) attending?
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8
BIRTH REGISTRATION. IF AGE 0-4 YEARS:
20. Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
101. How often does anyone smoke inside your house?
Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5
102. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER 96 (SPECIFY)___
103. Where is that water source located?
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. Do you do anything to the water to make it safer to drink?
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?
Anything else?
RECORD ALL MENTIONED.
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 X (SPECIFY)__
DON'T KNOW Z
107. What kind of toilet facility do members of your household
usually use? (3)
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER 96 (SPECIFY)__
108. Do you share this toilet facility with other households?
NO 2 (GO TO 110)
109. How many households use this toilet facility?
DON'T KNOW 98
110. Does your household have: (4)
Electricity?
A radio?
A non-mobile telephone?
A refrigerator?
A television?
A mobile telephone?
[ADD ADDITIONAL ITEMS. SEE FOOTNOTE 4.]
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
111. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER 96 (SPECIFY)___
112. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER 6 (SPECIFY) ___ (GO TO 114)
113. Do you have a separate room which is used as a kitchen?
NO 2
114. MAIN MATERIAL OF THE FLOOR. (3)
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
PARQUET OR POLISHED
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
115. MAIN MATERIAL OF THE ROOF. (3)
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
116. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION. (3)
CANE/PALM/TRUNKS 12
DIRT 13
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
117. How many rooms in this household are used for sleeping?
118. Does any member of this household own:
A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
119. Does any member of this household own any agricultural land?
NO 2 (GO TO 121)
120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.
DON'T KNOW 998
121. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 123)
122. How many of the following animals does this household own? (5)
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.
Cattle?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens?
123. Does any member of this household have a bank account?
NO 2 (GO TO 126)
124. (6) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2
DON'T KNOW 8 (GO TO 126)
125. (6) Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY)__ X
DON'T KNOW Z
126. (7) Does your household have any mosquito nets that can be used while sleeping?
NO (GO TO 137)
127. (7) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
128. (7) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN
THE HOUSEHOLD
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
129. (7) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
130. (7) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
BRAND B 12
OTHER/DK BRAND 16 (GO TO 134)
BRAND D 22
OTHER/DK BRAND 26 (GO TO 132)
DON'T KNOW BRAND 98
131. (7) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?
NO 2
NOT SURE 8
132. (7) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)
133. (7) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
NOT SURE 98
134. (7) Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 136)
NOT SURE 8 (GO TO 136)
135. (7) Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. RECORD UP TO FOUR PEOPLE.
136. (7) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.
137. Please show me where members of your household most often wash their hands.
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 4 (GO TO 140)
138. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HAND WASHING
WATER IS NOT AVAILABLE 2
139. OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.
ASH, MUD, SAND B
NONE C
140. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE. (8)
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) ____ 6
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5
201. CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
202. LINE NUMBER COLUMN 11
NAME FROM COLUMN 2
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?
MONTH ____
YEAR ____
204. CHECK 203:
CHILD BORN IN JANUARY 2005 (9) OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO 214)
REFUSED 9995
OTHER 9996
REFUSED 9995
OTHER 9996
207. MEASURED LYING DOWN OR STANDING UP?
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?
OLDER 2
209. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN ONE OF HOUSEHOLD SCHEDULE).
RECORD '00' IF NOT LISTED.
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 that all children born in 2005 (9) or later 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.
REFUSED 2
(SIGN) ___________
212. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET. (11)
REFUSED 995
OTHER 996
213. GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49
214. CHECK COLUMN 9 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
NAME FROM COLUMN 2
REFUSED 99995
OTHER 99996
REFUSED 9995
OTHER 9996
18-49 YEARS 2 (GO TO 223)
219. MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 223)
220. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.
221. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
As a 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 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 allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 228)
(SIGN) ___________
223. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
As a 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 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 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 test, 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.
RESPONDENT REFUSED 2 (GO TO 226)
(SIGN) ____________
225. PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
226. (12) AGE: CHECK COLUMN 7.
18-49 YEARS 2 (GO TO 230)
227. (12) MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 230)
228. (12) ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
As a 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. 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. 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 (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used 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?
229. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER ADULT RESPONSIBLE REFUSED 2 (GO TO 239)
(SIGN) _____________
230. (12) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
As part of the survey we also are asking about 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. 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. 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 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 take the HIV test?
231. (12) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (GO TO 239)
(SIGN) _____________
INTERVIEWER NO. ____
232. (12) AGE: CHECK COLUMN 7.
18-49 YEARS 2 (GO TO 236)
233. (12) MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 236)
234. (12) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests of research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?
235. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 238)
(SIGN) _____________
236. (12) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?
237. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME,
RESPONDENT REFUSED 2
(SIGN) _____________
238. (12) ADDITIONAL TESTS. CHECK 235 AND 237:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
239. (12) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
240. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET (11)
REFUSED 995
OTHER 996
(PUT THE 1ST BAR CODE LABEL HERE)
REFUSED 99995
OTHER 99996
PUT SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.
242. GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 243.
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-49
243. CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
244. LINE NUMBER FROM COLUMN 10 AND NAME FROM COLUMN 2.
NAME ____
REFUSED 99995
OTHER 99996
REFUSED 9995
OTHER 9996
18-49 YEARS 2 (GO TO 252)
248. MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 252)
249. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
250. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
As a 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 test for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide. Will you allow (NAME OF ADOLESCENT) to take the anemia test?
251. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 256)
(SIGN) ____________
252. 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 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 take the anemia test?
253. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2
(SIGN) ____________
254. (12) AGE: CHECK COLUMN 7.
18-49 YEARS 2 (GO TO 258)
255. (12) MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 258)
256. (12) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
As a 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. 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. 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 (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know his HIV status, I can provide him with a list of (nearby) facilities offering counseling and testing for HIV. I will also give him a voucher for free services than can be used at any of these facilities.
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 allow (NAME OF ADOLESCENT) to take the HIV test?
257. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 267)
(SIGN) ____________
258. (12) ASK FOR CONSENT FOR DBS COLLECTION FROM RESPONDENT:
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. 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 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 take the HIV test?
259. (12) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (GO TO 267)
(SIGN) ____________
260. (12) AGE: CHECK COLUMN 7.
18-49 YEARS 2 (GO TO 264)
261. (12) MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 264)
262. (12) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?
263. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 266)
(SIGN) ____________
264. (12) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?
265. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2
(SIGN) ____________
266. (12) ADDITIONAL TESTS. CHECK 263 AND 265:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
267. (12) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
268. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET. (11)
REFUSED 995
OTHER 996
269. (12) BAR CODE LABEL:
(PUT THE FIRST BAR CODE HERE)
REFUSED 99995
OTHER 99996
PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.
270. GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.
(1) This section should be adapted for country-specific survey design.
(2) In Q. 18, 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.
(3) Coding categories to be developed locally and revised based on the pretest; however, the broad categories
must be maintained.
(4) 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,
generator, washing machine, microwave oven, computer, VCR or DVD player, cassette or CD player, camera,
air conditioner or cooler, color TV, sewing machine.
(5) Add other country-specific animals, such as oxen, water buffalo, camels, llamas, alpacas, pigs, ducks, geese,
or elephants.
(6) The question should be deleted in countries that do not have an organized spraying program to prevent the
transmission of malaria.
(7) The question should be deleted in countries that are not affected by malaria.
(8) 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 used.
(9) Year of fieldwork is assumed to be 2010. For fieldwork beginning in 2011 or 2012, the year should be
2006 or 2007, respectively.
(10) In countries where the weighing scale shows the weight to only one decimal place, retain only one box after
the decimal point and delete the first '9' from the other three codes.
(11) 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.
(12) Questions should be omitted in countries in which HIV testing is not a component of the survey.