SEPTEMBER 2014

SURVEY OF MALARIA INDICATORS IN BURKINA FASO (EIPBF - 2014)
WOMAN'S QUESTIONNAIRE

BURKINA FASO
NATIONAL INSTITUTE OF STATISTICS AND DEMOGRAPHY (INSD)
PROGRAM TO SUPPORT HEALTH DEVELOPMENT (PADS)
NATIONAL PROGRAM IN FIGHT AGAINST MALARIA (PNLP)

IDENTIFICATION

NAME OF LOCALITY ______
NAME OF HEAD OF HOUSEHOLD ______
CLUSTER NUMBER ______
CONCESSION NUMBER ______
HOUSEHOLD NUMBER ______
ADMINISTRATIVE REGION ______
AREA (URBAN = 1, RURAL = 2) ______
SPECIFIC AREA (OUAGADOUGOU = 1, OTHER CITY = 2, RURAL = 3) ______
NAME AND LINE NUMBER OF WOMAN ______

INTERVIEWER VISITS

(repeat up to 3 visits)

DATE ______
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT:

DATE ______
TIME ______

FINAL VISIT

DAY ______
MONTH ______
YEAR 2014
INTERVIEWER NUMBER ______
RESULT ______

TOTAL NUMBER OF VISITS ______

RESULT CODES:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______

LANGUAGE OF QUESTIONNAIRE ______
LANGUAGE OF INTERVIEW ______
INTERPRETER (YES = 1, NO = 2) ______

LANGUAGE CODES:

1 FRENCH
2 MOORE
3 PEUHL/FULFUDE
4 DIOULA
5 GULMANTCHEMA
6 BISSA
7 DAGARA
8 OTHERS

TEAM LEADER

NAME ______

FIELD EDITOR

NAME ______

DATA ENTRY

NAME ______

SECTION 1. SOCIODEMOGRAPHIC BACKGROUND OF RESPONDENT

INTRODUCTION AND INFORMED CONSENT

INFORMED CONSENT
Hello. My name is ______ and I work for the National Institute of Statistics and Demography (INSD). We are conducting a national survey on malaria throughout the country. The information that we collect will help your government to improve health services. Your household was selected for this survey. The questions usually take between 20 and 30 minutes. All the information you give us is strictly confidential and will not be shared with anyone other than members of the survey team. You do not have to participate in this survey but we hope you will agree to participate because your opinion is very important. If I happen to ask a question that you do not want to answer, tell me and I will move on to the next question; you can also stop the interview at any time.

If you would like more information about the survey, you can contact the person whose name is on the card that was already given to your household.
Do you have any questions? May I begin the interview now?

SIGNATURE OF INTERVIEWER: ______
DATE: ______

1 RESPONDENT AGREES TO BE INTERVIEWED (Continue to 101)
2 RESPONDENT REFUSES TO BE INTERVIEWED (Skip to END)

101. RECORD THE TIME.

HOUR ______
MINUTES ______

102. In what month and what year were you born?

MONTH ______
98 DK MONTH
YEAR ______
9998 DK YEAR

103. How old were you on your last birthday?

COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

AGE IN COMPLETED YEARS ______

104. Have you ever been to school?

1 YES
2 NO (Skip to 108)

105. What is the highest level of education you have reached: primary, secondary, or higher?

1 PRIMARY
2 SECONDARY (1ST CYCLE)
3 SECONDARY (2ND CYCLE)
4 HIGHER

106. What is the highest (year/grade) that you have completed at this level?

IF LESS THAN ONE YEAR WAS COMPLETED AT THIS LEVEL, RECORD '00'.

[###translator's note: unable to translate "FPP" and "FPB" below]
(Table)

LEVEL

1 PRIMARY
2 SECONDARY 1ST CYCLE
3 SECONDARY 2ND CYCLE
4 HIGHER

PRIMARY GRADES

1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
6 6TH GRADE

1ST CYCLE GRADES

1 7TH GRADE
2 8TH GRADE
3 9TH GRADE
4 10TH GRADE
5 "FPP"

2ND CYCLE GRADES

1 11TH GRADE
2 12TH GRADE
3 "TERMINALE" COLLEGE PREP EXAMS
4 "FPB"

HIGHER

1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
4 5TH YEAR AND HIGHER

CLASS/YEAR ______

107. CHECK 105:

PRIMARY ______ (Continue to 108)
OTHER ______ (Skip to 109)

108. Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE:
Can you read part of the sentence?

1 CANNOT READ AT ALL
2 CAN ONLY READ PARTS OF THE SENTENCE
3 CAN READ ENTIRE SENTENCE
4 NO CARD IN RESPONDENT'S LANGUAGE (SPECIFY LANGUAGE) ______
5 BLIND/VISUALLY IMPAIRED

109. What is your religion?

1 MUSLIM
2 CATHOLIC
3 PROTESTANT
4 TRADITIONAL/ANIMIST
5 NO RELIGION/NONE
6 OTHER (SPECIFY) ______

110. What is your ethnicity (for Burkinabés)/your nationality (for foreigners)?

ETHNIC CODE (FOR BURKINABÉS)

01 BOBO
02 DIOULA
03 FULFULDE/PEULH
04 GOURMANTCH
05 GOUROUNSI
06 LOBI
07 MOSSI
08 SENOUFO
09 TOUAREG/BELLA
10 DAGARA
11 BISSA

NATIONALITY CODE (FOR FOREIGNERS)

12 ECOWAS COUNTRY
13 OTHER AFRICAN COUNTRY
14 OTHER NATIONALITY

96 OTHER ETHNICITY (SPECIFY) ______
98 DK

111. In the last 6 months, have you heard or seen any message about malaria?

1 YES
2 NO (Skip to 113)

112. Through what source did you hear or see a message about malaria?

PROBE: Other sources?

RECORD ALL MENTIONED.

A RADIO
B TELEVISION
C WALL POSTER
D COMMUNITY HEALTH AGENT
E COMMUNITY EVENT
F NGO/CHARITY FACILITATOR
G HEALTH PERSONNEL
H TOWN CRIERS
X OTHER (SPECIFY) ______

113. Have you heard of indoor residual spraying?

1 YES
2 NO (Skip to 115)

114. Would you like your residence to be sprayed?

1 YES
2 NO

115. In your opinion, what is the main cause of malaria?

[###Translator's note: possibly should read: If respondent replies "mosquito bite", then Probe]

MOSQUITO BITE

PROBE: No other way?

RECORD ALL MENTIONED

(codes B - Z, all skip to 117)

A MOSQUITO BITE
B OVER CONSUMPTION OF OIL
C TIRED DUE TO WORK
D INSUFFICIENT SLEEP
E DIRECT EXPOSURE TO SUN
F EATING MANGOS/SUGARY FRUIT
G DRINKING MILK
X OTHER (SPECIFY) _______
Z DK

116. At what time of day do mosquitos who transmit malaria bite?

1 ALL DAY
2 MORNING
3 NOON
4 EVENING
5 FIRST HALF OF NIGHT
6 SECOND HALF OF NIGHT
7 AT DAWN
8 DK

117. In your opinion, what are the symptoms of malaria?

PROBE: Other symptoms?

RECORD ALL MENTIONED.

A FEVER
B LACK OF APPETITE AND VOMITING
C HIGH FEVER WITH CONVULSIONS
D HIGH FEVER WITH FAINTING
E PERSISTANT FEVER
F CONVULSIONS
G JAUNDICE
X OTHER (SPECIFY) ______
Z DK

118. What are effective methods for preventing malaria?

PROBE: Any other method?

RECORD ALL MENTIONED.

A SLEEPING UNDER A MOSQUITO NET (UNTREATED)
B SLEEPING UNDER AN INSECTICIDE-TREATED MOSQUITO NET (TREATED)
C TAKING PREVENTIVE MEDICINE
D USING INSECTICIDE/DIFFUSERS/CREAMS/LOTIONS/REPELLANTS
E USING AN ANTI-MOSQUITO COIL
F PLANT OR ROOT JUICE DECOCTION TO DRINK AS PREVENTIVE
G BY CLEANING SURROUNDINGS
H INDOOR RESIDUAL SPRAYING
I SCREENS ON WINDOWS
J USING A FUMIGATING COIL
K USING ELECTRIC PLATES
L AIR CONDITIONERS/FANS
M POWDER (APPLICATION)
N COVERING UP BODY
W OTHER (SPECIFY) ______
X OTHER (SPECIFY) ______
Z DK

119. What methods do you use to protect yourself against malaria?

PROBE: Any other method?

RECORD ALL MENTIONED

120. Have you heard messages about malaria awareness on a regular basis on your local radio?

1 YES
2 NO (Continue to 121)

In what languages are these messages broadcast?

A FRENCH
B MOORE
C DIOULA
D PEUL/FULFUDE
E GOULMANTCHEMA
F BISSA
G DAGARA
X OTHER (SPECIFY) ______

Are these messages understandable?

1 YES
2 NO

What time of day are they broadcast?

A MORNING
B NOON
C AFTERNOON
D EVENING

121. Have you seen/heard messages about malaria awareness on a regular basis on your local television?

1 YES
2 NO (Continue to 122)

In what languages are these messages broadcast?

A FRENCH
B MOORE
C DIOULA
D PEUL/FULFUDE
E GOULMANTCHEMA
F BISSA
G DAGARA
X OTHER (SPECIFY) ______

Are these messages understandable?

1 YES
2 NO

What time of day are they broadcast?

A MORNING
B NOON
C AFTERNOON
D EVENING

122. Have you heard messages about malaria awareness on a regular basis from Community Health Agents, from grassroots Community Based Organizations?

1 YES
2 NO (Continue to 123)

In what languages are these messages broadcast?

A FRENCH
B MOORE
C DIOULA
D PEUL/FULFUDE
E GOULMANTCHEMA
F BISSA
G DAGARA
X OTHER (SPECIFY) ______

Are these messages understandable?

1 YES
2 NO

123. Have you heard messages about malaria awareness on a regular basis in places of worship (mosque, church) or from community leaders?

1 YES
2 NO (Continue to 124)

In what languages are these messages broadcast?

A FRENCH
B MOORE
C DIOULA
D PEUL/FULFUDE
E GOULMANTCHEMA
F BISSA
G DAGARA
X OTHER (SPECIFY) ______

Are these messages understandable?

1 YES
2 NO

124. In the last 12 months, have you

1 Heard songs or clips about the malaria awareness campaign on the radio?
2 Heard/seen any songs about the malaria awareness campaign on television?
3 Seen any clips about the malaria awareness campaign on television?

1 HEARD MESSAGE ON RADIO

1 YES
2 NO

2 HEARD/SEEN MESSAGE ON TELEVISION

1 YES
2 NO

3 SEEN CLIPS ON TELEVISION

1 YES
2 NO

125. What shape do you prefer for your treated mosquito nets?

1 CONICAL
2 RECTANGULAR

126. What color do you prefer for your treated mosquito net?

1 WHITE
2 GREEN
3 BLUE
4 NO PREFERENCE
6 OTHER (SPECIFY) ______

127. Do you own a treated mosquito net?

1 YES
2 NO (Skip to 129)

128. Are you satisfied with the size of your treated net?

1 YES
2 NO

129. Last night, did you sleep under a treated mosquito net?

1 YES (Skip to 201)
2 NO

130. Why didn't you sleep under a mosquito net last night?

PROBE: No other reason?

RECORD ALL MENTIONED.

A BAD SMELL
B CAUSES IRRITATIONS/COUGH
C MAKES SICK
D MAKES NAUSEOUS
E DANGEROUS CHEMICAL PRODUCT
F PRODUCT USED CAN KILL FETUS/CAUSE MISCARRIAGE
G CAN SUFFOCATE/BREATHING DIFFICULTIES
H DON'T LIKE SHAPE
I HEAT
J MOSQUITO NET GETS DIRTY QUICKLY
K DON'T LIKE MOSQUITO NET
L NO MOSQUITO NET
M WRONG SIZE
N MOSQUITO NET NOT EFFECTIVE
O NO REASON
X OTHER (SPECIFY) ______
Z DK

SECTION 2. REPRODUCTION

201. Now I would like to ask you some questions about all the births you have had in your lifetime. Have you ever given birth?

1 YES
2 NO (Skip to 206)

202. Do you have any sons or daughters to whom you gave birth who are currently living with you?

1 YES
2 NO (Skip to 204)

203. How many sons live with you?
And how many daughters live with you?

IF NONE, RECORD '00'.

SONS AT HOME ______
DAUGHTERS AT HOME ______

204. Do you have any sons or daughters to whom you gave birth who are still living but do not live with you?

1 YES
2 NO (Skip to 206)

205. How many sons are living but do not live with you?
How many daughters are living but do not live with you?

IF NONE, RECORD '00'.

SONS ELSEWHERE ______
DAUGHTERS ELSEWHERE ______

206. Have you ever given birth to a boy or girl who was born alive but who later died?

IF NO, PROBE: No baby who cried or showed signs of life but did not survive?

1 YES
2 NO (Skip to 208)

207. How many boys died?
How many girls died?

IF NONE, RECORD '00'.

DECEASED BOYS ______
DECEASED GIRLS ______

208. TOTAL UP THE ANSWERS TO 203, 205, AND 207 AND RECORD THE TOTAL.
IF NONE, RECORD '00'.

TOTAL BIRTHS ______

209. CHECK 208:

I would like to be sure I understood correctly: you have had a TOTAL of ______ births in your life. Is that correct?

YES ______ (Continue to 210)
NO ______ (PROBE AND CORRECT 201 TO 208 AS NECESSARY)

210. CHECK 208:

ONE BIRTH ______ (ask question)

Was this child born in the last six years?

TWO OR MORE BIRTHS ______ (ask question)

How many of these children were born in the last six years?

00 NONE (Skip to 224)

TOTAL IN LAST SIX YEARS ______

211. Now I would like to record the names of all the births you have had in the last six years (since 2008), whether they are still alive or not, beginning with the most recent birth.

RECORD THE NAME OF ALL BIRTHS IN LAST SIX YEARS (since 2008) IN Q. 212. RECORD TWINS/TRIPLETS ON SEPARATE LINES.

(Table)
(repeat 212 - 220 for up to 7 births)

212. What name was given to your (last/preceding) child?

(NAME) ______

213. Is (NAME) a boy or a girl?

1 BOY
2 GIRL

214. Is (NAME) a single birth or a multiple birth?

1 SINGLE
2 MULTIPLE

215. In what month and what year was (NAME) born?

PROBE:
What is his/her birthdate?

MONTH ______
YEAR ______

216. Is (NAME) still alive?

1 YES
2 NO (Go to next birth)

217. IF ALIVE:

How old was (NAME) on his/her last birthday?

RECORD AGE IN COMPLETED YEARS

AGE IN YEARS ______

218. IF ALIVE:

Does (NAME) live with you?

1 YES
2 NO

219. IF ALIVE:

NOTE THE CHILD'S LINE NUMBER FROM HOUSEHOLD SCHEDULE
(RECORD '00' IF CHILD IS NOT LISTED IN HOUSEHOLD)

LINE NUMBER ______ (Go to next birth)

220. Were there other live births between (NAME) and (NAME OF BIRTH FROM PRECEDING LINE)?

1 YES
2 NO

221. Have you had other live births since that of (NAME OF LAST BIRTH)? IF YES, RECORD THE BIRTH(S) IN THE BIRTH TABLE.

1 YES
2 NO

222. COMPARE 210 TO THE NUMBER OF BIRTHS RECORDED IN THE TABLE ABOVE AND CHECK OFF:

NUMBERS ARE SAME ______ (Continue to 223)
NUMBERS OF DIFFERENT ______ (PROBE AND CORRECT)

223. CHECK 215

RECORD THE NUMBER OF BIRTHS IN 2009 OR LATER

IF NONE, RECORD '0'.

NUMBER OF BIRTHS ______
0 NONE

224. Are you currently pregnant?

1 YES
2 NO (Skip to 226)
8 NOT SURE (Skip to 226)

225. How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS.

MONTHS ______

226. CHECK 223:

ONE OR MORE BIRTH IN 2009 OR LATER ______ (Continue to 301)
NO BIRTHS IN 2009 OR LATER ______ (Skip to 427)

SECTION 3. PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

301. NOTE THE NAME AND SURVIVAL STATUS OF LAST BIRTH IN 302.

Now I would like to ask you some questions about your last pregnancy in the last 6 years.

302. ACCORDING TO Q. 212 AND Q. 216 (LINE 01)

LAST BIRTH:

NAME: ______
LIVING ______ (Continue to 303)
DECEASED ______ (Continue to 303)

303. When you were pregnant with (NAME), did you see anyone for antenatal care?

1 YES
2 NO (Skip to 305)

304. Whom did you see?

Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEALTH PROFESSIONAL

A DOCTOR
B NURSE
C MIDWIFE
D MIDWIFE ASSISTANT
E VILLAGE MIDWIFE "MATRONE"/TRAINED BIRTH ATTENDANT

OTHER PERSONNEL

F TRADITIONAL BIRTH ATTENDANT
G COMMUNITY/VILLAGE HEALTH AGENT
X OTHER (SPECIFY) ______

305. During this pregnancy, how many antenatal consultations did you have?

NUMBER OF TIMES ______
98 DK

306. During this pregnancy, did you take any medicine to prevent malaria?

1 YES
2 NO (Skip to 314)
8 DK (Skip to 314)

307. What medicine did you take to prevent malaria?

RECORD ALL MENTIONED.

A INTERMITTENT PREVENTIVE TREATMENT (SP/FANSIDAR)
B CHLOROQUINE
C QUININE
X OTHER (SPECIFY) ______
Z DK

308. CHECK 307:

INTERMITTENT PREVENTIVE TREATMENT (SP/FANSIDAR) TAKEN FOR MALARIA

CODE 'A' CIRCLED ______ (Continue to 309)
CODE 'A' NOT CIRCLED ______ (Skip to 314)

309. How many times did you take the intermittent preventive treatment (SP/Fansidar) during your pregnancy?

IF 6 OR MORE TIMES, RECORD '6'

NUMBER OF TIMES ______
8 DON'T REMEMBER

310. How many pills did you take each time?

IF 6 OR MORE PILLS, RECORD '6'

NUMBER OF PILLS ______
8 DON'T REMEMBER

311. Did you take them in the presence of a health agent, at home, or elsewhere?

1 WITH HEALTH AGENT
2 AT HOME
3 ELSEWHERE

312. CHECK 304:

HAD ANTENATAL CARE FROM HEALTH PROFESSIONAL DURING THIS PREGNANCY?

CODE 'A', 'B', 'C', 'D', OR 'E' CIRCLED ______ (Continue to 313)
OTHER ______ (Skip to 314)

313. Did you get the intermittent preventive treatment (SP/Fansidar) during an antenatal visit, during a different visit in a health facility or from another source?

1 ANTENATAL VISIT
2 OTHER VISIT IN HEALTH FACILITY
6 OTHER SOURCE (SPECIFY) ______

314. CHECK 215 AND 216:

ONE OR MORE LIVING CHILDREN BORN IN 2009 OR LATER ______ (Continue to 401)
NO LIVING CHILD BORN IN 2009 OR LATER ______ (Skip to 427)

SECTION 4. CHILDREN'S HEALTH

401. CHECK 226:

ONE OR MORE BIRTHS IN 2009 OR LATER ______ (Continue to 402)
NO BIRTH IN 2009 OR LATER ______ (Skip to 427)

402. CHECK 215: IN THE TABLE, RECORD THE LINE NUMBER, THE NAME AND SURVIVAL STATUS OF EACH BIRTH FROM 2009 OR LATER FROM THE BIRTH HISTORY. ASK QUESTIONS ABOUT ALL THESE BIRTHS, BEGINNING WITH THE MOST RECENT BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE THE LAST TWO COLUMNS OF ADDITIONAL QUESTIONNAIRES).
Now I would like to ask you some questions about your children born in the last five years. (We will talk about one child at a time).

403. LINE NUMBER FROM 212 IN BIRTH HISTORY.

LAST BIRTH

BIRTH HISTORY NUMBER ______

SECOND TO LAST BIRTH

BIRTH HISTORY NUMBER ______

THIRD TO LAST BIRTH

BIRTH HISTORY NUMBER ______

404. FROM QUESTIONS 212 AND 216

(Repeat Q. 404 to Q. 426 for up to 3 births)

NAME ______
LIVING ______ (Continue to 405)
DECEASED ______ (GO TO 403 IN NEXT COLUMN OR IF THERE ARE NO MORE BIRTHS, SKIP TO Q. 427)

405. Was (NAME) sick with a fever at any time in the last 2 weeks?

1 YES
2 NO (GO TO Q. 403 IN NEXT COLUMN, OR IF THERE ARE NO MORE BIRTHS, SKIP TO Q. 427)
8 DK (GO TO Q. 403 IN NEXT COLUMN, OR IF THERE ARE NO MORE BIRTHS, SKIP TO Q. 427)

406. At any time during his/her illness, was blood taken from (NAME)'s finger or heel?

1 YES
2 NO
8 DK

407. Have you sought out any advice or treatment for the illness?

1 YES
2 NO (Skip to 411)

408. Where did you go for advice or treatment?

Anywhere else?

PROBE TO DETERMINE THE KIND OF PLACE.

IF UNBLE TO DETERMINE IF PLACE IS PUBLIC SECTOR OR PRIVATE SECTOR, RECORD THE NAME OF THE PLACE.
(NAME OF PLACE(S)) ______

PUBLIC SECTOR

A GOVERNMENT HOSPITAL
B GOVERNMENT HEALTH CENTRE
C GOVERNMENT RURAL HEALTH POST
D HEALTH AGENT
E OTHER PUBLIC SECTOR (SPECIFY) ______

PRIVATE MEDICAL SECTOR

F PRIVATE HOSPITAL/CLINIC
G PHARMACY
H PRIVATE DOCTOR
I MOBILE CLINIC
J HEALTH AGENT
K OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ______

OTHER PLACE

L COMMUNITY HEALTH AGENT
M SHOP
N TRADITIONAL PRACTITIONER
O MARKET
X OTHER (SPECIFY) ______

409. CHECK 408:

2 OR MORE CODES CIRCLED ______ (Continue to 410)
ONLY 1 CODE CIRCLED ______ (Skip to 411)

410. Where did you first go for advice or treatment?

USE CODES FROM 408.

FIRST PLACE ______

411. At any time during the illness did (NAME) take medicine for the illness?

1 YES
2 NO (GO TO 403 IN THE NEXT COLUMN OR IF THERE ARE NO MORE BIRTHS, SKIP TO Q. 427)
8 DK (GO TO 403 IN THE NEXT COLUMN OR IF THERE ARE NO MORE BIRTHS, SKIP TO Q. 427)

412. What medicine did (NAME) take?

Any other medicine?

RECORD ALL MENTIONED.

ANTIMALARIALS

A SP/FANSIDAR
B CHLOROQUINE
C AMODIAQUINE
D QUININE
E COMBINATION WITH ARTEMISININ
F OTHER ANTIMALARIAL (SPECIFY) ______

ANTIBIOTICS

G PILLS/SYRUP
H INJECTION

OTHER MEDICINE

I ASPIRIN/PARACETAMOL
J ACETAMINOPHEN
K IBUPROFEN
X OTHER (SPECIFY) ______
Z DK

413. CHECK 412:
ANY CODE A - F CIRCLED?

YES ______ (Continue to 414)
NO ______ (GO TO 403 IN NEXT COLUMN OR IF NO MORE BIRTHS, SKIP TO Q. 427)

414. CHECK 412:

SP/FANSIDAR ('A') GIVEN

CODE 'A' CIRCLED ______ (Continue to 415)
CODE 'A' NOT CIRCLED ______ (Skip to 416)

415. How soon after the beginning of the fever did (NAME) start taking (SP/Fansidar)?

0 SAME DAY
1 NEXT DAY
2 2 DAYS AFTER FEVER
3 3 OR MORE DAYS AFTER FEVER
8 DK

416. CHECK 412:

CHLOROQUINE ('B') GIVEN

CODE 'B' CIRCLED ______ (Continue to 417)
CODE 'B' NOT CIRCLED ______ (Skip to 418)

417. How soon after the fever began did (NAME) start taking chloroquine?

0 SAME DAY
1 NEXT DAY
2 2 DAYS AFTER FEVER
3 3 OR MORE DAYS AFTER FEVER
8 DK

418. CHECK 412:

AMODIAQUINE ('C') GIVEN

CODE 'C' CIRCLED ______ (Continue to 419)
CODE 'C' NOT CIRCLED ______ (Skip to 420)

419. How soon after the fever began did (NAME) start taking amodiaquine?

0 SAME DAY
1 NEXT DAY
2 2 DAYS AFTER FEVER
3 3 OR MORE DAYS AFTER FEVER
8 DK

420. CHECK 412:

QUININE ('D') GIVEN

CODE 'D' CIRCLED ______ (Continue to 421)
CODE 'D' NOT CIRCLED ______ (Skip to 422)

421. How soon after the fever began did (NAME) start taking quinine?

0 SAME DAY

1 NEXT DAY
2 2 DAYS AFTER FEVER
3 3 OR MORE DAYS AFTER FEVER
8 DK

422. CHECK 412:

COMBINATION WITH ARTEMISININ ('E') GIVEN

CODE 'E' CIRCLED ______ (Continue to 423)
CODE 'E' NOT CIRCLED ______ (Skip to 424)

423. How soon after the fever began did (NAME) start taking (COMBINATION WITH ARTEMISININ)?

0 SAME DAY
1 NEXT DAY
2 2 DAYS AFTER FEVER
3 3 OR MORE DAYS AFTER FEVER
8 DK

424. CHECK 412:

OTHER ANTIMALARIAL ('F') GIVEN

CODE 'F' CIRCLED ______ (Continue to 425)
CODE 'F' NOT CIRCLED ______ (RETURN TO 403 IN NEXT COLUMN OR IF NO MORE BIRTHS, SKIP TO 427)

425. How soon after the fever began did (NAME) start taking (OTHER ANTIMALARIAL)?

0 SAME DAY
1 NEXT DAY
2 2 DAYS AFTER FEVER
3 3 OR MORE DAYS AFTER FEVER
8 DK

426. RETURN TO 403 IN NEXT COLUMN OR IF NO MORE BIRTHS, CONTINUE TO Q. 427.
(IF NECESSARY) GO TO NEXT TO LAST COLUMN OF NEW QUESTIONNAIRE, OR IF NO MORE BIRTHS, CONTINUE TO Q. 427.

427. RECORD TIME

HOUR ______
MINUTES ______

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN ONCE INTERVIEW IS COMPLETED

COMMENTS ABOUT RESPONDENT
______

COMMENTS ABOUT PARTICULAR QUESTIONS
______

OTHER COMMENTS
______

TEAM LEADER'S OBSERVATIONS
______

TEAM LEADER'S NAME: ______
DATE: ______

SUPERVISOR'S OBSERVATIONS
______

SUPERVISOR'S NAME: ______
DATE: ______

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