HOUSEHOLD QUESTIONNAIRE
PLACE NAME/SUB-DISTRICT___
NAME OF HEAD OF HOUSEHOLD_____
PROVINCE______
MUNICIPALITY_______
DISTRICT NAME AND NUMBER_____
CLUSTER NUMBER_______
HOUSEHOLD NUMBER_______
RURAL 2
HOUSEHOLD SELECTED FOR MEN'S SURVEY/ANEMIA TEST/HIV TEST?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME______
RESULT _____
NEXT VISIT
DATE_____
TIME______
FINAL VISIT
DAY____
MONTH_____
YEAR______
INT. NUMBER______
RESULT _____
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____
TOTAL PERSONS IN HOUSEHOLD_____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_____
FIELD EDITOR
NAME_____
DATE______
OFFICE EDITOR _____
KEYED BY _____
Hello. My name is ____. I am working with the Institute of Statistics and Economic Study of Burundi, ISTEEBU. We are conducting a survey about health all over Burundi. 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 20 to 45 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 the interview?
SIGNATURE OF INTERVIEWER________
DATE________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
1) LINE NUMBER
2) USUAL RESIDENTS AND VISITORS:
Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
AFTER LISTING 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 THE APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 FOSTER/STEPCHILD
11 NOT RELATED
98 DON'T KNOW
4) SEX: Is (NAME) male or female?
FEMALE 2
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
6a) For how many years have (NAME) lived in this household?
IF LESS THAN 1 YEAR OR VISITOR, RECORD '00'.
7) AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'.
8) MARITAL STATUS: What is (NAME)'s current marital status?
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED TOGETHER
ELIGIBILITY:
9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59
11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:
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'.
EVER ATTENDED SCHOOL:
16) Has (NAME) ever attended school?
NO 2 (GO TO 20)
DON'T KNOW 8 (GO TO 20)
17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
LEVEL:
2 SECONDARY 1ST CYCLE
3 SECONDARY 2ND CYCLE
4 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE:
01 FIRST YEAR
02 SECOND YEAR
03 THIRD YEAR
04 FOURTH YEAR
05 FIFTH YEAR
06 SIXTH YEAR
98 DON'T KNOW
01 SEVENTH YEAR
02 EIGHTH YEAR
03 NINTH YEAR
04 TENTH YEAR
98 DON'T KNOW
01 ELEVENTH YEAR
02 TWELFTH YEAR
03 THIRTEENTH YEAR
04 FOURTEENTH YEAR
98 DON'T KNOW
01 FIRST YEAR
02 SECOND YEAR
03 THIRD YEAR
04 FOURTH YEAR
05 FIFTH YEAR
06 SIXTH YEAR
07 SEVENTH YEAR
98 DON'T KNOW
CURRENT/RECENT SCHOOL ATTENDANCE:
18) Did (NAME) attend school at any time during the (2009-2010) school year?
NO 2 (NEXT LINE)
19) During the 2010-2011 school year, what level and grade (is/was) (NAME) attending?
LEVEL:
2 SECONDARY 1ST CYCLE
3 SECONDARY 2ND CYCLE
4 HIGHER
6 PRESCHOOL
8 DON'T KNOW
GRADE:
02 SECOND YEAR
03 THIRD YEAR
04 FOURTH YEAR
05 FIFTH YEAR
06 SIXTH YEAR
98 DON'T KNOW
02 EIGHTH YEAR
03 NINTH YEAR
04 TENTH YEAR
98 DON'T KNOW
02 TWELFTH YEAR
03 THIRTEENTH YEAR
04 FOURTEENTH YEAR
8 DON'T KNOW
02 SECOND YEAR
03 THIRD YEAR
04 FOURTH YEAR
05 FIFTH YEAR
06 SIXTH YEAR
07 SEVENTH YEAR
98 DON'T KNOW
20) BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
2 REGISTERED
3 NEITHER
8 DON'T KNOW
TICK HERE IF CONTINUATION SHEET USED _____
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 many 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
20A) CHECK COLUMN 7: RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 LIVING IN THIS HOUSEHOLD
NO CHILD BETWEEN 5 AND 14 (GO TO 101)
Now I would like to ask you some questions on the type of work that children in your household did last week.
RECORD THE NAMES AND LINE NUMBERS OF ALL THE CHILDREN AGE 5 TO 14 IN THE ORDER FROM THE HOUSEHOLD SCHEDULE
21) In the last week, did (NAME) do any work for anyone who is not a member of this household?
IF YES: Was he/she paid in cash or in kind?
YES, NOT PAID 2
NO WORK 3 (GO TO 23)
22) Since last (day of the week), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.
23) In the last week, did (NAME) get water or wood for the household?
NO 2 (GO TO 25)
24) Since last (day of the week), approximately how many hours did he/she spend getting water or wood for the household? IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.
25) In the last week, did (NAME) do any paid or unpaid work on family land, or in a family business, or did he/she sell any merchandise on the street?
INCLUDE WORK IN A REGULAR JOB HELD BY THE CHILD ALONE OR WITH ONE OR MORE PARTNERS.
NO 2 (GO TO 27)
26) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing this work for the family or for himself/herself?
IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.
27) In the last week, did (NAME) do any household chores, like shopping, cleaning, clothes washing, cooking, or taking care of children, older people or sick people?
NO 2 (GO TO NEXT LINE)
28) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores? IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.
101) Does anyone smoke in your household?
IF YES: Would you say daily, weekly, monthly, less than monthly?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NO/NEVER 5
102) What is the main source of drinking water for members of your household?
PIPED INTO 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 (SPECIFY) _______ 96
103) Where is the water source located?
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104) How long does it take you to go there, get water, and come back?
DON'T KNOW 998
104A) Who usually goes to the water source to bring water to your household?
PROBE: Is this person 15 years or younger? Is this person a male or a female?
ADULT MALE (15 YEARS OR MORE) 2
YOUNG GIRL (15 YEARS OR LESS) 3
YOUNG BOY (15 YEARS OR LESS) 4
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 (SPECIFY) _____ X
DON'T KNOW Z
107) What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW 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 (SPECIFY) _____ 96
108) Do you share this toilet facility with other households?
NO 2 (GO TO 110)
109) How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
110) Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
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
BIOGAS 04
PETROLEUM 05
KEROSENE 06
COAL, LIGNITE 07
CHARCOAL 08
WOOD 09
STRAW/SHRUBS/GRASS 10
AGRICULTURAL CROP 11
ANIMAL DUNG 12
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) ____ 96
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 (SPECIFY) _____ 96 (GO TO 114)
113) Do you have a separate room which is used as a kitchen?
NO 2
114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION
THATCH/PALM LEAF/LEAVES 12
SOD 13
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
LOCAL TILES 32
WOOD 33
CALAMINE/CEMENT FIBER 34
INDUSTRIAL TILE/SLATE 35
CEMENT/CONCRETE 36
ROOFING SHINGLES 37
116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION
BAMBOO/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 your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
118a) Are you or is anyone else living in the household the owner of the dwelling?
NO, RENT FROM SOMEONE WHO LIVES ELSEWHERE 2
OTHER (SPECIFY) ______ 6
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 95.00
95 OF MORE HECTARES 95.00
DON'T KNOW 99.98
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?
IF NONE, ENTER '00'
IF 95 OR MORE, ENTER '95'
IF UNKNOWN, ENTER '98
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Chickens?
Guinea pigs?
Rabbits?
123) Does any member of this household have a bank account?
NO 2
124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (GO TO 126)
DON'T KNOW 8 (GO TO 126)
125) Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) _____ X
DON'T KNOW Y
126) Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 137)
127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
128) Ask the respondent to show you the nets in the household. Ask the following questions for each net. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
128a) Did you receive this mosquito net a) during the 2009 campaign, b) the 2010 campaign, c) during an antenatal consultation, d) during a vaccination session for a child, e) or on another occasion?
CAMPAIGN 2010 2
ANTENATAL VISIT 3
VACCINATION 4
OTHER 6
129) 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) 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
INTERCOT 12 (GO TO 134)
PERMANET 13 (GO TO 134)
OTHER/DON'T KNOW BRAND 16 (GO TO 134)
OTHER/DK BRAND 26 (GO TO 132)
DON'T KNOW BRAND 98
131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?
NO 2
DON'T KNOW/NOT SURE 8
132) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (GO TO 134)
DON'T KNOW/NOT SURE 8 (GO TO 134)
133) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'. IF MORE THAN 2 YEARS, RECORD THE NUMBER OF MONTHS
MORE THAN 24 MONTHS AGO 95
NOT SURE/DON'T KNOW 98
134) Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 136)
DON'T KNOW 8 (GO TO 136)
135) Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. RECORD ALL PERSONS WHO SLEPT UNDER EACH MOSQUITO NET LAST NIGHT.
136) 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 HANDWASHING.
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.
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 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE.
202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
203) IF MOTHER INTERVIEWED, COPY MOTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY. IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?
204) CHECK 203: CHILD BORN IN JANUARY 2005 OR LATER
NO 2 (GO TO 203 FOR NEXT CHILD, OR, IF NO MORE CHILDREN, GO TO 214)
NOT PRESENT 99.94
REFUSED 99.95
OTHER 99.96
NOT PRESENT 99.94
REFUSED 99.95
OTHER 99.96
207) MEASURE LYING DOWN OR STANDING UP?
STANDING UP 2
NOT MEASURED 3
208) CHECK 203: IS THE 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 1 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.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 member 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 THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET
NOT PRESENT 99.4
REFUSED 99.5
OTHER 99.6
213) GO BACK TO 202 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 TEST 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
NOT PRESENT 999.94
REFUSED 999.95
OTHER 999.96
NOT PRESENT 999.4
REFUSED 999.5
OTHER 999.6
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 RESPONSIBLE ADULT FOR ADOLESCENT. RECORD 00 IF NOT LISTED. LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT.
221) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 member 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 of adolescent) to participate in the anemia test?
222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 228)
223) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 member 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 in the anemia test?
224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 226)
225) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
18-49 YEARS 2 (GO TO 230)
227) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 230)
228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 239)
230) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 your HIV status, I can provide 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 239)
18-49 YEARS 2 (GO TO 236)
233) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 236)
234) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 238)
236) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN _____) (GO TO 239)
238) ADDITIONAL TESTS
CHECK 235 AND 237: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER
239) 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
NOT PRESENT 99.4
REFUSED 99.5
OTHER 99.6
241) BAR CODE LABEL
PUT THE 1ST BAR CODE HERE
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 243.
HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59
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
NAME FROM COLUMN 2
18-59 YEARS 2 (GO TO 252)
248) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 252)
249) RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD 00 IF NOT LISTED
250) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 member 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 of adolescent) to participate in the anemia test?
251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 256)
252) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 member 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 in the anemia test?
253) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN _____)
18-49 YEARS 2 (GO TO 258)
255) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 258)
256) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 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?
257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 267)
258) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
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 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 you HIV status, I can provide 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (SIGN ______) (GO TO 267)
18-59 YEARS 2 (GO TO 264)
261) MARITAL STATUS: CHECK COLUMN 248
OTHER 2 (GO TO 264)
262) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN ____) (GO TO 266)
264) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]
We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN ______) (GO TO 267)
266) ADDITIONAL TESTS
CHECK 263 AND 265: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER
267) 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
NOT PRESENT 99.4
REFUSED 99.5
OTHER 99.6
269) BAR CODE LABEL
PUT THE FIRST BAR CODE HERE
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
270) GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.