MINISTRY OF PLANNING, TERRITORY PLANNING, AND ECONOMIC INTEGRATION (MPATIE)
NATIONAL CENTER OF STATISTICS AND ECONOMIC STUDY (CNSEE)
IDENTIFICATION
NAME OF LOCALITY ___________
NAME OF HEAD OF HOUSEHOLD/HOUSEHOLD NUMBER __________________
STRUCTURE NUMBER __________
CLUSTER NUMBER (EDSC) _________
MUNICIPALITY/DISTRICT _________
NEIGHBORHOOD/COMMUNITY ________
RURAL 2
BRAZZAVILLE, POINTE NOIRE, DOLISIE, NKAYI, OTHER CITIES, RURAL:
POINTE NOIRE 2
DOLISIE/NKAYI 3
OTHER CITIES 4
RURAL 5
HOUSEHOLD SELECTED FOR MEN'S SURVEY AND ANEMIA TEST?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ____
INTERVIEWR'S NAME ____
RESULT* ____
NEXT VISIT
DATE _____
TIME _____
FINAL VISIT
DAY___
MONTH___
YEAR 200__
INTERVIEWER CODE ____
RESULT* ____
RESULT:
2 NO HOUSEHOLD MEMBER 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 OF A DWELLING
7 DWELLING DESTROYYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)
TOTAL NUMBER OF VISITS _____
TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NUMBER OF SURVEYED HOUSEHOLD ____
SUPERVISOR
NAME _________
DATE ____
FIELD EDITOR
NAME _______
DATE ____
OFFICE EDITOR _________
Now we would like some information about the people who usually live in your household or who are staying with you now.
1) LINE NUMBER:
2) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of household?
02 HUSBAND/WIFE/PARTNER
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 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER CHILD
12 STEPCHILD
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
7) AGE: How old is (NAME)?
IF LESS THAN ONE YEAR, RECORD '00'.
IF 95 YEARS OR MORE, RECORD '95'.
ELIGIBILITY:
8) CIRCLE THE LINE NUMBER OF ALL WOMEN AGE 15-49
9) CHECK COVER: HOUSEHOLD SELECTED FOR ANEMIA AND MEN? CIRCLE THE LINE NUMBER OF MEN AGE 15-59
9A) CHECK COVER: HOUSEHOLD SELECTED FOR ANEMIA AND MEN? CIRCLE THE LINE NUMBER OF CHILDREN UNDER AGE 6
10) PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD**: Is (NAME)'s natural mother alive?
NO 2
11) IF ALIVE: Does (NAME)'s natural mother live in this household? If yes, what is her name? RECORD MOTHER'S LINE NUMBER. IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE, RECORD '00'.
12) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
13) IF ALIVE: Does (NAME)'s natural father live in this household? If yes, what is his name? RECORD FATHER'S LINE NUMBER. IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE, RECORD '00'.
EDUCATION:
14) Has (NAME) ever attended school?
NO 2 (GO TO 20A)
15) What is the highest level of school (NAME) has attended?
SECONDARY FIRST CYCLE 2
SECONDARY SECOND CYCLE 3
HIGHER 4
DON'T KNOW 8
CP1 1
CP2 2
CE1 3
CE2 4
CM1 5
CM2 6
DON'T KNOW 8
FOR SECONDARY (FIRST CYCLE):
SIXTH GRADE 1
FIFTH GRADE 2
FOURTH GRADE 3
THIRD GRADE 4
FOR SECONDARY (SECOND CYCLE):
SECOND 1
FIRST 2
FINAL 3
DON'T KNOW 8
FOR HIGHER:
FIRST YEAR 1
SECOND YEAR 2
THIRD YEAR 3
FOUR OR MORE YEARS 4
DON'T KNOW 8
16) Is (NAME) currently attending school?
NO 2
17) During the 2004-2005 school year, did (NAME) attended school at any time?
NO 2 (GO TO 19)
18) During the current (2004-2005) school year, what level and grade [is/was] (NAME) attending?
SECONDARY FIRST CYCLE 2
SECONDARY SECOND CYCLE 3
HIGHER 4
DON'T KNOW 8
CP1 1
CP2 2
CE1 3
CE2 4
CM1 5
CM2 6
DON'T KNOW 8
FOR SECONDARY (FIRST CYCLE):
SIXTH GRADE 1
FIFTH GRADE 2
FOURTH GRADE 3
THIRD GRADE 4
FOR SECONDARY (SECOND CYCLE):
SECOND 1
FIRST 2
FINAL 3
DON'T KNOW 8
FOR HIGHER:
FIRST YEAR 1
SECOND YEAR 2
THIRD YEAR 3
FOUR OR MORE YEARS 4
DON'T KNOW 8
18A) During the current school year (2004-2005), is (NAME) attending a public or private school?
PRIVATE 2
19) During the previous school year (2003-2004), did (NAME) attend school at any time?
NO 2 (GO TO 20A)
20) During the previous school year (2003-2004), what level and grade did (NAME) attend?
SECONDARY FIRST CYCLE 2
SECONDARY SECOND CYCLE 3
HIGHER 4
DON'T KNOW 8
CP1 1
CP2 2
CE1 3
CE2 4
CM1 5
CM2 6
DON'T KNOW 8
FOR SECONDARY (FIRST CYCLE):
SIXTH GRADE 1
FIFTH GRADE 2
FOURTH GRADE 3
THIRD GRADE 4
FOR SECONDARY (SECOND CYCLE):
SECOND 1
FIRST 2
FINAL 3
DON'T KNOW 8
FOR HIGHER:
FIRST YEAR 1
SECOND YEAR 2
THIRD YEAR 3
FOUR OR MORE YEARS 4
DON'T KNOW 8
IF AGE 0-9 YEARS:
20A) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
NO 2
DON'T KNOW 8
20B) CHECK COLUMN 5 AND 7: Record the number of children between ages 5 and 17 living in this household:
NONE___ (GO TO 21)
20C) RECORD LINE NUMBERS OF ALL THE CHILDREN AGES 5 TO 14 IN THE ORDER FROM COLUMN 1 OF THE HOUSEHOLD SCHEDULE
20D) RECORD THE NAME OF EACH CHILD
20E) Since the last (DAY OF THE WEEK OF THE SURVEY), 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 20G)
20F) Since last (DAY OF THE WEEK OF THE SURVEY), 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).
20G) In the last 12 months, 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
20H) Since last (DAY OF THE WEEK OF THE SURVEY), do any household chores? For example, doing dishes, shopping, cleaning, clothes washing, getting water, or taking care of children?
NO 2 (GO TO 20J)
20I) Since last (DAY OF THE WEEK OF THE SURVEY), approximately how many hours did he/she spend doing these household chores?
20J) Since last (DAY OF THE WEEK OF THE SURVEY), did (NAME) do any other work on family land or in a family business?
NO 2 (GO TO NEXT LINE)
20K) Since last (DAY OF THE WEEK OF THE SURVEY), approximately how many hours did he/she spend doing this work on family land or in a family business?
21) What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 23)
NEIGHBOR 13
DRILLED SITE 22
PUBLIC 32
UNPROTECTED SOURCE 42
RIVER/STREAM/BACKWATER 43
RAINWATER 51 (GO TO 23)
TANKER TRUCK 52
BOTTLED WATER 53 (GO TO 23)
22) How long does it take you to go there, get water, and come back?
ON PREMISES 996
23) What kind of toilet facilities does your household have?
IMPROVED PIT/LATRINE 22
RUDIMENTARY PIT/LATRINE 21
NO FACILITY/BUSH/FIELD 31 (GO TO 25)
OTHER (SPECIFY) __________ 96
24) Do you share this toilet facility with other households?
NO 2
a) Electricity?
b) A radio/tape player?
c) A television?
d) A landline telephone?
e) A mobile telephone?
f) A computer?
g) A refrigerator/electric gas or petroleum freezer?
h) A portable gas stove?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26) What type of fuel does your household mainly use for cooking?
BOTTLED/NATURAL GAS 02
PETROLEUM 03
WOOD COAL 04
WOOD TO BURN 05
SAWDUST/WOOD CUTTINGS 06
OTHER (SPECIFY) 96
26A) How many rooms does your household use for sleeping?
27) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
VINYL/LINOLEUM/GERFLEX 32
TILE 33
CEMENT 44
CARPET 35
27A) MAIN MATERIAL OF ROOF. RECORD OBSERVATION.
TILES 22
27B) MAIN MATERIAL OF WALLS. RECORD OBSERVATION.
MUD BRICKS 22
SHEET METAL 23
CEMENT/CINDER BLOCKS 32
28) Does any member of your household own?
a) A bicycle?
b) A moped or motorcycle?
c) A car or truck?
d) A canoe without a motor?
e) A speedboat?
NO 2
NO 2
NO 2
NO 2
NO 2
29) Does your household have any mosquito nets that are used while sleeping?
NO 2 (GO TO 35)
29A) How many mosquito nets does your household have?
30) ASK THE RESPONDENT TO SHOW YOU THE NETS. ASK THE FOLLOWING QUESTIONS FOR EACH NET. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
31) How long ago did your household obtain this mosquito net?
3 YEARS OR MORE 96
32) OBSERVE OR ASK THE BRAND OF THE MOSQUITO NET
PRETREATED MOSQUITO NET.
PERMANET 2
OTHER (SPECIFY) ________ 3
DON'T KNOW/UNSURE 8
32A) Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (GO TO 32C)
UNSURE/DON'T KNOW 8 (GO TO 32C)
32B) How much time has passed since the mosquito net was last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'.
3 YEARS OR MORE 96
DON'T KNOW/UNSURE 98
32C) Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 32E)
DON'T KNOW 8 (GO TO 32E)
32D) Who slept under the mosquito net last night? RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
32E) GO BACK TO QUESTION 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 35.
35) ASK RESPONDENT FOR A TEASPOONFUL OF SALT USED FOR HOUSEHOLD NEEDS, THEN TEST THE SALT TO VERIFY THE PRESENCE OF IODINE.
RECORD THE PPM (PARTS PER MILLION). IF THE SALT IS NOT TESTED, PROVIDE THE REASON:
LESS THAN 15 PPM (LIGHT COLOR) 2
MORE THAN 15 PPM (DARK COLOR) 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED 5
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT
CHECK COLUMNS (8) AND (9A); RECORD THE LINE NUMBER, NAME, AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
WOMEN 15-49:
36) LINE NUMBER FROM COLUMN 8:
WEIGHT AND HEIGHT MEASUREMENTS OF WOMEN 15-49:
40) WEIGHT (KILOGRAMS)
NOT PRESENT 2
REFUSED 3
TECHNICAL PROBLEMS 4
OTHER 6
36) LINE NUMBER FROM COLUMN 9A:
39) What is the birth date of (NAME)?
WEIGHT AND HEIGHT MEASUREMENTS OF CHILDREN BORN IN 2000 OR LATER:
40) WEIGHT (KILOGRAMS)
42) MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
NOT PRESENT 2
REFUSED 3
TECHNICAL PROBLEMS 4
OTHER 6
MEASUREMENT OF HEMOGLOBIN LEVEL OF WOMEN AGE 15-49:
AGE 18-49 2 (GO TO 46)
45) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD "0" IF NOT LISTED IN HOUSEHOLD QUESTIONNAIRE.
46) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE AND SIGN.
REFUSED 2 (GO TO 49)
NO/DON'T KNOW 2
ABSENT 2
REFUSED 3
TECHNICAL PROBLEM 4
OTHER 6
HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 2000 OR LATER:
45) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD "0" IF NOT LISTED IN HOUSEHOLD QUESTIONNAIRE.
46) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE AND SIGN.
REFUSED 2 (GO TO 49)
ABSENT 2
REFUSED 3
TECHNICAL PROBLEM 4
OTHER 6
As a part of this survey, we are studying anemia in women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 2000 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 results told to you right away. The results will be kept strictly confidential.
May I now ask that you and (NAME OF CHILD[REN]) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
GO TO COLUMN 46 AND CIRCLE THE APPROPRIATE CODE.
58) CHECK QUESTIONS 47 AND 48 (FOR WOMEN):
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW CUTOFF POINT. LESS THAN 7 G/DL FOR CHILDREN AND WOMEN WHO ARE NOT PREGNANT (OR WHO DON'T KNOW IF THEY ARE PREGNANT); LESS THAN 9 G/DL FOR PREGNANT WOMEN.
59) DECLARATION: We detected a low level of hemoglobin in (your blood/the blood of (NAME OF CHILD). This indicates that (you/(NAME OF CHILD) have developed severe anemia, which is a serious health problem. We recommend that you go to a health center as soon as possible to be examined and to get treatment.
GIVE THEM THE REFERENCE SHEET FOR ANEMIA.