IDENTIFICATION

GOVERNORATE______
PSU/ SEGMENT NO._____
KISM/MARQAZ_______
BUILDING NUMBER______
SHIAKHA/VILLAGE_____
HOUSING UNIT NO._______
HOUSHOLD NO.___

LOCALITY

SUBSAMPLE

NAME OF HOUSEHOLD________
ADDRESS IN DETAIL________

INTERVIEWER VISITS:

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
TEAM______
INTERVIEWER______
SUPERVISOR_____
RESULT_______

RESULT CODES:

NEXT VISIT:
DATE_____
TIME______

FINAL VISIT
DAY___
MONTH_____
YEAR 2000
TEAM_____
INTERVIEWER______
SUPERVISOR______
RESULT______

TOTAL VISITS_____

TOTAL IN HOUSEHOLD______
TOTAL ELIGIBLE WOMEN______
LINE NO. OF RESPONDENT FROM HOUSEHOLD SCHEDULE_______

WOMAN/CHILD/ADOLESCENT REFERRED FOR SEVERE ANEMIA
ADDRESS CHECKED (BY NAME:______)
REINTERVIEW:

FIELD EDITOR
NAME____
DATE__/___ /2000
SIGNATURE_______

OFFICE EDITOR
NAME_____
DATE___/___/2000
SIGNATURE_______

CODER
NAME______
DATE___/___/2000

KEYER
NAME______
DATE___/___/2000

HOUSEHOLD SCHEDULE

We would like some information about people who usually live in your household or who are staying with you now.

001) LINE NUMBER

002) 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 NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT THE LISTING IS COMPLETE. THEN GO ON TO QUESTION 006.

006) RELATIONSHIP: What is the relationship of (NAME) to the head of the household?
(SEE CODES BELOW).

CODES FOR Q006

007) RESIDENCE: Does (NAME) usually live here?

008) RESIDENCE: Did (NAME) sleep here last night?

009) SEX: Is (NAME) male or female?

010) AGE: How old was (NAME) at his/her last birthday?

RECORD IN COMPLETED YEARS.

MARITAL STATUS

011) IF AGE 15 OR OLDER: What is (NAME'S) current marital status?

ELIGIBILITY

012) WOMEN: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW (i.e., EVER-MARRIED WOMEN AGE 15-49 YEARS WHO ARE USUAL RESIDENTS OR STAYED THERE ON THE NIGHT BEFORE THE INTERVIEW)

013) CHIILDERN: CIRCLE LINE NUMBER OF CHILDREN UNDER AGE 6

014) ADOLESCENTS: CIRCLE LINE NUMBER OF ALL MALE AND NEVER MARRIED FEMALE ADOLESCENTS AGE 11-19

JUST TO MAKE SURE THAT YOU HAVE A COMPLETE LISTING:

003) Are there any other persons such as small children or infants who are not listed here?

004) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?

005) Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?

CODES FOR Q006

PARENTAL SURVIVORSHIP AND RESIDENCE

015) IF 0-14 YEARS OLD: Is (NAME'S) natural mother still alive?

QUESTION REFERS TO CHILD'S BIOLOGICAL MOTHER.

IF ALIVE ASK 016, OTHERWISE GO TO 017

016) IF 0-14 YEARS OLD: IF ALIVE: Is (NAME'S) natural mother a usual household member or was she present in the household last night?

IF YES: What is her name?

CHECK 002 AND RECORD MOTHER'S LINE NUMBER.

IF NO: RECORD 00.

017) IF 0-14 YEARS OLD: Is (NAME'S) natural father still alive?
QUESTION REFERS TO CHILD'S BIOLOGICAL FATHER.
IF ALIVE ASK 018, OTHERWISE GO TO 019

018) IF 0-14 YEARS OLD: IF ALIVE: Is (NAME'S) natural father a usual household member or was he present in the household last night?
IF YES: What is his name?
CHECK 002 AND RECORD FATHER'S LINE NUMBER.
IF NO: RECORD 00.

EDUCATION

019) IF AGE 6 YEARS OR OLDER: Has (NAME) ever been to school?
IF YES: ASK QUESTIONS 020-028 AS APPROPRIATE.
IF NO: GO TO 029

020) IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended?

021) IF ATTENDED SCHOOL: What is the highest grade he/she successfully completed at that level?

CURRENT SCHOOL ATTENDANCE (IF AGE 3-24 YEARS)

022) Is (NAME) currently attending school?
IF NO: ASK QUESTION 023.
IF YES: ASK QUESTIONS 024-025.

023) During the current school year did (NAME) attend school at any time?
IF YES: ASK QUESTIONS 024-025.
IF NO: GO TO 026

024) IF ATTENDED SCHOOL: During this current school year what level was (NAME) attending?

025) IF ATTENDED SCHOOL: What grade was (he/she) attending?

RECENT SCHOOL ATTENDANCE

026) During the previous school year did (NAME) attend school at any time?
IF YES: ASK QUESTIONS 027-028.
IF NO: GO TO 029

027) IF ATTENDED SCHOOL: During that school year what level did (NAME) attend?

028) IF ATTENDED SCHOOL: What grade did (he/she) attend?

WORK STATUS

029) IF AGE 6 YEARS OR OLDER: Did (NAME) work during the last month?
IF YES: ASK 030.
IF NO: GO TO 006 FOR NEXT PERSON

030) IF AGE 6 YEARS OR OLDER: Is (NAME paid in cash or kind for the work (he/she) does?

031) CHECK 012 AND ENTER THE TOTAL NUMBER OF ELIGIBLE WOMEN:

______

032) CHECK 013 AND ENTER THE TOTAL NUMBER OF ELIGIBLE CHILDREN

_____

033) CHECK 014 AND ENTER THE TOTAL NUMBER OF ELIGIBLE ADOLESCENTS

____

034) TICK IF ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED

____

035) What type of dwelling does your household live in?

036) Is your dwelling owned by your household or not?
IF OWNED: Is it owned solely by your household or jointly with someone else?

037) MAIN MATERIAL OF THE FLOOR.
RECORD YOUR OBSERVATION

038) How many rooms does your household use for living (excluding the bathrooms, kitchens and stairway areas)?

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

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

041) What kind of toilet facility do most members of your household use?

042) Do you share this facility with other households?

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

044) Does your household have:

045) Does your household have:

046) Do you or any member of your household own:

047) Does your household have any place used for hand washing?

048) ASK TO SEE THE PLACE USED MOST OFTEN FOR HAND WASHING AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.

049) ASK RESPONDENT FOR A TEASPOON OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)

HEIGHT AND WEIGHT MEASUREMENT

050) CHECK QUESTIONS 012 AND 013 AND IDENTIFY ALL ELIGIBLE EVER-MARRIED WOMEN 15-49 AND CHILDREN UNDER AGE 6. RECORD THE LINE NUMBERS, NAMES AND AGES OF THE WOMEN AND CHILDREN FROM THE HOUSEHOLD SCHEDULE IN THE APPROPRIATE GRID BELOW. USE ADDITIONAL QUESTIONNAIRE IF THERE ARE NOT SUFFICIENT LINES TO RECORD ALL OF THE ELIGIBLE WOMEN AND CHILDREN.

ELIGIBLE WOMEN 15-49/ ELIGIBLE CHILDREN UNDER AGE 6

051) LINE NO.
CHECK COLUMN 001

052) NAME
CHECK COLUMN 002

053) AGE
CHECK COLUMN 010

054) What is NAME'S date of birth? [only ask ELIGIBLE CHILDREN UNDER AGE 6]

HEIGHT AND WEIGHT MEASUREMENT OF ELIGIBLE WOMEN 15-49/CHILDREN UNDER AGE 6

055) WEIGHT (KILOGRAMS)

056) HEIGHT (CENTIMETERS)

057) MEASURED: [ask only for ELIGIBLE CHILDREN UNDER AGE 6]

058) RESULT

059) TICK IF ADDITIONAL QUESTIONNAIRE USED TO RECORD MEASUREMENTS FOR:

WOMEN___
CHILDREN___

ANEMIA TEST

060) CHECK COVER PAGE TO DETERMINE IF HOUSEHOLD IS INCLUDED IN THE SUBSAMPLE FOR ANEMIA TESTING

CONSENT STATEMENT

As part of the survey, we are studying anemia among women, children, and adolescents. Anemia is a serious health problem which results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that all ever-married women aged 15-49, children under 6 and adolescents 11-19 participate in the anemia testing and give a drop of blood from the finger. The test uses sterile instruments that are clean and completely safe. The blood will be tested using special equipment and the results will be given to you right away. However, if you decide not to have the test done, it is your right and we will respect your decision. Now may I ask if (YOU/NAME OF CHILD OR ADOLESCENT) would participate in the anemia testing?

HEMOGLOBIN MEASUREMENT OF ELIGIBLE WOMEN

061) LINE NUMBER AND NAME OF WOMAN
CHECK 001-002

062) READ CONSENT STATEMENT TO EACH ELIGIBLE WOMAN

063) HEMOGLOBIN (G/DL)

064) RESULT

065) TICK IF ADDITIONAL QUESTIONNAIRE USED FOR ELIGIBLE WOMEN____

HEMOGLOBIN MEASUREMENT FOR ELIGIBLE CHILDREN

066) LINE NO. AND NAME OF CHILD UNDER AGE 6
CHECK 001-002

067) RECORD LINE NUMBER OF PARENT/RESPONSIBLE ADULT ASKED FOR CONSENT

068) READ CONSENT STATEMENT TO PARENT/ADULT RESPONSIBLE FOR EACH CHILD

069) HEMOGLOBIN LEVEL (G/DL)

070) RESULT:

071) TICK IF ADDITIONAL QUESTIONNAIRE USED FOR CHILDREN UNDER AGE 6

_____

HEMOGLOBIN MEASUREMENT OF ELIGIBLE ADOLESCENTS 11-19

072) LINE NO. AND NAME OF ADOLESCENTS AGE 11-19
CHECK 001-002

073) RECORD LINE NUMBER OF PARENT/RESPONSIBLE ADULT ASKED FOR CONSENT

074) READ CONSENT STATEMENT TO PARENT/ADULT RESPONSIBLE FOR EACH ADOLESCENT

075) HEMOGLOBIN LEVEL (G/DL)

076) RESULT:

077) TICK IF ADDITIONAL QUESTIONNAIRE USED FOR ADOLESCENTS___

078) NAME OF MEASURE/TESTER______
NAME OF ASSISTANT______

079) COMPLETE AN ANEMIA TEST RESULT CARD FOR EACH WOMAN, CHILD OR ADOLESCENT WHOSE HEMOGLOBIN LEVEL WAS TESTED.

080) CHECK QUESTIONS 063, 069, AND 075. INDICATE WHETHER ANY OF THE EVER-MARRIED WOMEN, CHILDREN UNDER 6 OR ADOLESCENT HAD A HEMOGLOBIN LEVEL BELOW 9 G/DL

ONE OR MORE PERSONS WITH HEMOGLOBIN LEVEL BELOW 9 G/DL___
NO PERSONS WITH HEMOGLOBIN LEVEL BELOW 9 G/DL___ (GO TO 082)

081) READ THE FOLLOWING STATEMENT TO EACH WOMAN WITH A HEMOGLOBIN LEVEL BELOW 9 G/DL AND/TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR EACH CHILD OR ADOLESCENT WITH A HEMOGLOBIN LEVEL BELOW 9 G/DL.

We detected a very low level of hemoglobin in (your blood/blood of (NAME OF CHILD/ADOLESCENT)). This may be a serious health problem. We would like to inform the doctor at (NEAREST MINISTRY OF HEATH REFERRAL FACILITY) about (your condition/the condition of (NAME OF CHILD/ADOLESCENT). This will assist you in obtaining appropriate treatment for the condition at this facility.

Do you agree that information about the level of hemoglobin in (your blood/the blood of (NAME OF CHILD/ADOLESCENT)) may be given to this facility? Whether you agree or not, we will give you a referral form to take to the facility.

FOR EACH WOMEN, CHILD OR ADOLESCENT WITH HEMOGLOBIN LEVEL OF 9 G/DL., MARK BELOW WHETHER THE REFERRAL TO THE MINISTRY OF HEALTH WAS ACCEPTED/

PREPARE A SEVERE ANEMIA REFERRAL FORM FOR EACH WOMAN, CHILD OR ADOLESCENT WITH A HEMOGLOBIN LEVEL BELOW 9 GD/L. GIVE THE WOMAN OR PARENT/OTHER RESPONSIBLE ADULT IN THE CASE OF A CHILD OR ADOLESCENT.

FOR INDIVIDUALS WHERE THERE IS AGREEMENT THAT THE MINISTRY OF HEALTH CAN BE INFORMED, COMPLETE THE INFORMATION ON THE CLUSTER SEVER ANEMIA REFERRAL RECORD AND FORWARD TO THE DHS OFFICE IN CAIRO.

NAME(S) OF PERSONS WITH HEMOGLOBIN LEVEL BELOW 9 G/DL
_________

FOR CHILDREN/ADOLESCENTS: NAME OF PARENT/OTHER RESPONSIBLE ADULT
________

AGREED/DID NOT AGREE TO REFERRAL

OBSERVATIONS

THANK THE RESPONDENT FOR PARTICIPATING IN THE SURVEY. COMPLETE QUESTIONS 082-083 AS APPROPRIATE. BE SURE TO REVIEW THE QUESTIONNAIRE FOR COMPLETENESS BEFORE LEAVING THE HOUSEHOLD.

082) DEGREE OF COOPERATION

083) INTERVIEWER'S COMMENTS:
________

084) FIELD EDITOR'S COMMENTS:
________

085) SUPERVISOR'S COMMENTS:
________

086) OFFICE EDITOR'S COMMENTS:
________