IDENTIFICATION

LOCALITY NAME ____________________

NAME OF HOUSEHOLD HEAD __________________________

CLUSTER NUMBER ___ ___ ___

HOUSEHOLD NUMBER ___ ___

REGION ___ ___

LARGE CITY/SMALL CITY/TOWN/RURAL:

ALTITUDE ___ ___ ___ ___

HOUSEHOLD SELECTED FOR MALE INTERVIEW?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE___
INTERVIEWER'S NAME____
RESULT___

NEXT VISIT:
DATE____
TIME___

FINAL VISIT
DAY ___ ___
MONTH ___ ___
YEAR ___ ___ ___ ___
INTERVIEWER NUMBER __ ___
RESULT ___

TOTAL NUMBER OF VISITS ___

TOTAL PERSONS IN HOUSEHOLD ___ ___
TOTAL ELIGIBLE WOMEN ___ ___
TOTAL ELIGIBLE MEN ___ ___
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___ ___

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF INTERVIEW:

LANGUAGE OF RESPONDENT:

TRANSLATOR USED:

SUPERVISOR
NAME _________________
DATE _________________ ___ ___

FIELD EDITOR
NAME _________________
DATE _________________ ___ ___

OFFICE EDITOR ___ ___

KEYED BY ___ ___

HOUSEHOLD SCHEDULE

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

1) LINE NO.

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 the household?

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

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

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

ELIGIBILITY:

8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

8A) CHECK COVER PAGE. IF HOUSEHOLD SELECTED FOR MALE INTERVIEW: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS:

10) Is (NAME)'s biological mother alive?

11) Does (NAME)'s biological mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. RECORD '00' IF PARENT NOT LISTED IN THE HOUSEHOLD SCHEDULE.

12) Is (NAME)'s biological father alive?

13) Does (NAME)'s biological father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. RECORD '00' IF PARENT NOT LISTED IN THE HOUSEHOLD SCHEDULE.

EDUCATION IF AGE 5 YEARS OLDER:

14) Has (NAME) ever attended school?

15) What is the highest grade (NAME) completed?

EDUCATION IF AGE 5-24 YEARS:

16) Did (NAME) attend school at any time during the 1997 E.C. school year?

17) During this/that school year, what grade [is/was] (NAME) attending?

18) Did (NAME) attend school at any time during the previous school year, that is 1996 E.C.?

19) During that school year, what grade did (NAME) attend?

BIRTH REGISTRATION IF AGE 0-4:

20) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the municipality/local authorities?

TICK HERE IF CONTINUATION SHEET USED___

Just to make sure that I have a complete household listing:

1) Are there any other persons such as small children or infants that we have not listed?

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

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

21. What is the main source of drinking water for members of household?

22. What is the main source of water used by your household for other purposes such as cooking and handwashing?

23. Where is that water source located?

24. How long does it take to go there, get water, and come back?

25. Who usually goes to this source to fetch the water for your household?

26. Do you treat your water in any way to make it safer to drink?

27. What do you usually do the water to make it safer to drink? Anything else?
RECORD ALL MENTIONED.

27A. How does your household primarily dispose of household waste?

28. What kind of toilet facility do members of your household usually use?

29. Do you share this toilet facility with other households?

30. How many households use this toilet facility?

31. Does your household have:

32. What type of fuel does your household mainly use for cooking?

33. In this household, is food cooked on a stove or an open fire?
PROBE FOR TYPE.

34. Is the cooking usually done in the house, in a separate building, or outdoors?

35. Do you have a separate room which is used as a kitchen?

36. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

37. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

38. MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.

39. TYPE OF WINDOWS.
RECORD OBSERVATION.

40. How many rooms in this household are used for sleeping?

41. Does any member of this household own:

42. Does any member of this household own any land that can be used for agriculture?

43. How many (LOCAL UNITS) of agricultural land do members of this household own?
IF MORE THAN 97, ENTER '97'. IF UNKNOWN, ENTER '98'

44. Does this household own any livestock, herds, or farm animals?

45. How many of the following animals does this household own?
Cattle?
Milk cows, oxen, or bulls?
Horses, donkeys, or mules?
Camels?
Goats?
Sheep?
Chickens?

IF NONE, ENTER '00'
IF MORE THAN 97, ENTER '97'
IF UNKNOWN, ENTER '98'

46. Does any member of this household have an account with a bank/credit association/micro finance?

48. Does your household have any mosquito nets that can be used while sleeping?

48A. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

48B. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

48C. How long ago did your household obtain the mosquito net?

48D. OBSERVE OR ASK THE BRAND OF MOSQUITO NET.

48E. When you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?

48F. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos or bugs?

48G. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

48H. Did anyone sleep under this mosquito net last night?

48I. Who slept under this mosquito net last night?

48J. GO BACK TO Q.48B FOR NEXT NET; OR IF NO MORE NETS, GO TO Q.48K.

48K. Has your house ever been sprayed with insecticide for malaria prevention by spraymen from the District Health Office?

48L. How many months ago was your house sprayed?
IF LESS THAN 1 MONTH, RECORD '00'.

48M. OBSERVE THE INNER WALLS OF THE ROOMS USUALLY USED FOR SLEEPING FOR VISIBLE WHITE INSECTICIDE POWDER.

49. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)

WEIGHT AND HEIGHT MEASUREMENT

CHECK COVER PAGE:

CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

50) LINE NO. FROM COL. (8)

51) NAME FROM COL. (2)

52) AGE FROM COL. (7)

53) What is (NAME'S) date of birth?
[FOR CHILDREN UNDER AGE 6 ONLY]
FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

54) WEIGHT (KILOGRAMS)

55) HEIGHT (CENTIMETERS)

56) MEASURED LYING DOWN OR STANDING UP
[FOR CHILDREN UNDER AGE 6 ONLY]

57) RESULT

TICK HERE IF CONTINUATION SHEET USED ___

HEMOGLOBIN MEASUREMENT

CHECK COVER PAGE:

58) CHECK COLUMN (52):

59) LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

60) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*

61) HEMOGLOBIN LEVEL (G/DL)

62) CURRENTLY PREGNANT
[FOR WOMEN 15-49 ONLY]

63) RESULT

2005 Ethiopia Demographic and Health Survey Informed Consent Anemia Testing

Hello, my name is _____ and I am from the Population and Housing Census Commission Office, which, in collaboration with the Federal Ministry of Health is currently carrying out Demographic and Health Survey, all over the country, in scientifically, sampled enumeration areas. As part of this survey we are collecting information on Anemia prevalence among women and children in the sampled households by conducting Anemia testing.

Anemia is a serious health problem that results from poor nutrition. The Anemia testing is being done to help the government to find out how common it is. This enables the government to develop programs to prevent and treat anemia. But to do this it needs reliable information. That is why we are now collecting a few drops of blood from a finger from women and from children under six years of age for the test. The instruments I use for taking the blood are completely clean, sterile and safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

Do you have any questions?

May I now ask that you and your child ___________ participate in the anemia test? However, if you decide not to have the test done, it is your right and I will respect your decision. Now please tell me if you agree to have the test done.

Yes ______ No __________
Signature of interviewer ________________________

64) CHECK 61 AND 62:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*

*The cutoff point is 9g/dl for pregnant women and ____ g/dl for children and for women who are not pregnant (or who don't know if they are pregnant), based on the altitude from the coverpage and the adjustment factor in the Editor's and Supervisor's Manual.

**If more than one woman or child is below the cutoff point, read the statement in Q.65 to each woman who is below the cutoff point and to each parent/responsible adult of a child who is below the cutoff point.

65) We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This is indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the doctor at _____________________ about (your condition/the condition of NAME OF CHILD(REN)).
This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in (your blood/the blood of NAME OF (CHILD(REN)) may be given to the doctor?

AGREES TO REFERRAL?

HIV TESTING-WOMEN AND MEN

CHECK COVER PAGE

CHECK COLUMNS (8) AND (8A): RECORD THE LINE NUMBER, SEX AND AGE OF ALL WOMEN AGE 15-49 AND MEN AGE 15-59. THIS PAGE WILL BE DESTROYED IN OFFICE BEFORE TEST RESULTS ARE ADDED TO DATA FILE

66) LINE NO. FROM COL. (8) OR (8A)

67) SEX FROM COL. (4)

68) AGE FROM COL. (7)

69) CHECK AGE FROM COL (68):

70) LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

71) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT* CIRCLE CODE (AND SIGN)

72) READ CONSENT STATEMENT TO WOMAN/MAN
CIRCLE CODE (AND SIGN)

73) RESULT

74) SAMPLE BAR CODE

PASTE FIRST LABEL HERE
PASTE SECOND LABEL ON FILTER PAPER
PASTE THIRD LABEL ON BLOOD SAMPLE TRANSMITTAL FORM

2005 Ethiopia Demographic and Health Survey Informed Consent HIV testing

Hello, my name is ____________ and I am from the Population and Housing Census Commission Office, which, in collaboration with the Federal Ministry of Health, is currently carrying out the Demographic and Health Survey, all over the country, in scientifically, sampled enumeration areas. As part of this survey we are collecting information on HIV prevalence among women and men in sampled households by collecting blood for conducting an HIV test.

HIV is the virus that causes AIDS. The HIV test is being done to help the government to find out how common it is and its rate of spreading. This enables the government to devise means of controlling and preventing the spread of the disease and also provide care and support for those who have it. But to do this it needs reliable information. That is why we are now collecting a few drops of your blood from a finger for the HIV test.

The instruments I use for taking the blood are completely clean, sterile and safe. The samples will be coded so that all the information will be kept anonymous.

The blood sample will be sent to the Ethiopian Health and Nutrition Research Institute (EHNRI) Laboratory, in Addis Ababa. No identifiers such as names will be attached to the test. So we will not be able to tell you the result. No one else will be able to know your test results either.

If you want to know whether you have HIV, I can provide a voucher for you to go to the nearest health institution, which provides VCT, that is, counseling and a test for HIV.

Do you have any questions so far?

May I now ask you to participate in the test? You can say yes to the test or you can say no. It is up to you to decide.

Will you take the test?

Yes __________ No _____________
Signature of interviewer _____________________

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:______________________________________

COMMENTS ON SPECIFIC QUESTIONS:___________________________________

ANY OTHER COMMENTS: ____________________________

SUPERVISOR'S OBSERVATIONS: ____________________________________________

NAME OF THE SUPERVISOR: _______________________________ DATE:_____________________________