LOCALITY NAME _______________
NAME OF HOUSEHOLD HEAD ______________
EA NUMBER _______
HOUSEHOLD NUMBER _____
REGION ____
DISTRICT ____
RURAL 2
CITY/LARGE TOWN/SMALL TOWN/VILLAGE ___
LARGE TOWN 2
SMALL TOWN 3
VILLAGE 4
INTERVIEWER VISIT 1
DATE ___
INTERVIEWER'S NAME ____
RESULT* ___
NEXT VISIT:
DATE____
TIME ____
INTERVIEWER VISITS 2
DATE ___
INTERVIEWER'S NAME ___
RESULT* ____
NEXT VISIT:
DATE____
TIME____
INTERVIEWER VISITS 3
DATE ___
INTERVIEWER'S NAME ___
RESULT* ____
FINAL VISIT
DAY __
MONTH__
YEAR 200__
NAME___
RESULT___
LINE NO. OF RESP TO HH QUESTION
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) _________
LANGUAGE OF QUESTIONNAIRE: ENGLISH
NO 2
AKAN 2
GA 3
EWE 4
NZEMA 5
DAGBANI 6
OTHER (SPECIFY) 7
SUPERVISOR
NAME _______
DATE _______
FIELD EDITOR
NAME ______
DATE ______
OFFICE EDITOR
_____
KEYED BY
_____
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?*
* CODES FOR Q.3
RELATIONSHIP TO HEAD OF 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 CO-WIFE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 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
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
9. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6
.
9A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59. IF HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY, LEAVE BLANK.
PARENTAL SURVIVORSHIP AND RESIDENCE
FOR PERSONS LESS THAN 18 YEARS OLD**
10. Is (NAME)'s biological mother alive?
NO 2
DK 8
11. (IF ALIVE) Does (NAME)'s biological mother live in this household? IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
12. Is (NAME)'s biological father alive?
NO 2
DK 8
13, (IF ALIVE) Does (NAME)'s biological father live in this household? IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
14. Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE)
15. What is the highest level of school (NAME) has attended?*** What is the highest grade (NAME) completed at that level?*** (15)
GRADE___
16. Is (NAME) currently attending school?
NO 2
17. During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 19)
18. During the current school year, what level and grade [is/was] (NAME) attending?***
GRADE___
19. During the previous school year, did (NAME) attend school at any time?
NO 2 (NEXT LINE)
20. During that school year, what level and grade did (NAME) attend?***
GRADE____
** Q.10 THROUGH Q.13
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.11 AND Q.13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.
***CODES FOR Qs.15, 18 AND 20
EDUCATION LEVEL:
2 MIDDLE/JSS
3 SECONDARY/SSS
4 HIGHER
8 DON'T KNOW
98 DON'T KNOW
TICK HERE IF CONTINUATION SHEET USED___
Just to make sure that I have a complete listing:
1) Are there any other persons such as small children or infants that we have not listed?
NO__
2) 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?
NO__
3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?
NO__
21. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 22A)
PUBLIC TAP 13 (GO TO 22A)
OPENWELL IN YARD/PLOT 22 (GO TO 22A)
OPEN PUBLIC WELL 23
PROTECTED WELL IN YARD/PLOT 32 (GO TO 22A)
PROTECTED PUBLIC WELL 33
RIVER/STREAM 42
POND/LAKE 43
DAM 44
TANKER TRUCK 61
BOTTLED WATER 71 (GO TO 22A)
SATCHEL WATER 81 (GO TO 22A)
OTHER (SPECIFY) ____ 96
22. How long does it take you to go there, get water, and come back?
ON PREMISES 996
22A. In the last two weeks, how frequently has water been available from this source?
SEVERAL HOURS EVERY DAY 2
A FEW TIMES A WEEK 3
LESS FREQUENTLY 4
NOT AT ALL 5
DON'T KNOW 8
22B. How does this household primarily dispose of household waste?
COLLECTED BY COMMUNITY ASSOCIATION 02
COLLECTED BY PRIVATE COMPANY 03
DUMPED IN COMPUND 04
DUMPED IN STREET/EMPTY PLOT 05
BURNED 06
BURIED 07
COMPOSTED 08
RECYCLED 09
FED TO ANIMALS 10
OTHER (SPECIFY) ____ 96
23. What kind of toilet facilities does your household have?
VENTILATED IMPROVED PIT (VIP LATRINE) 22
BUCKET/PAN 23
OTHER (SPECIFY) ____ 96
24. Do you share these facilities with other households?
NO 2 (GO TO 25)
24A. How many households do you share these facilities with?
3-4 2
5-9 3
10+ 4
Electricity?
A radio?
A television?
A video deck?
A telephone?
A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, LIGNITE 05
CHARCOAL 06
FIREWOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) ____ 96
26A. How likely is it that you could be evicted from this dwelling: Would you say very likely, somewhat likely, not at all likely?
SOMEWHAT LIKELY 2
NOT AT ALL 3
DON'T KNOW 4
27. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
MUD MIXED WITH DUNG 12
PALM/BAMBOO 22
LINOLEUM 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
TERRAZZO 36
28. Does any member of your household own:
A bicycle?
A motorcycle or motor scooter?
A car or truck?
A tractor?
A horse/cart?
NO 2
NO 2
NO 2
NO 2
NO 2
29. Does your household have any mosquito bed nets that can be used while sleeping?
NO 2 (GO TO 32F)
29A. How many mosquito bed nets does your household have?
29B. When do you use the nets?
DURING THE RAINY SEASON 2
OTHER (SPECIFY)____ 6
30. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. INFORMATION IS COLLECTED FOR EACH NET.
NOT OBSERVED 2
31. How long ago did your household obtain the mosquito bed net?
MORE THAN 3 YEARS AGO 96
31A. How did you obtain the net?
BOUGHT IT WITH VOUCHER OR OTHER SUBSIDY 2
RECEIVED IT FREE 3
OTHER (SPECIFY) ____ 6
DON'T KNOW 8
31B. When you got the mosquito bed net, was it treated with an insecticide?
NO, CAME WITH THE TREATMENT KIT AND I TREATED IT MYSELF 2 (SKIP TO 32A)
NO IT WAS NOT TREATED 3 (SKIP TO 32A)
OTHER (SPECIFY) ____ 6 (SKIP TO 32A)
DON'T KNOW 8 (SKIP TO 32A)
32. OBSERVE OR ASK THE BRAND OF MOSQUITO BED NET.
DAWA NET 2
OLYSET 3
LOCALLY MADE 4
OTHER 6
DON'T KNOW 8
32A. Since you got the mosquito bed net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?
NO 2 (SKIP TO 32C)
DON'T KNOW 8
32B. How long ago was the net last soaked or dipped? IF LESS THAN 1 MONTH, RECORD '00'.
MORE THAN 3 YEARS AGO 96
32C. Did anyone sleep under this mosquito bed net last night?
NO 2 (SKIP TO 32E)
DON'T KNOW (SKIP TO 32E)
32D. Who slept under this mosquito bed net last night? RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO____
32E. GO BACK TO 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 32F
32F In the past year, have you seen or heard messages about malaria:
On the television?
On the radio?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?
From a health worker?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
32G. Have you seen or heard any messages telling you to give a child with fever chloroquine tablets for three days?
NO 2
DON'T KNOW 8
32H. Have you ever listened to the radio program 'He Ha Ho?'
NO 2
DON'T KNOW 8
33. Where do you usually wash your hands?
SOMEWHERE ELSE 2 (GO TO 34A)
NOWHERE 3 (GO TO 34A)
34. ASK TO SEE THE PLACE AND OBSERVE IF THE FOLLOWING ITEMS ARE PRESENT.
NO 2
NO 2
NO 2
34A. Are you currently a member of a mutual health organization or health insurance scheme?
NO 2 (GO TO 34E)
DON'T KNOW 8 (GO TO 34E)
34B. What type of scheme are you a member of?
MHO 2
GVT. HEALTH COVERAGE 3
OTHER (SPECIFY) ____ 6
34C. What benefits does your scheme cover?
DRUGS B
LABORATORY COSTS C
X-RAY D
ADMISSION E
SURGERY F
SPECIALIST CARE G
EXTRA OR BETTER FEEDING IN HOSPITAL H
TRANSPORT I
ANTENATAL CARE J
NORMAL DELIVERY CARE K
COMPLICATED DELIVERY CARE L
FAMILY PLANNING M
OTHER (SPECIFY) ___ N
34D. Have you or any member of your family ever benefited from the scheme?
NO 2 (GO TO 35)
DON'T KNOW 8 (GO TO 35)
34E. Will you consider joining a scheme in the future?
NO 2
DON'T KNOW 8
35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION).
7 PPM 2
15 PPM 3
ABOVE 30 PPM 4
NO SALT IN HH 5
SALT NOT TESTED (SPECIFY REASON) 6
HEIGHT, WEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TESTING
CHECK COLUMNS (2), (7), (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.
WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49
2 NOT PRESENT
3 REFUSED
6 OTHER
39. What is (NAME)'s date of birth?
MONTH__
YEAR____
WEIGHT AND HEIGHT OF CHILDREN BORN IN 1998 OR LATER
42. MEASURED LYING DOWN OR STANDING UP
STAND. 2
2 NOT PRESENT
3 REFUSED
6 OTHER
TICK HERE IF CONTINUATION SHEET USED
* FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM Q215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.
HEMOGLOBIN MEASUREMENT OF WOMEN 15-49
AGE 18-49 2 (GO TO 46)
45. LINE NO. OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.
46. READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)
REFUSED 2 (NEXT LINE)
NO/DK 2
2 NOT PRESENT
3 REFUSED
6 OTHER
HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 1998 OR LATER
LINE NO. OF PARENT/ RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)
REFUSED 2 (NEXT LINE)
Hello, my name is (YOUR NAME) and I am from the Ghana Health Services and collaborating with the Ghana Statistical Service that is carrying out this health survey. As part of this survey, we are studying anemia among 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 1998 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely 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.
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.
Note:
In countries where some enumeration areas are higher than 1,000 meters, altitude information should be collected for each enumeration area higher than 1,000 meters so that the anemia estimates can be adjusted appropriately.
50. CHECK 47 AND 48:
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT*
51. We detected a low level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This 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?
NAME OF PERSON WITH HEMOGLOBIN BELOW THE CUTOFF POINT
NAME OF PARENT/RESPONSIBLE ADULT
(not necessary for women aged 18-49)
(indicate name of parent/responsible adult for women aged 15-17 and children)
NO 2
* The cutoff point is 9g/dl for pregnant women and 7g/dl for children and women who are not pregnant (or who don't know if they are pregnant.)
** If more than one woman or child is below the cutoff point, read the statement in Q.51 to each woman who is below the cutoff point and to each woman/parent/responsible adult of a child who is below the cutoff point.
CHECK COLUMNS (8) AND (9A): WRITE LINE NUMBER, NAME, SEX, AND AGE OF WOMEN 15-49 AND MEN 15-59. THIS PAGE TO BE DESTROYED IN OFFICE BEFORE TEST RESULTS ARE ADDED TO DATA FILE.
52. LINE NO.FROM COL.(8) OR (9A)
F 2
18+ 2 (GO TO 59)
57. LINE NO. OF PARENT/RESPONSIBLE ADULT
58. READ THE CONSENT STATEMENT TO THE PARENT OR RESPONSIBLE ADULT
CIRCLE CODE (AND SIGN)
REFUSES 2
NOT READ 3
59. READ THE CONSENT STATEMENT TO THE WOMAN OR MAN OR YOUTH
CIRCLE CODE (AND SIGN)
REFUSES 2
NOT READ 3
2 REFUSED
3 NOT PRESENT
4 TECH. PROBLEM
6 OTHER (SPECIFY)
SAMPLE BAR CODE (61)
Hello, my name is _______. I'm from the Ghana Health Services and collaborating with the Ghana Statistical Services. As part of this survey, we are studying HIV among women and men. As you know, HIV is the virus that causes AIDS. The government is trying to find out how common HIV is, so that they can develop programs to prevent HIV and care for those who have it.
We request that you participate in this test by giving a few drops of blood from a finger. For this test, I will use clean, sterile instruments that are completely safe. Blood will be tested later in the laboratory.
To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your test and no one will be able to trace the test back to you. If you want to know whether you have HIV, I can tell you where you can go to get tested.
Do you have any questions?
I hope you will agree to participate in the HIV testing. But if you decide not to have the test done, it is your right and I will respect your decision. Will you accept to participate in the HIV test?
GO BACK TO COLUMN (59). CIRCLE THE APPROPRIATE CODE AND SIGN.
IF RESPONDENT IS AGE 15-17, ASK PARENT/GUARDIAN: Now, will you tell me if you accept for (NAME OF YOUTH) to participate in the HIV test?
GO TO COLUMN (58). CIRCLE THE APPROPRIATE CODE AND SIGN. IF PARENT AGREES, READ THE PRECEDING PARAGRAPHS TO YOUTH FOR HIS/HER CONSENT AND RECORD IN COL. (59).
NOTE FOR THE INTERVIEWER:
THE RESPONDENT HAS THE RIGHT TO REFUSE THE HIV TEST, AND THEREFORE SHOULD NOT BE FORCED.