DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE
MAY 2012
REPUBLIC OF GUINEA
NATIONAL OFFICE OF STATISTICS
NAME OF PLACE________
NAME OF HEAD OF HOUSEHOLD____________
CLUSTER NUMBER___________
HOUSEHOLD NUMBER____________
ADMINISTRATIVE REGION__________
RURAL 2
CONAKRY/NATURAL CAPITAL REGION/OTHER CITY/RURAL
CAPITAL REGION 2
OTHER CITY 3
RURAL 4
HOUSEHOLD SELECTED FOR MEN'S SURVEY?
NO 2
DATE_____________
INTERVIEWER'S NAME______________
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)
FINAL VISIT
DAY_________
MONTH___________
YEAR _________
INTERVIEWER CODE___________
RESULT___________
NEXT VISIT_________________
DATE ____________
TIME___________
TOTAL NO. OF VISITS________________
TOTAL PERSONS IN HOUSEHOLD______________
TOTAL ELIGIBLE WOMEN___________
TOTAL ELIGIBLE MEN_____________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___________
SUPERVISOR_____________
NAME____________
DATE__________
FIELD EDITOR____________
NAME_______________
DATE_________
OFFICE EDITOR____________
KEYED BY_______________
Hello. My name is ___. I am working with the National Office of Statistics. We are conducting a survey about health all over Guinea. 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 15 to 20 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 AGREES TO BE INTERVIEWED_________ 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END
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 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?
SEE CODES BELOW.
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 ADOPTED/FOSTER
11 STEPCHILD
12 CO-SPOUSE
13 NOT RELATED
98 DON'T KNOW
4) SEX
Is (NAME) male or female?
F 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 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
9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49
10) CHECK THE COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY YES=1
CIRCLE LINE NUMBER OF ALL MEN 15-49
11) CHECK THE COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY YES=1
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)
DK 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)
DK 8 (GO TO 16)
15) Does (NAME)'s natural father 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)
17) What is the highest level of school (NAME) has attended?
SEE CODES BELOW.
What is the highest grade (NAME) completed at that level?
SEE CODES BELOW
1 PRIMARY
2 SECONDARY 1
3 SECONDARY 2
4 PROFESSIONAL A
5 PROFESSIONAL B
6 HIGHER
8 DON'T KNOW LEVEL
0 LESS THAN 1 YEAR
1 SMALL SECTION
2 MEDIUM SECTION
3 LARGE SECTION
PRIMARY
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR
SECONDARY 1
0 LESS THAN 1 YEAR
1 7TH YEAR
2 8TH YEAR
3 9TH YEAR
4 10TH YEAR
SECONDARY 2
0 LESS THAN 1 YEAR
1 11TH YEAR
2 12TH YEAR
3 FINAL
PROFESSIONAL A
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
PROFESSIONAL B
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
HIGHER
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR
98 DON'T KNOW GRADE
CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during the (2011-2012) school year?
NO 2 (GO TO 20)
19) During this/that school year, what level and grad (is/was) (NAME) attending?
SEE CODES BELOW.
(USE 00 FOR Q 17 ONLY. THIS CODE NOT ALLOWED FOR Q 19)
1 PRIMARY
2 SECONDARY 1
3 SECONDARY 2
4 PROFESSIONAL A
5 PROFESSIONAL B
6 HIGHER
8 DON'T KNOW LEVEL
0 LESS THAN 1 YEAR
1 SMALL SECTION
2 MEDIUM SECTION
3 LARGE SECTION
PRIMARY
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR
SECONDARY 1
0 LESS THAN 1 YEAR
1 7TH YEAR
2 8TH YEAR
3 9TH YEAR
4 10TH YEAR
SECONDARY 2
0 LESS THAN 1 YEAR
1 11TH YEAR
2 12TH YEAR
3 FINAL
PROFESSIONAL A
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
PROFESSIONAL B
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
HIGHER
0 LESS THAN 1 YEAR
1 1ST YEAR
2 2ND YEAR
3 3RD YEAR
4 4TH YEAR
5 5TH YEAR
6 6TH YEAR
98 DON'T KNOW GRADE
BIRTH REGISTRATION
20) 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) In addition, 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
101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
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
TAP AT NEIGHBOR'S HOUSE 14
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
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
105) Do you do anything to the water to make it safer to drink?
NO 2 (GO TO 107)
DK 8 (GO TO 107)
106) What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED
B ADD BLEACH/CHLORINE
C STRAIN THROUGH A CLOTH
D USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.)
E SOLAR DISINFECTION
F LET IT STAND AND SETTLE
X OTHER (SPECIFY)
Z DON'T KNOW
107) What kind of toilet facility do members of your household usually use?
CONNECTED FLUSH
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
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:
ELECTRICITY?
NO 2
A RADIO?
NO 2
A TELEVISION?
NO 2
A MOBILE TELEPHONE?
NO 2
A NON-MOBILE TELEPHONE?
NO 2
A REFRIGERATOR?
NO 2
A TABLE?
NO 2
A CHAIR?
NO 2
A WARDROBE/BOOKCASE?
NO 2
A STOVE/PORTABLE STOVE?
NO 2
A FREEZER?
NO 2
A HUNTING RIFLE?
NO 2
A PLOW?
NO 2
111) What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
SAW/SHRUBS/GRASS 09
AGRICULTURAL CROP/SAWDUST 10
ANIMAL DUNG 11
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) 6 (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
GRAVEL 12
OTHER PLANT 22
VINYL/ASPHALT 32
TILE 33
CEMENT 34
115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION
THATCH/PALMS/LEAVES 12
SOD 13
CARDBOARD 22
WOOD 32
ZINC/CEMENT FIBER 33
TILE 34
CEMENT 35
116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 13
STONE WITH MUD 22
BAMBOO/WOOD WITH MUD 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
COOKED/STABILIZED BRICKS 32
STONE WITH CEMENT 33
WOOD PLANKS 34
117) How many rooms in this household are used for sleeping?
118) Does any member of your household own:
A CANOE?
NO 2
A BICYCLE?
NO 2
A MOTORCYCLE OR MOTOR SCOOTER?
NO 2
AN ANIMAL-DRAWN CART?
NO 2
A CAR OR TRUCK?
NO 2
A BOAT WITH A MOTOR?
NO 2
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 950
95 OF MORE HECTARES 950
DON'T KNOW 998
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
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)
DK 8 (GO TO 126)
125) Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) X
DON'T KNOW Z
126) Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 136D)
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.
If more than 3 nets, use additional questionnaire(s).
NOT OBSERVED 2
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 97
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
PERMENET 12 (GO TO 134)
INTERCEPTOR 13 (GO TO 134)
SERENA 14 (GO TO 134)
OTHER/DK BRAND 16 (GO TO 134)
OTHER/DK BRAND 26 (O TO 132)
DK BRAND 98
131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?
NO 2
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)
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.
MORE THAN 24 MONTHS AGO 95
NO SURE 98
134) Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 136)
DK 8 (GO TO 136)
135) Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE
LINE NUMBER
136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 136A
136a) FILTER
CHECK Q 131.
IF NO OR NOT SURE, CODE 2 OR CODE 8 CIRCLED (GO TO 136G)
136b) When you received the insecticide-soaked mosquito net (MII), were you given advice?
NO 2 (GO TO 136E)
DON'T KNOW 8 (GO TO 136E)
136c) What advice/information were you given?
PROBE: What else?
B HOW TO INSTALL NET
C HOW TO WASH NET
D WHERE TO RE-SOAK NET
E WHEN TO RE-SOAK NET
X OTHER (SPECIFIC REASON)
136d) Do you think the insecticide-soaked mosquito net is an effective protection against malaria?
NO 2
DON'T KNOW 8
136e) How much would you spend on a long-lasting insecticide-treated net?
FREE 99995
136f) What shape of mosquito net do you prefer?
CONIC/CIRCULAR 2 (GO TO 137)
DOESN'T MATTER 3 (GO TO 137)
136g) Why don't you use a insecticide-soaked mosquito net?
PROBE: What else?
B NET CAUSES SUFFOCATION
C NET COSTS TOO MUCH/NOT ENOUGH MONEY TO BUY
X OTHER (SPECIFY)
137) How does one get malaria?
PROBE: Any other way?
RECORD ALL MENTIONED
B MOSQUITO BIT
C FATIGUE DUE TO WORK
D INSUFFICIENT SLEEP
E DIRECT EXPOSURE TO SUN
F CONSUMPTION OF MANGOES/SWEET FRUITS
W OTHER (SPECIFY)
X OTHER (SPECIFY)
Z DON'T KNOW
138) What do you believe is the main symptom of malaria?
LOSS OF APPETITE AND VOMITING 12
HIGH TEMPERATURE WITH CONVULSIONS 13
HIGH TEMPERATURE AND FAINTING 14
PERSISTENT TEMPERATURE 15
CONVULSIONS 16
JAUNDICE 17
OTHER (SPECIFY) 96
DON'T KNOW 98
138a) What are effective ways to prevent malaria?
PROBE: Any other way?
RECORD ALL MENTIONED
B SLEEPING UNDER AN INSECTICIDE-SOAKED MOSQUITO NET
C TAKING PREVENTATIVE DRUGS
D ENEMA WITH INSECTICIDE/DIFFUSERS/CREAMS/LOTIONS/REPELLENTS
E USING AN ANTI-MOSQUITO STEAMER
F BREW/PLANT JUICE/ROOT
G BY AVOIDING DIRECT EXPOSURE TO SUNLIGHT WHILE DRINKING PROTECTIVE DRINK
H CLEANING SURROUNDINGS
I DOMICILIARY SPRAYING
J NOT CONSUMING FAT
K REST
W OTHER (SPECIFY)
X OTHER (SPECIFY)
Z DON'T KNOW
139) What people are most vulnerable to malaria?
PROBE: Anyone else?
RECORD ALL MENTIONED.
B CHILDREN
C YOUNG PEOPLE
D PREGNANT WOMEN
E WOMEN
F MEN
G ELDERLY PEOPLE
H EVERYONE
X OTHER (SPECIFY)
Z DON'T KNOW
140) When was your last malaria outbreak?
MORE THAN 180 DAYS AGO 995 (GO TO 146)
141) In your research on malaria treatment, did you go to a health care establishment?
NO 2 (GO TO 144)
142) How much time after the beginning of the outbreak did you go to a health care establishment?
THE NEXT DAY 2
MORE THAN A DAY LATER 3
143) Where you healed upon receiving care?
NO 2 (GO TO 145)
144) Why didn't you go to a health care establishment?
PROBE: What else?
B PREFERRED TRADITIONAL MEDICINE
C BAD WELCOME AT THE HOSPITAL
D NOT HEALTH CARE ESTABLISHMENT NEARBY
X OTHER (SPECIFY)
145) What did you go to get better and heal?
PROBE: What else?
B TOO DRUGS PURCHASED FROM A PHARMACY/HOSPITAL
C TREATED BY A TRADITIONAL PRACTITIONER
D PERFORMED AN ENEMA
E DRANK BREWS
F TREATED WITH PLANT/BARK/ROOT VAPORS
G NOTHING
X OTHER (SPECIFY)
146) How do members of your family deal with mosquitoes?
PROBE: What else?
B SMOKE COILS
C MOSQUITO NET
D INSECTICIDE-SOAKED MOSQUITO NET
E SANITATION
F FAN
G NOTHING
X OTHER (SPECIFY)
Z DON'T KNOW
147) Please show me where members of your household most often wash their hands.
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 150)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 150)
NOT OBSERVED, OTHER REASON 4 (GO TO 150)
148) OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.
WATER IS NOT AVAILABLE 2
149) OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.
B ASH, MUD, SAND
C NONE
150) 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
WORK OF CHILDREN AGE 5-14 YEARS
151) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD (COLUMN 5=1):
151a) CHECK Q 151: NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:
NO CHILDREN (GO TO 200)
ASK THE FOLLOWING QUESTIONS TO THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE FEWER THAN 8 CHILDREN, USE THE ADDITIONAL QUESTIONNAIRE):
Now I would like to ask you some questions on the type of work that children in your household did last week.
152) RECORD THE LINE NUMBER FOR EACH CHILD LIVING IN THE HOUSEHOLD IN THE ORDER OF COLUMN 1 OF THE HOUSEHOLD SCHEDULE.
153) RECORD THE NAME OF EACH CHILD
154) Since the last (DAY OF THE WEEK OF THE INTERVIEW), 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 UNPAID 2
NO 2 (GO TO 156)
155) Since the last (DAY OF THE WEEK OF THE INTERVIEW), 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.
156) In the last week, did (NAME) go get water or wood for the household?
NO 2 (GO TO 157)
156a) Since the last (DAY OF THE WEEK), approximately how many hours did he/she spend getting water or wood for the household?
157) In the last week, did (NAME) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?
NO 2 (GO TO 159)
158) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing work for his/her family or him/herself?
159) In the last week, did (name) do any household chores, such as shopping, cleaning, clothes washing, cooking, or taking care of children, old people, or sick people?
NO 2 (GO TO NEXT LINE)
160) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?
WEIGHT, HEIGHT, ANEMIA, AND MALARIA TEST FOR CHILDREN AGE 0-5
200) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANTHROPOMETRY, ANEMIA AND HIT TEST?
NO (END HOUSEHOLD QUESTIONNAIRE)
201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202 ACCORDING TO LINE NUMBER ORDER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
NO CHILDREN 0-5 YEARS (GO TO 241)
202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
NAME
203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF CHILD'S BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth day?
MONTH
YEAR
204) CHECK 203:
CHILD BORN IN JANUARY 2007 OR LATER?
NO 2 (GO TO 603 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO END INTERVIEW)
NOT PRESENT 994
REFUSED 995
OTHER 996
206) HEIGHT IN CENTIMETERS
IF CHILD IS LESS THAN 2 YEARS OLD, MEASURE THE CHILD LYING DOWN, IF NOT STANDING UP
NOT PRESENT 994
REFUSED 995
OTHER 996
207) MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
NOT MEASURED 3
208) CHECK 203:
IF CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?
OLDER 2
209) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD 00 IF NOT LISTED.
210) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.
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 2007 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 take the anemia test?
NAME FROM COLUMN 2
211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2 SIGN_______________
ABSENT 5
OTHER 6
212) ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.
We are asking all of the children in this country to participate in a malaria test. Malaria a serious health problem that can result from mosquito bites. This survey will assist the government to develop programs to prevent and treat anemia.
We ask that all children born in 2007 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. (We use the blood from the same needle prick as for the anemia test)
The blood will be tested for malaria immediately, and the result will be told to you right away. Some drops will be saved on one or more slides and sent to a laboratory to be tested. You will not find out the results of the lab test. 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 take the anemia test?
213) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2 SIGN____________
ABSENT 5
OTHER 6
214) PREPARE THE INSTRUMENTS NECESSARY ONLY FOR THE TEST(S) FOR WHICH CONSENT WAS OBTAINED AND PROCEED WITH THE TEST(S).
215) BAR CODE STICKER FOR MALARIA TEST
PUT FIRST BAR CODE HERE
REFUSED 99995
OTHER 99996
PUT THE 2ND ON THE SLIDE, AND THE 3RD ON THE TRANSMISSION SHEET
216) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA AND MALARIA BROCHURE
NOT PRESENT 994
REFUSED 995
OTHER 996
217) RECORD THE RESULT CODE FROM THE MALARIA TDR (RAPID DIAGNOSTIC TEST) HERE
ABSENT 2 (GO TO 219)
REFUSED 3 (GO TO 219)
OTHER 6 (GO TO 219)
218) RECORD THE RESULT CODE FROM THE MALARIA TDR (RAPID DIAGNOSTIC TEST) HERE AND ON THE ANEMIA AND MALARIA BROCHURE.
POSITIVE TYPE 2
POSITIVE P (F AND OMV) 3
ALL SKIP TO 221
NEGATIVE 4
OTHER 6
219) CHECK 216:
HEMOGLOBIN LEVEL
8.0 G/DL OR HIGHER 2 (GO TO 232)
ABSENT 4 (GO TO 232)
REFUSED 5 (GO TO 232)
OTHER 6 (GO TO 232)
220) REFERENCE DECLARATION FOR SEVERE ANEMIA
The anemia diagnostic test show that (NAME OF CHILD) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.
(GO TO 232)
221) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms: IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y
NONE OF ABOVE SYMPTOMS Y
B HEART PROBLEMS?
C LOSS OF CONSCIOUSNESS?
D RAPID OR DIFFICULTY BREATHING?
E CONVULSIONS?
F ABNORMAL BLEEDING?
G JAUNDICE/YELLOW SKIN?
H DARK URINE?
Y NONE OF THE SYMPTOMS
222) CHECK 221:
IS A CODE A-H CIRCLED
ONLY CODE Y CIRCLED 2
223) CHECK 216:
HEMOGLOBIN LEVEL
6.0 D/DL OR HIGHER 2 (GO TO 225)
NOT PRESENT 4 (GO TO 225)
REFUSED 5 (GO TO 225)
OTHER 6 (GO TO 225)
224) REFERENCE DECLARATION FOR SERIOUS MALARIA
The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. Your child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. Your child is seriously ill and must be taken to a health care establishment immediately. (GO TO 231)
225) In the last two weeks, has (NAME) taken or was (NAME) given CTA [##translator note: CTA is an antimalarial drug, combination therapy] by a doctor or health care establishment to treat malaria?
CHECK BY ASKING TO SEE THE TREATMENT
NO 2 (GO TO 227)
226) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.
You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment to ask for further testing.
(GO TO 231)
227) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.
The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?
228) CIRCLE THE APPROPRIATE CODE AND SIGN.
REFUSED 2 (GO TO 231)
OTHER 6 (GO TO 231)
230) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST
CHILD LESS THAN ONE YEAR OLD OR LESS THAN 8 KGS.
25 mg tablet of Artesunate and 67.5 mg of Amodiaquine (Rose striped brochure)
Day 1 (1 tablet)
Day 2 (1 tablet)
Day 3 (1 tablet)
CHILD AGE 1-5 YEARS OR 8-17 KGS.
50 mg tablet of Artesunate and 135 mg of Amodiaquine (Purple striped brochure)
Day 1 (1 tablet)
Day 2 (1 tablet)
Day 3 (1 tablet)
TELL THE PARENTS/ADULT RESPONSIBLE FOR CHILD: If (NAME) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you must take him/her to a health professional for treatment immediately.
231) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET
DRUG REFUSED 2
REFERRED FOR SEVERE MALARIA 3
REFERRED BECAUSE CHILD ALREADY TOOK CTA 4
OTHER 6
232) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, END THE INTERVIEW
.
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TEST FOR WOMEN 15-49
241) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN FROM QUESTION 242. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)
NOT A SINGLE WOMAN AGE 15-49 (GO TO 280)
242) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN
NAME____________
ABSENT 9994
REFUSED 9995
OTHER 9996
ABSENT 9994
REFUSED 9995
OTHER 9996
18-49 YEARS 2 (GO TO 250)
246) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 250)
247) RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD 00 IF NOT LISTED.
248) Ask consent for the anemia test from the parent/other adult identified in 247 as responsible for women age 15-17 who have never been in a union.
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 test, we need a 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 to (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 take the anemia test?
249) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2 _______________(SIGNATURE)
(IF REFUSED, SKIP TO 255)
250) ASK CONSENT FROM RESPONDENT FOR THE ANEMIA TEST
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 test, we need a 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, or you can say no to the test. It is up to you to decide.
Will you take the anemia test?
251) CIRCLE APPROPRIATE CODE AND SIGN
RESPONDENT REFUSED 2 ____________(SIGNATURE)
(IF REFUSED, SKIP TO 253)
252) PREGNANCY: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
ARE YOU PREGNANT?
NO 2
DON'T KNOW 8
18-49 YEARS 2 (GO TO 257)
254) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 257)
255) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 247 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
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 Guinea.
For the HIV test, we need a 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. 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 the results of (NAME OF ADOLESCENT) test 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 you a voucher for free services for you 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 allow (NAME OF ADOLESCENT) to take the HIV test?
256) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2 ___________(SIGNATURE)
(IF REFUSED, SKIP TO 266)
257) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
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 Guinea.
For the HIV test, we need a 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. 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, or you can say no to the test. It is up to you to decide.
Will you take in the HIV test?
258) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.
RESPONDENT REFUSED 2 ___________(SIGNATURE)
(IF REFUSED, SKIP TO 266)
18-49 YEARS 2 (GO TO 263)
260) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 263)
261) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 247 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.
We ask you to allow the National Statistical Institute/Ministry of Planning 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?
262) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 __________(SIGNATURE)
(IF REFUSED, GO TO 265)
263) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow NATIONAL STATISTICAL INSTITUTE/MINISTRY OF PLANNING 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?
264) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 __________(SIGNATURE)
(IF REFUSED, GO TO 266)
CHECK 262 AND 264: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER
266) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
267) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET
NOT PRESENT 994
REFUSED 995
OTHER 996
268) 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.
269) GO BACK TO 242 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 280.
HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59
280) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 281. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
END QUESTIONNAIRE
281) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2
NAME______________
18-59 YEARS 2 (GO TO 289)
285) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 289)
286) RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD 00 IF NOT LISTED
287) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 286 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
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?
288) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2__________(SIGNATURE)
(IF REFUSED, GO TO 293)
289) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT
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?
290) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2__________(SIGNATURE)
18-49 years 2 (GO TO 295)
292) MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 295)
293) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 286 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
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 Guinea.
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?
294) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2_____________(SIGNATURE)
(IF REFUSED, GO TO 304)
295) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
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 Guinea.
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?
296) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2___________(SIGNATURE)
(IF REFUSED, GO TO 304)
18-59 YEARS 2 (GO TO 301)
298) MARITAL STATUS: CHECK COLUMN 285
OTHER 2 (GO TO 301)
299) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 286 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
We ask you to allow the National Statistical Institute/Ministry of Planning 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?
300) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2__________(SIGNATURE)
(IF REFUSED, GO TO 303)
301) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow National Statistical Institute/Ministry of Planning 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?
302) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2__________(SIGNATURE)
(IF REFUSED, GO TO 304)
CHECK 300 AND 302: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
304) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
305) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET
NOT PRESENT 994
REFUSED 995
OTHER 996
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
307) GO BACK TO 281 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT RESPONDENT:
COMMENTS ON SPECIFIC QUESTIONS:
ANY OTHER COMMENTS:
SUPERVISOR'S OBSERVATIONS______________
NAME OF SUPERVISOR___________________
DATE_______________
EDITOR'S OBSERVATIONS__________________
NAME OF EDITOR____________________
DATE_______________