The Hashemite Kingdom of Jordan
JORDAN POPULATION AND FAMILY HEALTH SURVEY 2017
BIOMARKER QUESTIONNAIRE
Survey Contents Confidential by Statistical Law
CLUSTER NUMBER _________
HOUSEHOLD NUMBER __
NAME OF HOUSEHOLD HEAD ________________
HOUSEHOLD SELECTED FOR CHILD DISCIPLINE, CHILD DEVELOPMENT, AND BIOMARKER FOR WOMEN?
NO 2
FIRST VISIT
DATE
FIELDWORKER'S NAME
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
FIELDWORKER'S NAME
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
FIELDWORKER'S NAME
FINAL VISIT
DAY
MONTH
YEAR
NOTES:
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TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE CHILDREN ___
SUPERVISOR
NAME ____________
NUMBER _____
WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5
101) CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
ANSWER 102-114 FOR ALL CHILDREN BETWEEN THE AGES 0-5.
102) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.
NAME ________________
103) IF MOTHER INTERVIEWED: COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED ASK: What is (NAME)'s date of birth?
MONTH __
YEAR ____
104) CHECK 103: CHILD BORN IN 2012-2017?
NO 2 (SKIP TO 114)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996 (SKIP TO 108)
MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
108) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
109) CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
OLDER 2
110) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.
(RECORD '00' IF NOT LISTED)
111) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT.
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 2012 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 members of our survey teams.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
112) CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN) ____________________
REFUSED 2
(SIGN) ____________________
NOT PRESENT/OTHER 3 (SKIP TO 114)
113) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
REFUSED 995
OTHER 996
114) GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49
200) CHECK COVER: HOUSEHOLD SELECTED FOR CHILD DISCIPLINE, CHILD DEVELOPMENT, AND BIOMARKER FOR WOMEN?
HOUSEHOLD NOT SELECTED (END)
201) CHECK COLUMN 9A IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL WOMEN AGE 15-49 IN 202, 203, AND 204.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
ANSWER 202-231 FOR ALL WOMEN BETWEEN THE AGES 15-49.
202) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9A
NAME FROM COLUMN 2.
NAME __________
203) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-49 YEARS 2
204) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
204A) PREGNANY STATUS:
FIRST CHECK COLUMN 8 IN HOUSEHOLD QUESTIONNAIRE:
IF NEVER MARRIED (CODE 1), CIRCLE '2'
IF EVER MARRIED (CODES 2-5), ASK:
NO/NEVER MARRIED 2
DON'T KNOW 8
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
18-49 YEARS 2 (SKIP TO 210)
209) CHECK 204: MARITAL STATUS
OTHER 2
NAME FROM COLUMN 2.
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
210) ASK CONSENT FOR 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. The survey will assist the government to develop programs to prevent and treat anemia.
For anemia testing, we will 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 we take your blood. 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 members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
211) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN)
(SIGN) __________________
(IF GRANTED, SKIP TO 229, OTHERWISE SKIP TO 233)
NOT PRESENT/OTHER 3 (SKIP TO 233)
216) RECORD LINE NUMBER OR PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
(RECORD '00' IF NOT LISTED)
217) ASK CONSENT FOR ANEMIA TEST FROM PARENT/ADULT
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. The survey will assist the government to develop programs to prevent and treat anemia.
For anemia testing, we will 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 (NAME OF MINOR) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to take the anemia test?
218) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)
(SIGN) __________________________
(IF REFUSED, SKIP TO 233)
NOT PRESENT/OTHER 3 (SKIP TO 233)
NAME FROM COLUMN 2
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
219) 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. The survey will assist the government to develop programs to prevent and treat anemia.
For anemia testing, we will 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 we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
220) CIRCLE THE CODE AND SIGN YOUR NAME
MINOR RESPONDENT REFUSED 2 (SIGN)
(SIGN) ___________________________
(IF REFUSED, SKIP TO 233)
NOT PRESENT/OTHER 3 (SKIP TO 233)
229) PREPARE EQUIPMENT AND SUPPLIES FOR ANEMIA TESTING
231) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
233) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END OF QUESTIONNAIRE.
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
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