22 October 2015

MINISTRY OF HEALTH
(DEPARTMENT OF PUBLIC HEALTH)

IDENTIFICATION

STATE/REGION _____

DISTRICT _____

TOWNSHIP/SUB-TOWNSHIP____

WARD/VILLAGE TRACT _____

CLUSTER NUMBER____

HOUSEHOLD NUMBER _____

HOUSEHOLD SELECTED FOR MAN'S SURVEY, SALT AND URINE TESTING?

ALTITUDE (METERS)____

INTERVIEWER VISITS

FIRST VISIT REPEAT FOR SECOND AND THIRD VISITS)

NEXT VISIT

FINAL VISIT

*RESULT CODES

TOTAL NUMBER OF VISITS _____

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

LANGUAGE OF INTERVIEW:

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

SUPERVISOR

FIELD EDITOR

KEYED BY____

INTRODUCTION AND CONSENT

Mingalabar. My name is ____________________. I am working with the Ministry of Health. We are conducting a survey about health all over Myanmar. 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. We will then interview women and men age 15 to 49 with individual questionnaires and also measure height and weight of women 15 to 49 and children age 5 years. Further, we will conduct anemia tests among women 15 to 49 and children 6 months to age 5. The household questions usually take about 20 to 30 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 now?

SIGNATURE OF INTERVIEWER __________________
DATE ______

HOUSEHOLD SCHEDULE

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.
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 COLUMN 5-20 FOR EACH PERSON.

2A. Just to make sure that I have a complete listing: are there any other people such as small children or infants that we have not listed?

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

2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

3. RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

4. SEX
Is (NAME) male or female?

5. RESIDENCE
Does (NAME) usually live here?

6. RESIDENCE
Did (NAME) stay here last night?

7. AGE
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

8. IF AGE 15 OR OLDER -- MARITAL STATUS
What is (NAME)'s current marital status?

ELIGIBILITY

9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

11A. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 2-14

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

12. Is (NAME)'s natural mother alive?

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?

15. Does (NAME)'s natural father usually live in this household or was he a guest last night? IF YES: What was his name? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

15A) IF AGE 2-14 YEARS
PRIMARY CARETAKER
Who is the primary caretaker of (NAME)? RECORD PRIMARY CARETAKER'S LINE NUMBER. IF NOT IN HOUSEHOLD RECORD '00'.

AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL
16. Has (NAME) ever attended school?

17. What is the highest grade (NAME) completed at school?
SEE CODES BELOW.

CHECK COLUMN 7, IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE

18. Did (NAME) attend school at any time during the (2015/2016) school year?

19. During this/that school year, what grade is/was (NAME) attending?
SEE CODES BELOW

20. IF AGE 0 TO 4 YEARS
BIRTH REGISTRATION
Does (NAME) have a birth certificate? IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

HOUSEHOLD CHARACTERISTICS

101. How often does anyone smoke insider your house? Would you say daily, weekly, montly, less than monthly, or never?

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

103. Where is that water source located?

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

105. Do you do anything to the water to make it safer to drink?

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

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

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

109. How many households in total use this toilet facility?

110. Does your household have:
a) Electricity?
b) A radio?
c) A television?
d) A mobile telephone?
e)A landline telephone?
f) A refrigerator?
g) A table?
h) A chair?
i) A sofa?
j) A bed?
k) A cupboard?
l) An electric fan?
m) Air conditioner?
n) A sewing machine?
o) A computer?

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

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

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

114. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

115. MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

116. MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

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

118. Does any member of this household own:

a) A watch?
b) A bicycle?
c) A motorcycle or motor scooter?
d) An animal-drawn cart?
e) A car or truck?
f) A tuk tuk/htawlargyi?
g) A boat with a motor?
h) A boat without a motor?

119. Does any member of this household own any agricultural land?

120. How many acres of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLED '950'.

121. Does this household own any livestock, herds, other farm animals, or poultry?

122. How many of the following animals does this household own?
IF NONE, RECORD '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.

a) Cattle?
b) Milk cows or bulls?
c) Horses, donkeys, or mules?
d) Goats?
e) Sheep?
f) Chickens?
g) Ducks?

123. Does any member of this household have a bank account?

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

127. How many mosquito nets does your household have?
IF 8 OR MORE NETS, RECORD '8'.

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

129. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

129A) How did you get this mosquito net?

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.

131. When you got the net, was it already treated with an insecticide to kill or repel mosquitos?

132. Since you got the net, was it ever soaked or dipped in a liquid (insecticide) to kill or repel mosquitoes?

133. How many months ago was the net last soaked or dipped? IF LESS THAN ONE MONTH AGO, RECORD '00'.

134. Did anyone sleep under this mosquito net last night?

135. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.

136. GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137. Please show me where members of your household most often wash their hands?

138. OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

139. OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

140. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.

CHILD DISCIPLINE

141. CHECK HOUSEHOLD SCHEDULE, COLUMN 11A:

142. RANK NUMBER____

143. LINE NUMBER FROM COLUMN 11A IN HOUSEHOLD SCHEDULE

144. NAME OF THE CHILD FROM COLUMN 2 IN THE HOUSEHOLD SCHEDULE

145. CHILD'S AGE FROM COLUMN 7

146. CHECK 15A AND WRITE PARENT'S OR CARETAKER'S LINE NUMBER FROM COLUMN 1 AND NAME FROM COLUMN 2 IN THE HOUSEHOLD SCHEDULE.

147. CHECK COLUMN 145:

RANDOM NUMBER TABLE FOR SELECTION OF CHILDREN FOR THE CHILD DISCIPLINE QUESTIONS

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE.
LOOK AT COLUMN 145 AND RECORD THE TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 2 TO 14 ____ . THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE.
IF THERE ARE MORE THAN 8 ELIGIBLE CHILDREN IN THE HOUSEHOLD, CIRCLE '8' IN THE ROW AT THE TOP OF THE TABLE.
FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE RANK NUMBER OF THE ELIGIBLE CHILD WHOSE PARENT OR CARETAKER WILL BE ASKED THE QUESTIONS ON CHILD DISCIPLINE.
THEN, GO TO COLUMN 143 AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED CHILD AND RECORD CHILD'S HOUSEHOLD LINE NUMBER AND NAME IN QUESTION 148 AND RECORD CHILD'S PARENT OR OTHER FOR EXAMPLE, IF THE HOUSEHOLD NUMBER IS "716", GO TO ROW 6 AND CIRCLE THE ROW NUMBER ('6').
IF THERE ARE THREE ELIGIBLE CHILDREN IN THE HOUSEHOLD, GO TO COLUMN 3 AND CIRCLE THE COLUMN NUMBER ('3').
DRAW LINES FROM ROW 6 AND COLUMN 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT ('2'). THIS MEANS YOU HAVE TO SELECT THE SECOND ELIGIBLE CHILD.
SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE CHILDREN ARE '02', '03', AND '07'; THEN THE ELIGIBLE CHILD FOR THE QUESTIONS ON CHILD DISCIPLINE IS THE SECOND ELIGIBLE CHILD, I.E., THE CHILD WITH HOUSEHOLD LINE NUMBER '03'.
PUT A * NEXT TO THIS CHILD'S LINE NUMBER IN COLUMN 143 AND ALSO ENTER THE TWO DIGIT LINE NUMBER AND CHILD'S NAME IN QUESTION 148.
THEN, RECORD THE LINE NUMBER AND A NAME OF CHILD'S PARENT OR OTHER MOST KNOWLEDGEABLE

LAST DICIT OF THE HOUSEHOLD NUMBER 0-9
TOTAL NUMBER OF CHILDREN AGE 2-14 IN THE HOUSEHOLD 1-8+

148) LINE NUMBER AND NAME OF THE SELECTED CHILD AGE 2 TO 14 YEARS FROM COLUMNS 143 AND [TRANSCRIPTION NOTE: TEXT CUTS OFF]

149) LINE NUMBER AND NAME OF CHILD'S MOTHER, FATHER OR OTHER PRIMARY CARETAKER FROM COLUMN 146.

THE FOLLOWING QUESTIONS 150 TO 161 ON CHILD DISCIPLINE ARE TO BE ADMINISTERED ONLY TO THE MOST KNOWLEDGEABLE ADULT (MOTHER, FATHER, OTHER PRIMARY CARETAKE OR A GUARDIAN OF A CHILD).

150) All adults use certain ways to teach or to address a behavior problem. I will read various methods that are used. I want you to tell me if you or anyone else in the house has used this method with (NAME) in the past month.

Took away privileges, forbade something (NAME) liked or did not allow him/her to leave the house (in the past month)?

151) Explained why some behavior was wrong (in the past month)?

152) Shook him/her (in the past month)?

153) Shouted, yelled or screamed at (NAME) in the past month?

154) Gave him/her something else to do (in the past month)?

155) Spanked, hit or slapped him/her on the bottom with bare hand (in the past month)?

156) Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other (in the past month)?

157) Called him/her dumb, lazy, or a similar name (in the past month)?

158) Hit or slapped him/her on the face, head or ears (in the past month)?

159) Hit or slapped him/her on the hand, arm or leg (in the past month)?

160) Beat her/him up with an implement (hit over and over as hard as one could) (in the past month)?

161) Do you believe that in order to bring up (raise, educate) (NAME) properly, you need to physically punish him/her?

162) CHECK THE IDENTIFICATION SEXTION OF HOUSEHOLD QUETIONNAIRE. IS THIS HOUSEHOLD SELECTED FOR MEN INTERVIEW?

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15 TO 49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

LAST DIGIT OF THE HOUSEHOLD NUMBER 0-9
TOTAL NUMBER OF ELIGILBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 9 1-8

NAME OF SELECTED WOMAN ________________________________
HH LINE NUMBER OF SELECTED WOMAN ___

WEIGHT, HEIGHT, MUAC, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0 TO 5

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN AGE 0 TO 5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

204) CHECK 203: CHILD BORN IN JANUARY 2010 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

207A) MUAC IN CENTIMETERS

208) CHECK 203: IS CHILD AGE 0 TO 5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD '00' IF NOT LISTED.

210) ASK CONSENT FOR ANEMIA TEST FROM 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 2010 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 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 participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTINNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

214) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LNE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

216) WEIGHT IN KILOGRAMS

217)
IN CENTIMETERS

218) AGE: CHECK COLUMN 7.

219) MARITAL STATUS: CHECK COLUMN 8.

220) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

221) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15 TO 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 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 ADOLESCENT) 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 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?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) 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 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 members 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 the anemia test?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

225) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

239) PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST AND PROCEED WITH THE TEST.

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END THE QUESTIONNAIRE.