NIGERIA DEMOGRAPHIC AND HEALTH SURVEYS 2018
BIOMARKER QUESTIONNAIRE
FORMATTING DATE: 09 Jun 2015
ENGLISH LANGUAGE: 26 May 2018
NIGERIA
LOCAL GOVT. AREA ______
LOCALITY ______
ENUMERATION AREA ______
NAME OF HOUSEHOLD HEAD ______
CLUSTER NUMBER ______
HOUSEHOLD NUMBER ______
HOUSEHOLD SELECTED FOR MAN'S SURVEY
NO 2
HOUSEHOLD SELECTED FOR MICROSCOPY OR DBS?
SELECTED FOR DBS 2
FEILDWORKER'S NAME ____
TIME ____
VISIT TWO
FEILDWORKER'S NAME ____
NEXT VISIT: DATE ____
TIME ____
VISIT THREE
FEILDWORKER'S NAME ____
FINAL VISIT
MONTH ____
YEAR ____
TOTAL NUMBER OF VISITS ____
TOTAL ELIGIBLE CHILDREN ____
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW
HAUSA 02
YORUBA 03
IGBO 04
NATIVE LANGUAGE OF RESPONDENT
HAUSA 02
YORUBA 03
IGBO 04
NUMBER _____
FIELD EDITOR
NUMBER ____
WEIGHT, HEIGHT, AND HEMOGLOBIN, GENOTYPE, AND MALARIA MEASURMENT FOR CHILDREN AGES 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).
102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.
CHILD 1
NAME ____
CHILD 2
NAME ____
CHILD 3
NAME ____
CHILD 4
NAME ____
CHILD 5
NAME ____
CHILD 6
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?
CHILD 1
MONTH ___
YEAR ___
CHILD 2
MONTH ___
YEAR ___
CHILD 3
MONTH ___
YEAR ___
CHILD 4
MONTH ___
YEAR ___
CHILD 5
MONTH ___
YEAR ___
CHILD 6
MONTH ___
YEAR ___
104. CHECK 103: CHILD BORN IN 2013-2018?
CHILD 1
NO 2 (GO TO 130)
CHILD 2
NO 2 (GO TO 130)
CHILD 3
NO 2 (GO TO 130)
CHILD 4
NO 2 (GO TO 130)
CHILD 5
NO 2 (GO TO 130)
CHILD 6
NO 2 (GO TO 130)
CHILD 1
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD 2
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD 3
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD 4
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD 5
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD 6
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD 1
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
CHILD 2
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
CHILD 3
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
CHILD 4
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
CHILD 5
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
CHILD 6
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
107. MEASURED LYING DOWN OR STANDING UP?
CHILD 1
STANDING UP 2
CHILD 2
STANDING UP 2
CHILD 3
STANDING UP 2
CHILD 4
STANDING UP 2
CHILD 5
STANDING UP 2
CHILD 6
STANDING UP 2
108. MEASURE: ENTER YOUR FIELDWORKER NUMBER.
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5
CHILD 6
109. CHECK 103: CHILD AGE 1-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
CHILD 1
OLDER 2
CHILD 2
OLDER 2
CHILD 3
OLDER 2
CHILD 4
OLDER 2
CHILD 5
OLDER 2
CHILD 6
OLDER 2
110. NAME AND RELATIONSHIP TO THE CHILD OF ADULT RESPONSIBLE FOR THE CHILD. GET LINE NUMBER FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.
CHILD 1
RELATIONSHIP TO CHILD ____
LINE NUMBER ____
(RECORD '00' IF NOT LISTED)
CHILD 2
RELATIONSHIP TO CHILD ____
LINE NUMBER ____
(RECORD '00' IF NOT LISTED
CHILD 3
RELATIONSHIP TO CHILD ____
LINE NUMBER ____
(RECORD '00' IF NOT LISTED
CHILD 4
RELATIONSHIP TO CHILD ____
LINE NUMBER ____
(RECORD '00' IF NOT LISTED)
CHILD 5
RELATIONSHIP TO CHILD ____
LINE NUMBER ____
(RECORD '00' IF NOT LISTED
CHILD 6
RELATIONSHIP TO CHILD ____
LINE NUMBER ____
(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 2013 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 or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
111A. CIRCLE THE CODE AND SIGN YOUR NAME.
CHILD 1
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 2
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 3
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 4
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 5
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 6
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
112. Has (NAME) had blood transfusion in the past 3 months?
CHILD 1
NO 2
CHILD 2
NO 2
CHILD 3
NO 2
CHILD 4
NO 2
CHILD 5
NO 2
CHILD 6
NO 2
112A. As part of this survey, we are asking children all over the country to take a test to see if they have sickle cell anemia (SS) or its trait (AS). Sickle cell disease (SCD) is an inherited blood disorder, which affects children early in life often with repeated episodes of catastrophic illness and bone pains with varying periods of relative good health in between. This survey will assist the government to develop programs for the prevention and management of sickle cell disease.
We ask all children born in 2013 and later take part in genotype testing in this survey and give a few drops of blood from a finger or heel. One blood drop will be tested for genotype immediately, and the results will be told to you right away. 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 results 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 CHILD) to participate in the genotype test?
112B. CIRCLE THE CODE AND SIGN YOUR NAME.
CHILD 1
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 2
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 3
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 4
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 5
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
CHILD 6
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 130)
112C. ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT.
As part of this survey, we are asking children all over the country to take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by mosquito bites. This survey will assist the government to develop programs to prevent malaria.
We ask all children born in 2013 or later to take part in malaria testing in this survey and give a few drops of blood from a finger or heel. The blood will be tested for malaria immediately, and the results will be told to you right away. All results will be kept strictly confidential and will not be told to 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.
112D. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
CHILD 1
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)
________
________
CHILD 2
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)
________
________
CHILD 3
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)
________
________
CHILD 4
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)
________
________
CHILD 5
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)
________
________
CHILD 6
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)
________
________
112E. PREPARE EQUIPTMENT AND SUPPLIES FOR TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
112F. PLACE BAR CODE LABEL FOR MALARIA LAB OR GENOTYPE CONFIRMATORY LAB TEST
MENTION WHERE BAR CODE PLACED BASED ON THE TEST.
CHILD 1
NOT PRESENT 99994
REFUDED 99995
OTHER 99996
SLIDE A
DBS B
TRANSMITTAL FORM C
CHILD 2
NOT PRESENT 99994
REFUDED 99995
OTHER 99996
SLIDE A
DBS B
TRANSMITTAL FORM C
CHILD 3
NOT PRESENT 99994
REFUDED 99995
OTHER 99996
SLIDE A
DBS B
TRANSMITTAL FORM C
CHILD 4
NOT PRESENT 99994
REFUDED 99995
OTHER 99996
SLIDE A
DBS B
TRANSMITTAL FORM C
CHILD 5
NOT PRESENT 99994
REFUDED 99995
OTHER 99996
SLIDE A
DBS B
TRANSMITTAL FORM C
CHILD 6
NOT PRESENT 99994
REFUDED 99995
OTHER 99996
SLIDE A
DBS B
TRANSMITTAL FORM C
113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE PAMPHLET.
CHILD 1
NOT PRESENT 994
REFUSED 995
OTHER 996
CHILD 2
NOT PRESENT 994
REFUSED 995
OTHER 996
CHILD 3
NOT PRESENT 994
REFUSED 995
OTHER 996
CHILD 4
NOT PRESENT 994
REFUSED 995
OTHER 996
CHILD 5
NOT PRESENT 994
REFUSED 995
OTHER 996
CHILD 6
NOT PRESENT 994
REFUSED 995
OTHER 996
113A. CIRCLE THE CODE FOR THE GENOTYPE TEST.
CHILD 1
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 2
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 3
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 4
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 5
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 6
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
113B. RECORD THE RESULT OF THE GENOTYPE RDT HERE AND IN THE PAMPHLET.
CHILD 1
AS 2 (GO TO 114)
AC 3 (GO TO 114)
SC 4 (GO TO 114)
SS 5
CHILD 2
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 3
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 4
AS 2 (GO TO 114)
AC 3 (GO TO 114)
SC 4 (GO TO 114)
SS 5
CHILD 5
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
CHILD 6
NOT PRESENT 2 (GO TO 114)
REFUSED 3 (GO TO 114)
OTHER 6 (GO TO 114)
113C. SICKLE CELL ANEMIA (SS) referral
RECORD THE RESULT OF THE GENOTYPE TEST ON THE REFERRAL FORM.
The genotype test shows that (NAME OF CHILD) has sickle cell anemia. Your child is very ill and must be taken to a health facility immediately.
114. CIRCLE THE CODE FOR THE MALARIA RDT.
CHILD 1
NOT PRESENT 2 (GO TO 128)
REFUSED 3 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 2
NOT PRESENT 2 (GO TO 128)
REFUSED 3 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 3
NOT PRESENT 2 (GO TO 128)
REFUSED 3 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 4
NOT PRESENT 2 (GO TO 128)
REFUSED 3 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 5
NOT PRESENT 2 (GO TO 128)
REFUSED 3 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 6
NOT PRESENT 2 (GO TO 128)
REFUSED 3 (GO TO 128)
OTHER 6 (GO TO 128)
115. RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE PAMPHLET.
CHILD 1
NEGATIVE 2 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 2
NEGATIVE 2 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 3
NEGATIVE 2 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 4
NEGATIVE 2 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 5
NEGATIVE 2 (GO TO 128)
OTHER 6 (GO TO 128)
CHILD 6
NEGATIVE 2 (GO TO 128)
OTHER 6 (GO TO 128)
118. Does (NAME) suffer from any of the following illnesses or symptoms?
a) Extreme weakness?
b) Heart problems?
c) Loss of consciousness?
d) Rapid of difficult breathing?
e) Seizures?
f) Abnormal bleeding?
g) Jaundice or yellow skin?
h) Dark urine?
CHILD 1
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
CHILD 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
CHILD 3
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
CHILD 4
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
CHILD 5
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
CHILD 6
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
119. CHECK 118: ANY 'YES' CIRCLED?
CHILD 1
NO (GO TO 120)
CHILD 2
NO (GO TO 120)
CHILD 3
NO (GO TO 120)
CHILD 4
NO (GO TO 120)
CHILD 5
NO (GO TO 120)
CHILD 6
NO (GO TO 120)
120. CHECK 113: HEMOGLOBIN RESULT
CHILD 1
8.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
CHILD 2
8.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
CHILD 3
8.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
CHILD 4
8.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
CHILD 5
8.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
CHILD 6
8.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
121. In the past 2 weeks has (NAME) taken or is taking ACT given by a doctor or health center to treat malaria?
VERIFY BY ASKING TO SEE TREATMENT.
CHILD 1
NO 2 (GO TO 124)
CHILD 2
NO 2 (GO TO 124)
CHILD 3
NO 2 (GO TO 124)
CHILD 4
NO 2 (GO TO 124)
CHILD 5
NO 2 (GO TO 124)
CHILD 6
NO 2 (GO TO 124)
122. SEVERE MALARIA REFERRAL
RECORD THE RESULT OF THE MALARIA RDT ON THE REFERRAL FORM.
The malaria test shows that (NAME OF CHILD) has malaria. Your child also has symptoms of severe malaria. The malaria treatment I have will not help your child, and I cannot give you the medication. Your child is very ill and must be taken to a health facility right away. (GO TO 128)
123. ALREADY TAKING ACT REFERRAL STATEMENT.
You have told me that (NAME OF CHILD) had already received ACT for malaria. Therefore, I cannot give you additional ACT. However, the test shows that he/she has malaria. If your child has a fever for two days after the last dose of ACT, you should take your child to the nearest health facility for further examination. (GO TO 130)
124. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER.
The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called ACT. ACT is very effective and in a few days it should get rid of the fever and other symptoms. You do not have to give your child the medicine. It is up to you. Please tell me whether you accept the medicine or not.
125. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
CHILD 1
REFUSED 2
OTHER 6
CHILD 2
REFUSED 2
OTHER 6
CHILD 3
REFUSED 2
OTHER 6
CHILD 4
REFUSED 2
OTHER 6
CHILD 5
REFUSED 2
OTHER 6
CHILD 6
REFUSED 2
OTHER 6
126. CHECK 125: MEDICATION ACCEPTED
CHILD 1
REFUSED 2 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 2
REFUSED 2 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 3
REFUSED 2 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 4
REFUSED 2 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 5
REFUSED 2 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 6
REFUSED 2 (GO TO 130)
OTHER 6 (GO TO 130)
127. TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS.
TREATMENT WITH ACT
WEIGHT (in kg)
5-14 KGS= 1 TABLET TWICE A DAY FOR 3 DAYS
15-25 KGS= 2 TABLETS TWICE A DAY FOR 3 DAYS
AGE
6 MONTHS- THREE YEARS= 1 TABLET TWICE A DAY FOR 3 DAYS
4-8 YEARS= 2 TABLETS TWICE A DAY FOR 3 DAYS
IF CHILD WEIGHS LESS THAN 5 KGS, DO NOT LEAVE DRUGS. TELL PARENTS TO TAKE CHILD TO HEALTH FACILITY.
ALSO TELL THE PARENT/ADULT: If (NAME) has a high fever, rapid of difficult breathing, is not able to drink or breastfeed gets sicker or does not get better in two days, you should take him/her to a health professional for treatment right away. (GO TO 130)
128. CHECK 113: HEMOGLOBIN RESULT
CHILD 1
8.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 2
8.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 3
8.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 4
8.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 6
8.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
CHILD 6
8.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.
The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately.
130. GO BACK TO 103 IN THE NEXT COLUMN OF THE QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.
SECTION 2. WEIGH, HEIGHT, AND HEMOGLOBIN MEASURMENT FOR WOMEN 15-49
201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 8.
NAME FROM COLUMN 2.
WOMAN 1
NAME ____
WOMAN 2
NAME ____
WOMAN 3
NAME ____
203. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
WOMAN 1
18-49 YEARS 2
WOMAN 2
18-49 YEARS 2
WOMAN 3
18-49 YEARS 2
204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
WOMAN 1
OTHER 2
WOMAN 2
OTHER 2
WOMAN 3
OTHER 2
WOMAN 1
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
WOMAN 2
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
WOMAN 3
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
WOMAN 1
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
WOMAN 2
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
WOMAN 3
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
WOMAN 1
WOMAN 2
WOMAN 3
WOMAN 1
18-29 YEARS 2 (GO TO 210)
WOMAN 2
18-29 YEARS 2 (GO TO 210)
WOMAN 3
18-29 YEARS 2 (GO TO 210)
209. CHECK 204: MARITAL STATUS
WOMAN 1
OTHER 2
WOMAN 2
OTHER 2
WOMAN 3
OTHER 2
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
210. ASK CONSENT FOR ANEMIA TEST.
As part of the survey, we are asking people all over the country to take an anemia test. Anemia is a serious health issue 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 will need a few drops of blood from your 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 immediately be tested for anemia, and the results 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 SIGH YOUR NAME.
WOMAN 1
RESPONDENT REFUSED 2 ______ (GO TO 233)
NOT PRESENT/OTHER 3 (GO TO 233)
WOMAN 2
RESPONDENT REFUSED 2 ______ (GO TO 233)
NOT PRESENT/OTHER 3 (GO TO 233)
WOMAN 3
RESPONDENT REFUSED 2 ______ (GO TO 233)
NOT PRESENT/OTHER 3 (GO TO 233)
211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
WOMAN 1
NO 2 (GO TO 229)
DON'T KNOW 8 (GO TO 229)
WOMAN 2
NO 2 (GO TO 229)
DON'T KNOW 8 (GO TO 229)
WOMAN 3
NO 2 (GO TO 229)
DON'T KNOW 8 (GO TO 229)
216. NAME AND RELATIONSHIP TO THE ADOLESCENT OF ADULT RESONSIBLE FOR THEM. GET LINE NUMBER FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.
WOMAN 1
NO 2 (GO TO 229)
DON'T KNOW 8 (GO TO 229)
WOMAN 2
NO 2 (GO TO 229)
DON'T KNOW 8 (GO TO 229)
WOMAN 3
NO 2 (GO TO 229)
DON'T KNOW 8 (GO TO 229)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
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. 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 results will be told to you and (NAME OF MINOR) right away. The result will be kept strictly and will not be shared with anyone other than members of our survey team.
Do you have an questions?
You can say yes or not. 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.
Woman 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 233) _________
Woman 2
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 233) _________
Woman 3
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 233) _________
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. 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 results will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) right away. The result will be kept strictly 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.
Woman 1
MINOR RESPONDENT REFUSED 2 _______
Woman 2
MINOR RESPONDENT REFUSED 2 _______
Woman 3
MINOR RESPONDENT REFUSED 2 _______
22A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
Woman 1
NO 2
DON'T KNOW 8
Woman 2
NO 2
DON'T KNOW 8
Woman 3
NO 2
DON'T KNOW 8
PREPARE EQUIPTMENT AND SUPPLIES ONLY FOR THOSE WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST.
231. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
Woman 1
NOT PRESENT 994
REFUSED 995
OTHER 996
Woman 2
NOT PRESENT 994
REFUSED 995
OTHER 996
Woman 3
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 WOMAN, END INTERVIEW.
FIELDWORKER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
SUPERVISOR'S OBSERVATIONS
EDITOR'S OBSERVATIONS
REFERENCE DATES
YEAR OF FIELDWORK: 2018
FIVE YEARS BEFORE SURVEY: 2013
CHILD OLDER THAN 5: 2012
CHILD UNDER 4: 2015
CHILD UNDER 3: 2016
CHILD UNDER 16: 2003