HOUSEHOLD QUESTIONNAIRE
LOCALITY NAME ________
NAME OF HOUSEHOLD HEAD ______
PROVINCE ______
DISTRICT ________
CLUSTER NUMBER ______
STRUCTURE NUMBER __________
HOUSEHOLD NUMBER _________
URBAN/RURAL (URBAN=1, RURAL=2) ________
CITY/LARGE TOWN/SMALL TOWN/VILLAGE
OTHER CITY 2
RURAL 3
VISIT 1
DATE _________
INTERVIEWER'S NAME________
RESULT* __________
NEXT VISIT:
DATE_________
TIME__________
VISIT 2
DATE________
INTERVIEWER'S NAME_________
RESULT*__________
NEXT VISIT:
DATE__________
TIME_________
VISIT 3
DATE_________
INTERVIEWER'S NAME__________
RESULT*___________
FINAL VISIT
DAY_______
MONTH_________
YEAR 200_______
NAME_______
RESULT______
TOTAL NO. OF VISITS________
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 ADDESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ____________
TOTAL PERSONS IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN _________
TOTAL ELIGIBLE MEN __________
LINE NO. OF RESP. TO HOUSEHOLD QUEST. ___________
SUPERVISOR
NAME _______
DATE_______
FIELD EDITOR
NAME________
DATE_______
INFORMED CONSENT
Hello. My name is ____________ and I am working with the National Institute of Statistics. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete.
In this survey, I would like to first ask you some questions about your household. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since yours views are important.
At this time, do you want to ask me anything about the survey? May I begin the interview now?
Signature of interviewer: _______________
Date: ____________
RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
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?*
SEE CODES BELOW.
*CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD
02= WIFE OR HUSBAND
03= SON OR DAUGHTERS
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
RESIDENCE
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
IF 15+ YEARS
What is the marital status of (NAME)? ______
ELIGIBILITY
8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59
10) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
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
101) What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 103)
PUBLIC TAP 13
OPEN WELL IN YARD/PLOT 22 (GO TO 103)
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 (GO TO 103)
BOTTLED WATER 71 (GO TO 103)
OTHER 96 (SPECIFY) _________ (GO TO 103)
102) How long does it take you to go there, get water, and come back?
ON PREMISES 996
103) What kind of toilet facilities does your household have?
PIT TOILET/LATRINE
VENTILATED IMPORAVED PIT (VIP) LATRINE 22
OTHER 96 (SPECIFY) ___________
104) Do you share these facilities with other households?
NO 2
105) Does your household have: electricity? A radio? A television? A land line telephone? A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
106) 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 96 (SPECIFY) ___________
107) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
MUD MIXED WITH DUNG 12
PALM/BAMBOO 22
LINOLEUM 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
108) Does any member of your household own: A bicycle? A motorcycle or motor scooter? A car or truck? A mobile phone?
NO 2
NO 2
NO 2
NO 2
108A) Are your household members covered by health insurance?
NO 2 (GO TO 108D)
108B) What type of health insurance do you have?
RAMA B (GO TO 108D)
MMI C (GO TO 108D)
PRIVATE INSURANCE D (GO TO 108D)
OTHER X (SPECIFY) ______ (GO TO 108D)
108C) How many of your household members are covered by MUTELLE DE SANTE?
NO. OF CHILDREN LESS THAN 5 _________
108D) CHECK IF PROVINCE IS 'KIGALI'
IF NO, GO TO 109
108E) Between August and October 2007, did someone come to spray the walls of your home against mosquitoes?
NO 2
DON'T KNOW 8
109) Does your household have any mosquito bed nets that can be used while sleeping?
NO 2 (GO TO TABLE FOR MALARIA)
109A) How many mosquito bed nets does your household have? IF THERE IS 7 OR MORE RECORD '7.'
110) ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD.
OLYSET 2
DON'T KNOW 3
NOT OBSERVED 4
111) How long ago did your household obtain the mosquito bed net?
MORE THAN 3 YEARS AGO 96
DON'T KNOW 98
111A) VERIFY Q.111 IF MORE THAN 6 MONTHS AGO
NO 2 (GO TO 112)
111B) Where did you obtain the net?
COMMUNITY HW 13
OTHER 16 (SPECIFY) ________
PHARMACY 22
PRIVATE DOC 23
DISPENSARY 25
OTHER 26 (SPECIFY) __________
CHURCH 32
PARENT/FRIEND 33
111BB) How did you obtain the net?
DURING SPECIAL IMMUNIZATION CAMPAIGIN IN 2006 2
DURING ANC VISITS 3
MARKET/STORE 4
VOLUNTEER OR THE MALARIA PROGRAM 5
OTHER 6 (SPECIFY) ___________
111C) How much did you pay for the net?
FREE 9996
DON'T KNOW 9998
112) OBSERVE OR ASK FOR THE BRAND OF MOSQUITO NET
MAMANET 2
OTHER 4
DON'T KNOW/NOT SURE 5
112D) Did anyone sleep under this mosquito bed net last night?
NO 2 (GO TO 112F)
DON'T KNOW 8 (GO TO 112F)
112DD) Did anyone sleep under this mosquito bed net the night before last night?
NO 2 (GO TO 112F)
DON'T KNOW 8 (GO TO 112F)
112E) Who slept under this mosquito bed net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. _______
112F) GO BACK TO 111 IN THE FIRST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE NETS, GO TO MALARIA TABLE.
TABLE FOR MALARIA DIAGNOSIS FOR CHILDREN
INFORMED CONSENT STATEMENT FORM ANEMIA FOR CHILDREN
In this survey we measure the level of anemia in women and children aged less than 5 years. We ask the women and the children to participate in the malaria and anemia testing part of this survey by giving a few drops of blood from a finger. The tests use disposable sterile instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.
Now I would like to ask that you and (NAME OF CHILDREN) agree to 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 done.
Do you have any questions?
Now please tell me if you agree to have the test done.
SKIP TO COLUMN 113 AND CIRCLE THE APPROPRIATE CODES.
113) LINE NO. FROM COL. (9) _________
114) NAME FROM COL. (2) _______
116) What is (NAME)'s date of birth?* _____________
117) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE. ___________
118) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)
REFUSED OR NOT READ 2 (GO TO 120)
NEGATIVE 2
INDETERMINANT 3
2 THICK SMEAR
3 ABSENCE
4 REFUSED
5 TEACH/PROBE
6 OTHER (SPECIFY) _________
PUT FIRST BAR CODE HERE
PUT SECOND BAR CODE ON RAPID TEST FOR MALARIA
PUT THIRD BAR CODE ON THE SLIDE
TABLE FOR MALARIA DIAGNOSIS FOR WOMEN
INFORMED CONSENT STATEMENT FORM ANEMIA FOR WOMEN
We request that you and all children aged less than 5 years participate in the anemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.
Do you have any questions?
Now please tell me if you agree to have the test done. IF WOMEN AGES 15-17, ASK THE CONSENT STATEMENT FROM THE RESPONSIBLE PARENT/GUARDIAN.
Now please tell me if you agree to have the test done for (NAME OF THE WOMAN 15-17). SKIP TO COLUMN 122 AND CIRCLE APPROPRIATE CODES.
122) LINE NO. FROM COL. (9) _______
123) NAME FROM COL. (2) __________
124) AGE FROM COL. (7) ________
AGE 18+ 2 (SKIP TO 127)
126) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT* CIRCLE CODE (AND SIGN)
REFUSE 2
DID NOT READ 3
SIGN ________
127) READ CONSENT STATEMENT TO THE WOMEN. CIRCLE CODE (AND SIGN).
REFUSE 2
DID NOT READ 3
SIGN _______
128) RESULT OF THE RAPID TEST. IF 127 NOT EQUAL 1 GO TO 130.
NEGATIVE 2
INDETERMINANT 8
NO 2
DON'T KNOW 3
2 THICK SMEAR
3 ABSENCE
4 REFUSED
5 TEACH/PROBE
6 OTHER (SPECIFY) ________
131) PLACE BAR CODES
PUT FIRST BAR CODE HERE
PUT SECOND BAR CODE ON RAPID TEST FOR MALARIA
PUT THIRD BAR CODE ON THE SLIDE
TABLE FOR HEMOGLOBIN FOR CHILDREN
GO TO COLUMN 132 AND CIRCLE APPROPRIATE CODES
132) LINE NO. FROM COL. (11) __________
133) NAME FROM COL. (2) _________
134) AGE FROM COL. (7) _________
135) What is (NAME)'s date of birth?*
DAY ______
MONTH ________
YEAR _______
136) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LSITED IN HOUSEHOLD SCHEDULE.** ____________
137) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
REFUSED 2 (GO TO 139)
138) HEMOGLOBIN LEVEL (G/DL) ______ . ____
2 ABSENCE
3 REFUSED
4 TEACH/PROBE
6 OTHER (SPECIFY) _________
*FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY (SECTION 2), SUCH AS ORPHAN, ADOPTED CHILDREN, ETC., ASK DAY, MONTH, AND YEAR OF BIRTH. FOR ALL OTHER CHILDREN COPY MONTH AND YEAR FROM Q. 125 IN MOTHER'S BRITH HISTORY (SECTION 2) AND ASK DAY OF BIRTH.
** RECORD '00' IF NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE
.
TABLE FOR HEMOGLOBIN FOR WOMEN.
SKIP TO COLUMN 121 AND CIRCLE APPROPRIATE CODES.
140) LINE NO. FROM COL. (9) ________
141) NAME FROM COL. (2) _________
142) AGE FROM COL. (7) _______
AGE 18+ 2 (GO TO 145)
144) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT*. CIRCLE CODE (AND SIGN).
REFUSE 2
DID NOT READ 3
SIGN ________
145) READ CONSENT STATEMENT TO THE WOMEN. CIRCLE CODE (AND SIGN).
REFUSE 2
DID NOT READ 3
SIGN ________
146) LEVEL OF HEMOGLOBIN (G/DL). IF 145 NOT EQUAL 1 SKIP TO 148.
_____ . ____
NO 2
DON'T KNOW 8
2 ABSENCE
3 REFUSED
4 TEACH/PROBE
6 OTHER (SPECIFY) _________
149) CHECK QUESTIONS 48 (FOR CHILDREN) AND 56/57 (FOR ADULTS):
NUMBER OF HOUSEHOLD MEMBERS FOR WHICH THE LEVEL OF HEMOGLOBIN IS BELOW THE CUT-OFF POINTS: LESS THAN 7 G/DL FOR CHILDREN, FOR MEN, AND FOR WOMEN WHO ARE NOT PREGNANT (OR WHO DO NOT KNOW IF THEY ARE PREGNANT); LESS THAN 9 G/DL FOR PREGNANT WOMEN.
ONE OR MORE: GIVE EACH WOMEN, MAN, OR RESPONSIBLE ADULT THE RESULTS OF THE HEMOGLOBIN TEST. READ THE DECLARATION BELOW (Q.150) TO THESE PERSONS WITH HEMOGLOBIN LEVELS BELOW CUT-OFF POINTS.
NONE: GIVE EACH WOMAN, MAN, OR RESPONSIBLE ADULT THE RESULTS OF THE HEMOGLOBIN TEST.
150) The results of the test show that (your blood/the blood of NAME OF CHILD/CHILDREN) has a very low level of hemoglobin. This indicates that (you/NAME OF CHILD/CHILDREN) are severely anemic, which is a serious health problem. We recommend that you visit a health facility as soon as possible to be examined and obtain the proper treatment. GIVE THE ADULT THE REFERENCE FORM FOR ANEMIA.