Republic of Senegal
Ministry of Health and Medical Prevention

Macro International
Center of Research for Human Development ("CRDH")

IDENTIFICATION

REGION ______
HEALTH DISTRICT ______
MUNICIPALITY/RURAL COMMUNITY ______
CLUSTER NUMBER ______
NAME OF HEAD OF CONCESSION _______
CONCESSION NUMBER ______
NAME OF HEAD OF HOUSEHOLD ______
HOUSEHOLD NUMBER IN SAMPLE ______
NAME OF LOCALITY (MUNICIPAL DISTRICT IN DAKAR, MUNICIPALITY, RURAL COMMUNITY) ______
URBAN/RURAL (URBAN = 1, RURAL = 2) ENVIRONMENT ______
DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL (DAKAR = 1, REGIONAL CAPITAL = 2, OTHER CITY = 3, RURAL = 4) DETAILED ENVIRONMENT ______
HOUSEHOLD SAMPLE (OF THE 30 IN CLUSTER)? (YES = 1, NO = 2) ______
HOUSEHOLD CHOSEN FOR ANEMIA AND MALARIA TESTS (YES = 1, NO = 2)? ______

INTERVIEWER VISITS

(Repeat for up to 3 visits)

DATE _____
NAME OF INTERVIEWER ______
RESULT ______

NEXT VISIT
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR 200______
INTERVIEWER NUMBER ______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

RESULT CODES:
1 COMPLETED
2 NO FAMILY MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR LONG PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR NO DWELLING AT ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ______

TOTAL IN HOUSEHOLD ______
TOTAL NUMBER OF WOMEN AGE 15 - 49______
RESPONDENT'S LINE NUMBER FOR HOUSEHOLD QUESTIONNAIRE ______

TEAM LEADER
NAME ______
DATE ______

SUPERVISOR
NAME ______
DATE ______

OFFICE EDITOR
______

KEYED BY
______

INTRODUCTION AND CONSENT

Hello. My name is ______ and I work for the Ministry of Health. We are carrying out a national survey on malaria. We would like you to participate in this survey. The information that you provide us will help the Government to plan health services.

The interview usually takes between 10 and 20 minutes. All the information that you give us will be strictly confidential and will not be shared with anyone other than members of the survey team.

Participation in this survey is voluntary; if there is a question that you do not wish to answer, let me know and I will go on to the next question. You can also stop the interview at any time. However, we hope that you will participate in this survey for your opinion is very important to us.

Do you have any questions about the survey?
May I begin the interview now?

Respondent's signature: ______
Date: ______

1 RESPONDENT AGREES TO ANSWER (Continue to Household Schedule)
2 RESPONDENT DOES NOT AGREE TO ANSWER QUESTIONS (Skip to END)

HOUSEHOLD SCHEDULE

(Repeat Q. 1 - 10 for up to 32 household members)

Now we would like some information about the people who usually live in your household or who are currently living in your household.

1. LINE NUMBER

2. HABITUAL 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?

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD
01 HEAD OF HOUSEHOLD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW/DAUGHTER-IN-LAW
05 GRANDSON/GRANDDAUGHTER
06 FATHER/MOTHER
07 FATHER-IN-LAW/MOTHER-IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 NIECE/NEPHEW
11 OTHER RELATIVES
12 ADOPTED/FOSTER/STEPCHILD
13 NO FAMILY RELATION
98 DK

4. GENDER
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)?

8. WOMEN AGE 15 - 49
CIRCLE THE LINE NUMBERS OF ALL WOMEN AGE 15 - 49

9. PREGNANT NOW?
FOR ALL ELIGIBLE WOMEN ASK:
Is (NAME) pregnant now?

10. CHILDREN UNDER AGE OF 6
CIRCLE THE LINE NUMBERS OF ALL CHILDREN AGE 0 - 5.

CHECK OFF HERE IF ANOTHER SHEET IS USED: ______
Just to be sure that I have a complete list:

A) Are there other people such as small children or infants that we have not put on the list?
YES ______ RECORD EACH ONE IN THE SCHEDULE
B) Besides that, are there other people who are perhaps not family members such as servants, renters, or friends who usually live here?
YES ______ RECORD EACH ONE IN THE SCHEDULE
C) Are there any guests or visitors in your home or other people who spent the night here last night and who were not listed?
YES ______ RECORD EACH ONE IN THE SCHEDULE

HOUSEHOLD CHARACTERISTICS

101. Where does the drinking water used by members of your household mainly come from?

102. What kind of toilets do members of your household usually use?

103. In your household, is there:

Electricity?
A radio?
A television?
A mobile phone?
A landline phone?
A refrigerator/freezer?
A gas/electric hotplate/stovetop?
An improved hearth?

104. What type of fuel is mainly used for cooking in your household?

105. MAIN MATERIAL OF FLOORING

106. MAIN MATERIAL OF ROOF
RECORD OBSERVATION

107. MAIN MATERIAL OF EXTERIOR WALLS.
RECORD OBSERVATION.

108. Of all the rooms in your household, how many are generally used by household members for sleeping?

109. In your household, does anyone own:

Bicycles?
Mopeds or motorcycles?
A personal car?
Business cars or trucks?
Wagons?
Plows?
Horses?
Cattle?
Camels?
Donkeys?
Sheep/goats?
Flat-bottomed boats/fishing nets?
Poultry?

109A. Do the windows of the rooms for residential use have screens to prevent mosquitos from entering?

109B. Do the doors of the rooms for residential use have screens or curtains to prevent mosquitos from entering?

110. In the last 12 months, has anyone come to spray the interior walls of your dwelling for mosquitos?

111. How many months ago was this spraying of interior walls done?
IF LESS THAN ONE MONTH, RECORD '00' MONTHS.

112. Who sprayed the walls of your dwelling?

112A. Since the walls of your dwelling were sprayed, have you touched them up, for example by applying lime or paint, applying a coating, or washing them?

113. In your household, do you have any mosquito nets that can be used for sleeping?

114. How many mosquito nets do you have in your household?

IF 96 OR MORE MOSQUITO NETS, RECORD '96'.

114A. Do you use the mosquito nets outside of bedrooms: for example in the courtyard, under the trees?

114B. Do people in your household make a habit of sleeping under mosquito nets all year round?

114C. Why don't members of your household sleep under mosquito nets all year long?

114D. Why aren't there any mosquito nets that can be used in your household?

115. ASK RESPONDENT TO SHOW YOU THE MOSQUITO NETS. ASK THE FOLLOWING QUESTIONS ABOUT EACH MOSQUITO NET.
IF MORE THAN 3 MOSQUITO NETS, USE ADDITIONAL QUESTIONNAIRE.

115A. OBSERVE OR ASK THE SHAPE OF MOSQUITO NET.

115B. OBSERVE OR ASK THE SIZE OF MOSQUITO NET.

116. How long has your household owned this mosquito net?

117. OBSERVE OR ASK THE BRAND OF MOSQUITO NET (1)

118. When you got this mosquito net, had the manufacturer already treated it with an insecticide that kills or repels mosquitos or insects?

119. Since you have had this mosquito net, has it been soaked or dipped in a liquid that kills or repels mosquitos or insects?

120. How much time has gone by since the mosquito net was soaked or dipped the last time in a liquid insecticide?

IF LESS THAN 1 MONTH, RECORD '00'.
IF LESS THAN 2 YEARS, RECORD THE NUMBER OF MONTHS.

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

122. Who slept under this mosquito net last night?

CARRY OVER THE LINE NUMBER FROM HOUSEHOLD SCHEDULE.
RECORD ALL THE PEOPLE WHO SLEPT UNDER EACH MOSQUITO NET LAST NIGHT.

(Repeat for up to 5 people per net)

122A. In the last 12 months, how many months did a member of your household sleep under this mosquito net?

122B. Was this mosquito net made in a factory or was it made by a tailor?

122C. CHECK 121:

122D. Why didn't anyone sleep under this mosquito net last night?

IF SEVERAL REASONS ARE MENTIONED, ASK AND RECORD THE MAIN ONE.

122E. Where did this mosquito net come from?

122F. How was this mosquito net acquired?

122G. How much money did you pay for this mosquito net?
RECORD IN CFA FRANCS.

122H. CHECK 117 AND 119:

LLIN OR OTHER TYPES OF MOSQUITO NETS.

122I. a- Has this mosquito net been washed since you got it?
b- Has this mosquito net been washed since it was dipped the last time?

122J. How many times was this mosquito net washed in the last 12 months?

122K. How many months ago was the last washing of the mosquito net?
IF 12 OR MORE MONTHS, RECORD '12'.

123. RETURN TO 115 FOR NEXT MOSQUITO NET; OR, IF NO MORE MOSQUITO NETS IN HOUSEHOLD: CONTINUE TO 201.

NOTE (1): You may find one of the following references on the mosquito nets
A) Long-Lasting Insecticidal Net (LLIN):
1) PERMANET:PERMANET, www.permanet.com, www.vestergard-frandsen.com;
2) OLYSETNET: OLYSET NET, Registered Trademark of Sumitomo Chemical Co Ltd.
3) DAWA PLUS: DAWA, DAWA PLUS, TANA NETTING CO LTD BY SIAMDUTCH;
4 ICONLIFE: Iconlife, Insecticide treated net Syngenta.

B) Other treated mosquito nets:
1) K-O NET: Siamdutch, Mosquito Netting Co Ltd;
2) Netto: Netto Extra Treated Net;
3) SENTINELLE: Sentinelle, Treated mosquito net;
4) INTERCEPTOR: BASF THE CHEMICAL COMPANY LLIN

ANEMIA AND MALARIA TESTING FOR CHILDREN AGE 0 - 5

201. CHECK COLUMN 10. RECORD LINE NUMBER AND NAME OF ALL CHILDREN BORN IN 2003 OR LATER IN Q.202.
IF 7 OR MORE CHILDREN, USE ADDITIONAL QUESTIONNAIRES. RECORD THE FINAL RESULT FOR ALL CHILDREN ELIGIBLE FOR

THE ANEMIA TEST IN 209 AND FOR THE MALARIA TEST IN 211.

202. LINE NUMBER IN COLUMN 10
NAME IN COLUMN 2

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

204. CHECK 203:
CHILD BORN IN JANUARY 2003 OR LATER?

205. CHECK 203:
CHILD AGE 0 - 5 MONTHS, THAT IS, BORN IN MONTH OF INTERVIEW OR IN 5 PRECEDING MONTHS?

206. LINE NUMBER OF CHILD'S PARENT OR RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED.

207. READ CONSENT REQUEST FOR ANEMIA TEST TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
CIRCLE CODE AND SIGN.

208. READ CONSENT REQUEST FOR MALARIA TEST TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
CIRCLE CODE AND SIGN.

CARRY OUT TESTS FOR EACH CHILD FOR WHOM CONSENT HAS BEEN GIVEN AND CONTINUE TO 209

209. RECORD RESULT CODE FOR ANEMIA TEST.

210. RECORD HEMOGLOBIN LEVEL.

211. RECORD RESULT CODE FOR MALARIA TEST (RAPID TEST)

212. RESULT OF MALARIA TEST (RAPID TEST)

214. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT TO CHILD'S PARENT OR OTHER RESPONSIBLE ADULT.
CIRCLE CODE AND SIGN.

[###translator's note: error: all code results should sign according to instructions]

214A. BARCODE STICKERS

[###translator's note: when this question is repeated for children 4, 5, and 6, it includes "THICK SMEAR AND THIN SMEAR" after "BARCODE STICKERS"]

ATTACH THE FIRST STICKER HERE ______

215. RETURN TO NEXT COLUMN IN 203 OF THIS QUESTIONNAIRE OR TO THE FIRST COLUMN IN ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, CONTINUE TO 201A.

DECLARATION OF CONSENT FOR ANEMIA TEST.
In the survey, we are asking children under the age of 6 all over the country to take an anemia test. Anemia is a serious health issue which is often due to poor nutrition, infections, and chronic illnesses.

The results of this survey will allow the government to set up programs to prevent and treat anemia.

We are asking all children born in 2003 or later to participate in the anemia test by giving a few drops of blood from a finger (or heel if baby is under 6 months old). To collect these drops, we will use clean and completely safe equipment which has never been used before and which will be thrown away after each blood draw.

The blood will be tested for anemia and you will get the result right away. The result will remain confidential.

Do you have any questions about the anemia test?

You can say yes to the test or you can say no. It is your decision.
Will you allow (NAME OF CHILDREN) to participate in the anemia test?

DECLARATION OF CONSENT FOR MALARIA TEST
In this survey, we are asking children all over the country who are under the age of 6 to take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by mosquito bites. The results of this survey will allow the government to put programs into place to prevent and treat malaria.

We are asking all children born in 2003 or later to participate in the malaria testing by giving a few drops of blood from a finger (or heel if baby is under 6 months old). To collect these drops, we will use clean and completely safe equipment which has never been used before and which will be thrown away after each blood draw.

The blood will be tested for malaria and the result will be given to you immediately. Part of these drops of blood will be sent on to the Laboratory for confirmation. The result will remain confidential.

Do you have any questions about the malaria test?

You can say yes to the test or you can say no. It is your decision.
Will you allow (NAME OF CHILDREN) to participate in the malaria diagnosis test?

TREATMENT OF CHILDREN WITH POSITIVE MALARIA TEST

IF THE MALARIA TEST IS POSITIVE: The malaria test shows that your child has malaria. We can give you free medicine. This medicine is called ACT.
ACT is very effective and in a few days the fever and other symptoms should be gone.
ACT is also very safe. However, with any medication, there are side effects, and this medicine can have some.
Common side effects are dizziness, fatigue, lack of appetite, palpitations. ACT should not be taken by people who have serious heart problems or severe malaria (for example cerebral) or problems regulating body salts.
ASK IF CHILD SUFFERS FROM ANY OF THESE PROBLEMS, THAT THE MOTHER IS AWARE OF; IF YES, DO NOT OFFER ACT.
EXPLAIN THE RISKS OF MALARIA AND REFER THE CHILD TO THE NEAREST HEALTH FACILITY.
You do not have to give the medicine to the child. It is your decision. Please tell me: will accept the medication or not?

(Table)
TREATMENT WITH ACT (Falcimon)
Artesunate (tablet dosed at 50 mg) + Amodiaquine (tablet dosed at 153 mg base)

Weight (in kg) - approximate age
Less than 10 kg (under age 1)
Dosage
Day 1 (in one take)
1/2 Artesunate tablet + 1/2 Amodiaquine tablet
Day 2 (in one take)
1/2 Artesunate tablet + 1/2 Amodiaquine tablet
Day 3 (in one take)
1/2 Artesunate tablet + 1/2 Amodiaquine tablet

Weight (in kg) - approximate age
10 - 20 kg (age 1 to 7)
Dosage
Day 1 (in one take)
1 Artesunate tablet + 1 Amodiaquine tablet
Day 2 (in one take)
1 Artesunate tablet + 1 Amodiaquine tablet
Day 3 (in one take)
1 Artesunate tablet + 1 Amodiaquine tablet

YOU MUST ALSO SAY THIS TO CHILD'S PARENT/RESPONSIBLE ADULT:
IF (NAME OF CHILD) has any of the following symptoms, you must take him/her immediately to a health professional for care:
High fever
Convulsions, coma
Fast or difficult breathing
Unable to drink or nurse
Gets sicker or doesn't improve in 2 days

(Repeat Q.202 - 214A for up to 3 more children)

ANEMIA TESTS IN WOMEN AGE 15 - 49

201A. CHECK COLUMN 8. RECORD THE LINE NUMBER AND NAME OF ALL WOMEN AGE 15 - 49 IN Q.202A. IF 7 OR MORE WOMEN, USE ADDITIONAL QUESTIONNAIRES. THE FINAL RESULT WILL BE RECORDED FOR ELIGIBLE WOMEN FOR ANEMIA IN 209A.

202A. (Repeat for up to 3 women)
LINE NUMBER IN COLUMN 8
NAME IN COLUMN 2

203A. IF WOMAN IS INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM HER INDIVIDUAL QUESTIONNAIRE.

IF MONTH UNKNOWN, RECORD '98'.

204A. CHECK (07):
WOMAN AGE 18 - 49?

206A. LINE NUMBER OF GIRL'S PARENT OR RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED.

207A. READ CONSENT FOR ANEMIA TEST TO WOMAN OR CHILD'S PARENT/RESPONSIBLE ADULT. CIRCLE CODE AND SIGN.

209A. RECORD THE RESULT CODE OF THE ANEMIA TEST.

210A. RECORD HEMOGLOBIN LEVEL.

215A. RETURN TO NEXT COLUMN IN 203A OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, END INTERVIEW.

DECLARATION OF CONSENT FOR ANEMIA TEST

In this survey, we are asking all the women all over the country to take the anemia test. Anemia is a serious health issue which is often caused by poor nutrition, infections, and chronic illnesses. The results of this study will allow the government to put programs into place to prevent and treat anemia.

We are asking you to participate in the anemia test by giving a few drops of blood from a finger. To collect these drops, we will use clean and completely safe equipment. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia and you will know the result right away. The result will remain confidential.

Do you have any questions about the anemia test?

You can say yes to the test or you can say no. It is your decision.
Do you agree to participate in this anemia test?

IF RESPONDENT IS AGE 15 - 17, FIRST ASK CONSENT OF PARENT/RESPONSIBLE ADULT:
Will you allow (NAME OF YOUNG PERSON) to participate in this anemia test?

(Repeat Q. 201A - 215A for up to 3 additional women)

OBSERVATIONS OF INTERVIEWER

TO BE FILLED OUT ONCE THE INTERVIEW IS FINISHED

COMMENTS ABOUT THE RESPONDENT
______

COMMENTS ABOUT PARTICULAR QUESTIONS
______

OTHER COMMENTS
______

OBSERVATIONS OF TEAM LEADER
______

NAME OF TEAM LEADER: ______
DATE: ______