THE UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ____
HOUSEHOLD NUMBER ____
HOUSEHOLD SELECTED FOR MAN'S SURVEY, SALT AND URINE TESTING?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
INTERVIEWER'S NAME __________
NEXT VISIT
TIME _____
FINAL VISIT
MONTH _____
YEAR _____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN _____
NOTES: ________________________________________________
KISWHAILI 02
LANGUAGE 3 03
LANGUAGE 4 04
LANGUAGE 5 05
LANGUAGE 6 06
LANGUAGE OF INTERVIEW ____
KISWHAILI 02
LANGUAGE 3 03
LANGUAGE 4 04
LANGUAGE 5 05
LANGUAGE 6 06
TRANSLATOR
NO 2
NUMBER _____
FIELD EDITOR
NUMBER _____
OFFICE EDITOR
KEYED BY
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND MALARIA TESTING 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).
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 2010-2016
NO 2 (GO TO 130)
REFUSED 9995
OTHER 9996
REFUSED 9995 (GO TO 109)
OTHER 9996 (GO TO 109)
107. 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 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 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.
REFUSED 2
NOT PRESENT/OTHER 3 (GO TO 112B)
112A. 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 a mosquito bite. This survey will assist the government to develop programs to prevent malaria.
We ask that all children born in 2010 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. One blood drop will be tested for malaria immediately, and the result will be told to you right away. A few blood drops will be collected on slide(s) and taken to a laboratory for testing. You will not be told the results of the laboratory testing. All 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 malaria test?
112B. CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2
NOT PRESENT/OTHER 3
112D. PLACE BAR CODE LABEL FOR MALARIA LAB TEST.
REFUSED 99995
OTHER 99996
113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
REFUSED 995
OTHER 996
114. CIRCLE THE CODE FOR THE MALARIA/RDT.
NOT PRESENT 2 (GO TO 116)
REFUSED 3 (GO TO 116)
OTHER 6 (GO TO 116)
115. RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
NEGATIVE 2
OTHER 6
116. CHECK 113:
HEMOGLOBIN RESULT
7.0 G/DL OR ABOVE 2 (GO TO 130)
NOT PRESENT 3 (GO TO 130)
REFUSED 4 (GO TO 130)
OTHER 6 (GO TO 130)
117. SEVERE ANEMIA REFERRAL.
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.
MAINLAND TANZANIA (GO TO 118)
117B. MALARIA REFERRAL.
RECORD THE RESULT OF THE MALARIA TEST ON THE REFERRAL FORM.
118. Does (NAME) suffer from any of the following illnesses or symptoms:
IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y
HEART PROBLEMS B
LOSS OF CONSCIOUSNESS C
RAPID BREATHING D
SEIZURES E
BLEEDING F
JAUNDICE G
DARK URINE H
NONE OF THE ABOVE SYMPTOMS Y
119. CHECK 118:
ANY CODE A-H CIRCLED?
ANY CODE A-H CIRCLED 2 (GO TO 122)
120. CHECK 113:
HEMOGLOBIN RESULT
7.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
121. In the past two weeks has (NAME) taken or is taking ALU given by a doctor or health center to treat the malaria?
VERIFY BY ASKING TO SEE TREATMENT
NO 2 (GO TO 124)
122. SEVERE MALARIA REFERRAL.
RECORD THE RESULT OF THE MALARIA RDT ON THE REFERRAL FORM.
(GO TO 130)
123. ALREADY TAKING [FIRST LINE MEDICATION] REFERRAL STATEMENT
(GO TO 130)
124. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATMENT TO PARENT/OTHER
125. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2
OTHER 6
126. CHECK 125: MEDICATION ACCEPTED
REFUSED 2 (GO TO 130)
OTHER 3 (GO TO 130)
127. READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER ADULT.
15 to less than 25 - 3 to 8 years of age: 2 tablets ALu twice daily for 3 days
with fatty food or drinks like milk or breast milk. Make sure that the FULL 3 days treatment is taken.
130. GO BACK TO 103 IN NEXT COLUMN OF THIS PAGE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.
WEIGHT AND HEIGHT MEASUREMENT, HEMOGLOBIN AND URINE (FOR IODINE) TEST FOR WOMEN AGE 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 9.
NAME __________
203. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7:
18-49 YEARS 2
204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
204A. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 3 (RELATIONSHIP):
OTHER 2
REFUSED 99995
OTHER 99996
REFUSED 9995
OTHER 9996
207. MEASURER: ENTER YOUR INTERVIEWER NUMBER.
18-49 YEARS (GO TO 210)
209. CHECK 204: MARITAL STATUS
OTHER 2 (GO TO 210)
OTHER (GO TO 216)
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. 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 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.
211. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)
211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?
NO 2 (GO TO 221)
DON'T KNOW 8 (GO TO 221)
216. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.
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 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?
218. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)
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 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.
220. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)
220A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?
NO 2
DON'T KNOW 8
221. CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE. HOUSEHOLD SELECTED FOR MAN'S SURVEY AND IODINE
NOT SELECTED 2 (GO TO 229B)
18-49 YEARS (GO TO 224)
OTHER 2 (GO TO 224)
223A. CHECK 204A: RELATIONSHIP
OTHER 2 (GO TO 226)
ADULT RESPONDENT CONSENT FOR URINARY IODINE TEST
224. ASK CONSENT FOR IODINE TEST.
As part of this survey, we are also asking women all over the country to take test for iodine deficiency. Iodine deficiency is a health problem that usually results from poor nutrition. This survey will assist the government to develop programs to prevent and treat iodine deficiency.
For the iodine test, we need a small amount of urine. The urine will be tested at the Tanzania Food and Nutrition Laboratory. 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.
225. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (GO TO 229B)
NOT PRESENT/OTHER 3 (GO TO 229B)
226. RECORD LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.
PARENTAL/RESPONSIBLE ADULT CONSENT FOR URINARY IODINE TEST
227. ASK CONSENT FOR IODINE TEST FROM PARENT/ADULT
As part of this survey, we are also asking women all over the country to take test for iodine deficiency. Iodine deficiency is a health problem that usually results from poor nutrition. This survey will assist the government to develop programs to prevent and treat iodine deficiency.
For the iodine test, we need a small amount of urine. The urine will be tested at the Tanzania Food and Nutrition Laboratory. 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 provide us with a small amount of urine?
228. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 229B)
NOT PRESENT/OTHER 3 (GO TO 229B)
MINOR RESPONDENT CONSENT FOR URINARY IODINE TEST
229. ASK CONSENT FOR IODINE TEST FROM RESPONDENT
As part of this survey, we are also asking women all over the country to take test for iodine deficiency. Iodine deficiency is a health problem that usually results from poor nutrition. This survey will assist the government to develop programs to prevent and treat iodine deficiency.
For the iodine test, we need a small amount of urine. The urine will be tested at the Tanzania Food and Nutrition Laboratory. 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.
229A. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3
229B. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S)
230. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
REFUSED 995
OTHER 996
231. BAR CODE LABEL: URINARY IODINE
232. OUTCOME OF URINARY IODINE TEST PROCEDURE
NOT PRESENT/OTHER 2
REFUSED 3
233. GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE ELIGIBLE WOMEN, END THE BIOMARKER COLLECTION.
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
_____________________________________________________________
SUPERVISOR'S OBSERVATIONS _____________________________________________
EDITOR'S OBSERVATIONS __________________________________________________