2016 UGANDA DEMOGRAPHIC AND HEALTH SURVEY BIOMARKER QUESTIONNAIRE
EA NAME___
FIRST VISIT
DATE____
FIELDWORKER'S NAME___
NEXT VISIT:
DATE___
TIME___
SECOND VISIT
DATE____
FIELDWORKER'S NAME___
NEXT VISIT:
DATE___
TIME___
THIRD VISIT
DATE____
FIELDWORKER'S NAME___
FINAL VISIT
DAY__
MONTH___
YEAR___
LANGUAGE OF QUESTIONNAIRE**___
LANGUAGE OF INTERVIEW**___
NATIVE LANGUAGE OF RESPONDENT**___
TRANSLATOR___
NO = 2
LANGUAGE OF QUESTIONNAIRE**_____
**LANGUAGE CODES:
02 LUGANDA
03 LUO
04 LUGBARA
05 ATESO
06 NGAKARIMOJONG
07 RUNYANKOLE/RUKIGA
08 LUSOGA
96 OTHER_____(SPECIFY)
NUMBER____
NUMBER____
NUMBER____
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND MALARIA, VITAMIN A 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) What is (NAME)'s date of birth?
MONTH___
YEAR___
104) CHECK 103: CHILD BORN IN 2011-2016?
NO 2 (SKIP TO 114)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996 (SKIP TO 107A)
107) MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
107A) OBSERVE: IS THE CHILD AN ALBINO?
NO 2
DON'T KNOW 8
NOT PRESENT 4
OTHER 6
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 (CONTIUE TO 110)
110) NAME OF PARENT / OTHER ADULT RESPONSIBLE FOR THE CHILD.
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 2011 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____(SIGN) 2
NOT PRESENT/OTHER 3
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 2011 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. 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____(SIGN) 2
NOT PRESENT/OTHER 3
112C) ASK CONSENT FOR VITAMIN A TEST FROM PARENT/OTHER ADULT.
As part of this survey, we are asking people all over the country to take a vitamin A deficiency test. Vitamin A deficiency is a serious health problem that usually results from poor nutrition. This survey will assist the government to develop programs to prevent and treat vitamin A deficiency. We ask that all children born in 2011 or later take part in vitamin A deficiency 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.
A few blood drops will be collected on a paper card and taken to a laboratory for testing. No names will be attached so we will not be able to tell you the test results. No one else will be able to know the test results either.
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 vitamin A deficiency test?
112D) CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED____(SIGN) 2
NOT PRESENT/OTHER 3
112E) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT.
We ask you to allow the Uganda Bureau of Statistics/Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the vitamin A testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
112F) CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED____(SIGN) 2
NOT PRESENT/OTHER 3
112G) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
112H) ADDITIONAL TESTS.
CHECK 112F: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
113) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
113A) CIRCLE THE CODE FOR THE MALARIA RDT.
NOT PRESENT 2 (SKIP TO 113C)
REFUSED 3 (SKIP TO 113C)
OTHER 6 (SKIP TO 113C)
113B) RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
P.V. ONLY 2 (SKIP TO 113E)
BOTH 3 (SKIP TO 113E)
NEGATIVE 4 (CONTINUE TO 113C)
OTHER 6 (CONTINUE TO 113C)
113C) CHECK 113: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2 (SKIP TO 114)
NOT PRESENT 3 (SKIP TO 114)
REFUSED 4 (SKIP TO 114)
OTHER 6 (SKIP TO 114)
113D) SEVERE ANEMIA REFERRAL: 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.
(SKIP TO 114)
113E) Does (NAME) suffer from any of the following illnesses or symptoms:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
113F) CHECK 113E: ANY 'YES' CIRCLED?
YES___ (SKIP TO 113I)
113G) CHECK 113: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2 (CONTINUE TO 113H)
NOT PRESENT 3 (CONTINUE TO 113H)
REFUSED 4 (CONTINUE TO 113H)
OTHER 6 (CONTINUE TO 113H)
113H) In the past two weeks has (NAME) taken or is taking COARTEM/ACT given by a doctor or health center to treat the malaria? VERIFY BY ASKING TO SEE TREATMENT)
NO 2 (SKIP TO 113K)
113I 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.
(SKIP TO 113O)
113J) ALREADY TAKING COARTEM/ACT REFERRAL STATEMENT
You have told me that (NAME OF CHILD) had already received COARTEM/ACT for malaria. Therefore, I cannot give you additional COARTEM/ACT. However, the test shows that he/she has malaria. If your child has a fever for two days after the last dose of COARTEM/ACT, you should take the child to the nearest health facility for further examination.
(SKIP TO 114)
113K) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER ADULT.
The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called COARTEM/ACT. COARTEM/ACT is very effective and in a few days it should get rid of the fever and other symptoms. You do not have to accept the medicine. This is up to you. Please tell me whether you accept the medicine or not.
113L) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED____(SIGN) 2
OTHER 6
113M) CHECK 113L: MEDICATION ACCEPTED
REFUSED 2 (SKIP TO 114)
OTHER 6 (SKIP TO 114)
113N) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT/OTHER ADULT.
TREATMENT WITH COARTEM/ACT
(Weight in Kg - Approximate age, Dosage*)
*Co-formulated tablets containing 20 mg Artemether and 120 mg Lumefantrine per tablet.
First day starts by taking first dose followed by the second one 8 hours later; on subsequent days the recommendation is simply "morning" and "evening" (usually around 12 hours apart).Take the medicine (crushed for smaller children) with high fat food or drinks like milk.
Make sure that the FULL 3 days treatment is taken at the recommended times, otherwise the infection may return. If your child vomits within an hour of taking the medicine, you will need to get additional tablets and repeat the dose.
ALSO TELL THE PARENT/ADULT RESPONSIBLE FOR THE CHILD: If [NAME] has a high fever, fast or 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.
(SKIP TO 114)
113O) CHECK 113: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2 (SKIP TO 114)
NOT PRESENT 3 (SKIP TO 114)
REFUSED 4 (SKIP TO 114)
OTHER 6 (SKIP TO 114)
113P) SEVERE ANEMIA REFERRAL: 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.
114) GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.
WEIGHT AND HEIGHT AND HEMOGLOBIN MEASUREMENT 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:
NAME (FROM COLUMN 2)_____
203) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-49 YEARS 2
204) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
206A) OBSERVE: IS THE WOMAN AN ALBINO?
NO 2
DON'T KNOW 8
207) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
18-49 YEARS 2 (SKIP TO 210)
209) CHECK 204: MARITAL STATUS
OTHER 2 (CONTINUE TO 210)
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. Will you take the anemia test?
211) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED______(SIGN) 2 (SKIP TO 231)
NOT PRESENT/OTHER 3 (SKIP TO 231)
NO 2 (SKIP TO 231)
DON'T KNOW 8 (SKIP TO 231)
216) RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
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?
You can say yes or no. 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.
PARENT/OTHER RESPONSIBLE ADULT REFUSED _____(SIGN) 2 (SKIP TO 231)
NOT PRESENT/OTHER 3 (SKIP TO 231)
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.
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.
MINOR RESPONDENT REFUSED_____(SIGN) 2 (SKIP TO 231)
NOT PRESENT/OTHER 3 (SKIP TO 231)
NO 2
DON'T KNOW 8
231) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
232) CHECK 231: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2 (SKIP TO 234)
NOT PRESENT 3 (SKIP TO 234)
REFUSED 4 (SKIP TO 234)
OTHER 6 (SKIP TO 234)
233) SEVERE ANEMIA REFERRAL: RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.
The anemia test shows that (you have/(NAME) has) severe anemia. (You are/(NAME) is) very ill and must be taken to a health facility immediately.
234) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR MEN AGE 15-54
301) CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303, AND 304. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
302) CHECK HOUSEHOLD QUESTIONNAIRE:
NAME (FROM COLUMN 2)_____
303) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-54 YEARS 2
304) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
306A) OBSERVE: IS THE MAN AN ALBINO?
NO 2
DON'T KNOW 8
307) MEASURER: ENTER YOUR FIELDWORKER NUMBER
18-54 YEARS (SKIP TO 310)
309) CHECK 304: MARITAL STATUS
OTHER 2 (CONTINUE TO 310)
310) 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 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 take the anemia test?
311) CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED_____(SIGN) (SKIP TO 331)
NOT PRESENT/OTHER 3 (SKIP TO 331)
316) RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
317) 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?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to take the anemia test?
318) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED_____(SIGN) 2 (SKIP TO 331)
NOT PRESENT/OTHER 3 (SKIP TO 331)
319) 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.
Do you have any questions?
You can say yes or no. It is up to you to decide. Will you take the anemia test?
320) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED_____(SIGN) 2 (SKIP TO 331)
NOT PRESENT/OTHER 3 (SKIP TO 331)
331) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
332) CHECK 331: HEMOGLOBIN RESULT
8.0 G/DL OR ABOVE 2 (SKIP TO 334)
NOT PRESENT 3 (SKIP TO 334)
REFUSED 4 (SKIP TO 334)
OTHER 6 (SKIP TO 334)
333) SEVERE ANEMIA REFERRAL: RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.
The anemia test shows that (you have/(NAME) has) severe anemia. (You are/(NAME) is) very ill and must be taken to a health facility immediately.
334) GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.
FIELDWORKER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
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SUPERVISOR'S OBSERVATIONS
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EDITOR'S OBSERVATIONS
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