Survey Text
Bangladesh 2018
No questionnaire text is available for this sample.
Benin 1996
Survey form
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1011) NAME OF MEASURER __________________________
NAME OF ASSISTANT __________________________
Benin 2017
Survey form
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307. MEASURER: ENTER YOUR INTERVIEWER NUMBER.
INTERVIEWER NUMBER __ __ __
Burkina Faso 1993
Survey form
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912. NAME OF OPERATOR _____
OPERATOR CODE _____
NAME OF ASSISTANT _____
ASSISTANT CODE _____
MOTHER 90
OTHER HOUSEHOLD MEMBER 91
OTHER PERSONS 92
Burkina Faso 1998
Survey form
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1111. NAME OF OPERATOR _____
OPERATOR CODE _____
NAME OF ASSISTANT _____
ASSISTANT CODE:
MOTHER 90
OTHER HOUSEHOLD MEMBERS 91
OTHER PERSONS 92
Burundi 2016
Survey form
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108) MEASURER: ENTER YOUR INTERVIEWER NUMBER
INTERVIEWER NUMBER___
Cameroon 1991
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Cameroon 1998
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Cameroon 2018
Survey form
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108) MEASURER: ENTER YOUR HEALTH TECHNICIAN NUMBER.
HEALTH TECH. NUMBER______
Central African Republic 1995
Survey form
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1111) NAME OF MEASURER____
NAME OF ASSISTANT____
Chad 1996
Survey form
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A11)
NAME OF MEASURER: ___
NAME OF ASSISTANT: ___
MOTHER 90
OTHER MEMBERS OF HOUSEHOLD 91
OTHER PEOPLE 92
Cote d'Ivoire 1994
Survey form
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1011) NAME OF MEASURER______
NAME____
NAME OF ASSISTANT______
NAME____
ASSISTANT'S RELATIONSHIP TO CHILD____
MOTHER 90
OTHER MEMBERS OF HOUSEHOLD 91
OTHER PERSONS 92
Cote d'Ivoire 1998
Survey form
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1011)
NAME OF MEASURER: ___
NAME OF ASSISTANT*: ____
*CODES: IF THE ASSISTANT IS A TEAM MEMBER, RECORD HIS/HER CODE, OTHERWISE USE THE FOLLOWING CODES: MOTHER (190); OTHER MEMBERS OF THE HOUSEHOLD (191); OTHER PERSONS (192).
Egypt 1988
Survey form
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808. NAME OF MEASURER AND ASSISTANT.
NAME OF MEASURER_______
NAME OF ASSISTANT_______
Egypt 1992
Survey form
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811) NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Egypt 1995
Survey form
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911) NAME OF MEASURER ______
NAME OF ASSISTANT ______
Egypt 2000
Survey form
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078) NAME OF MEASURE/TESTER______
NAME OF ASSISTANT______
Egypt 2003
Survey form
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065. NAME OF MEASURER_______
NAME OF ASSISTANT_______
Egypt 2005
Survey form
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TICK HERE IF CONTINUATION SHEET USED ___
215) NAME OF MEASURER/TESTER __ __
NAME OF ASSISTANT __ __
* CONSENT STATEMENT
As part of this survey, we are studying anemia among women, children and adolescents. 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 request that you (and all children under age 6, and all male and never married female adolescents aged 10-19) to participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILD[REN]/ADOLESCENT) 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(s) done.
Egypt 2008
Survey form
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CHECK IN THE IDENTIFICATION SECTION ON THE COVER PAGE IF THE HOUSEHOLD IS INCLUDED IN THE HEPATITIS C TESTING SUBSAMPLE:
IN THE HEPATITIS C TESTING SUBSAMPLE (GO TO 301)
NOT IN THE HEPATITIS C TESTING SUBSAMPLE (GO TO 401)
TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED ____
Name of Measurer __________
Name of Assistant __________
Egypt 2014
Survey form
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309. NAME OF MEASURER
__________
NAME OF ASSISTANT
___________
Ethiopia 2016
Survey form
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207. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
FIELDWORKER NUMBER ___
Gabon 2000
No questionnaire text is available for this sample.
Ghana 1988
Survey form
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808. NAME OF MEASURER: ____
NAME OF ASSISTANT: ____
Ghana 1993
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Guinea 1999
Survey form
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1311. NAME OF MEASURER _____
MEASURER CODE ____
Guinea 2018
No questionnaire text is available for this sample.
India 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
India 1998
Survey form
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809. NAME OF MEASURER _______
NAME OF ASSISTANT_______
India 2019
No questionnaire text is available for this sample.
Jordan 1990
Survey form
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811) NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Jordan 1997
Survey form
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1011. NAME OF MEASURER_____________ NAME OF ASSISTANT______________
Jordan 2012
No questionnaire text is available for this sample.
Jordan 2017
No questionnaire text is available for this sample.
Kenya 1993
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Liberia 2019
Survey form
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207. MEASURER: ENTER YOUR FIELDWORKER NUMBER
FIELDWORKER NUMBER _____________
Madagascar 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Madagascar 1997
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Malawi 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Malawi 2016
Survey form
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207. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
FIELDWORKER NUMBER ___
Mali 1995
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Mali 2012
No questionnaire text is available for this sample.
Mali 2018
Survey form
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113) What type of fuel does your household mainly use for cooking?
ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KAROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95-SKIP TO 116
OTHER (SPECIFY) 96
Mozambique 1997
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Namibia 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Niger 1992
Survey form
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913)
NAME OF MEASURER: ___
NAME OF ASSISTANT: ___
MOTHER 90
OTHER MEMBERS OF HOUSEHOLD 91
OTHER PERSONS 92
Niger 1998
No questionnaire text is available for this sample.
Nigeria 1999
Survey form
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1011. NAME OF MEASURER: __________ __
NAME OF ASSISTANT: _________ __
Nigeria 2018
No questionnaire text is available for this sample.
Pakistan 2017
Survey form
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108) MEASURER: ENTER YOUR FIELDWORKER NUMBER
FIELDWORKER NUMBER ________
207) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
FIELDWORKER NUMBER ________
Rwanda 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Rwanda 2019
No questionnaire text is available for this sample.
Senegal 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Sierra Leone 2019
Survey form
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108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
FIELDWORKER NUMBER______
South Africa 2016
No questionnaire text is available for this sample.
Sri Lanka 1987
No questionnaire text is available for this sample.
Tanzania 1991
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Tanzania 1996
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Tanzania 2015
Survey form
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108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
FIELDWORKER NUMBER _____
Togo 1998
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Tunisia 1988
Survey form
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118) Do you listen to the radio?
EVERY DAY 1
SEVERAL TIMES A WEEK 2
LESS OFTEN 3
NEVER 4
Uganda 1988
Survey form
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808. NAME OF MEASURER AND ASSISTANT.
NAME OF MEASURER___________
NAME OF ASSISTANT___________
Uganda 2016
Survey form
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108) MEASURER: ENTER YOUR FIELDWORKER NUMBER.
FIELDWORKER NUMBER____
Zambia 1992
Survey form
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811 NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________
Zambia 1996
Survey form
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910. RESULT:
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF MEASURER __________
NAME OF ASSISTANT __________
Zimbabwe 1988
Survey form
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808. NAME OF MEASURER AND ASSISTANT.
NAME OF MEASURER___________
NAME OF ASSISTANT___________
Zimbabwe 1994
Survey form
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911) NAME OF MEASURER ______
NAME OF ASSISTANT ______
Zimbabwe 2015
Survey form
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108. MEASURER: ENTER YOUR INTERVIEWER NUMBER.
INTERVIEWER NUMBER ___