Cluster Number
Household Number
Woman’s Line Number
See Household Questionnaire
WOMEN (15-49 YEARS)
Label
TEAM CODE
Yes
VERBAL CONSENT OBTAINED FROM ELIGIBLE WOMAN
No
If NO = Do Not Continue
1.
Woman’s name:
2.
Woman’s age
3. W HAT IS YOUR HIGHEST GRADE OF EDUCATION
COMPLETED?
YU PINISIM WANEM GRET LONG SKUL?
(0= No school completed
1-3=Elementary School
4-8= Primary School
9-12=Secondary school)
4. DID YOU SLEEP UNDER A MOSQUITO NET LAST NIGHT?
years
years
Highest grade completed
Refused ..................................................... 7
Other (specify) .......................................... 8
Don’t know ................................................ 9
Yes ............................................................ 1
No .............................................................. 2
YU BIN SLIP ANINIT LONG MOSKITO NET O TAUNAM
LONG LAS NAIT?
5. HOW MANY MOSQUITO NETS DOES YOUR HOUSEHOLD
HAVE?
HAUS BILONG YU I GAT HAMAS TAUNAM?
Refused ..................................................... 7
Don’t know ................................................ 9
2  Q. 6
7  Q. 6
9  Q. 6
Number of nets
Yes ............................................................. 1
6. DO YOU SMOKE?
YU SAVE SMOK TU?
7. HOW MANY STICKS DO YOU SMOKE PER DAY?
HAMASPELA STIK SIMUK YU SAVE SMOKIM INSAIT
LONG WANPELA DE?
8.
HAVE YOU EVER BEEN PREGNANT?
YU BIN GAT BEL TU?
(Should be asked by female or with female
present.)
No............................................................... 2
2Q.8
Refused ..................................................... 7
7Q.8
Don’t know ............................................... 9
9Q.8
Number per day
Yes ............................................................ 1
No .............................................................. 2
2Q.17
Refused ...................................................... 7
7Q.17
Don’t know ................................................ 9
9Q.17
Page 1
9. HAVE YOU GIVEN BIRTH TO A CHILD IN THE LAST 36
MONTHS?
INSAIT LONG LASPELA TRIPELA YIA, YU BIN KARIM
WANPELA PIKININI TU?
Yes .............................................................. 1
No .............................................................. 2
2Q.17
Refused ...................................................... 7
7Q.17
Don’t know ................................................. 9
9Q.17
(This includes both live births and still births BUT
NOT miscarriages)
(Ask for meri book if available)
10. W HEN YOU WERE PREGNANT WITH YOUR LAST
CHILD, DID YOU RECEIVE IRON TABLETS?
TAIM YU BIN BEL LONG LASPELA PIKININI BILONG YU,
YU SAVE KISIM AIN TABLET?
Yes ............................................................. 1
No ............................................................... 2
2Q.12
Refused ....................................................... 7
7Q.12
Don’t know ................................................. 9
9Q.12
Health centre ............................................. 1
Health workers on patrol ........................... 2
VBA ........................................................... 3
VHV ............................................................ 4
Refused ...................................................... 7
Other (specify ) ......................................... 8
Don’t know ................................................. 9
Yes ............................................................ 1
No .............................................................. 2
Refused ...................................................... 7
Don’t know ................................................ 9
2Q.15
7Q.15
9Q.15
(Show an example of the iron tablet)
11. W HO DID YOU RECEIVE THE IRON TABLETS FROM?
YU BIN KISIM OL AIN TABLET LONG HUSAT?
12. W AS YOUR LAST BORN CHILD WEIGHED AT BIRTH?
OL BIN SKELIM LASPELA PIKININI BILONG YU TAIM YU
KARIM?
13. W HAT WAS THIS CHILD’S WEIGHT
WANEM MAK LONG WEIT O HEVI BILONG EM?
(Record weight from baby book/health card, if
available.)
Grams
Don’t Know…………………………………..9
From recall .............................................. 1
14. Write down where information on the birth weight
was obtained from.
From clinic book ........................................ 2
Other (specify) ........................................... 8
15. W HEN YOU WERE PREGNANT WITH YOUR LAST CHILD,
DID YOU HAVE DIFFICULTY SEEING DURING THE DAY?
TAIM YU BIN BEL WANTAIM LASPELA PIKININI BILONG
YU, YU BIN GAT HEVI LONG LUKLUK LONG SAN?
Yes ........................................................... 1
No ............................................................. 2
Refused ..................................................... 7
Don’t know ............................................... 9
16. W HEN YOU WERE PREGNANT WITH YOUR LAST CHILD
Yes ........................................................... 1
DID YOU HAVE ANY DIFFICULTY SEEING AT DUSK?
No .............................................................. 2
TAIM YU BIN BEL WANTAIM LASPELA PIKININI BILONG
Refused ..................................................... 7
YU, YU BIN GAT HEVI LONG LUKLUK TAIM EM I LAIK
TUDAK?
Don’t know ................................................ 9
Yes ........................................................... 1
17. ARE YOU CURRENTLY PREGNANT?
YU GAGT BEL NAU?
No ............................................................. 2
(If YES end the interview. DO NOT take
Refused ..................................................... 7
anthropometric measurements or urine or blood
Don’t know ................................................ 9
samples)
Weigh and measure each woman after all questionnaires have been completed. DO NOT measure
any woman with casts, heavy bandages or disabilities that prevent them being measured. DO NOT
measure women who are pregnant.
1END,
Thank
You
Cluster Number
Household Number
Woman’s Line Number
See Household Questionnaire
ANTHROPOMETRY MODULE
18. Woman’s weight
kg
19. Woman’s height
cm
20. Circle result for height and weight measurement
Measured .................................................... 1
Refused ........................................................ 7
Other (specify) ............................................. 8
Unable .......................................................... 9
SPECIMEN COLLECTION MODULE
Do NOT take urine or blood samples from pregnant women
21. Was urine sample collected from this woman?
Yes ..................................................... 1
No ......................................................... 2
Refused ............................................... 7
Other (specify)....................................... 8
22. Ask “WE WOULD LIKE TO TAKE SOME OF YOUR BLOOD
FROM YOUR FINGER, FOR TESTING. IS THIS OK?
"MIPELA I LAIK KISIM SAMPELA BLUT LONG PINGA BILONG
YU LONG KARIMAUT TES. EM I ORAIT WANTAIM YU?
Yes ...................................................... 1
No ........................................................ 2
Other (specify) ..................................... 8
23. Write down the hemoglobin level
(If the Hb is 7 or less then write the result in the
space provided and also on a referral sheet and on a
referral slip for the health center)
g/dl
Yes ...................................................... 1
24. Was finger stick blood sample collected from this
woman?
Not available ....................................... 2
Refused ............................................... 7
Other (specify)....................................... 8
25. Approximately how many microlitres of finger stick
blood were collected from this woman.
microl
Page 3
FOR NCD CLUSTERS ONLY
Yes ...................................................... 1
26. Was a venous blood sample collected from this
woman?
Not available ....................................... 2
Refused ................................................ 7
Other (specify) ..................................... 8
27. Approximately how many milliliters of venous blood
were collected from this woman
ml
THANK the participant for their cooperation
CHECK that all the data collection form has been completed correctly
CHECK that the identification numbers are at the top of each page.
Data Entry Information Panel
(To be completed by the data entry clerks)
First data entry
clerk ID number
Second data entry
clerk ID number