COMMUNICABLE DISEASE TOOLKIT

IRAQ CRISIS

2. HEALTH SURVEY
SAMPLE FORMS

March 2003

WORLD HEALTH ORGANIZATION

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

HOUSEHOLD SURVEY SAMPLE FORM

1. Basic Data

Record number:

_______________

1. Date of study (dd/mm/yy):

____/____/______

2. Section number:

_______________

3. Name of village/camp/site:
4. Date of arrival in area/site (dd/mm/yy)

_______________
____/____/______

5. Name of head of household:

_______________

6. Male or female-headed household:

7. Total number of people in household:

_______________

8. Total number of children under 5 years:

_______________

9. Total number of pregnant or lactating women:

_______________

10. Total number of elderly persons (over 65 years):

_______________

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

2. Member Information List

Main respondent: Wife of head of household and mother of the children (if there are any children)
___________________
Head of the household: male female / refugee status no refugee status

other (specify)

( yes / no )Present at interview?

Sex ( m / f )

(if under 2 years)Age in months

(if 2 years or older)Age in years

Head of household (x)

Main respondent ( x )

Household member number

List below all individuals who since onset of crisis, are or have been living for at least one month in the household, including those who died or are
missing:

Household member is
1.
2.
3.

Core family
Extended family
Other (specify)

Household member is today

1. Alive, always lived in this household
2. Alive, moved in, still present
3. Alive, moved out
4. Alive in prison
5. Died, had always lived in this household
6. Died, moved in/out
7. Missing/Unknown

If dead or
missing,
since when?
(date: dd / mm)

10

11

12

World Health Organization

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

3. Retrospective Mortality

Death Number

Total number of deaths since start of crisis ____________________

Age
in years

Age in
months

Age in
months

(if 2 years or
older)

(12 to 23
months )

(under 12
months)

Sex
( M /F)

Month of
Death
2 = Feb 2003
3 = Mar 2003;
4 = Apr 2003;
5 = May 2003;
6 = Jun 2003
etc

Cause of Death
1 = watery diarrhoea
2 = bloody diarrhoea
3 = measles
4 = cough +/- difficulty breathing
5 = fever of unknown origin
6 = trauma/injury ie
6a=mine/ UXO, 6b= war-related other than
mine/UXO, 6c=road traffic accident, or 6d=other.
7 = death during or right after childbirth
8 = other (SPECIFY)

1
2
3
4
5
6
7
8
9
10
11
12

World Health Organization

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

numberHousehold member

4. Nutritional Status and Vaccination Coverage in children under 5 years

Sex

Age

Weight

M /F

in
months

(in kg, precision to

100g)

Length or
Height
(in cm,
precision to
0.5 cm)

Presence of
bilateral pitting
oedema

Date of measles
vaccination
(card)

OPV (all 4
doses at
appropriate time
intervals)
(vacc.card)

DPT (all 4 doses

at appropriate
time intervals) or
DT (vacc. card)

Y/N

Y/N

Y/N

Y/N

1
2
3
4
5
6
7
8
9
10
11
12

World Health Organization

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

5. Communicable Diseases in children under five years (Fever, ALRI, Diarrhoea)

In the last 2 weeks, has any child under 5 years of age in the household suffered from a cough or cold, diarrhoea or any fever?
yes
no

Household Number

IF YES, complete table

IF NO, cross out table

Number of Episodes of

Cough or
cold wthout
fever

Fever
with
cough
(+/difficult
breathing)

Did you access

medical assistance
during any episode?
Fever
with rash

Diarrhoea

(yes / no)

If accessed medical assistance, at

what level?
1. Traditional Healer
2. Community Health
Worker
3. Health Centre
4. Hospital
(Mark option with cross)

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

1. ____ 2.____ 3.____ 4.____

10

1. ____ 2.____ 3.____ 4.____

11

1. ____ 2.____ 3.____ 4.____

12

1. ____ 2.____ 3.____ 4.____

World Health Organization

Did you receive

medications?
(yes / no)

If received
medications, what
were they?
1. Antibiotics
2. ORS
3. Other/
Unknown
(Mark option with
cross)
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1. ____2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____
1.____ 2.____
3.____

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

6. Non Communicable Diseases (Hypertension, Diabetes Mellitus, Heart Disease and Cancer)

Household member No.

Since crisis,
has there been anyone in the household with hypertension (diagnosed by a physician) ?
anyone in the household with diabetes (diagnosed by a physician) ?
anyone in the household with heart disease (diagnosed by a physician) ?
anyone in the household with cancer (diagnosed by a physician) ?
If YES: complete table (one line per person and disease, same person can have more than one disease)
If NO: cross out table
Disease

Information
source:

1.Hypertension
2.Diabetes
3.Heart Disease
4.Cancer

1.Health card
2.Self-reported
3.Household
member (other
than the patient)

(one line per

person and
disease)

(list all sources

below)

Has been or is
under regular
medical
follow-up?

Any scheduled
appointment missed?

Has been / is
on regular
drug
treatment?

yes
yes
yes
yes

Interruption in drug
treatment of any length?

(yes/no)
(yes/no)

(yes/no)

(yes/no)
In the
last
month

Since (date)

In the
last
month

no
no
no
no

As of today,
is he/she:
1.Alive, home
2.Alive, in hospital
3.Alive,elsewhere
4.Died, at home
5.Died, in hospital
6.Died, elsewhere

Since (date)

1
2
3
4
5
6
7
8
9
10
11
12
World Health Organization

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

7. Maternal Health (Antenatal care)

Household member No.

Since crisis, has there been anybody pregnant or become pregnant?

IF YES, complete table
IF NO, cross out table
Guess how
many
months
since day
conceived

Information
source:
1. Antenatal
card
2. Self
reported
3. Household
member
other than
the one
pregnant

How many
times
gone for
antenatal
care?
Write
zero if
never
gone

Anti-tetanus
vaccination
given?
+ HB + urine
check
1. NO
2. YES,
verified
by card
3. YES,
reported
orally

Asked to
attend
more
than one
check per
month?

If yes,
always
gone?

(yes/no)

(yes/no)

yes no

If no,
rank up to
3 reasons

FLASH CARD

Admitted to
hospital
during
pregnancy
to ensure
adequate
follow-up?

Any
medicine
prescribed
during
pregnancy?

(yes/no)

(yes/no)

If yes, was /
is it
possible to
complete
the
treatment?

If no,
rank up to
3 reasons

FLASH CARD
(yes/no)

list all sources

below
1

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

1._________
2._________
3._________

World Health Organization

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

8. Maternal Health (Delivery / Stillbirth / Abortion / Post-natal Care)

Since crisis has any woman in the household given birth or lost a child during pregnancy/immediately after childbirth?

yes

no

Household member No.

IF YES, complete table

IF NO, cross out table
Baby born:
1.Alive, weight
more than 2500g
2.Alive, weight
less than 2500g
3.Alive, weight
not known
4.Dead, born
after 28th week
5.Baby lost before
end of 28th week

1
2
3
4
5

World Health Organization

Date
conceived
(dd / mm)

(if not known

exactly,
make best
guess)

Date
of delivery
or loss of
baby
(dd / mm)
(if not known
exactly,
make best
guess)

Baby
born
through:
1.Normal
(vaginal)
delivery or
abort
2.Caesarean
section

Where did the

delivery (or loss
of baby) take
place?
1. Home
2. MCH
3. PHC
4. Hospital
5. On the way to
hospital
6. Other (specify)
(eg Ambulance)
Private transport

If at MCH,
PHC
or
Hospital,
how long did it
take to get
there?
1. 1 hour
or less
2. 1-2 hours
3. 2-4 hours
4. more than
4 hours

If home
delivery
was
it
own
choice?

If no,
rank up to
3 reasons

(ye
s/no)

FLASH CARD

If home delivery,
assisted
by
whom?
1. Nobody
2. Family/friend
3. Nurse
4. Midwife
5. Doctor
6. TBA

Gone for any

post-natal
care
visit ?
(yes/no)

1___ 2___ 3___

1___ 2___ 3___
1___ 2___ 3___
1___ 2___ 3___
1___ 2___ 3___

Communicable Disease Toolkit: Health Survey Forms. IRAQ MARCH 2003

RECORD NUMBER: _____________________

9. Environment

Shelter
1. Type of habitation (circle):

4 (specify) _________________________

1=plastique roof only; 2=simple hut; 3=tent; 4=other

Sanitation
2. Latrines (circle):

5 (specify) _________________________

1=one latrine/toilet per household 1=collective latrines; 2=trench; 3=defecation field; 4=no specific area; 5=other
Water
3. Distance form public tap/water point:
4. Head of household has knowledge about use of disinfected water:
5. Number of water containers (20L) per household (eg for 10L):
6. Number of times water containers filled per day:
7. Availability of washing and bathing facilities:
8. Presence of stagnant water near house:

_______________ m
Y
N
_______________
_______________
Y
N
Y
N

Non-food items
9. Number of blankets in household

_______________

10. Adequate clothing (at least one change of clothes, adapted to climate):

11. Adequate amount of fuel and cooking pots

5 (specify) _________________________

Refuse
12. Refuse disposal method

1=designated communal pits; 2= haphazard piling; 3= household pit; 4=no specific area; 5=other

World Health Organization

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