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REPUBLIC OF ANGOLA
MULTIPLE INDICATORS AND HEALTH SURVEYS -IIMS 215

BIOMARKER QUESTIONNAIRE

IDENTIFICATION

STATISTICAL CONFIDENTIALITY: BY THE TERMS GIVEN IN ARTICLE 11 OF THE LAW NO. 3/11, FROM THE 14TH OF JANUARY, LAW OF THE NATIONAL STATISTICS SYSTEM, ALL INDIVIDUAL DATA COLLECTED BY OFFICIAL STATISTICS ORGANIZATIONS, IN THIS CASE THE INE, ARE STRICTLY CONFIDENTIAL. COLLECTED DATA IS PROTECTED FROM ANY NON-STATISTICAL PURPOSES OR FROM ANY UNAUTHORIZED DISSEMINATION, ONLY TO BE USED FOR THE PRODUCTION OF OFFICIAL STATISTICS.

PLACE NAME _____
NAME OF HOUSEHOLD HEAD_____
CLUSTER NUMBER OF ICIM/IDS _____
HOUSEHOLD NUMBER____
HOUSEHOLD SELECTED FROM MAN’S SURVEY?

YES 1
NO 2

FIELDWORK VISITS

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 ____

TOTAL NUMBER OF VISITS_________

NOTES: ________

TOTAL NO. OF WOMEN AGES 15-49_________
TOTAL NO. OF MEN AGES 15-54_________
TOTAL NO. OF CHILDREN AGES 0-5____

LANGUAGE OF QUESTIONNAIRE:

PORTUGUESE 1
CHOKWE/KIOKO 2
FIOTE 3
KIKONGO/UKONGO 4
KIMBUNDU 5
KWANHAMA 6
LUVALE 7
MUHUMBI 8
NGANGUELA 9
NHANECA 10
UMBUNDU 11
OTHER (SPECIFY) ________ 96

TRANSLATOR USED:

YES 1
NO 2

SUPERVISOR
NAME_____
NUMBER_____

KEYED BY:
NAME_____
NUMBER____


SECTION 1: WEIGHT, HEIGHT, HEMOGLOBIN AND MALARIA MEASUREMENT FOR CHILDREN AGE 0 TO 5

100) CHECK FRONT PAGE: IS THIS HOUSEHOLD SELECTED FOR MAN’S SURVEY?

NO
YES (GO TO 201)

101) CHECK COLUMN 11 OF HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN AGES 0-5 IN QUESTION 102. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

102) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 1 NAME FROM COLUMN 2

LINE NUMBER_______
NAME______

103) What is (NAME)’s birth date?

DAY __
MONTH__
YEAR__

104) CHECK 103: CHILD BORN IN 2010 TO 2016?

YES 1
NO 2 (GO TO 133)

105) WEIGHT IN KILOGRAMS

KILOGRAMS ____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

106. HEIGHT IN CENTIMETERS

CENTIMETERS ____
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)

107) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

108) MEASURER: ENTER YOUR FIELDWORKER NUMBER

FIELDWORK NUMBER___

109) CHECK 103: CHILD AGE 0 THROUGH 5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

0 THROUGH 5 MONTHS 1 (GO TO 133)
OLDER 2

110) PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD

MOTHER 1
FATHER 2
OTHER ADULT RESPONSIBLE FOR THE CHILD 6

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 from 6 months old to 5 years old 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 (NAME) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

(NAME), do you have any questions?
Will you allow (NAME OF CHILD) to participate in the anemia test?

112) RECORD THE ANSWER GIVEN BY THE PARENT/ADULT RESPONSIBLE FOR CHILD AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 (SIGN) ___________
REFUSED 2 (SIGN) ___________
NOT PRESENT/OTHER 3

113) ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT RESPONSIBLE FOR CHILD

As part of this survey, we are asking people all over the country to take a malaria test. Malaria is a serious health problem that usually results from parasites transmitted by mosquito bites. This survey will assist the government to develop programs to prevent and treat malaria.

We ask that all children from 6 months old to 5 years old take part in malaria 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 malaria quickly, and the result will be told to (NAME) in fifteen minutes. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

(NAME), do you have any questions?
Will you allow (NAME OF CHILD) to participate in the malaria test?

114) CIRCLE THE ANSWER GIVEN BY THE PARENT/OTHER ADULT

GRANTED 1 (SIGN) ___________
REFUSED 2 (SIGN) ___________
NOT PRESENT/OTHER 3

115) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

116) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA PAMPHLETS

G/DL ___.__
REFUSED 995
OTHER 996

117) RECORD THE CORRESPONDING CODE FOR MALARIA RAPID TEST

TESTED 1
NOT PRESENT 2 (GO TO 119)
REFUSED 3 (GO TO 119)
OTHER 4 (GO TO 119)

118) RECORD MALARIA RAPID TEST RESULT HERE AND IN THE MALARIA PAMPHLET

POSITIVE 1
NEGATIVE 2 (GO TO 119)
OTHER 3 (GO TO 119)

118A) RECORD MALARIA RAPID TEST RESULT

ONLY PF 1 (GO TO 121)
ONLY PV 2 (GO TO 121)
BOTH PF AND PV 3 (GO TO 121)

119) CHECK: 116 HEMOGLOBIN LEVEL

LESS THAN 7.0 G/GDL, SEVERE ANEMIA 1
7.0 G/DL OR MORE 2 (GO TO 133)
NOT PRESENT 3 (GO TO 133)
REFUSED 4 (GO TO 133)
OTHER 6 (GO TO 133)

120) MEDICAL REFERRAL FOR ANEMIA TREATMENT
RECORD ANEMIA TEST RESULT IN THE MEDICAL REFERRAL FORM

The anemia test indicates that (NAME OF CHILD) has severe anemia. Your child is very sick and needs immediate medical attention. (GO TO 133)

121) Does (NAME OF CHILD) have any of the following symptoms?

Feebleness?
Heart problems?
Loss of consciousness/ fainting?
Accelerated breathing?
Epilepsy attacks?
Abnormal bleeding?
Yellowed eyes?
Dark urine?

FEEBLENESS
YES 1
NO 2
HEART PROBLEM
YES 1
NO 2
FAINTING
YES 1
NO 2
BREATHING
YES 1
NO 2
EPILEPSY
YES 1
NO 2
BLEEDING
YES 1
NO 2
EYES
YES 1
NO 2
URINE
YES 1
NO 2

122) CHECK 121 (A THROUGH H):

NO "YES" 1
AT LEAST ONE "YES" 2 (GO TO 125)

123) CHECK 116: HEMOGLOBIN LEVEL

LESS THAN 7.0 G/GDL, SEVERE ANEMIA 1 (GO TO 125)
7.0 G/DL OR MORE 2
NOT PRESENT 3
REFUSED 4
OTHER 6

124) In the past 2 weeks, has (NAME OF CHILD) taken any antimalarial medication with artemisinin base (TCA) given by a health worker?
ASK TO SEE THE MEDICINE

YES 1 (GO TO 126)
NO 2 (GO TO 127)

125) MEDICAL REFERRAL FOR SEVERE MALARIA TREATMENT

RECORD ANEMIA TEST RESULT IN THE MEDICAL REFERRAL FORM

The malaria test indicates that (NAME OF CHILD) has malaria. Your child has severe malaria symptoms. The medication we have available will not help your child, therefore I cannot offer any medication. Your child is very sick and needs immediate medical attention.

(GO TO 131)

126) MEDICAL ADVICE FOR CHILDREN TAKING OR HAVE TAKEN TCA

(NAME) says that (NAME OF CHILD) is taking or has taken an antimalarial medicine with artemisinin base. Therefore I cannot offer any additional medication. However, the test indicates that your child has malaria. If your child continues with fever after two days of the last dose of the antimalarial medicine with artemisinin base, you have to seek for immediate medical attention.

(GO TO 133)

127) READ CONSENT AND INFORMATION ABOUT MALARIA TREATMENT TO THE PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD

The malaria test indicates that (NAME OF CHILD) has malaria. We can give you free medical treatment. The name of the medicine is Coartem and it is very efficient, in a few days your child will stop having fever or other malaria symptoms. The medicine is optional. Please let me know if you accept or not this medical treatment.

128) RECORD THE ANSWER AND SIGN WITH YOUR NAME (FIELDWORKER)

GRANTED 1 (SIGNATURE)___
REFUSED 2 (SIGNATURE)___
OTHER 3

129) CHECK 128:
ACCEPTED THE MEDICINE

CHILD 1
ACCEPTED 1
REFUSED 2 (GO TO 133)
OTHER 3 (GO TO 133)

130) READ CONSENT AND INFORMATION ABOUT MALARIA TREATMENT TO THE PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD

[ADD DOSAGE INSTRUCTIONS]

TELL THE FATHER/MOTHER/OTHER ADULT RESPONSIBLE FOR THE CHILD: If (NAME OF CHILD) has high fever, breathing difficulty or accelerated breathing or if the child does eat or is breastfeeding, or if the child has any other symptom and does not get better in two days, you have to seek immediate medical attention.

(GO TO 133)

131) CHECK 116: HEMOGLOBIN LEVEL

LESS THAN 7.0 G/GDL, SEVERE ANEMIA 1
7.0 G/DL OR MORE 2 (GO TO 133)
NOT PRESENT 3 (GO TO 133)
REFUSED 4 (GO TO 133)
OTHER 6 (GO TO 133)

132) MEDICAL REFERRAL FOR SEVERE ANEMIA

RECORD ANEMIA TEST RESULT IN THE MEDICAL REFERRAL FORM

The anemia test indicates that (NAME OF CHILD) has severe anemia. Your child is very sick and needs immediate medical attention.

133. GO TO 103 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, END THE QUESTIONNAIRE.

SECTION 2: HIV TESTING FOR WOMEN AGE 15 TO 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.
IN THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

202) CHECK HOUSEHOLD QUESTIONNAIRE:
LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

LINE NUMBER ____
NAME_____

203) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE)

15 TO 17 YEARS 1
18 TO 49 YEARS 2 (GO TO 205)

204) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS)

CODE 5 (SINGLE/NEVER IN UNION) 1 (GO TO 209)
OTHER 2

ADULT RESPONDENT CONSENT FOR DBS COLLECTION
205) ASK CONSENT FOR DBS COLLECTION.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV in Angola.

For this HIV testing, we 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. No names will be attached so we will not be able to tell you the test results. The results are strictly confidential and no one else will be able to know your test results either.

If you want to know whether you have HIV, I can provide you with a list of nearby Health Units offering counseling and testing for HIV.

(NAME) has any questions?
Do you accept or not to take the blood test for HIV?

206) RECORD THE CODE, SIGN YOUR NAME AND ENTER YOUR FIELDWORKER NUMBER

GRANTED 1 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) ____
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) ____(IF REFUSED GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)

207) ASK CONSENT FOR ADDITIONAL TESTING

We ask you to allow the Ministry of Health to store part of blood sample at the laboratory for additional test 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 can still participate in the HIV testing even if you do not want the blood sample stored for additional testing.

Will you allow us to keep the blood sample stored for additional testing?

208) CIRCLE DE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 _____ (SIGN AND GO TO 218)
RESPONDENT REFUSED 2 _____ (SIGN AND GO TO 218)

209) PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT

MOTHER 1
FATHER 2
OTHER ADULT RESPONSIBLE 6

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
210) ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The IHV testing is being done to see how many people have HIV in Angola.

For this HIV testing, we 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. No names will be attached so we will not be able to tell you the test results. The results are strictly confidential and no one else will be able to know (NAME OF MINOR) test results either.

If (NAME OF MINOR) wants to know her HIV status, I can provide you with a list of nearby Health Units offering counseling and testing for HIV.

(NAME) has any questions?
Will you allow (NAME OF MINOR) to give blood for HIV testing?

211) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER

GRANTED 1 ____ (SIGN AND ENTER YOUR FIELDWORKER NUMBER)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2____ (SIGN AND ENTER YOUR FIELDWORKER NUMBER) (IF REFUSED, GO TO 221)
NOT PRESENT/ OTHER 3 (GO TO 221)

MINOR RESPONDENT CONSENT FOR DBS COLLECTION
212) ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The IHV testing is being done to see how many people have HIV in Angola.

For this HIV testing, we 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. No names will be attached so we will not be able to tell you the test results. The results are strictly confidential and no one else will be able to know your test results either.

If you want to know whether you have HIV, I can provide you with a list of nearby Health Units offering counseling and testing for HIV.

(NAME) has any questions?
Do you accept or not to take the blood test for HIV?

213) CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 ____ (SIGN) (IF REFUSED, GO TO 221)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2____ (SIGN) (IF REFUSED, GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
214) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT

We ask you to allow the Ministry of Health to store part of blood sample at the laboratory for additional test 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 (NAME OF MINOR). (NAME OF MINOR) can still participate in the HIV testing even if you do not want the blood sample stored for additional testing.

Will you allow us to keep the blood sample stored for additional testing?

215) CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 _____ (SIGN AND GO TO 218)
RESPONDENT REFUSED 2 _____ (SIGN AND GO TO 218)

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
216) ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT

We ask you to allow the Ministry of Health to store part of blood sample at the laboratory for additional test 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 can still participate in the HIV testing even if you do not want the blood sample stored for additional testing.

Will you allow us to keep the blood sample stored for additional testing?

217) CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 (SIGN)____
MINOR RESPONDENT REFUSED 2 (SIGN)____

218) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S)

219) ADDITIONAL TESTS
IF ADULT RESPONDENT, CHECK 208; IF MINOR RESPONDENT, CHECK 215 AND 217

220) PLACE BAR CODE LABEL

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT’S FILTER PAPER (DBS) AND THE 3RD ON THE TRANSMITTAL FORM.

PUT THE 1ST BAR CODE LABEL HERE ____
NOR PRESENT 99994
REFUSED 99995
OTHER 99996

221) 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.

SECTION 3: HIV TESTING FOR MEN AGE 15 TO 54

301) CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303 AND 304.
IN THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

302. CHECK HOUSEHOLD QUESTIONNAIRE:
LINE NUMBER FROM COLUMN 10

LINE NUMBER ____
NAME_____

303) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE)

15 TO 17 YEARS 1
18 TO 54 YEARS 2 (GO TO 305)

304) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS)

CODE 5 (SINGLE/NEVER IN UNION) 1 (GO TO 309)
OTHER 2

ADULT RESPONDENT CONSENT FOR DBS COLLECTION
305) ASK CONSENT FOR DBS COLLECTION.

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The IHV testing is being done to see how many people have HIV in Angola.

For this HIV testing, we 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. No names will be attached so we will not be able to tell you the test results. The results are strictly confidential and no one else will be able to know your test results either.

If you want to know whether you have HIV, I can provide you with a list of nearby Health Units offering counseling and testing for HIV.

(NAME) has any questions?
Do you accept or not to take the blood test for HIV?

306) RECORD THE CODE, SIGN YOUR NAME AND ENTER YOUR FIELDWORKER NUMBER

GRANTED 1 (SIGN AND ENTER YOUR FIELDWORKER NUMBER)____(IF REFUSED GO TO 321)
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER)____(IF REFUSED GO TO 321)
NOT PRESENT/OTHER 3 (GO TO 321)

307) ASK CONSENT FOR ADDITIONAL TESTING

We ask you to allow the Ministry of Health to store part of blood sample at the laboratory for additional test 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 can still participate in the HIV testing even if you do not want the blood sample stored for additional testing.

Will you allow us to keep the blood sample stored for additional testing?

308. CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 _____ (SIGN AND GO TO 318)
RESPONDENT REFUSED 2 _____ (SIGN AND GO TO 318)

309) PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT

MOTHER 1
FATHER 2
OTHER ADULT RESPONSIBLE 6

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
310) ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The IHV testing is being done to see how many people have HIV in Angola.

For this HIV testing, we 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. No names will be attached so we will not be able to tell you the test results. The results are strictly confidential and no one else will be able to know (NAME OF MINOR) test results either.

If (NAME OF MINOR) wants to know her HIV status, I can provide you with a list of nearby Health Units offering counseling and testing for HIV.

(NAME) has any questions?
Will you allow (NAME OF MINOR) to give blood for HIV testing?

311) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER

GRANTED 1 ____ (SIGN AND ENTER YOUR FIELDWORKER NUMBER) (IF REFUSED, GO TO 321)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2____ (SIGN AND ENTER YOUR FIELDWORKER NUMBER) (IF REFUSED, GO TO 321)
NOT PRESENT/ OTHER 3 (GO TO 321)

MINOR RESPONDENT CONSENT FOR DBS COLLECTION
312. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT

As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The IHV testing is being done to see how many people have HIV in Angola.

For this HIV testing, we 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. No names will be attached so we will not be able to tell you the test results. The results are strictly confidential and no one else will be able to know your test results either.

If you want to know whether you have HIV, I can provide you with a list of nearby Health Units offering counseling and testing for HIV.

(NAME) has any questions?
Do you accept or not to take the blood test for HIV?

313. CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 ____ (SIGN) (IF REFUSED, GO TO 321)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2____ (SIGN) (IF REFUSED, GO TO 321)
NOT PRESENT/ OTHER 3 (GO TO 321)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
314. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT

We ask you to allow the Ministry of Health to store part of blood sample at the laboratory for additional test 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 (NAME OF MINOR). (NAME OF MINOR) can still participate in the HIV testing even if you do not want the blood sample stored for additional testing.

Will you allow us to keep the blood sample stored for additional testing?

315. CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 _____ (SIGN AND GO TO 318)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 _____ (SIGN AND GO TO 318)

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
316. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT

We ask you to allow the Ministry of Health to store part of blood sample at the laboratory for additional test 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 can still participate in the HIV testing even if you do not want the blood sample stored for additional testing.

Will you allow us to keep the blood sample stored for additional testing?

317. CIRCLE THE CODE AND SIGN YOUR NAME (FIELDWORKER)

GRANTED 1 (SIGN)____
MINOR RESPONDENT REFUSED 2 (SIGN)____

318. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S)

319. ADDITIONAL TESTS

IF ADULT RESPONDENT, CHECK 308; IF MINOR RESPONDENT, CHECK 315 AND 317
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER (DBS).

320. PLACE BAR CODE LABEL
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT’S FILTER PAPER (DBS) AND THE 3RD ON THE TRANSMITTAL FORM.

PUT THE 1ST BAR CODE LABEL HERE ____
NOR PRESENT 99994
REFUSED 99995
OTHER 99996

321. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN END THE INTERVIEW.

FIELDWORKER OBSERVATIONS
TO FILLED IN AFTER COMPLETING BIOMARKERS _____________

SUPERVISOR’S OBSERVATIONS____