IDENTIFICATION

PLACE NAME/SUB-DISTRICT___

NAME OF HEAD OF HOUSEHOLD_____

PROVINCE______

MUNICIPALITY_______

DISTRICT NAME AND NUMBER_____

CLUSTER NUMBER_______

HOUSEHOLD NUMBER_______

URBAN-RURAL MILIEU:

HOUSEHOLD SELECTED FOR MEN'S SURVEY/ANEMIA TEST/HIV TEST?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME______
RESULT _____

NEXT VISIT
DATE_____
TIME______

FINAL VISIT
DAY____
MONTH_____
YEAR______
INT. NUMBER______
RESULT _____

RESULT CODE:

TOTAL NO. OF VISITS______

TOTAL PERSONS IN HOUSEHOLD_____

TOTAL ELIGIBLE WOMEN______

TOTAL ELIGIBLE MEN______

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_____

SUPERVISOR
NAME____
DATE_____

FIELD EDITOR
NAME_____
DATE______

OFFICE EDITOR _____

KEYED BY _____

INTRODUCTION AND CONSENT

Hello. My name is ____. I am working with the Institute of Statistics and Economic Study of Burundi, ISTEEBU. We are conducting a survey about health all over Burundi. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 20 to 45 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on this card.

Give card with contact information

Do you have any questions?
May I begin the interview?

SIGNATURE OF INTERVIEWER________
DATE________

HOUSEHOLD SCHEDULE

1) LINE NUMBER

2) USUAL RESIDENTS AND VISITORS:
Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK THE APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

4) SEX: Is (NAME) male or female?

RESIDENCE:

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

6a) For how many years have (NAME) lived in this household?
IF LESS THAN 1 YEAR OR VISITOR, RECORD '00'.

7) AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

IF AGE 12 OR OLDER:

8) MARITAL STATUS: What is (NAME)'s current marital status?

ELIGIBILITY:
9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF AGE 0-17 YEARS:

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:

12) Is (NAME)'s natural mother alive?

13) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.

14) Is (NAME)'s natural father alive?

15) Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?

RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

IF AGE 5 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

16) Has (NAME) ever attended school?

17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

LEVEL:

GRADE:

IF AGE 5-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school at any time during the (2009-2010) school year?

19) During the 2010-2011 school year, what level and grade (is/was) (NAME) attending?

LEVEL:

GRADE:

IF AGE 0-30 YEARS:

20) BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

TICK HERE IF CONTINUATION SHEET USED _____

2A) Just to make sure that I have a complete listing: are there any other persons such as small children or infants that we have not listed?

2B) Are there any other people who many not be members of your family, such as domestic servants, lodgers or friends who usually live here?

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

CHILDREN'S WORK

20A) CHECK COLUMN 7: RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 LIVING IN THIS HOUSEHOLD

20B) CHECK Q. 20A

Now I would like to ask you some questions on the type of work that children in your household did last week.

RECORD THE NAMES AND LINE NUMBERS OF ALL THE CHILDREN AGE 5 TO 14 IN THE ORDER FROM THE HOUSEHOLD SCHEDULE

21) In the last week, did (NAME) do any work for anyone who is not a member of this household?

IF YES: Was he/she paid in cash or in kind?

22) Since last (day of the week), approximately how many hours did he/she work for someone who is not a member of this household?

IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

23) In the last week, did (NAME) get water or wood for the household?

24) Since last (day of the week), approximately how many hours did he/she spend getting water or wood for the household? IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.

25) In the last week, did (NAME) do any paid or unpaid work on family land, or in a family business, or did he/she sell any merchandise on the street?

INCLUDE WORK IN A REGULAR JOB HELD BY THE CHILD ALONE OR WITH ONE OR MORE PARTNERS.

26) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing this work for the family or for himself/herself?

IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.

27) In the last week, did (NAME) do any household chores, like shopping, cleaning, clothes washing, cooking, or taking care of children, older people or sick people?

28) Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores? IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.

HOUSEHOLD CHARACTERISTICS

101) Does anyone smoke in your household?
IF YES: Would you say daily, weekly, monthly, less than monthly?

102) What is the main source of drinking water for members of your household?

103) Where is the water source located?

104) How long does it take you to go there, get water, and come back?

104A) Who usually goes to the water source to bring water to your household?
PROBE: Is this person 15 years or younger? Is this person a male or a female?

105) Do you do anything to the water to make it safer to drink?

106) What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED.

107) What kind of toilet facility do members of your household usually use?

108) Do you share this toilet facility with other households?

109) How many households use this toilet facility?

110) Does your household have:

111) What type of fuel does your household mainly use for cooking?

112) Is the cooking usually done in the house, in a separate building, or outdoors?

113) Do you have a separate room which is used as a kitchen?

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

117) How many rooms in this household are used for sleeping?

118) Does any member of your household own:

118a) Are you or is anyone else living in the household the owner of the dwelling?

119) Does any member of this household own any agricultural land?

120) How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 95.00

121) Does this household own any livestock, herds, other farm animals, or poultry?

122) How many of the following animals does this household own?
IF NONE, ENTER '00'
IF 95 OR MORE, ENTER '95'
IF UNKNOWN, ENTER '98

Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Chickens?
Guinea pigs?
Rabbits?

123) Does any member of this household have a bank account?

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

125) Who sprayed the dwelling?

126) Does your household have any mosquito nets that can be used while sleeping?

127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

128) Ask the respondent to show you the nets in the household. Ask the following questions for each net. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

128a) Did you receive this mosquito net a) during the 2009 campaign, b) the 2010 campaign, c) during an antenatal consultation, d) during a vaccination session for a child, e) or on another occasion?

129) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

132) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

133) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'. IF MORE THAN 2 YEARS, RECORD THE NUMBER OF MONTHS

134) Did anyone sleep under this mosquito net last night?

135) Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. RECORD ALL PERSONS WHO SLEPT UNDER EACH MOSQUITO NET LAST NIGHT.

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137

137) PLEASE SHOW ME WHERE MEMBERS OF YOUR HOUSEHOLD MOST OFTEN WASH THEIR HANDS.

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

139) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE.

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

203) IF MOTHER INTERVIEWED, COPY MOTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY. IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

204) CHECK 203: CHILD BORN IN JANUARY 2005 OR LATER

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURE LYING DOWN OR STANDING UP?

208) CHECK 203: IS THE CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD 00 IF NOT LISTED.

210) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

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 2005 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 member of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (name of child) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

212) RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

213) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TEST FOR WOMEN AGE 15-49

214) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

216) WEIGHT IN KILOGRAMS

217) HEIGHT IN CENTIMETERS

218) AGE: CHECK COLUMN 7

219) MARITAL STATUS: CHECK COLUMN 8

220) RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD 00 IF NOT LISTED. LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT.

221) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

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 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 adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes to the test for (name of adolescent), or you can say no. It is up to you to decide.
Will you allow (name of adolescent) to participate in the anemia test?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

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 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 member of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take in the anemia test?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

225) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

226) AGE: CHECK COLUMN 7

227) MARITAL STATUS: CHECK COLUMN 8

228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (country).

For the HIV test, we need a few (more) 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. 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 (name of adolescent)'s test results either. If (name of adolescent) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (name of adolescent) to take the HIV test?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

230) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (country).

For the HIV test, we need a few (more) 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. 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 your test results either. If you want to know your HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

231) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.

232) AGE: CHECK COLUMN 7

233) MARITAL STATUS: CHECK COLUMN 8

234) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify (name of adolescent). You do not have to agree. If you do not want the blood sample stored for additional testing (name of adolescent) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

235) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

236) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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 HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

237) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

238) ADDITIONAL TESTS
CHECK 235 AND 237: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

241) BAR CODE LABEL
PUT THE 1ST BAR CODE HERE

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 243.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

243) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

244) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

247) AGE: CHECK COLUMN 7

248) MARITAL STATUS: CHECK COLUMN 8

249) RECORD LINE NUMBER OF PARENT/OTHER RESPONSIBLE ADULT FOR ADOLESCENT. RECORD 00 IF NOT LISTED

250) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

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 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 adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

Do you have any questions?
You can say yes to the test for (name of adolescent), or you can say no. It is up to you to decide.
Will you allow (name of adolescent) to participate in the anemia test?

251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

252) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

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 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 member of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take in the anemia test?

253) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

254) AGE: CHECK COLUMN 7

255) MARITAL STATUS: CHECK COLUMN 8

256) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (country).

For the HIV test, we need a few (more) 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. 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 (name of adolescent)'s test results either. If (name of adolescent) wants to know his HIV status, I can provide him with a list of [nearby] facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (name of adolescent) to take the HIV test?

257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

258) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (country).

For the HIV test, we need a few more 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. 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 your test results either. If you want to know you HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

259) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER NUMBER.

260) AGE: CHECK COLUMN 247

261) MARITAL STATUS: CHECK COLUMN 248

262) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify (name of adolescent). You do not have to agree. If you do not want the blood sample stored for additional testing (name of adolescent) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

263) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

264) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

[##translator note: There is no text here in French, only in the other language (likely Swahili). The consent script that follows from the standard English questionnaire. It is not a translation from the Burundi 2010 survey, as there is not French text here, only Swahili]

We ask you to allow [Survey implementing organization/Ministry of heath] to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test 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 HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

265) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

266) ADDITIONAL TESTS
CHECK 263 AND 265: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

268) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

269) BAR CODE LABEL
PUT THE FIRST BAR CODE HERE

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

270) GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.