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REPUBLIC OF BURUNDI THIRD DEMOGRAPHIC AND HEALTH SURVEY 2016 BIOMARKER QUESTIONNAIRE

IDENTIFICATION

PLACE NAME

NAME OF HEAD OF HOUSEHOLD

PROVINCE

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MAN’S SURVEY?

1=YES
2=NO

INTERVIEWER VISITS
1 2 3
DATE
INTERVIEWER’S NAME

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR

TOTAL NO. OF VISITS

NOTES:

TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF INTERVIEW:

LANGUAGE CODES:

01 FRENCH
02 KIRUNDI
96 OTHER (SPECIFY)
OLD KIRUNDI (FROM PAPER)

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

YES=1
NO=2

LANGUAGE OF QUESTIONNAIRE: FRENCH

SUPERVISOR
NAME
NUMBER

WEIGHT, HEIGHT, ANEMIA, AND MALARIA TEST FOR CHILDREN AGE 0-5

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

102) CHECK LINE NUMBER FROM COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE:

NAME____________
LINE NUMBER___

103) IF MOTHER INTERVIEWED: COPY CHILD’S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED, ASK: What is (name)’s date of birth?

DAY___
MONTH___
YEAR___

104) CHECK 102: CHILD BORN IN 2011-2016?

YES 1
NO 2 (GO TO 137)

105) WEIGHT IN KILOGRAMS

_________KG
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

106) HEIGHT IN CENTIMETERS

_______CM
NOT PRESENT 9994 (GO TO 107A)
REFUSED 9995 (GO TO 107A)
OTHER 9996 (GO TO 107A)

107) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

107A) PERIMETER OF ARM IN CENTIMETERS

_______CM
NOT PRESENT 994
REFUSED 995
OTHER 996

108) MEASURER: ENTER YOUR INTERVIEWER NUMBER

INTERVIEWER NUMBER___


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

0-5 MONTHS 1 (GO TO 137)
OLDER 2


110) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.

LINE NUMBER___
RECORD 00 IF NOT LISTED.

CONSENT FROM PARENT/OTHER ADULT RESPONSIBLE FOR ANEMIA TEST

111) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT:

As part of this survey, we are asking children 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 2011 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 members of our survey team. If the test shows that your child has severe anemia, meaning a hemoglobin level below 8g.dl, we will refer him/her to the closest health center for follow up.

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 take the anemia test?

112) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
REFUSED 2 (SIGN)
NOT PRESENT 3

CONSENT FROM PARENT/OTHER ADULT RESPONSIBLE FOR MALARIA TEST

113) As part of this survey, we are asking children all over the country to take a malaria test. Malaria is a serious health problem caused by a parasite transmitted from a mosquito bite. This survey will assist the government to develop programs to prevent and treat malaria.

We ask that all children born in 2011 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. We use the blood from the same finger as for the anemia test. The blood will be tested for malaria immediately, and the result will be told to you right away. Treatment will be offered to children with mild malaria if they are not already on treatment. Children with severe malaria will be referred to a health facility. Some drops will be saved on one or more slides and sent to a laboratory to be tested. The result will be kept strictly confidential and will not be shared with anyone other than members 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 take the anemia test?

114) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
REFUSED 2 (SIGN)
NOT PRESENT 3

CONSENT FROM PARENT/OTHER ADULT RESPONSIBLE FOR MALARIA TEST

115) Ask consent for DBS collection from parent/other adult

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 in this survey to understand how many people have contracted the virus.

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 the results of (name of child’s) test either. If you want to know if (name of child) has HIV, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you 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 CHILD) to take the HIV test?

118) CIRCLE THE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER NUMBER

GRANTED 1
REFUSED 2
(SIGN AND RECORD YOUR INTERVIEWER NUMBER)
ABSENT/OTHER 3

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

120) ADDITIONAL TESTS: CHECK 118: IF CONSENT HAS NOT BEEN GRANTED, WRITE “NO ADDITIONAL TEST” ON THE FILTER PAPER.

121) PLACE BAR CODE STICKERS HERE.

PUT THE 1ST BAR CODE HERE
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE LABEL ON THE TDR, THE 3RD ON THE THICK SMEAR SLIDE, THE 4TH ON THE THIN SMEAR SLIDE, THE 5TH ON THE CHILD'S FILTER PAPER, THE 6TH ON THE MALARIA TRANSMISSION SHEET AND THE 7TH ON THE DBS TRANSMISSION CARD.

122) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA AND MALARIA PAMPHLET:

____G/DL
REFUSED 995
OTHER 996


123) RECORD TDR AND MALARIA RESULT CODE:

TESTED 1
ABSENT 2 (GO TO 125)
REFUSED 3 (GO TO 125)
OTHER 5 (GO TO 125)

124) RECORD THE TDR AND MALARIA RESULT HERE AND IN THE BROCHURE ON ANEMIA AND MALARIA.

POSITIVE FALCIPARUM 1 (GO TO 127)
POSITIVE VIVAX 2 (GO TO 127)
POSITIVE FALCIPARUM AND VIVAX 3 (GO TO 127)
NEGATIVE 4
OTHER 6

125) Check 122: Hemoglobin level

BELOW 8.0 G/DL SEVERE ANEMIA 1
8.0 G/DL OR HIGHER 2 (GO TO 137)
ABSENT 3 (GO TO 137)
REFUSED 4 (GO TO 137)
OTHER 6 (GO TO 137)

126) REFERENCE DECLARATION FOR SEVERE ANEMIA:

The anemia diagnostic test show that (NAME OF CHILD) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately.

GO TO 137.

127) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms:

Extreme weakness?
Heart problems?
Loss of consciousness?
Rapid breathing or difficulty breathing?
Has or has had convulsions?
Abnormal bleeding?
Icterus/jaundice?
Dark urine?

If none of the above symptoms, circle code Y.

EXTREME WEAKNESS A
HEART PROBLEMS B
LOSS OF CONSCIOUSNESS C
RAPID BREATHING OR DIFFICULTY BREATHING D
HAS OR HAS HAD CONVULSIONS E
ABNORMAL BLEEDING F
ICTERUS/JAUNDICE G
DARK URINE H

NONE OF ABOVE SYMPTOMS Y

128) CHECK 127: IS THERE A CODE CIRCLED IN A-H?

CODE A-H CIRCLED 1 (GO TO 130)
ONLY CODE Y CIRCLED 2

129) CHECK 122: HEMOGLOBIN LEVEL

UNDER 8.0 G/DL 1
8.0 D/DL OR HIGHER 2 (GO TO 131)
NOT PRESENT 4 (GO TO 131)
REFUSED 5 (GO TO 131)
OTHER 6 (GO TO 131)

130) REFERENCE DECLARATION FOR SERIOUS MALARIA

The diagnostic test for malaria shows that (NAME OF CHILD) has malaria. You child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. You child is seriously ill and must be taken to a health care establishment immediately.

GO TO 136.

131) In the last two weeks, has (NAME) taken or is (NAME) taking an antimalarial drug given by a doctor, a health care center, or a community health agent to treat malaria? CHECK BY ASKING TO SEE THE TREATMENT.

YES 1
NO 2 (GO TO 133)

132) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.

You told me that (NAME OF CHILD) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment for further testing.

GO TO 136.

133) READ INFORMATION FOR MALARIA TREATMENT AND THE DECLARATION OF CONSENT TO THE PARENTS OR OTHER ADULT RESPONSIBLE FOR THE CHILD.

The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

134) CIRCLE THE APPROPRIATE CODE AND SIGN.

DRUG ACCEPTED 1 (SIGNATURE)
REFUSED 2 (GO TO 136)
OTHER 6 (GO TO 136)

135) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TEST:

DOSAGE INSTRUCTIONS:

WEIGHT (IN KG)/AGE:

4.5 KG TO 8KG (6-11 MONTHS):
DAY 1: 1 TABLET ARTESUNATE 25 MG TABLET AND AMODIAQUINE 67.5 MG OF (ROSE STRIPED BROCHURE)
DAY 2: 1 TABLET ARTESUNATE 25 MG TABLET AND AMODIAQUINE 67.5 MG OF (ROSE STRIPED BROCHURE)
DAY 3: 1 TABLET ARTESUNATE 25 MG TABLET AND AMODIAQUINE 67.5 MG OF (ROSE STRIPED BROCHURE)

9-17 KG (1-5 YEARS):
DAY 1: TABLET OF ARTESUNATE 50 MG AND AMODIAQUINE 135 MG (PURPLE STRIPED BROCHURE)
DAY 2: TABLET OF ARTESUNATE 50 MG AND AMODIAQUINE 135 MG (PURPLE STRIPED BROCHURE)
DAY 3: TABLET OF ARTESUNATE 50 MG AND AMODIAQUINE 135 MG (PURPLE STRIPED BROCHURE)

TELL THE PARENTS/ADULT RESPONSIBLE FOR CHILD: If (NAME) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn’t get better in two days, you must take him/her to a health professional for treatment immediately.

136) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET.

DRUG GIVEN 1
DRUG REFUSED 2
REFERRED FOR SEVERE MALARIA 3
REFERRED BECAUSE CHILD ALREADY TOOK CTA 4
OTHER 6

137) GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, GO TO 201.

WEIGHT, HEIGHT, ANEMIA, AND MALARIA TEST FOR WOMEN AGE 15-49

201) CHECK COLUMN 11 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AND MARITAL STATUS for ALL WOMEN ELIGIBLE FOR Q 202, 203, AND 204. IF MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

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

LINE NUMBER___
NAME__________

203) CHECK HOUSEHOLD QUESTIONNAIRE: COLUMN 7 (AGE):

15-17 YEARS 1
18-49 YEARS 2

204) CHECK HOUSEHOLD SCHEDULE: COLUMN 8 (MARITAL STATUS):

CODE 4 (NEVER IN UNION) 1
OTHER 2

205) WEIGHT IN KILOGRAMS

______Kg
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

_____Cm
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206A) PERIMETER OF ARM IN CENTIMETERS

_____Cm
NOT PRESENT 994
REFUSED 995
OTHER 996

207) MEASURER: ENTER YOUR INTERVIEWER NUMBER

INTERVIEWER NUMBER____

208) CHECK 203: AGE

15-17 YEARS 1 (GO TO 209)
18-49 YEARS 2 (GO TO 210)

209) CHECK 204: MARITAL STATUS

CODE 4 (NEVER IN UNION (GO TO 216)
OTHER 2

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

210) ASK FOR CONSENT FOR ANEMIA TEST.

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 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 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 members 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 the anemia test?

211) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
REFUSED 2 (SIGN) (GO TO 212)
NOT PRESENT 3 (GO TO 212)

211A) CHECK 226 IN WOMAN’S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON’T KNOW 8

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

212) 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 in this survey to understand how many people have contracted the virus.

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 the results of (NAME OF CHILD)'s test either. If you want to know if you have HIV, 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 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 give blood for the HIV testing?

213) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGNATURE/INTERVIEWER NUMBER)
REFUSED 2 (SIGNATURE/INTERVIEWER NUMBER) (GO TO 229)
ABSENT/OTHER 3 (GO TO 229)

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

214) ASK CONSENT FOR ADDITIONAL TESTING.

We ask you to allow ISTEEBU to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done. These tests will be necessary for the good of the country.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

215) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN AND GO TO 229)
RESPONDENT REFUSED 2 (SIGN AND GO TO 229)

216) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.

LINE NUMBER____

RECORD 00 IF NOT LISTED.

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST

217) ASK FOR 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.

For the anemia testing, we will 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 each test. The blood will be tested for anemia immediately, and the result will be told to you and (name of minor) right away. The result will be kept strictly confidential and will not be shared with anyone other than members 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 MINOR) to take the anemia test?

218) CIRCLE THE APPROPRIATE CODE AND SIGN.

GRANTED 1 (SIGN)
REFUSED 2 (SIGN) (GO TO 221)
ABSENT/OTHER 3 (GO TO 221)

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

219) ASK FOR CONSENT FOR ANEMIA TEST FROM RESPONDENT.

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 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 each test. The blood will be tested for anemia immediately, and the result will be told to you and (name of parent/responsible adult) right away. The result will be kept strictly confidential and will not be shared with anyone other than members 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 the anemia test?

220) Circle the code and sign your name.

GRANTED 1 (SIGN)
MINOR RESPONDENT REFUSED 2 (SIGN) (GO TO 221)
NOT PRESENT 3 (GO TO 221)

220A) CHECK 226 IN WOMAN’S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON’T KNOW 8

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

221) ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/ADULT.

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 in this survey to understand how many people have contracted the virus.

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 the results of (name of minor)’s test either. If you want to know if (name of minor) has HIV, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you 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 MINOR) to take the HIV test?

222) CIRCLE THE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGN/INTERVIEWER NUMBER)
REFUSED 2 (SIGN/INTERVIEWER NUMBER) (GO TO 229)
ABSENT/OTHER 3 (GO TO 229)

223) MINOR RESPONDENT CONSENT FOR DBS COLLECTION

ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT

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 in this survey to understand how many people have contracted the virus.

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 the results of your test either. If you want to know if you have HIV, 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 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 give blood for the HIV testing?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
MINOR RESPONDENT REFUSED 2 (SIGN) (GO TO 229)
ABSENT/OTHER 3 (GO TO 229)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

225) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT

We ask you to allow ISTEEBU to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done. These tests will be necessary for the good of the country.

The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.

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

226) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 229)

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

227) ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.

We ask you to allow ISTEEBU to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done. These tests will be necessary for the good of the country.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

228) Circle the code and sign your name.

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

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

230) ADDITIONAL TESTS:

IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 226 AND 228: IF CONSENT HAS NOT BEEN GRANTED, WRITE “NO ADDITIONAL TEST” ON THE FILTER PAPER

231) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

_____G/DL
ABSENT 994
REFUSED 995
OTHER 996

232) PLACE BAR CODE STICKERS HERE

PUT THE 1ST BAR CODE HERE
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

233) 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.

DBS FOR MEN AGE 15-59 YEARS

301) CHECK COLUMN 10 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AND MARITAL STATUS FOR ALL MEN ELIGIBLE FOR Q 302, 303, AND 304. IF MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE(S).

302) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 10 AND NAME FROM COLUMN 2

LINE NUMBER___
NAME__________

303) CHECK HOUSEHOLD QUESTIONNAIRE: COLUMN 7 (AGE):

15-17 YEARS 1
18-59 YEARS 2

304) CHECK HOUSEHOLD SCHEDULE: COLUMN 8 (MARITAL STATUS):

CODE 4 (NEVER IN UNION) 1
OTHER 2

308) CHECK 303: AGE

15-17 YEARS 1
18-59 YEARS 2 (GO TO 312)

309) CHECK 204: MARITAL STATUS

CODE 4 (NEVER IN UNION) 1 (GO TO 316)
OTHER 2

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

312) 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 in this survey to understand how many people have contracted the virus.

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 the results of (NAME OF CHILD)'s test either. If you want to know if you have HIV, 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 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 give blood for the HIV testing?

313) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGN/INTERVIEWER NUMBER)
REFUSED 2 (SIGN/INTERVIEWER NUMBER) (GO TO 329)
ABSENT/OTHER 3 (GO TO 329)

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

314) ASK CONSENT FOR ADDITIONAL TESTING.

We ask you to allow ISTEEBU to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done. These tests will be necessary for the good of the country.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

315) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) (GO TO 329)
RESPONDENT REFUSED 2 (SIGN) (GO TO 329)

316) RECORD THE LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.

LINE NUMBER___

RECORD '00' IF NOT LISTED.

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

321) ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/ADULT

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 in this survey to understand how many people have contracted the virus.

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 the results of (NAME OF MINOR)’s test either. If you want to know if (NAME OF MINOR) has HIV, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you 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 MINOR) to take the HIV test?

322) CIRCLE THE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER NUMBER

GRANTED 1 (SIGN/INTERVIEWER NUMBER)
REFUSED 2 (SIGN/INTERVIEWER NUMBER) (GO TO 329)
ABSENT/OTHER 3 (GO TO 329)

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

323) ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT

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 in this survey to understand how many people have contracted the virus.

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 the results of your test either. If you want to know if you have HIV, 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 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 give blood for the HIV testing?

324) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
MINOR RESPONDENT REFUSED 2 (SIGN) (GO TO 329)
ABSENT/OTHER 3 (GO TO 329)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

325) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT

We ask you to allow ISTEEBU to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done. These tests will be necessary for the good of the country.

The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.

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

326) CIRCLE THE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN)
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 329)

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

327) ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.

We ask you to allow ISTEEBU to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done. These tests will be necessary for the good of the country.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

328) CIRCLE THE CODE AND SIGN YOUR NAME.

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

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

330) ADDITIONAL TESTS: IF ADULT RESPONDENT, CHECK 315; IF MINOR RESPONDENT, CHECK 326 AND 328: IF CONSENT HAS NOT BEEN GRANTED, WRITE “NO ADDITIONAL TEST” ON THE FILTER PAPER.

331) PLACE BAR CODE STICKERS HERE:

PUT THE 1ST BAR CODE HERE
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

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

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

INTERVIEWER OBSERVATIONS: TO BE FILLED IN AFTER COMPLETING BIOMARKERS

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SUPERVISOR’S OBSERVATIONS:

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EDITOR’S OBSERVATIONS:

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