IDENTIFICATION

DEPARTMENT_________
COMMUNE __________
DISTRICT_______

URBAN/RURAL

VILLAGE/NEIGHBORHOOD___________
CLUSTER NUMBER_________
STRUCTURE NUMBER ____________
NAME OF HEAD OF HOUSEHOLD____________
HOUSEHOLD NUMBER _________

HOUSEHOLD SELECTED FOR MAN'S QUESTIONNAIRE, HIV, ANEMIA, MALARIA AND BLOOD PRESSURE 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 2011
INTERVIEWER CODE_________
RESULT ____

RESULT CODES:

TOTAL NO. OF VISITS__________

TOTAL PERSONS IN HOUSEHOLD________

TOTAL ELIGIBLE WOMEN________

TOTAL ELIGIBLE MEN___________

TOTAL PEOPLE AGE 6 OR OLDER_________

TOTAL PEOPLE AGE 18 OR OLDER_______

TOTAL PEOPLE UNDER AGE 6__________

NAME AND NUMBER OF RESPONDENT_________

QUESTIONNAIRE USED: FRENCH

LANGUAGE OF INTERVIEW

INTERPRETER

RESPONDENT NUMBER_____

SUPERVISOR
NAME_______
DATE________

FIELD EDITOR
NAME_______
DATE_________

OFFICE EDITOR________

KEYED BY__________

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Office of Statistics and Economic Analysis (INSAE). We are conducting a survey about health all over Benin. 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 15 to 20 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 (IT'S A BADGE).

GIVE CARD WITH CONTACT INFORMATION FOR THESE PEOPLE.

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

SIGNATURE OF INTERVIEWER____________
DATE______

HOUSEHOLD SCHEDULE

1) LINE NO.

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 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?
SEE CODES BELOW.

4) SEX
Is (NAME) male or female?

RESIDENCE
5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

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

8) MARITAL STATUS IF AGE 10 OR OLDER
What is (NAME)'s current marital status?

EDSB ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-64

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

EMICOV ELIGIBILITY
11A) CIRCLE LINE NUMBER OF ALL PEOPLE AGE 6 OR OLDER

11B) CIRCLE LINE NUMBER OF ALL PEOPLE AGE 18 OR OLDER

11C) CIRCLE LINE NUMBER OF ALL LAND OWNERS (INCLUDING THROUGH INHERITANCE) OR RENTERS (INCLUDING SHARECROPPERS) OF A PLOT IN THE LAST 12 MONTHS.

SOCIOCULTURAL CHARACTERISTICS:

11D) ETHNICITY
What is (NAME)'s ethnicity?
SEE CODES BELOW

11E) RELIGION
What is (NAME)'s religion?
SEE CODES BELOW

MIGRATION DURING LIFE FOR RESIDENTS:

11F) BIRTHPLACE
In what municipality was (NAME) born?
RECORD MUNICIPALITY OR COUNTRY FOR FOREIGNERS.

11G) FORMER RESIDENCE
In what residential municipality did (NAME) live before moving here?
RECORD MUNICIPALITY OR COUNTRY FOR FOREIGNERS

11H) LENGTH OF CURRENT RESIDENCE
How long did (NAME) stay in that municipality?

RECORD: 1 AND THE NUMBER OF MONTHS FOR STAYS SHORTER THAN 1 YEAR OR 2 AND NUMBER OF YEARS FOR STAYS LONGER THAN 1 YEAR AND 998 IF SINCE BIRTH.

11I) RETURNED MIGRATION
Is (NAME) back in this municipality after having stayed there for less than 6 months?

11J) MIGRATION STATUS
CONCLUDE MIGRATION STATUS

RECORD:
1 NON MIGRANT IF QUESTION 11H=9 98
2 RETURNED MIGRANT IF QUESTION 11H DOES NOT EQUAL 9 98 AND Q11H =1
3 OTHER MIGRANT IF QUESTION 11H DOES NOT EQUAL 9 98 AND Q11H=2

11K) REASON FOR SETTLING
What is the main reason for which (NAME) settled in this municipality?

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS

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.

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER

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?

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

18) Did (NAME) attend school at any time during the (2010-2011) school year?

19) During this/that school year, what level and grade (is/was) (NAME) attending?
SEE CODES BELOW.

BIRTH REGISTRATION IF AGE 0-4 YEARS

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

ASSISTANCE FOR ORPHANS IF AGE 0-17 YEARS AND IF CODE 2 CIRCLED IN COLUMN 12 OR 14

20A) AT LEAST ONE PARENT DEAD:
Did (NAME) receive at least one form of outside assistance in the last 12 months?
IF YES, which ones? IF NO, CIRCLE CODE 'F' (NONE)

LITERACY IF AGE 6 OR OLDER

20B) Does (name) know how to read, write and understand at least one language?
IF YES, which ones?

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?

WORK OF CHILDREN AGE 5-14 YEARS

21) CHECK COLUMN 7:
RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

21A) CHECK Q.21

21B) LINE NUMBER

21C) LIST OF CHILDREN AGE 5-14 YEARS
CHECK COLUMN 7 OF HOUSEHOLD TABLE.
RECORD THE NAMES AND LINE NUMBERS OF ALL THE CHILDREN AGE 5-14 YEARS IN THE ORDER OF THE HOUSEHOLD TABLE.

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

IF AGE 5-14 YEARS

21D) 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?

1: PAID WORK
2: UNPAID WORK
3: NO WORK

21E) IF YES:
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.

21F) In the last week, did (NAME) go get water or wood for the household?

21G) IF YES:
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 TIME, ADD UP ALL THE HOURS.

21H) In the last week, did (NAME) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?
INCLUDE WORK DONE FOR A BUSINESS DONE BY THE CHILD ALONE OR DONE WITH ONE OR SEVERAL PARTNERS.

21I) IF YES:
Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing work for his/her family or him/herself?
IF MORE THAN ONCE, ADD UP ALL THE HOURS.

21J) In the last week, did (NAME) do any household chores, such as shopping, cleaning, clothes washing, cooking, or taking care of children, old people, or sick people?

21K) IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?
IF MORE THAN ONCE, ADD UP ALL THE HOURS.

HOUSEHOLD CHARACTERISTICS

101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

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?

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:

Electricity?
A generator?
A radio?
A stove?
Hi-fi system?
A CD/DVD player?
A video recorder?
A washing machine?
A television?
A mobile telephone?
A non-mobile telephone?
A computer?
Internet connection?
A refrigerator?

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

116A) Where do you usually throw away your household waste?

116B) Where do you usually throw away your used water?

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

118) Does any member of your household own:

A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A canoe?
A car or truck?
A boat with a motor?

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 '950'

121) Does this household own any livestock, herds of 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'

Cattle?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens?

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 ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

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'.

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

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

136A) Where was this mosquito net obtained?

136B) How did you acquire this mosquito net?

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 WHERE MEMBERS OF THE HOUSEHOLD WASH THEIR HANDS

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.

SECTION 6. WEIGHT, HEIGHT, MALARIA, AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

600) CHECK COVER PAGE:

601) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS (UNDER 6 YEARS) IN QUESTION 602. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). THE FINAL RESULT OF THE WEIGHT AND HEIGHT MEASUREMENTS MUST BE RECORDED IN Q605 AND Q 606, THE ANEMIA TEST IN Q613 AND THE MALARIA TEST IN Q 613A.

602) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

603) What is (NAME)'s date of birth?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth day?

604) CHECK 603:
CHILD BORN IN JANUARY 2006 OR LATER?

605) WEIGHT IN KILOGRAMS

606) HEIGHT IN CENTIMETERS

607) MEASURED LYING DOWN OR STANDING UP?

607A) PRESENCE OF BILATERAL EDEMA ON FEET?

609) CHECK 603:
IF CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

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

611) READ THE CONSENT STATEMENT FOR ANEMIA AND MALARIA TEST TO PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
REQUEST FOR CONSENT FOR THE ANEMIA AND MALARIA 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. The results of this survey will allow the government to develop and put in place programs to prevent and treat anemia and malaria.

We ask that all children born in 2006 or later take part in anemia and malaria testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood for this test 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 and malaria 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.

611A) ASK FOR CONSENT FOR THE ANEMIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
ASK FOR CONSENT FOR THE ANEMIA TEST
Will you allow (NAME OF CHILD(REN)) to participate in the anemia test?

611B) CIRCLE THE APPROPRIATE CODE FOR THE ANEMIA TEST AND SIGN YOUR NAME.

611C) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
ASK FOR CONSENT FOR THE MALARIA TEST
Will you allow (NAME OF CHILD(REN)) to participate in the anemia test?

611D) CIRCLE THE APPROPRIATE CODE FOR THE MALARIA TEST AND SIGN YOUR NAME.

611E) CHECK 611B AND 611D:

612) CONSENT WAS OBTAINED FOR THE CHILD, CONTINUE WITH THE TEST. PREPARE THE THICK DROPS OF BLOOD ON THE TWO MICROSCOPE SLIDES IF THE CONSENT WAS OBTAINED FOR THE MALARIA TEST AND CONTINUE TO 613.

613) RESULT CODE FOR MALARIA TEST

IF TEST WAS ACCEPTED, STICK BAR CODES:
PUT FIRST BAR CODE HERE
PUT A STICKER ON EACH OF THE TWO SLIDES
PUT ONE ON THE RAPID DIAGNOSTIC TEST (TDR)
PUT THE FIFTH ON THE SAMPLE TRANSMISSION SHEET

614) RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

615) CHECK 613:

616) RECORD TDR RESULT ON MALARIA PAMPHLET

617) ASK IF THE CHILD IS CURRENTLY RECEIVING TREATMENT FOR MALARIA PRESCRIBED BY A DOCTOR OR ANOTHER HEALTH PROFESSIONAL.
Is the child currently receiving treatment prescribed by a doctor or another health professional?
CIRCLE A CODE AND CONTINUE.

618) CONSENT AND TREATMENT FOR CHILDREN WITH A POSITIVE RESULT ON THE RAPID DIAGNOSTIC TEST (TDR)
READ THE INFORMATION FOR MALARIA TREATMENT AND THE CONSENT TO THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. CIRCLE A CODE AND SIGN.

The diagnostic test for malaria shows that your child has malaria. We can offer you free drugs. These drugs are called CTA. CTA are very effective and in a few days, should eliminate the fever and other symptoms. CTA is also very safe. However, like with all drugs, there are side effects, and this drug can have some. The most common side effects are dizziness, fatigue, loss of appetite, and palpitations. CTA should never be taken by people with serious heart problems or with severe malaria (for example, cerebral malaria) or problems regulating salt in the body.

ASK IF THE MOTHER IS AWARE THAT THE CHILD HAS ANY OF THESE PROBLEMS. IF YES, DO NOT OFFER THE CTA. EXPLAIN THE RISKS OF MALARIA, AND REFER THE CHILD TO THE CLOSEST HEALTH ESTABLISHMENT.

You do not have to give your child this drug. It is for you to decide.
Please tell me if you accept the drugs or not.

619) CIRCLE THE APPROPRIATE CODE AND SIGN

620) RECORD THE RESULT OF MALARIA TREATMENT.

621) GO BACK TO 603 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE FOR CHILD 4-6; IF NO MORE CHILDREN, GO TO 701.

TREATMENT OF BASIC MALARIA WITH CTA ACCORDING TO THE NATIONAL TREATMENT PROTOCOL FOR THE BENIN, 2011 IN CASES RANGING FROM SIMPLE MALARIA TO PLASMODIUM FALCIPARUM

ACCORDING TO AVAILABILITY IN THE TERRAIN, DOSE TO ADMINISTER WILL BE AS FOLLOWS, ON THE 1ST DAY, 2ND DAY, AND 3RD DAY.

YOU MUST ALSO TELL THE PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD:
If (NAME) has any of the following symptoms, you must take him/her to a health professional immediately to received care:
High fever
Convulsions, coma
Rapid breathing or difficulty breathing
Not able to drink or breastfeed
Gets sick or doesn't get better in 2 days

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

700) CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL WOMEN AGE 15-49 IN 701. IF THERE ARE MORE THAN SIX WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

THE FINAL MEASUREMENTS RESULTS OF WEIGHT AND HEIGHT MUST BE RECORDED IN Q. 702 AND Q. 703, IN Q712 FOR THE ANEMIA TEST, AND IN Q712B FOR THE HIV TEST.

701) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

702) WEIGHT IN KILOGRAMS

703) HEIGHT IN CENTIMETERS

705) AGE: CHECK COLUMN 7

706) MARITAL STATUS: CHECK COLUMN 8

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

708) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 707 AS RESPONSIBLE FOR ADOLESCENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST FROM THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT

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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and AIDS.

For the anemia and HIV test, 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 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.

For the HIV 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 THE ADOLESCENT) either.

If you want to know (NAME OF ADOLESCENT)'s HIV status, I can provide a list of [nearby] facilities to (NAME OF ADOLESCENT) that offer counseling and testing for HIV. I will also give you a voucher for free services for (NAME OF ADOLESCENT) to 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.

708A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE ANEMIA TEST
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

708B) CIRCLE THE APPROPRIATE CODE FOR THE CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

708C) ASK FOR CONSENT FOR THE HIV TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE HIV TEST
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

708D) CIRCLE THE APPROPRIATE CODE FOR THE HIV TEST AND SIGN YOUR NAME.

708E) CHECK 708B AND 708D:

708F) CHECK 708B AND 708D:

708G) CHECK 708B AND 708D:

708H) READ THE DECLARATION OF CONSENT FOR MALARIA TEST TO THE RESPONDENT
DECLARATION OF CONSENT FOR MALARIA TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE ANEMIA TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 test, 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 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.

708I) NEXT GO TO 709A

708J) CONSENT FOR HIV TEST FOR RESPONDENT

READ THE DECLARATION OF CONSENT FOR HIV TEST TO THE RESPONDENT
DECLARATION OF CONSENT FOR HIV TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE HIV TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 to see how big the AIDS problem is in the Benin.

This survey will assist the government to develop programs to prevent and treat HIV.

For the HIV test, 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 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 that offer 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.

708K) THEN GO TO 709C

709) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO BE READ TO 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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and HIV.

For the anemia and HIV test, 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 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.

For the HIV 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.

709A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE ANEMIA TEST
Will you take the anemia test?

709B) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

709C) CONSENT FOR THE HIV TEST FROM THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE HIV TEST
Will you take the HIV test?

709D) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE HIV TEST AND SIGN YOUR NAME.

710) CHECK 709B AND 709D:

711) CHECK ONCE AGAIN 709B AND 709D AND PREPARE THE INSTRUMENTS NECESSARY FOR THE TESTS FOR WHICH CONSENT WAS OBTAINED. THEN, PERFORM THE TEST. FOR EACH ELIGIBLE WOMAN, THE RESULT CODE FOR THE HIV TEST MUST BE RECORDED IN 712 AND FOR THE ANEMIA TEST IN 713, EVEN IF SHE WASN'T PRESENT, REFUSED, OR COULD NOT BE TESTED FOR OTHER REASONS.

712) RESULT CODE FOR HIV TEST:
IF HIV TEST WAS ACCEPTED, STICK BAR CODES

713) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA BROCHURE

714) GO BACK TO Q 702 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT WOMAN. IF THERE ARE MORE THAN 3 WOMEN, USE THE ADDITIONAL QUESTIONNAIRE. IF THERE ARE NO MORE WOMEN, GO TO 800.

700) IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE

HEMOGLOBIN AND HIV TEST FOR MEN AGE 15-64

800) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME OF ALL MEN AGES 15-59 IN QUESTION 801. IF THERE ARE MORE THAN 6 MEN, USE THE ADDITIONAL QUESTIONNAIRE.

THE FINAL RESULTS OF THE MEASUREMENTS FOR THE ANEMIA TEST MUST BE RECORDED IN Q 812 AND IN 812 BE FOR THE HIV TEST [##translator note: the original document does not indicate which test, the text is cut off. I indicated the HIV test because of the section heading, referring to the HIV test]

LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

805) AGE: CHECK COLUMN 7

806) MARITAL STATUS: CHECK COLUMN 8

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

808) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 807 AS RESPONSIBLE FOR ADOLESCENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST FROM THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT

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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and HIV.

For the anemia and HIV test, 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 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.

For the HIV 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 THE ADOLESCENT) either.

If you want to know (NAME OF ADOLESCENT)'s 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 (NAME OF ADOLESCENT) to 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.

808A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE ANEMIA TEST
Will you allow (name of adolescent) to take the anemia test?

808B) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.

808C) ASK FOR CONSENT FOR THE HIV TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE HIV TEST
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

808D) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE HIV TEST AND SIGN YOUR NAME.

808E) CHECK 808B AND 808D:

808F) CHECK 808B AND 808D:

808G) CHECK 808B AND 808D:

808H) READ THE DECLARATION OF CONSENT FOR THE ANEMIA TEST TO THE RESPONDENT
DECLARATION OF CONSENT FOR MALARIA TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE ANEMIA TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 test, 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 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.

808I) NEXT GO TO 809A

808J) READ CONSENT FOR HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR HIV TEST TO BE READ TO THE RESPONDENT
(NOTE: THIS DECLARATION OF CONSENT IS READ TO THE RESPONDENT ONCE THE HIV TEST ALONE HAS BEEN AGREED TO BY THE PARENT/OTHER ADULT RESPONSIBLE FOR THE 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 to see how big the AIDS problem is in the Benin.

This survey will assist the government to develop programs to prevent and treat AIDS.

For the HIV test, 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 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 that offer 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.

808K) THEN GO TO 809C

809) READ THE DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO RESPONDENT

DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST TO BE READ TO 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.

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 the Benin.

This survey will assist the government to develop programs to prevent and treat anemia and HIV.

For the anemia and HIV test, 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 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.

For the HIV 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 that offer 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.

809A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE ANEMIA TEST
Will you take the anemia test?

809B) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME. [##translator note: the original document asks for consent for the "anemiele" test, which is not a word that I was able to find. I believe it is a typographical error, and thus have translated the test to "anemia," based on the other information in the text]

809C) REQUEST CONSENT FOR THE HIV TEST FROM THE RESPONDENT
REQUEST FOR CONSENT FROM RESPONDENT FOR THE HIV TEST
Will you take the HIV test?

809D) CIRCLE THE APPROPRIATE CODE FOR THE REQUEST FOR CONSENT FOR THE HIV TEST AND SIGN YOUR NAME.

810) CHECK 809B AND 809D:

811) CHECK ONCE AGAIN 809B AND 809D AND PREPARE THE INSTRUMENTS NECESSARY FOR THE TESTS FOR WHICH CONSENT WAS OBTAINED. THEN, PERFORM THE TEST. FOR EACH ELIGIBLE MAN, THE RESULT CODE FOR THE HIV TEST MUST BE RECORDED IN 812 AND FOR THE ANEMIA TEST IN 813, EVEN IF HE WASN'T PRESENT, REFUSED, OR COULD NOT BE TESTED FOR OTHER REASONS.

812) PUT FIRST BAR CODE HERE____

813) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA BROCHURE

814) GO BACK TO Q 802 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT MAN. IF THERE ARE MORE THAN 3 MEN, USE THE ADDITIONAL QUESTIONNAIRE

800) IF THERE ARE MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE

814) GO BACK TO Q 802 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT MAN. IF THERE ARE MORE THAN 3 MEN, END OF QUESTIONNAIRE