MINISTRY OF PLANNING
CONGO DEMOCRATIC REPUBLIC

IDENTIFICATION

RESPONDENT POOL _________

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) ______

NAME OF HOUSEHOLD HEAD _______

CLUSTER NUMBER _____

HOUSEHOLD NUMBER _____

PROVINCE _____

URBAN/RURAL

RESIDENCE

INTERVIEWER VISITS:

FIRST VISIT: (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
NAME OF INTERVIEWER ______
RESULT* _____

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE _____
TIME _____

FINAL VISIT:
DAY ___
MONTH ___
YEAR 2007
INTERVIEWER NUMBER ___
RESULT ___

RESULT CODES:

TOTAL NUMBER OF VISITS __

TOTAL PERSONS IN HOUSEHOLD _____

TOTAL ELIGIBLE WOMEN _____

TOTAL ELIGIBLE MEN _____

LINE NO. OF SURVEYED HOUSEHOLD _____

LANGUAGE OF QUESTIONNAIRE: FRENCH

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY ______

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are currently staying with you.

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 household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, COLUMN 3 AND 4, ASK THE 3 QUESTIONS AT THE END OF THE TABLE TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-25 FOR EACH PERSON

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

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

5) RESIDENCE: Does (NAME) usually live here?

6) RESIDENCE: Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

8) MARITAL STATUS IF 15 OR OLDER: What is (NAME)'s current marital status? SEE CODES BELOW.

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

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

11) ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

12) SICK ADULT IF AGE 18-59 YEARS: Has (NAME) been very sick for at least 3 months during the past 12 months?

13) BIRTH REGISTRATION IF AGE 0-4 YEARS: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
SEE CODES BELOW.

14) PARENTAL SURVIVORSHIP AND RESIDENCE IF AGE 0-17 YEARS: Is (NAME)'s natural mother alive?

15) PARENTAL SURVIVORSHIP AND RESIDENCE IF AGE 0-17 YEARS: Does (NAME)'s natural mother live in this household?

IF YES: what is her name? RECORD LINE NUMBER OF MOTHER.
IF NO: RECORD '00'

16) PARENTAL SURVIVORSHIP AND RESIDENCE IF AGE 0-17 YEARS: IF MOTHER NOT LISTED IN HOUSEHOLD: Has (NAME)'s mother been very sick for at least 3 months during the past 12 months?

17) PARENTAL SURVIVORSHIP AND RESIDENCE IF AGE 0-17 YEARS: If (NAME)'s natural father alive?

18) PARENTAL SURVIVORSHIP AND RESIDENCE IF AGE 0-17 YEARS: Does (NAME)'s natural father live in this household?

IF YES: what is his name? RECORD LINE NUMBER OF FATHER.
IF NO: RECORD '00'

19) PARENTAL SURVIVORSHIP AND RESIDENCE IF AGE 0-17 YEARS: IF FATHER NOT LISTED IN HOUSEHOLD: Has (NAME)'s father been very sick for at least 3 months during the past 12 months?

20) EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

21) EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER: What is the highest level of school (NAME) has attended?

What is the highest grade (NAME) completed at that level?

22) CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: Did (NAME) attend school at any time during the 2006-2007 school year?

23) CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: During this school year, what level and grade is/was (NAME) attending?
SEE CODES BELOW.

24) CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: Did (NAME) attend school at any time during the previous school year, that is 2005-2006?

25) CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: During that school year, what level and grade did (NAME) attend?
SEE CODES BELOW.

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?

In addition, are there any other people who many not be members of your family, such as domestic servants, renters, or friends who usually live here?

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

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

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

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

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

105) Does your household have:

Electricity?
A radio?
A television?
A non-mobile telephone?
A mobile telephone?
A refrigerator?
A portable stove/gas or electric cooker?
A chair/chairs?
A bed/beds?
A lamp/lamps?
An oven?
A hoe/hoes?
A sewing machine?

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

106A) How many rooms in this household are used for sleeping?

107) MAIN MATERIAL OF FLOOR: RECORD OBSERVATION.

107A) MAIN MATERIAL OF ROOF: RECORD OBSERVATION.

108) Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A car or truck?
A canoe?

108A) How much time does it take to get from here (meaning your home) to the closest working health center?

108B) Why type of health center is it?

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

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

111) ASK THE RESPONDENT TO SHOW YOU THE NETS. ASK THE FOLLOWING QUESTIONS FOR EACH NET.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

112) How long ago did your household obtain this mosquito net?

113) How much did this mosquito net cost you?

114) When you got this mosquito net, was it treated with an insecticide to kill or repel mosquitoes?

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

116) How much time has passed since the mosquito net was last soaked or dipped in a liquid insecticide? IF LESS THAN ONE MONTH, RECORD '00'.

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

118) Who slept under the mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. (UP TO 6 PEOPLE)

119) GO BACK TO Q111 FOR NEXT NET; OR, IF NO MORE NETS, GO TO Q120.

120) CHECK ALL COLUMNS OF 115:

121) How much did it cost to soak or re-soak a mosquito net?

121A) What are the reasons for which you don't have a mosquito net to use for sleeping in your household? Any other reason?
RECORD ALL REASONS MENTIONED.

122) Ask respondent for a teaspoonful of salt used for household needs, then test the salt to verify the presence of iodine. ASK RESPONDENT FOR A TEASPOON OF SALT USED FOR HOUSEHOLD NEEDS, THEN TEST THE SALT TO VERIFY THE PRESENCE OF IODINE.
RECORD THE PPM (PARTS PER MILLION)

CHILDREN'S WORK

201) CHECK COLUMNS (5) AND (7):
RECORD THE NUMBER OF CHILDREN BETWEEN AGES 5 AND 17 LIVING IN THIS HOUSEHOLD.

ASK THE FOLLOWING QUESTIONS TO THE PERSON IN CHARGE OF EACH CHILD (IF THERE ARE MORE THAN 6 CHILDREN, USE AN ADDITIONAL QUESTIONNAIRE): Now I would like to ask you some questions about the types of work of the children who live in this household.

202) RECORD THE LINE NUMBER OF EVERY CHILD IN THE ORDER FROM COLUMN 1 OF THE HOUSEHOLD SCHEDULE.

203) RECORD THE NAME OF EACH CHILD.

204) Since last (DAY OF THE WEEK OF THE SURVEY), 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?

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

206) In the last 12 months, 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?

207) Since last (DAY OF THE WEEK OF THE SURVEY), does (NAME) do any household chores? For example, doing dishes, shopping, cleaning, clothes washing, getting water, or taking care of children?

208) Since last (DAY OF THE WEEK OF THE SURVEY), approximately how many hours did he/she spend doing these household chores?

209) Since last (DAY OF THE WEEK OF THE SURVEY), did (NAME) do any other work on family land or in a family business?

210) Since last (DAY OF THE WEEK OF THE SURVEY), approximately how many hours did (NAME) spend doing this work on family land or in a family business?

ORPHANS AND CHILDREN VULNERABLE TO "THE RISK OF AIDS"

401) CHECK COLUMN 7 OF HOUSEHOLD SCHEDULE: ANY CHILD AGE 0-17?

402) I would like for you to think about the last 12 months. Did a member of your household die in the last 12 months?

403) Of those who died in the last 12 months, were there any whose age was between 18 and 59 years?

404) Of those who died in the last 12 months and whose age was between 18 and 59, were any of them seriously ill for the 3 months over the last 12 months before they died?

405) CHECK COLUMNS 14 AND 17 IN THE HOUSEHOLD SCHEDULE.

406) CHECK COLUMN 12 IN THE HOUSEHOLD SCHEDULE: ANY ADULT AGE 18-59 VERY ILL FOR AT LEAST 3 MONTHS IN THE LAST 12 MONTHS?

407) CHECK COLUMNS 16 AND 19 IN THE HOUSEHOLD SCHEDULE: ONE MOTHER OR ONE FATHER ILL DURING AT LEAST 3 MONTHS IN THE LAST 12 MONTHS?

408) LIST ALL THE CHILDREN AGES 0-17. RECORD THE NAMES, LINE NUMBERS, AND AGES OF ALL THE CHILDREN. ASK ALL THE QUESTIONS FOR EACH CHILD BEFORE MOVING ON TO THE NEXT CHILD.

409) NAME (COLUMN 2)

LINE NUMBER (COLUMN 1)

AGE (COLUMN 7)

410) I would like to ask you about any formal, organized help or support for (NAME) that your household may have received for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based. It is important to remember that this is only about support for which you did not pay.

411) Now I would like to ask you about the support your household received for (NAME).

In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies, or medicine, for which you did not have to pay?

412) In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home and for which you did not have to pay?

413) Did you household receive any of this emotional or psychological support in the past 3 months?

414) In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

415) Did your household receive any of this material support in the past 3 months?

416) In the last 12 months, has your household received any social support for (name) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

417) Did you household receive any of this social support in the past 3 months?

418) CHECK 409:
AGE OF CHILD

419) In the last 12 months, has your household received any support for (NAME)'s schooling, such as allowance, free admission, books or supplies, for which you did not have to pay?

420) GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 500A.

500A) CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE (SECTION 10), NOT MALE RESPONDENT.

500B) SELECTION TABLE FOR WOMAN FOR "DOMESTIC VIOLENCE"

THESE QUESTIONS ARE ASKED OF ALL THE HOUSEHOLDS IN THE SAMPLE WHERE THERE IS NO MALE RESPONDENT.
MEANWHILE, ONLY ONE WOMAN WILL BE SURVEYED PER HOUSEHOLD FOR THIS SECTION: THE TABLE BLOW ALLOWS YOU TO PICK THE WOMAN IN THIS HOUSEHOLD RANDOMLY.

1 .THERE IS NOT A SINGLE ELIGIBLE WOMAN IN THE HOUSEHOLD:

ON THE FIRST LINE OF THE FOLLOWING TABLE, RECORD THE NAME, AGE, AND LINE NUMBER OF THE WOMAN (SEE COLUMN 7) FROM THE HOUSEHOLD SCHEDULE: THIS WOMAN WILL BE SURVEYED ON "DOMESTIC VIOLENCE".

2. THERE ARE SEVERAL WOMEN IN THE HOUSEHOLD.

1. IN THE TABLE RECORD THE NAME, AGE, AND LINE NUMBER OF ALL THE ELIGIBLE WOMEN (SEE COLUMN 7) FROM THE HOUSEHOLD SCHEDULE, STARTING WITH THE OLDEST AND ENDING WITH THE YOUNGEST.
2. TAKE THE LAST DIGIT OF THE HOUSEHOLD NUMBER RECORDED ON THE COVER PAGE OF THE QUESTIONNAIRE AND CIRCLE THE CORRESPONDING DIGIT IN THE TITLED LINE FROM THE FOLLOWING TABLE. GO DOWN THE COLUMN IDENTIFIED BY THIS DIGIT TO THE LINE CORRESPONDING TO THE LAST WOMAN RECORDED IN THE TABLE. CIRCLE THE DIGIT CORRESPONDING TO THE INTERSECTION OF THIS COLUMN AND THIS LINE.
3. THIS DIGIT GIVES YOU THE ORDER NUMBER OF THE WOMAN SELECTED FOR SECTION 10 OF THE WOMEN'S QUESTIONNAIRE (THE 1ST, 2ND, 3RD WOMAN LISTED). THEN CIRCLE THE LINE NUMBER OF THE SELECTED WOMAN IN THE TABLE.

500C) CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR MEN'S SURVEY/ANEMIA AND HIV TEST/ANTHROPOMETRY?

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

501) CHECK COLUMN 11. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN AGES 0-5 YEARS IN Q502. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE.

502) LINE NUMBER FROM COLUMN 11

NAME FROM COLUMN 2

503) What is (NAME)'s birth date?

IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK THE DAY; IF MOTHER NOT INTERVIEWED, ASK THE DAY, MONTH, AND YEAR OF BIRTH.

504) CHECK 503: CHILD BORN IN JANUARY 2002 OR LATER?

505) WEIGHT IN KILOGRAMS:

506) HEIGHT IN CENTIMETERS:

507) MEASURED LAYING DOWN OR STANDING UP?

507A) EDEMAS?

508) RESULT: WEIGHT AND HEIGHT MEASUREMENT.

509) CHECK 503:
IS THE CHILD AGE 0-5 MONTHS, THAT IS, WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

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

511) READ CONSENT STATEMENT TO PARENT/OTHER RESPONSIBLE ADULT FOR CHILD. CIRCLE CODE AND SIGN.

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

513) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.

514) GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

CONSENT STATEMENT FOR CHILDREN'S 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.

We ask that all children born in 2002 or later take part in anemia testing in this survey and give 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.
Will you allow (NAME(S) OF CHILD(REN)) to participate in the anemia test?

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

515) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL WOMEN AGE 15-49 IN QUESTION 516. IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). FOR EACH ELIGIBLE WOMAN, THE RESULT CODE OF THE ANEMIA TEST MUST BE RECORDED IN 528 AND FOR THE HIV TEST IN 530.

516) LINE NUMBER FROM COLUMN 9

NAME FROM COLUMN 2

517) WEIGHT IN KILOGRAMS

518) HEIGHT IN CENTIMETERS

519) RESULT: WEIGHT AND HEIGHT MEASUREMENT

520) AGE: CHECK COLUMN 7

521) MARITAL STATUS: CHECK COLUMN 8

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

523) READ ANEMIA TEST CONSENT STATEMENT FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST:

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 523 IF RESPONDENT CONSENTS TO ANEMIA TEST AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT IN 522 BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 523 IF THE PARENT/OTHER ADULT REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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.

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 participate in the anemia test? (RESPONDENT: Do you agree to participate in the anemia test?)

524) CHECK Q226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

525) READ THE HIV CONSENT STATEMENT FOR NEVER-IN-UNION WOMEN AGE 15-17. ASK CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

526) CHECK 523 AND 525 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S). FOR EACH ELIGIBLE WOMAN, THE FINAL OUTCOME FOR THE ANEMIA TEST MUST BE RECORDED IN 528 AND FOR THE HIV TEST IN 530 EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

527) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

528) RECORD RESULT OF ANEMIA TEST:

529) 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.

530) OUTCOME OF HIV TEST PROCEDURE:

CONSENT STATEMENT FOR HIV TEST:

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 525 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES.
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT IN 522 BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 525 IF THE PARENT/OTHER ADULT REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT/OTHER ADULT AND THE ADOLESCENT CONSENT.

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 Democratic Congo.

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 the 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 allow (NAME OF ADOLESCENT) to take the HIV test? (RESPONDENT: Do you agree to participate in the HIV test?)

530A) CHECK 530:
OUTCOME OF HIV TEST.

530B) READ THE CONSENT STATEMENT FOR ADDITIONAL TEST. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

530C) ADDITIONAL TESTS
CHECK 530B: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.

CONSENT STATEMENT FOR ADDITIONAL TESTS:

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 530B IF RESPONDENT CONSENTS TO THE ADDITIONAL TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT IN 522 BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 530B IF THE PARENT/OTHER ADULT REFUSES.

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) 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/NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for later use (you/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?

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

531) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MAN IN QUESTION 532. IF THERE ARE MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE(S).

FOR EACH ELIGIBLE MAN, THE FINAL OUTCOME MUST BE RECORDED FOR THE ANEMIA TEST N 543 AND FOR THE HIV TEST PROCEDURE IN 545.

532) LINE NUMBER FROM COLUMN 10

NAME FROM COLUMN 2

536) AGE: CHECK COLUMN 7

537) MARITAL STATUS: CHECK COLUMN 8

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

539) READ ANEMIA TEST CONSENT STATEMENT FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST:

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 523 IF RESPONDENT CONSENTS TO ANEMIA TEST AND CODE '3' IF HE REFUSES.
FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT IN 538 BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 539 IF THE PARENT/OTHER ADULT REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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.

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 participate in the anemia test? (Respondent: Do you agree to participate in the anemia test?)

540) READ THE HIV CONSENT STATEMENT FOR NEVER-IN-UNION MEN AGE 15-17. ASK CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

541) CHECK QUESTIONS 539 AND 540 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S). FOR EACH ELIGIBLE MAN, THE FINAL OUTCOME FOR THE ANEMIA TEST MUST BE RECORDED IN 543 AND FOR THE HIV TEST IN 545 EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

542) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

543) RECORD RESULT OF ANEMIA TEST:

544) BAR CODE LABEL:

PUT THE 1ST BAR CODE HERE. PUT THE 2ND BAR LABEL ON THE RESPONDENT RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

545) OUTCOME OF HIV TEST PROCEDURE:

CONSENT STATEMENT FOR HIV TEST:

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 540 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF HE REFUSES.
FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT IN 538 BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 540 IF THE PARENT/OTHER ADULT REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT/OTHER ADULT AND THE ADOLESCENT CONSENT.

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 Democratic Congo.

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 the 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 allow (NAME OF ADOLESCENT) to take the HIV test? (RESPONDENT: Do you agree to participate in the HIV test?)

545A) CHECK 545:
OUTCOME OF HIV TEST

545B) READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FORM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

545C) ADDITIONAL TESTS

CHECK 545B: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.

CONSENT STATEMENT FOR ADDITIONAL TESTS:

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 545B IF RESPONDENT CONSENT TO THE ADDITIONAL TESTS AND CODE '3' IF HE REFUSES.
FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT IN 538 BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 545B IF THE PARENT/OTHER ADULT REFUSES.

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) 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/NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for later use (you/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?