MINISTRY OF HEALTH AND OF THE FIGHT AGAINST AIDS, NATIONAL OFFICE OF STATISTICS

IDENTIFICATION

PLACE NAME_________
NAME OF HEAD OF HOUSEHOLD__________
CLUSTER NUMBER_____
STRUCTURE NUMBER________
HOUSEHOLD NUMBER________
REGION_______

RESIDENTIAL TYPE/ MILIEU______

LARGE CITY/CITY/SMALL CITY/RURAL/ CITY_______

HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANEMIA, HIV, AND MALARIA TEST

INTERVIEWER VISITS

INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____ /201
INTERVIEWER'S NAME
RESULT*____

NEXT VISIT
(REPEAT FOR INTERVIEWER 2)
DATE____ /201
TIME______

FINAL VISIT
DAY_______
MONTH_______
YEAR 201
INTERVIEWER CODE________
RESULT______

TOTAL NO. OF VISITS___________

RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD_____________________
TOTAL ELIGIBLE WOMEN_________
TOTAL ELIGIBLE MEN________
LINE NO. OF RESPONDENT TO HOUSEHOLD INTERVIEW______

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 (INS) and the Ministry of Health and the Fight Against AIDS (MSLS). We are conducting a survey about health in Cote d'Ivoire. 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 would like more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

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

Signature of interviewer__________
Date_________

Household schedule

1) Line no.

USUAL RESIDENTS AND VISITORS

2) 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.

RELATIONSHIP TO HEAD OF HOUSEHOLD

3) What is the relationship of (NAME) to the head of the household?

SEX

4) Is (NAME) male or female?

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

AGE

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

IF AGE 15 OR OLDER, MARITAL STATUS

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

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN 15-49
CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY

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?
IF YES: ADD EACH IN TABLE

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?
IF YES: ADD EACH IN TABLE

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
IF YES: ADD EACH IN TABLE

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

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

13) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD 00.

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

15) Does (NAME)'s natural father live in this household or was he a guest last night?
IF YES: what is his name?
RECORD FATHER'S LINE NUMBER.
IF NO, RECORD 00.

IF AGE 3 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school or pre-school?

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

IF AGE 3-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school or pre-school at any time during the (2012-2013) school year?

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

IF AGE 0-17 YEARS

BIRTH REGISTRATION

20) Does (NAME) have a birth certificate?

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

IF AGE 0-17 YEARS

HEALTH INSURANCE COVERAGE

21) Does (NAME) have health insurance?

CODES FOR QUESTIONS 17 AND 19: EDUCATION

WORK OF CHILDREN AGE 5-14 YEARS

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

23) CHECK QUESTION 22

LIST OF CHILDREN AGE 5-14 YEARS

24) 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

25) 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

26) 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.

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

28) 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.

29) 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.

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

31) 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?

32) 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) Does anyone ever 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

106a) How do you usually store drinking water in your household?
Anything else?
RECORD ALL MENTIONED

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

107a) Where is this toilet facility located?

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 radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
A TV5 antenna
A subscription to Canal?
A washing machine?
A portable stove/gas or electric stove?
An improved fireplace?
A CD/DVD player?
An air conditioner?
A computer?
Internet?

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?

113a) Do you cook on an open fireplace, an open stove, or a closed stove in this household?

113b) Does this (fireplace/stove) include a chimney, a hood, or neither?

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

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

118) Does any member of your household own:
A watch?
Plows?
A bicycle/tricycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A canoe/or fishing nets?
A tractor?
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, 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?
Pigs?
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 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?
(Anyone else?)
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

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

137) Please show me where members of your household most often wash their hands.

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

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

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

141) Selection table for women for "domestic violence"

THIS SECTION APPLIES TO ALL THE SAMPLING HOUSEHOLDS, MEANWHILE ONE WOMAN WILL BE INTERVIEWED PER HOUSEHOLD FOR THIS SECTION: THE TABLE BELOW WILL ALLOW YOU TO RANDOMLY SELECT THIS WOMAN IN THE HOUSEHOLD.

1- IF THERE IS ONLY ONE ELIGIBLE WOMAN IN THE HOUSEHOLD
On the first line of the following table, record the name, age, line number of the woman (see column 9) from the household schedule: this woman will be surveyed on "domestic violence.")

2-IF THERE ARE SEVERAL ELIGIBLE WOMEN IN THE HOUSEHOLD

1- In the table, record the NAME, age and line number of all of the eligible women (see column 9 in household schedule), starting with the oldest and ending with the youngest.

2-Take the last digit from the structure number recorded on the cover page of the questionnaire and circle the corresponding number in the title line of the following table. Go down the column identified by the number to the line corresponding to the last women recorded on the bale. Circle the number corresponding to the crossing of this column and this line.

3. This number will give you the order number of the women selected for section 13 of the woman's questionnaire (the 1st, 2nd, 3rd, etc listed woman). Then circle the line number of the selected women in the table.

NAME of woman

Age of woman

Line number from household schedule

[##translator note: numbers omitted from translation]

Section 6. Weight, height, malaria and hemoglobin measurement test for children age 0-5

600) CHECK COVER PAGE

601) Check column 11 of the household table. Record the line number and the age of each eligible child 0-5 years. If there are more than 6 children, use an additional questionnaire. The final weight and height measurements should be recorded in question 608, in question 613 for the anemia tests, and question 613A for malaria.

602) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

603) What is (NAME)'s date of birth)?
IF THE MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY TABLE 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?

608) RESULT: MEASURE OF WEIGHT AND HEIGHT

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 (COLUMN 1). RECORD 00 IF NOT LISTED.

LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

611) READ THE DECLARATION OF CONSENT FOR THE ANEMIA AND MALARIA TEST TO THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.

Declaration of consent for 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.

Within the framework of the survey, we are also doing a survey of malaria among children under age 5. As you may know, malaria is a serious health problem that results from an exposure to mosquito bites.

This survey will assist the government to develop and set up 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. For this test, 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 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 your decision.
611a) ASK FOR CONSENT FOR THE ANEMIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.
Request for consent for anemia test.
Will you allow (NAME(s) of child(ren)) to participate in the anemia test?

611b)

611c) ASK FOR CONSENT FOR THE MALARIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 610 AS RESPONSIBLE FOR CHILD.

Request for consent for malaria test.
Will you allow (NAME(s) of child(ren)) to participate in the malaria test?

611d)

612) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) THAT YOU GOT CONTENT FOR AND CONTINUE WITH THE TESTS. PREPARE THICK DROPS OF BLOOD ON TWO BLADES OF THE MICROSCOPE IF CONSENT WAS OBTAINED FOR THE MALARIA TEST, AND CONTINUE TO 613.

613) RECORD THE HEMOGLOBIN LEVEL HERE ON THE ANEMIA PAMPHLET.

613a) RECORD TDR RESULT ON MALARIA PAMPHLET [##TDR refers to Rapid Diagnostic Test]

614) 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 [##translator note: Combinaison Thérapeutique à base d'artemisinine--Artemisinine-based combination therapy]. 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.

614a)

614b) 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.

614c) RECORD THE RESULT OF MALARIA TREATMENT.

615) BAR CODE LABEL
PUT THE 2ND BAR CODE ON THE SLIDE WITH THICK DROPS
PUT THE 3RD BAR CODE ON THE TRANSMISSION SHEET FOR THE THICK DROPS

616) Go back to 603 in next column of this questionnaire or in the first column of an additional questionnaire; if no more children, go to 700.

[##translator note: section 6 repeated for child 4-6]

616) GO BACK TO 603 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN, GO TO 700.
[##translator note: repeated with different skip instructions]

Treatment of basic malaria with CTA according to the national treatment protocol for the Ivory Coast.
The dose is 4mg/kg/day of artesunate + 10 mg/kg/day of base amoniaquine the first day, second day, and third day

AGE (APPROXIMATE WEIGHT IN KG)

Treatment of basic malaria with CTA according to the national treatment protocol for the Ivory Coast.
The dose is 4mg/kg/day of artemether + 24 mg/kg/day of base Lumefantrine the first day, second day, and third 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 (above 39C)
Convulsions, coma
Rapid breathing or difficulty breathing
Not able to drink or breastfeed
Gets sick or doesn't get better in 2 days
Frequent vomiting

Weight, height, hemoglobin measurement, HIV, malaria test and consent for the VCT visit for women 15-49 [##translator note: VCT is volunteer counseling and testing]

(Malaria test is only for pregnant women)

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 Q704, IN Q713 FOR THE ANEMIA TEST, IN Q714 FOR HIV TEST AND Q715A FOR MALARIA.

701) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

702) WEIGHT IN KILOGRAMS

703) HEIGHT IN CENTIMETERS

704) RESULT: WEIGHT AND HEIGHT MEASUREMENTS

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) Declaration of consent for anemia test
READ THE CONSENT TO EACH RESPONDENT. CIRCLE CODE 1 IN 708 IF THE RESPONDENT ACCEPTS THE ANEMIA TEST AND CODE 3 IF SHE REFUSES.

FOR WOMEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HER PARENT/OTHER ADULT IDENTIFIED IN 707 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE 2 IN 708 IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT 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. The results of 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, or you can say no to the test. It is up to you to decide.
Will you allow (NAME of adolescent) to take the anemia test?

Declaration of consent for HIV test

READ THE CONSENT TO EACH RESPONDENT. CIRCLE CODE 1 IN 709 IF THE RESPONDENT ACCEPTS THE HIV TEST AND CODE 3 IF SHE REFUSES.

FOR WOMEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HER PARENT/OTHER ADULT IDENTIFIED IN 707 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE 2 IN 709 IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT 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 Ivory Coast. HIV treatment is free. 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 (RESULTS OF THE ADOLESCENT) either.

If you want to know if you have HIV or not, 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?

710) CHECK Q 226 FROM WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

710a) DECLARATION OF CONSENT FOR MALARIA TEST
READ THE CONSENT TO EACH RESPONDENT. CIRCLE CODE 1 IN 710A IF THE RESPONDENT ACCEPTS THE TEST AND CODE 3 IF SHE REFUSES.

FOR WOMEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HER PARENT/OTHER ADULT IDENTIFIED IN 707 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE 2 IN 710A IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT RESPONDENT.

As part of this survey, we are also doing a survey of malaria among women and children under age 5. As you may know, malaria is a serious health problem that results from an exposure to mosquito bites. This survey will assist the government to develop and set up programs to prevent and treat anemia and malaria.

For this 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 malaria immediately, and the result will be told to you right away. The result will be kept strictly confidential.

If you have malaria based on the rapid blood diagnostic test, you will receive an appropriate treatment and you will be referred to the closest health center, based on the severity of the malaria. Additionally, if you have malaria based on the rapid test, we will take a few more drops of blood onto two lab slides to perform an analysis of the state of malaria, but we will not be able to give you the results.

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?

710b) CHECK 708, 709, AND 710A

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

711) AGAIN, CHECK 708, 709, AND 710A AND PREPARE THE INSTRUMENTS REQUIRED FOR THE TESTS FOR WHICH CONSENT WAS OBTAINED, THEN CONDUCT THE TESTS. SIMILARLY, PREPARE THE THICK DROPS OF BLOOD ON THE TWO MICROSCOPE SLIDES IF CONSENT WAS OBTAINED FROM THE PREGNANT WOMAN FOR THE MALARIA TEST. FOR EACH ELIGIBLE WOMAN, THE RESULT CODE OF THE ANIMA TEST MUST BE RECORDED IN 713, FOR THE HIV TEST IN 714, AND FOR THE MALARIA TEST IN 715A, EVEN IF SHE WASN'T PRESENT, REFUSED, OR COULDN'T BE TESTED FOR OTHER REASONS. REMEMBER THAT THE MATERIALS FOR THE MALARIA TEST CAN ONLY BE PREPARED FOR PREGNANT WOMEN WHO ACCEPTED THE TEST IN 710A.

712) RECORD THE HEMOGLOBIN LEVEL HERE ON THE ANEMIA PAMPHLET.

713) RESULT CODE FOR ANEMIA TEST

714) RESULT CODE FOR HIV TEST

715) CHECK Q 710. IF THE WOMAN PREGNANT?

715a) RECORD TDR RESULT FOR EACH WOMAN TESTED FOR MALARIA [##TDR refers to Rapid Diagnostic Test]

715b) THE RESULTS OF YOUR RAPID DIAGNOSTIC TESTS FOR MALARIA INDICATE THAT YOU HAVE MALARIA. WE MUST GIVE YOU A TREATMENT NOW. HOWEVER, GIVEN THAT YOU ARE PREGNANT, WE CAN GIVE YOU A REFERENCE SHEET THAT WILL ALLOW YOU TO GO TO A HEALTH ESTABLISHMENT TO RECEIVE AN APPROPRIATE TREATMENT FOR YOUR MALARIA, FOR FREE.

RECORD THE RESULT OF THE TREATMENT OF MALARIA

715c) BAR CODE LABEL
2ND: PAPER FILTER
3RD: PAPER FILTER TRANSMISSION SHEET
IF MALARIA DONE
4TH: THICK DROPS
5TH: TRANSMISSION SHEETS FOR BLOOD DROPS

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

716a) AGE: CHECK 705

716b) MARITAL STATUS: CHECK Q 706

716c) DECLARATION OF CONSENT FOR CDV TO READ TO PARENT/ADULT RESPONSIBLE FOR RESPONDENT
CONSENT IS ACCEPTED FOR THE CDV VISIT IN THE HOUSEHOLD AND CODE 2 IF REFUSED
[##translator note: CDV is Volunteer Testing and Council]

As you know, we are asking people all over the country to participate in an HIV test, and we cannot provide the results of the test because the test is anonymous.

But a team with experience in Volunteer Testing and Council will come to your community in a few days to offer again a free HIV test with consultation. The HIV treatment is tree. If (NAME OF ADOLESCENT) wants to know if she has HIV or not, this team will be able to perform the test, give her the results, and provide the necessary council. If (NAME OF ADOLESCENT) accepts, I will ask the team to come to your home to perform the test with consultation. Other members of your household can also participate in the test at this time if they wish.

Would you like the CV team to come to you home for consultation and testing of (NAME OF ADOLESCENT)?

716d) Declaration of consent for CDV to read to respondent

As you know, we are asking people all over the country to participate in an HIV test, and we cannot provide the results of the test because the test is anonymous.

A team with experience in Volunteer Testing and Council will come to your community in a few days to offer again a free HIV test with consultation. If you want to know if you have HIV or not, this team will be able to perform the test, give you the results, and provide the necessary council. If you accept, I will ask the team to come to your home to perform the test with consultation.

Would you like the CV team to come to you home for consultation and testing?

716e) RECORD THE NAME OF THE HEAD OF HOUSEHOLD, HOUSEHOLD NUMBER, NAME OF RESPONDENT AND HER LINE NUMBER, HER AGE AND HER SEX ON THE REQUEST SHEET FOR CDV AT HOME. SKIP TO 716G.

716f) Inform the adolescent
A team with experience in Volunteer Testing and Council will come to your community in a few days to offer again a free HIV test with consultation. The HIV treatment is tree. If you want to know if you have HIV or not, this team will be able to perform the test, give you the results, and provide the necessary council. The team will be based at (NAME OF PLACE WHERE CDV TEAM IS BASED). You can go to (NAME OF PLACE) for the test.

716g) GO BACK TO Q. 702 IN NEXT COLUMN OF THE QUESTIONNAIRE FOR THE NEXT WOMAN.
IF THERE ARE MORE THAN 3 WOMEN, USE THE ADDITIONAL QUESTIONNAIRE.
IF NO MORE WOMEN, GO TO 801 FOR THE MEN.
IF MORE THAN 3 WOMEN, USE THIS ADDITIONAL QUESTIONNAIRE.

[##translator note: questions 711-716g repeated for women 4-6]

If no more women, go to 801 for the men.

HIV test and consent for VCT visit for men aged 15-59

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 WEIGHT AND HEIGHT MUST BE REGISTERED IN Q 804, IN Q 813 FOR THE ANEMIA TEST AND IN Q 814 FOR THE HIV TEST.

801) 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) Declaration of consent for anemia test
READ THE CONSENT TO EACH RESPONDENT. CIRCLE CODE 1 IN 808 IF THE RESPONDENT ACCEPTS THE ANEMIA TEST AND CODE 3 IF HE REFUSES.

FOR MEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HIS PARENT/OTHER ADULT IDENTIFIED IN 807 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HIMSELF. CIRCLE CODE 2 IN 808 IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT 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, or you can say no to the test. It is up to you to decide.
Will you allow (NAME of adolescent) to take the anemia test?

809) Declaration of consent for HIV test
READ THE CONSENT TO EACH RESPONDENT. CIRCLE CODE 1 IN 809 IF THE RESPONDENT ACCEPTS THE HIV TEST AND CODE 3 IF HE REFUSES.

FOR MEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HIS PARENT/OTHER ADULT IDENTIFIED IN 807 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HIMSELF. CIRCLE CODE 2 IN 809 IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT 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 Ivory Coast. HIV treatment is free. 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/his) test results (results of the adolescent) 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?

810b) CHECK 808 AND 809:

811) AGAIN, CHECK 808 AND 809 AND PREPARE THE INSTRUMENTS REQUIRED FOR THE TESTS FOR WHICH CONSENT WAS OBTAINED, THEN CONDUCT THE TESTS. FOR EACH ELIGIBLE MAN, THE RESULT CODE OF THE ANIMA TEST MUST BE RECORDED IN 813, FOR THE HIV TEST IN 814, EVEN IF HE WASN'T PRESENT, REFUSED, OR COULDN'T BE TESTED FOR OTHER REASONS.

812) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA PAMPHLET.

812b) Stick bar code label for HIV

813) RESULT CODE FOR ANEMIA TEST

814) RESULT CODE FOR HIV TEST

816) Voluntary testing and council (CDV) HIV
LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

816a) AGE: CHECK 805

816b) MARITAL STATUS: CHECK Q 806

816c) Declaration of consent for CDV to read to parent/adult responsible for respondent
CONSENT IS ACCEPTED FOR THE CDV VISIT IN THE HOUSEHOLD AND CODE 2 IF REFUSED
[##translator note: CDV is Volunteer Testing and Council]

As you know, we are asking people all over the country to participate in an HIV test, and we cannot provide the results of the test because the test is anonymous.

But a team with experience in Volunteer Testing and Council will come to your community in a few days to offer again a free HIV test with consultation. If (NAME OF ADOLESCENT) wants to know if he has HIV or not, this team will be able to perform the test, give him the results, and provide the necessary council. If you prefer and if (NAME of adolescent) accepts, I will ask the team to come to your home to perform the test with consultation. Other members of your household can also participate in the test at this time if they wish.

Would you like the CDV team to come to you home for consultation and testing of (NAME OF ADOLESCENT)?

816d) Declaration of consent for CDV to read to respondent
CONSENT IS ACCEPTED FOR CDV VISIT IN THE HOUSEHOLD AND CODE 2 IF REFUSED

As you know, we are asking people all over the country to participate in an HIV test, and we cannot provide the results of the test because the test is anonymous.

A team with experience in Volunteer Testing and Council will come to your community in a few days to offer again a free HIV test with consultation. The HIV treatment is tree. If you want to know if you have HIV or not, this team will be able to perform the test, give you the results, and provide the necessary council. If you accept, I will ask the team to come to your home to perform the test with consultation.

Would you like the CDV team to come to you home for consultation and testing?

816e) RECORD THE NAME OF THE HEAD OF HOUSEHOLD, HOUSEHOLD NUMBER, NAME OF RESPONDENT AND HIS LINE NUMBER, HIS AGE AND HIS SEX ON THE REQUEST SHEET FOR CDV AT HOME. (SKIP TO 816g)

816f) Inform the adolescent
A team with experience in Volunteer Testing and Council will come to your community in a few days to offer again a free HIV test with consultation. The HIV treatment is tree. If you want to know if you have HIV or not, this team will be able to perform the test, give you the results, and provide the necessary council. The team will be based at (NAME OF PLACE WHERE CDV TEAM IS BASED). You can go to (NAME OF PLACE) for the test.

816g) GO BACK TO Q. 802 IN NEXT COLUMN OF THE QUESTIONNAIRE FOR THE NEXT MAN.
IF THERE ARE MORE THAN 6 MAN, USE THE ADDITIONAL QUESTIONNAIRE.
IF NO MORE MEN, END OF HOUSEHOLD QUESTIONNAIRE
IF THERE ARE MORE THAN 3 MEN, USE THIS ADDITIONAL QUESTIONNAIRE

Interviewer's observations
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

Supervisor's observations

Editor's observations