IDENTIFICATION
GOVERNORATE __________
PSU/SEGMENT NO. _____________
KISM/MARKAZ __________
BUILDING NO. ________________
HOUSING UNIT NO.___________
SHIAKHA/VILLAGE____________
HOUSEHOLD NUMBER ___________

URBAN/RURAL_________

LOCALITY _____

HEPATITIS C TESTING SUBSAMPLE:

NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________

TELEPHONE:
CELLULAR _________
LANDLINE _________

GOVERNATE _________
PSU/SEGMENT NO.__________
HOUSEHOLD NO.________
SUBSAMPLE_____

INTERVIEWER VISITS
DATE _____
TEAM _____
INTERVIWER _____
SUPERVISOR _____
RESULT ______

NEXT VISIT:
DATE _____
TIME ______

FINAL VISIT
DAY ____
MONTH ____
YEAR ____
TEAM ____
INT. NUMBER _____
SUP. NUMBER _____
RESULT _____
TOTAL NUMBER OF VISITS __

RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
TOTAL ELIGIBLE RESPONDENTS HEPATITIS C TESTING SUBSAMPLE __
LINE NO. RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

ADDRESSED CHECKED:

REINTERVIEW: _________

FIELD EDITOR
NAME _______
DATE _______
SIGNATURE _______

OFFICE EDITOR
NAME _______
DATE _______
SIGNATURE _______

CODER
NAME _______
DATE _______
SIGNATURE _______

KEYER
NAME _______
DATE _______
SIGNATURE _______

Introduction and Consent

Hello. My name is _______________________________________ and we are working with the Ministry of Health and Population. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 to 15 minutes to complete.

As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ___________ Date: _________

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END

HOUSEHOLD SCHEDULE

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

001. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

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

AFTER LISTING NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT THE LISTING IS COMPLETE. THEN GO ON TO QUESTION 006.

003. Are there any other persons such as small children or infants that we have not listed?

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

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

006. (RELATIONSHIP) What is the relationship of (NAME) to the head of the household? (SEE CODES BELOW)

007. (RESIDENCE) Does (NAME) usually live here?

008. (RESIDENCE) Did (NAME) sleep here last night?

009. (SEX) Is (NAME) male or female?

010. (AGE) How old was (NAME) at his/her last birthday? RECORD IN COMPLETED YEARS.

011. (MARITAL STATUS, IF AGE 15 OR OLDER) What is (NAME'S) current marital status?

012. (ELIGIBLE FOR WOMAN QUESTIONNAIRE, EVER-MARRIED AGE 15-49) FOR ALL HOUSEHOLD: CIRCLE LINE NUMBER OF EVER-MARRIED WOMEN AGE 15-49.

013. (ELIGIBLE FOR HEALTH ISSUES INTERVIEW AND HEPATITIS C TESTING, ALL PERSONS AGE 15-59) FOR ALL HOUSEHOLD IN HEPATITIS C SUBSAMPLE: CIRCLE ALL PERSONS AGE 15-49.

ELIGIBLE FOR HEIGHT AND WEIGHT MEASURES

014. (CHILDREN AGE 0-5) FOR ALL HOUSEHOLDS: CIRCLE LINE NUMBER OF CHILDREN AGE 0-5.

015. (PERSONS AGE 10-19) FOR ALL HOUSEHOULDS: CIRCLE LINE NUMBER OF PERSONS AGE 10-19.

016. (EVER-MARRIED WOMEN AGE 20-49) FOR HOUSEHOLDS NOT IN HEPATITIS C TESTING SUBSAMPLE: CIRCLE LINE NUMBER OF EVER-MARRIED WOMEN AGE 20-49.

017. (PERSONS AGE 20-59) FOR HOUSEHOLDS IN HEPATITIS C TESTING SUBSAMPLE: CIRCLE LINE NUMBER OF ALL PERSONS AGE 20-59.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

018. (IF AGE 0-17 YEARS) Is (NAME)'s natural mother alive?
QUESTION REFERS TO CHILDREN'S BIOLOGICAL MOTHER.

019. (IF AGE 0-17 YEARS) Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.IF NO: RECORD 00.

020. (IF AGE 0-17 YEARS) Is (NAME)'s natural father alive?
QUESTION REFERS TO CHILDREN'S BIOLOGICAL FATHER.

021. (IF AGE 0-17 YEARS) Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.IF NO: RECORD 00.

EDUCATION

022. (IF AGE 6 YEARS OR OLDER) Has (NAME) ever attended school?

023. (IF AGE 6 YEARS OR OLDER) What is the highest level of school (NAME) has attended? What is the highest grade of school (NAME) completed at that level? (SEE CODES BELOW)

024. (IF AGE 6-24 YEARS) Did (NAME) attend school at any time during the this school year? That is, the 2007/2008 school year?

025. (IF AGE 6-24 YEARS) During this school year, that is, the 2007/2008 school year, what level and grade [is/was] (NAME) attending? (SEE CODES BELOW)

026. (IF AGE 6-24 YEARS) Did (NAME) attend school at any time during the previous school year, that is, in the 2006-2007 school year?

027. During that school year, that is, the 2006/2007 school year, what level and grade did (NAME) attend? (SEE CODES BELOW)

028. (IF AGE 3-5 YEARS) Has (NAME) ever attended kindergarten, private nursery or other program to prepare (him/her) for primary school? (SEE CODES BELOW)

ELGIBLE FOR WOMAN INTERVIEW

029. CHECK 012 AND ENTER THE TOTAL NUMBER OF ELIGIBLE EVER-MARRIED WOMEN AGE 15-49

ELGIBLE FOR HEPATITIS C SUBSAMPLE

030. CHECK 013 AND ENTER THE TOTAL NUMBER OF ELIGIBLE PERSONS AGE 15-59 YEARS

ELIGIBLE FOR ANTHROPOMETRY

031. CHECK 014 AND ENTER THE TOTAL NUMBEROF CHILDREN AGE 0-5 YEARS

032. CHECK 015 AND ENTER THE TOTAL NUMBER OF PERSONS AGE 10-19 YEARS

033. CHECK 016 AND ENTER THE TOTAL NUMBER OF EVER-MARRIED WOMEN AGE 20-49 YEARS

034. CHECK 017 AND ENTER THE TOTAL NUMBER OF ADULTS AGE 20-49 YEARS

035. TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED

CODES FOR COLUMNS 023, 025, AND 027

EDUCATION LEVEL:

EDUCATION GRADE:

CODES FOR COLUMN 028

101. What type of dwelling does your household live in?

102. Is your dwelling owned or rented by your household? IF OWNED: Is it owned solely by your household or jointly with someone else?

103. What is the main source of drinking water for members of your household?

104. What is the main source of water used by your household for other purposes such as cooking and handwashing?

105. Where is (SOURCE IN 103 OR 104) located?

106. How long does it take to go there, get water, and come back?

107. Who usually goes to this source to fetch the water for your household?

108. During the last two weeks, was there any time when water was not available from (SOURCE IN 103 OR 104)?

109. Did this happen on a daily or almost daily basis, only a few times per week, or less frequently?

110. Do you treat your water in any way to make it safer to drink?

111. What do you usually do to the water to make it safer to drink? PROBE: Anything else? RECORD ALL MENTIONED.

112. Is the water this household uses for drinking stored?

113. ASK TO SEE THE CONTAINER(S) IN WHICH WATER IS STORED: Could you show me in which container(s) you store water? OBSERVE: Are the container(s) covered?

114. OBSERVE: Do the storage containers have wide or narrow mouths?

115. How is water taken from the storage containers?

116. What kind of toilet facility do members of your household usually use?

117. Into where does this toilet flush drain?

118. Including your own household, how many households use this toilet?

119. Does your household have: Electricity? A radio with cassette recorder? A color television? A black and white television? A video or DVD player? A mobile? A telephone? A personal home computer? A sewing machine? An electric fan? An air conditioner?

120. Does your household own a satellite dish? IF NO: In your home, are you connected to satellite from elsewhere?

121. How does your household mainly dispose of kitchen waste and trash? RECORD MAIN METHOD OF DISPOSAL ONLY. IF TWO OR MORE METHODS ARE USED EQUALLY, RECORD THE METHOD HIGHEST ON THE LIST.

122. Does your household have: A refrigerator? A freezer? A water heater? A dishwasher? An automatic washing machine? Any other washing machine? A bed? A sofa? A hanging lamp (yellow with no cover)? A table? A tablia (very low round table)? A chair? Kolla/Zeer (a container for reserving water)?

123. How many rooms does your household use for living (excluding the bathrooms, kitchens and stairway areas)?

124. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

125. Does any member of this household own: A watch? A bicycle? A motorcycle or motor scooter? An animal-drawn cart? A car or truck?

126. Does any member of your household have an account in a bank or any saving institution?

127. Does any member of this household own any land that can be used for agriculture?

128. How many feddans or kirates of agricultural land do members
of this household own? IF MORE THAN 95, ENTER '9995'

129. Does your household own any livestock, herds, or farm animals?

130. How many of the following does your household own? Cattle (buffalo, calf)? Milk cows or bulls? Horses, donkeys, or mules? Goats? Sheep? IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.

131. INTERVIEWER: RECORD IF YOU OBSERVE POULTRY/BIRDS: INSIDE DWELLING UNIT? OUTSIDE/NEAR DWELLING UNIT?

132. Does your household own any poultry or birds?

133. How many of the following does your household have? Chickens? Geese? Ducks? Pigeons? Quail? Turkey? Ornamental/song birds? Any other birds? IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.

134. Is your household currently keeping any poultry or birds that belong to another household, e.g., to breed?

135. CHECK 132 AND 134:
OWNS AND/OR KEEPS POULTRY/BIRDS FOR ANOTHER HOUSEHOLD (Go to 136)

NEITHER OWNS NOR KEEPS POULTRY/BIRDS FOR ANOTHER (Go to 147)

136. Now I would like to ask some questions about the poultry or birds that your household owns (and/or that belong to another household).

Does your household keep any of the poultry or birds: Within the family living area? In the dwelling but away from the family living area? On the rooftop? Outside but near dwelling? Elsewhere?

137. CHECK 134
DOES NOT HAVE POULTRY/BIRDS BELONGING TO TO ANOTHER HOUSEHOLD (Go to 138)
HAS POULTRY/BIRDS BELONGING TO TO ANOTHER HOUSEHOLD (Go to 139)

138. CHECK 133:
HAS BOTH DUCKS AND OTHER POULTRY/BIRDS (Go to 139)
DOES NOT OWN DUCKS (Go to 140)
OWNS DUCKS ONLY (Go to 140)

139. Is your household keeping any ducks (even if they do not belong to your household) in the same location as other poultry or birds?

140. CHECK 136:
KEEPS POULTRY/BIRDS IN/NEAR DWELLING (Go to 141)
NO POULTRY/BIRDS KEPT IN/NEAR DWELLING (Go to 147)

141. Do you have a cage(s) or enclosure(s) for the birds you keep at home? IF YES: When do you put the poultry/birds in the cage(s)/ enclosure(s)?
RECORD ALL MENTIONED.

142. Did you keep poultry/birds in cage(s)/enclosure(s) prior to the avian influenza outbreak in 2006?

143. ASK TO SEE ALL LOCATIONS WHERE THE POULTRY/BIRDS ARE KEPT IN/NEAR THE HOME.

144. INDICATE IF ALL THE POULTRY/BIRDS WERE CAGED/ENCLOSED IN THE LOCATIONS OBSERVED.

145. INDICATE IF THE OBSERVED CAGE(S)/ENCLOSURE(S) HAD LOCKS/CLOSED SECURELY.

146. INDICATE IF THE OBSERVED CAGE(S)/ENCLOSURE(S) WERE ADEQUATE TO PREVENT TO POULTRY/BIRDS INCLUDING SMALL CHICKS FROM GETTING OUT.

147. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION)

148. THANK THE RESPONDENT AND ADVISE THAT THE RESPONDENT OR OTHER MEMBERS OF THE HOUSEHOLD MAY BE ASKED TO PARTICIPATE AGAIN IN INTERVIEWS OR OTHER SURVEY ACTIVITIES IN THE FUTURE.

Thank you for taking the time to answer these questions.
We may return to interview you or other members of your household again or to ask you to participate in other survey activities in the future. We hope that you will agree at that time.

149. COMPLETE THE QUESTIONS FROM 201-204 AND FROM 309-319 WHEN APPROPRIATE BEFORE INTERVIEWING ANY ELIGIBLE RESPONDENT FOR THE WOMAN OR HEALTH ISSUES QUESTIONNAIRE.

Section 2. WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AND ADOLESCENTS

HEIGHT AND WEIGHT MEASURES SHOULD BE OBTAINED FOR CHILDREN AGE 0-5 YEARS AND YOUTH/ADOLESCENTS AGE 10-19 YEARS IN ALL OF THE SURVEY HOUSEHOLDS.

CHECK COLUMN 014 AND RECORD THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL CHILDREN AGE 0-5 YEARS IN THE FIRST BLOCK BELOW.

THEN CHECK COLUMN 015 AND RECORD THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL YOUTH AND ADOLESCENTS AGE 10-19 IN THE SECOND BLOCK BELOW.

CHILDREN AGE 0-5

201. LINE NO. (FROM 014)

202. NAME (FROM 002)

203. AGE (FROM 010)

204. What is (NAME'S) date of birth?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY.
IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH, AND YEAR.

WEIGHT AND HEIGHT MEASUREMENT OF PERSONS AGE 0-5

205. WEIGHT (KILOGRAMS)

206. HEIGHT (CENTIMETERS)

207. MEASURED LYING DOWN OR STANDING UP

208. RESULT

YOUTH AND ADOLESCENTS AGE 10-19

201. LINE NO. (FROM 015)

202. NAME (FROM 002)

203. AGE (FROM 010)

204. What is (NAME'S) date of birth?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY.
IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH, AND YEAR.

WEIGHT AND HEIGHT MEASUREMENT OF PERSONS AGE 10-19

205. WEIGHT (KILOGRAMS)

206. HEIGHT (CENTIMETERS)

207. MEASURED LYING DOWN OR STANDING UP

208. RESULT

WEIGHT AND HEIGHT MEASUREMENT FOR EVER-MARRIED WOMEN AGE 20-49 OR ADULTS AGE 20-59

IN ALL HOUSEHOLDS NOT IN THE HEPATITIS C TESTING SUBSAMPLE, HEIGHT AND WEIGHT MEASURES SHOULD BE OBTAINED FOR ALL EVER-MARRIED WOMEN AGE 20-49.

IN HOUSEHOLDS IN THE HEPATITIS C TESTING SUBSAMPLE, HEIGHT AND WEIGHT MEASURES SHOULD BE OBTAINED FOR ALL ADULTS AGE 20-59 YEARS.

CHECK IN THE IDENTIFICATION SECTION ON THE COVER PAGE IF THE HOUSEHOLD IS INCLUDED IN THE HEPATITIS C TESTING SUBSAMPLE:

NOT IN THE HEPATITIS C TESTING SUBSAMPLE: CHECK COLUMN 016 AND RECORD NAMES OF EVER-MARRIED WOMEN AGE 20-49

IN THE HEPATITIS C TESTING SUBSAMPLE: CHECK COLUMN 017 AND RECORD NAMES OF ALL ADULTS AGE 20-59

EVER-MARRIED WOMEN/ADULTS AGE 20-59

201. LINE NO. (FROM 016 OR 017)

202. NAME (FROM 002)

203. AGE (FROM 010)

204. What is (NAME'S) date of birth?

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN/ADULTS

205. WEIGHT (KILOGRAMS)

206. HEIGHT (CENTIMETERS)

207. MEASURED LYING DOWN OR STANDING UP (RESPONSES BLACKED OUT)

208. RESULT

CHECK IN THE IDENTIFICATION SECTION ON THE COVER PAGE IF THE HOUSEHOLD IS INCLUDED IN THE HEPATITIS C TESTING SUBSAMPLE:

IN THE HEPATITIS C TESTING SUBSAMPLE (GO TO 301)
NOT IN THE HEPATITIS C TESTING SUBSAMPLE (GO TO 401)

TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED ____

Name of Measurer __________
Name of Assistant __________

Section 3. BLOOD TESTING DECISIONS

301. IDENTIFICATION OF ELIGIBLE RESPONDENTS AGE 15-59 YEARS

CHECK COLUMN 013 AND RECORD IN Q.309-313 THE LINE NUMBER(S), NAME(S), AND AGE(S) OF ALL PERSONS AGE 15-59 YEARS IN THE SAME ORDER IN WHICH THE INDIVIDUALS ARE LISTED IN THE HOUSEHOLD SCHEDULE.

IF AN ELIGIBLE RESPONDENT IS ABSENT DURING ALL OF THE VISITS YOU MAKE TO THE HOUSEHOLD FOR THE HEPATITIS C TESTING, RECORD CODE 2 ('NOT PRESENT') IN Q. 314, 315 AND 320.

302. ADMINISTRATION OF INFORMED CONSENT FOR HEPATITIS C TESTING TO PARENT/GUARDIANS.

FOR ALL NEVER-MARRIED ADOLESCENTS AGE 15-17, CHECK Q.011 AND RECORD IN Q.312 IF THE RESPONDENT IS NEVER-MARRIED OR ELSE.

FOR ALL NEVER-MARRIED ADOLESCENTS AGE 15-17, RECORD IN Q.313 THE LINE NUMBER OF THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT AT THE TIME OF THE SURVEY VISIT.

REQUEST INFORMED CONSENT FROM PARENT/GUARDIAN BEFORE ASKING RESPONDENT FOR CONSENT.

RESPONDENT NEVER-MARRIED AGE 15-17 LIVING WITH PARENT/GUARDIAN: ASK PARENT/GUARDIAN Q 303 AND RECORD RESULT IN Q.314

PARENT/GUARDIAN AGREES: GO TO Q.303

PARENT/GUARDIAN REFUSES: RECORD REFUSED IN Q.314 AND Q.320 AND SIGN YOUR NAME BELOW Q. Q314. THEN GO ON TO NEXT RESPONDENT. IF NO MORE RESPONDENTS, GO TO Q.321.

PARENT/GUARDIAN ABSENT: RECORD ABSENT IN Q.314 AND Q.320 AND SIGN YOUR NAME BELOW Q.314. THEN GO TO NEXT RESPONDENT. IF NO MORE RESPONDENTS, GO TO Q.321.

ALL OTHER RESPONDENTS: GO TO Q.303

303. REQUEST CONSENT FOR HEPATITIS C TESTING FROM RESPONDENT.

Good morning/afternoon. My name is ______ and I am from the Ministry of Health and Population and part of the survey team. As you know, we are conducting a national survey about health issues, including hepatitis C. Hepatitis C is a result of an infection with the hepatitis C virus. It may cause liver damage and other serious health problems. As part of the survey, we are asking people to give a small amount of blood to test later in the laboratory in order to know how many people have the hepatitis C virus. This information is very important to help the Ministry of Health and Population to plan for programs to treat this disease. The results will be kept confidential. If you agree to take part, I will ask you to let us take about teaspoonful of blood, from a vein in your arm. The risk to you from this testing is small. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test. You may get some bruising where the blood is taken from your arm. If you have any bleeding, swelling or other problem later, you should tell our study staff or your health worker.

LABORATORY TECHNICIAN: CHECK Q.311 AND 312. IF THE RESPONDENT IS AGE 15-17 YEARS AND NEVER MARRIED, ADVISE THE RESPONDENT THAT THEIR PARENT OR GUARDIAN WILL ALSO BE GIVEN THE RESPONDENT'S TEST RESULT AT THE TIME OF THE CALL BACK VISIT.

The blood will be sent to the Central Laboratory of the Ministry of Health and Population in Cairo for the hepatitis C test. We will return to give you [and your parent/guardian] the results of the testing in about two months. If the test shows that you have the hepatitis C virus, we will give you a referral to a special Liver Disease Treatment Center or other health facility for counseling and advice about treatment.
Do you have any questions so far?

LABORATORY TECHNICIAN: ENCOURAGE THE RESPONDENT TO ASK ANY QUESTIONS.

If you have any questions at any time, please ask me.
You can also speak to the head of this survey team. I can also give you information on how to contact the directors of this survey in Cairo.

LABORATORY TECHNICIAN: IF CONTACT NUMBERS ARE REQUESTED, OFFER TO PROVIDE THE RESPONDENT WITH A CELL PHONE TO USE TO MAKE THE CALL AND/OR GIVE THE FOLLOWING TELEPHONE NUMBERS:
Ministry of Health and Population
Dr. Nasr El-Sayed
Assistant Minister for Health and Population for Primary Health Care and Preventative and Family Planning Affairs
101 Kasr El Ainy Street
Cairo
Egypt
Telephone: 20-2-2794-8555; Fax: 20-2-2792-4156

El-Zanaty and Associates:
Dr. Fatma El-Zanaty
12 Gamal Salem Street, 3rd Floor
Dokki, Giza
Egypt
Telephone: 20-2-3762-2310; Fax: 20-2-3336-4120

LABORATORY TECHNICIAN: IF THE RESPONDENT IS A NEVER-MARRIED MINOR OR IS NOT HIGHLY EDUCATED, TAKE EXTRA TIME REVIEWING THE HEPATITIS C TESTING IN ORDER TO BE SURE THE RESPONDENT UNDERSTANDS THE PROCESS BEFORE ASKING FOR CONSENT.

You can say yes or not to giving blood. However, we will be grateful if you can allow us to take a small blood sample. Would you allow me to take a sample of your blood from your arm for the hepatitis C testing?

304. RECORDING RESPONDENT'S DECISION CONCERNING HEPATITIS C TEST

RECORD THE RESPONDENT'S DECISION IN Q.315
RESPONDENT AGREES: GO TO 305
RESPONDENT REFUSES: RECORD REFUSED IN Q.315 AND AND Q.320. THEN GO ON TO NEXT RESPONDENT. IF NO MORE RESPONDENTS, GO TO Q.321

305. REQUEST FOR CONSENT TO STORE AND USE BLOOD SAMPLE FOR FUTURE TESTS

BEFORE DRAWING BLOOD SAMPLE, ASK ALL RESPONDENTS WHO CONSENT TO THE HEPATITIS C TEST FOR PERMISSION TO STORE REMAINING BLOOD FOR FUTURE TESTS. RECORD RESPONSE IN Q.316.

We ask you to allow the Ministry of Health and Population to store part of the blood sample at the Central Laboratory in Cairo to be used for testing or research in the future. We are not certain exactly what tests will be done but they will involve testing for infections or chemicals that may be associated with health or illness.

We will not be keeping your name on the blood sample after we give back the result of the hepatitis C test. Therefore, we will not be able to contact you with results from future testing. However, if you allow your blood to be used, we may be able to find out things that will help improve health situation for Egyptians.

You may join in this study without having your blood sample stored for future studies.
If you have any questions at any time, we want you to tell us. Again you can speak to the head of this survey team or I can give you information about how to contact the survey directors in Cairo.

LABORATORY TECHNICIAN: CHECK Q.303 AND PROVIDE CONTACT NUMBERS FOR MINISTRY OF HEALTH AND/OR EL-ZANATY AND ASSOCIATES IF REQUESTED.

Will you allow us to keep the blood sample stored for later testing or research?

306. PLACEMENT AND CHECKING OF BAR CODE LABEL FOR EACH RESPONDENT WHO CONSENTS TO TESTING

RECORD THE HOUSEHOLD NUMBER AND LINE NUMBER OF THE RESPONDENT ON THE SPECIMEN TRACKING FORM. BEGIN WITH A NEW SET OF BAR CODE LABELS.

(a) PLACE A BAR CODE LABEL ON THE QUESTIONNAIRE IN Q.317 FOR THE RESPONDENT.

(b) PLACE A SECOND LABEL WITH THE SAME BAR CODE ON THE TUBE WHICH YOU WILL USE IN TAKING THE SAMPLE.

(c) PLACE A THIRD LABEL WITH THE SAME BAR CODE ON THE SPECIMEN TRACKING FORM NEXT TO THE RESPONDENT'S

CHECK THAT YOU HAVE USED A NEW SET OF LABELS. ALSO CHECK THAT THE BAR CODE ASSIGNED TO THE RESPONDENT IN THE QUESTIONNAIRE MATCHES THE CODE YOU HAVE PLACED ON THE TUBE YOU WILL USE TO DRAW THE RESPONDENT'S BLOOD AND ON THE SPECIMEN TRACKING FORM.

SIGN IN Q. 318 TO INDICATE THAT YOU HAVE CHECKED AND THE BAR CODES MATCH.

307. COLLECTION OF VENOUS BLOOD SAMPLE
DRAW THE VENOUS BLOOD SAMPLE.
BLOOD SAMPLE OBTAINED: RECORD CODE 1 ('COLLECTED') IN Q. 320. THEN CONTINUE WITH Q.308.

BLOOD SAMPLE NOT OBTAINED BECAUSE RESPONDENT REFUSED: RECORD CODE 2 ('REFUSED') IN Q.320 AND CHANGE RESPONSE IN Q.315 TO REFUSED

BLOOD SAMPLE NOT OBTAINED DUE TO TECHNICAL PROBLEMS: RECORD CODE 6 ('OTHER') IN Q.320.

(FOR BLOOD SAMPLE NOT OBTAINED) CROSS OUT THE REMAINING BAR CODE LABELS THAT WERE ASSIGNED TO THE RESPONDENT ON THE BAR CODE SHEET.

THANK THE RESPONDENT AND GO ON TO THE NEXT ELIGIBLE RESPONDENT. IF THERE ARE NO ADDITIONAL RESPONDENTS, PROCEED TO Q.321.

308. CHECK OF BAR CODE LABEL ASSIGNMENT BY ASSISTANT

AFTER THE TECHNICIAN HAS DRAWN THE BLOOD SAMPLE, THE ASSISTANT SHOULD VERIFY THE RESPONDENT'S NAME. THEN CHECK THAT THE BAR CODE ON TUBE MATCHES THE BAR CODE IN Q. 317 IN THE QUESTIONNAIRE FOR THAT RESPONDENT.

ALSO CHECK THAT THE RESPONDENT'S LINE NUMBER WAS CORRECTLY RECORDED ON THE SPECIMEN TRACKING FORM. THEN CHECK THAT THE BAR CODE NEXT TO RESPONDENT'S LINE NUMBER MATCHES THE NUMBER ON THE TUBE AND IN Q. 317. SIGN IN Q. 319 TO INDICATE YOU CHECKED AND THE BAR CODES MATCH.

RECORD OF BLOOD TESTING DECISIONS

309. LINE NO. FROM 013

310. NAME FROM 002

311. AGE FROM 010

312. MARITAL STATUS FROM 011

313. LINE NO. OF PARENT OR OTHER RESPONSIBLE ADULT FROM 001

314. IF NEVER-MARRIED AND LT 18 YRS, READ CONSENT TO PARENT/OTHER RESP. ADULT AND RECORD RESPONSE (PARENTAL CONSENT)

315. IF 18-59 YEARS OR LT 18 YEARS AND PARENT/OTHER RESP. ADULT AGREED, READ CONSENT STATEMENT AND RECORD RESPONSES FOR TEST AND BLOOD STORAGE (TEST).

316. IF 18-59 YEARS OR LT 18 YEARS AND PARENT/OTHER RESP. ADULT AGREED, READ CONSENT STATEMENT AND RECORD RESPONSES FOR TEST AND BLOOD STORAGE (STORAGE).

317. BAR CODE LABEL

318. TECHNICIAN: CHECK BAR CODES ON QUESTIONNAIRE, TUBE AND FIELD FORM MATCH.
_____________ (SIGNATURE)

319. ASSISTANT: CHECK BAR CODES ON QUESTIONNAIRE, TUBE AND FIELD FORM MATCH.
_____________ (SIGNATURE)

320. SAMPLE CELLECTED?

321. IDENTIFICATION OF RESPONDENTS FROM WHOM BLOOD SPECIMENS COLLECTED
CHECK Q.309, 310, AND 320. RECORD THE NAME AND LINE NUMBER OF EACH RESPONDENT FROM WHOM A BLOOD. SAMPLE WAS OBTAINED IN Q.326-327.

322. IDENTIFICATION OF RESPONDENTS WHO ARE NOT USUAL HOUSEHOLD RESIDENTS. CHECK COLUMN 010 IN THE HOUSEHOLD SCHEDULE AND RECORD IN Q.328 IF THE RESPONDENT IS A USUAL RESIDENT OF THE HOUSEHOLD.

323. REQUEST FOR CONTACT INFORMATION FROM RESPONDENTS WHO ARE NOT USUAL RESIDENTS

We would like to contact you in two to three months to return the result of the hepatitis C testing. Can you give me the address and telephone number for the place where you expect to be living at that time?

RECORD CONTACT INFORMATION Q329. IF THE RESPONDENT SAYS THAT THEY WILL STILL BE LIVING IN THIS HOUSEHOLD, WRITE 'EXPECTS TO BE LIVING IN EDHS HOUSEHOLD'.

324. REQUEST CONSENT TO LEAVE HEPATITIS C TEST RESULT WITH ANOTHER HOUSEHOLD MEMBER DURING CALLBACK VISIT. ASK EACH RESPONDENT FROM WHOM A SPECIMEN WAS COLLECTED.

As I told you, we will come back in about 3 months to give you the result of your test. If you are not at home at that time, may we leave your result in a sealed envelope with another household member? RECORD RESPONSE IN Q.330.

325. COMPLETE AND GIVE THE RESPONDENT THE CALL BACK IDENTIFICATION FORM. ASK THE RESPONDENT TO KEEP THE FORM AND PRESENT IT TO THE EDHS STAFF MEMBER WHO WILL RETURN THE RESPONDENT'S TEST RESULT. EXPLAIN THAT THE FORM WILL HELP THE CALL BACK TEAM TO CORRECTLY IDENTIFY THE RESPONDENT.

THANK THE RESPONDENT FOR PARTICIPATING IN THE HEPATITIS C TESTING AND GO ON TO THE NEXT ELIGIBLE RESPONDENT. IF THERE ARE NO ADDITIONAL RESPONDENTS, GO TO Q.404.

326. LINE NO. FROM 309

327. NAME FROM 310

328. USUAL RESIDENT FROM 007

329. ADDRESS: _______________
TELEPHONE: ______________

330. CONSENT TO LEAVE RESULTS WITH ANOTHER HOUSEHOLD MEMBER

INTERVIEWER OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

401. COMMENTS ABOUT RESPONDENT:
_______________________________________

402. COMMENTS ON SPECIFIC QUESTIONS:
_______________________________________

403. ANY OTHER COMMENTS:
_______________________________________

404. TECHNICIAN'S OBSERVATION
_______________________________________

405. SUPERVISOR'S OBSERVATIONS
_______________________________________

NAME OF SUPERVISOR: ___________
DATE: ___________

406. EDITOR'S OBSERVATIONS
________________________________________

NAME OF EDITOR: ___________
DATE: ____________