MINISTRY OF HEALTH, GHANA

GHANA STATISTICAL SERVICE

IDENTIFICATION

LOCALITY NAME _____

NAME OF HOUSEHOLD HEAD _____

CLUSTER NUMBER _____

STRUCTURE NUMBER _____

HOUSEHOLD NUMBER _____

REGION _____

DISTRICT _____

URBAN/RURAL:

HOUSEHOLD SELECTED FOR MEN SURVEY:

INTERVIEWER VISITS:

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

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

FINAL VISIT
DAY _____
MONTH _____
YEAR 2014
INT. NUMBER _____
RESULT ___

RESULT CODES:

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____

TOTAL ELIGIBLE WOMEN _____

TOTAL ELIGIBLE MEN _____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

LANGUAGE OF QUESTIONNAIRE: 1

LANGUAGE OF INTERVIEW:

LANGUAGE OF RESPONDENT:

TRANSLATOR USED:

LANGUAGE OF QUESTIONNAIRE:

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY _____

INTRODUCTION AND CONSENT

Hello. My name is __________. I am working with Ghana Statistical Service and the Ministry of Health. We are conducting a survey about health all over Ghana. 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 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.

GIVE CARD WITH CONTACT INFORMATION.

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

SIGNATURE OF INTERVIEWER: _____
DATE: _____

HOUSEHOLD SCHEDULE

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 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

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 may 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?

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?

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

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

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

8) MARITAL STATUS IF AGE 15 OR OLDER: What is (NAME)'s current marital status?

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

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

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

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 here last night? IF YES: What is his name? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

EVER ATTENDED SCHOOL IF AGE 3 YEARS OR OLDER:

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

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

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 3-24 YEARS:

18) Did (NAME) attend school or pre-school at any time during the (2014-2015) school year?

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

20) 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?

TABLE FOR SELECTION OF ONE CHILD FOR THE CHILD EDUCATION QUESTIONS:

31) CHECK COLUMN 7:

INSTRUCTIONS HOW TO USE THE SELECTION TABLE:

LOOK AT THE LAST DIGIT OF THE EA (CLUSTER) NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE IN THE TABLE. LOOK AT THE COLUM 7 AND COUNT THE TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 4-15. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE. FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE ELIGIBLE CHILD WHOSE PARENT OR CARETAKER WILL BE ASKED THE QUESTIONS ON CHILD EDUCATION. THEN, GO TO COLUMN (1) AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED CHILD AND RECORD CHILD'S NAME AND HOUSEHOLD LINE NUMBER IN Q.32, AND RECORD CHILD'S PARENT OR OTHER MOST KNOWLEDGEABLE ADULT'S NAME AND LINE NUMBER IN Q.33.

FOR EXAMPLE, IF THE CLUSTER NUMBER IS '316', GO TO ROW 6 AND CIRCLE THE ROW NUMBER ('6'). IF THERE ARE THREE ELIGIBLE CHILDREN AGE 4-15 IN THE HOUSEHOLD, GO TO COLUMN 3 AND CIRCLE THE COLUMN NUMBER ('3'). DRAW LINES FROM ROW 6 AND COLUMN 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT ('2'). THIS MEANS YOU HAVE TO SELECT THE SECOND ELIGIBLE CHILD. SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE CHILDREN ARE '02', '03', AND '07'; THEN THE ELIGIBLE CHILD FOR THE QUESTIONS ON CHILD EDUCATION IS THE SECOND ELIGIBLE CHILD, I.E., THE CHILD WITH HOUSEHOLD LINE NUMBER '03'. PUT A * NEXT TO THIS CHILD'S LINE NUMBER IN COLUMN (1) OF THE HOUSEHOLD SCHEDULE AND ALSO ENTER THE TWO DIGIT LINE NUMBER AND CHILD'S NAME IN Q.32. THEN, RECORD THE LINE NUMBER AND A NAME OF CHILD'S PARENT OR OTHER MOST KNOWLEDGEABLE ADULT IN Q.33.

CHILD EDUCATION FOR SELECTED CHILD AGE 4-15

32) CHECK COLUMN 1 AND RECORD LINE NUMBER AND NAME OF THE SELECTED CHILD AGE 4-15 YEARS:

33) CHECK COLUMNS 1, 13 AND 15 AND RECORD LINE NUMBER AND NAME OF CHILD'S MOTHER, FATHER OR OTHER CARETAKER.

IF MOTHER, FATHER OR CARETAKER OF SELECTED CHILD IS NOT LISTED IN HH RECORD "00" AND SKIP TO Q. 101

CHILD EDUCATION MODULE

ASK MOTHER/FATHER OR CARETAKER QUESTION 34 THROUGH 41 ABOUT SELECTED:

34) How often do you or someone in your household read to (NAME)? Would you say that you or someone in your household read to (NAME) a few times a week, about once a week, about once a month, about every six months or not at all?

35) During the past seven days, did you or someone in your household help (NAME) learn in the following ways:

a)Help (NAME) with homework?
b) Buy or borrow books for (NAME) to read?
c) Take (NAME) to the library?
d) Take (NAME) to a reading event?
e) Talk with (NAME) teacher or head teacher about (NAME)'s learning progress?
f) Participate in the Parent Teacher Association?
g) Participate in the School Management Committee?
h) Regularly read to (NAME)?
i) Encourage (NAME) to read?
j) Communicate to (NAME) that you have high expectations for him/her?
k) Provide (NAME) with a lantern/torch/lamp?
l) Relieve (NAME) of some household chores?
x) Other?

36) How many children's books and reading materials do you have in the house today?

37) Do you want (NAME) to be taught in their home language or in English?

38) CHECK 18:
CHILD EVER ATTENDED SCHOOL

39) How often does (NAME) bring textbooks and other reading materials home from school?

40) How does (NAME) usually get to school?

41) How long does it take (NAME) to get to school?

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 that water source located?

104) How long does it take 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 does your household store drinking water?
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?

109A) Where is this toilet facility located?

109B) How long does it take to go there, use it, and come back?

110) Does your household have:

a) Electricity?
b) A wall clock?
c) A radio?
d) A black/white television?
e) A color television?
f) A mobile telephone?
g) A land-line telephone?
h) A refrigerator?
i) A freezer?
j) Electric generator/Invertor(s)?
k) Washing machine?
l) Computer/Tablet computer?
m) Photo camera? (NOT ON PHONE)
n) Video deck/DVD/VCD?
o) Sewing machine?
p) Bed?
q) Table?
r) Cabinet/cupboard?
s) Access to the internet in any device?

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

111A) What type of oil 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 THE 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 this household own:

a) A wrist watch?
b) A bicycle?
c) A motorcycle or motor scooter?
d) An animal-drawn cart?
e) A car or truck?
f) A boat with a motor?
g) A boat without a motor?

119) Does any member or this household own any agricultural land?

120) How many hectares or acres or plots of agricultural land do members of this household own?

IF 99.5 OR MORE ACRES, RECORD IN HECTARES. 100 ACRES = 1 HECTARE
IF 95 OR MORE HECTARES, CIRCLE '9995'.

121) Does this household own any livestock, herds, or other farm animals, or poultry?

122) How many of the following animals does this household own?

a) Cattle?
b) Milk cows or bulls?
c) Horses, donkeys, or mules?
d) Goats?
e) Pigs?
f) Rabbits?
g) Grasscutter?
h) Sheep?
i) Chickens?
j) Other poultry?
k) Other?

IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.

123) Does any member of this household have a bank account?

123A) How many household members are covered by health insurance?
IF NONE, RECORD '00'.

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?
RECORD ALL MENTIONED.

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 THE 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'.

129A) Where did you get this net?

129B) How much did it cost you to obtain this net?
RECORD '00.00' IF FREE OF CHARGE.

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURE 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?

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

135) Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. LIST UP TO FOUR PEOPLE.

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 136A.
136) [NET #3 ONLY] GO TO 128 IN FIRST COLUMN OF A NEW QUESTIONNAIRE; OR, IF NO MORE NETS, GO TO 136A

136A) During the last 12 months has any member of your household disposed of any treated net?

136B) How did you dispose of your last treated mosquito net?

136C) How long did you use the net before disposing of it?

136D) What was the main reason for disposing of this net?

136E) In the past 6 months, have you seen or heard any messages telling you that:

a) Treatment should be sought from health facilities within 24 hours or onset of fever, especially for children under 5 years?

b) The Ghana Health Service recommends ACT (Artesunate Amodiaquine/AA, Artemether Lumefantrin/AL, Dihydroartemisinine-Piperaquine/DHAP) as medicine for malaria treatment?

c) The full course of malaria medicine, ACT (artesunate Amodiaquine, Artemether Lumefantrin, Dihydroartemisinine-Piperaquine) should be completed?

d) Pregnant women should attend ANC and take 3 doses of SP/Fansidar during pregnancy to prevent malaria?

e) Families should sleep under Insecticides Treated Net to protect them from Malaria, especially pregnant women and children under five years?

136F) In the past 6 months, have you seen or heard any of the messages about malaria:

On the television?
On the radio?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?
From a health worker?
From a Community volunteer/CHW/CBA?
Anyone/anywhere else? Where/Whom?

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.

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

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE FOR NUMBER OF ELIGIBLE CHILDREN AGE 0-5:

202) LINE NUMBER FROM COLUMN 11:
NAME FROM COLUMN 2:

203) 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 date?

204) CHECK 203:
CHILD BORN IN JANUARY 2009 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

208) CHECK 203:
IS CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

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

210) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

As part of this survey, we are asking that children all over the country 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 2009 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

211A) ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will help the government to develop programs to prevent malaria.

We ask that all children born in January 2009 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (We will use blood from the same finger prick made for the anemia test). One blood drop will be tested for malaria immediately, and the result will be told to you right away. A few blood drops will be collected on a slide and taken to a laboratory for testing. You will not be told the results of the laboratory testing. All results will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria testing?

211B) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

211C) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

211D) BARCODE LABEL
PUT THE 1ST BARCODE LABEL HERE. PUT THE 2ND BARCODE LABEL ON THE SLIDE AND THE 3RD ON THE TRANSMITTAL FORM AND THE 4TH ON THE RDT.

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND HEIGHT/WEIGHT BROCHURE AND IN THE ANEMIA AND MALARIA BROCHURE.

212A) RECORD RESULT CODE OF THE MALARIA RDT.

212B) RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA BROCHURE.

212C) RECORD THE CLASSIFICATION OF THE MALARIA RDT.

212D) CHECK 212:
HEMOGLOBIN RESULT

212E) SEVERE ANEMIA REFERRAL STATEMENT:

The anemia test shows that (NAME OF CHILD) has severe anemia. Your child must be taken to a health facility right away. (GO TO 213)

212F) Does (NAME) suffer from the any of the following illnesses or symptoms:

a) Extreme weakness?
b) Inability to drink or breastfeed?
c) Vomiting everything?
d) Loss of consciousness?
e) Deep and laboured breathing?
f) Multiple convulsions?
g) Abnormal spontaneous bleeding?
h) Yellow eyes/jaundice?

IF NO SYMPTOMS, CIRCLE CODE Y.

212G) CHECK 212F:
ANY CODE CIRCLED?

212H) CHECK 212:
HEMOGLOBIN RESULT

212I) In the past two weeks has (NAME) taken or is taking ACT given by a doctor or health center to treat the malaria?
VERIFY BY ASKING TO SEE TREATMENT.

212J) SEVERE MALARIA REFERRAL STATEMENT:

The malaria test shows that (NAME OF CHILD) has malaria. Your child also has symptoms of severe malaria. The malaria treatment I have will not help your child, and I cannot give you the medication. Your child is very ill and must be taken to a health facility right away. (GO TO 212Q)

212K) ALREADY TAKING ACT REFERRAL STATEMENT:

You have told me that (NAME OF CHILD) has already received ACT for malaria. Therefore, I cannot give you additional ACT. However, the test shows that he/she is positive for malaria. If your child has a fever for four days after the last does of ACT, you should take him/her to the nearest health facility for further examination. (GO TO 212Q)

212L) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD.

The malaria test shows that (NAME OF CHILD) has malaria. We can give you free medicine. The medicine is called ACT. ACT is very effective and in a few days it should get rid of the fever and other symptoms. ACT is also very safe. However all medicines can have unwanted effects. Sometimes ACT can cause dizziness, weakness, lack of appetite for eating, and rapid heartbeats. You do not have to give (NAME OF CHILD) the medicine. This is up to you. Please tell me whether you accept the medicine or not.

212M) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212N) CHECK 212M:
MEDICATION ACCEPTED

212P) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS:

TREATMENT WITH ARTESUNATE-AMODIAQUINE (AA)

WEIGHT (IN KG) -- APPROXIMATE AGE AND DOSAGE:

Give the child one tablet each day for three consecutive days. Take the medicine (for children, put the tablet in a little water, mix water and tablet well, and give to the child) with fatty food or drinks like milk or breast milk. Make sure that the FULL 3 days treatment is taken otherwise the infection may return. If your child vomits within an hour of taking the medicine, repeat the dose and get additional tablets.

ALSO TELL THE PARENT/GUARDIAN: If (NAME OF CHILD) has any of the following symptoms, you should take him/her to a health professional for treatment immediately:

-- High temperature
-- Fast or difficult breathing
-- Not able to drink or breastfeed
-- Gets sicker or does not get better in 2 days

212Q) RECORD THE RESULT CODE OF MALARIA TREATMENT AND REFERRAL

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO Q214.

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

HOUSE SELECTED FOR MAN'S SURVEY?

214) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE FOR NUMBER OF ELIGIBLE WOMEN AGE 15-49:

215) LINE NUMBER FROM COLUMN 9:
NAME FROM COLUMN 2:

216) WEIGHT IN KILOGRAMS:

217) HEIGHT IN CENTIMETERS:

218) AGE:
CHECK COLUMN 7.

219) MARITAL STATUS:
CHECK COLUMN 8.

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

221) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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 malaria.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?
Do you have any questions?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

(IF REFUSED, GO TO 226)

225) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:

Are you pregnant?

226) AGE:
CHECK COLUMN 7.

227) MARITAL STATUS:
CHECK COLUMN 8.

228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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 Ghana.
For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

230) ASK CONSENT FOR DBS COLLECTION FROM 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 Ghana. For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know whether you have HIV, I can provide you with 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 take the HIV test?

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

232) AGE:
CHECK COLUMN 7.

233) MARITAL STATUS:
CHECK COLUMN 8.

234) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional test 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 (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (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?

235) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

236) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow 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 tests might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

237) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

238) ADDITIONAL TESTS:

CHECK 235 AND 237:

IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

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

242) GO BACK TO 215 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 243.

WEIGHT, HEIGHT, AND HIV TESTING FOR MEN AGE 15-59

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

243) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGIBLE MEN AGE 15-59 FOR WEIGHT, HEIGHT, AND HIV.
IF THERE ARE MORE THAN THREE MEN USE ADDITIONAL QUESTIONNAIRE(S).

244) LINE NUMBER FROM COLUMN 10:
NAME FROM COLUMN 2:

245) WEIGHT IN KILOGRAMS:

246) HEIGHT IN CENTIMETERS:

247) AGE:
CHECK COLUMN 7.

248) MARITAL STATUS:
CHECK COLUMN 8.

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

256) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

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 Ghana.
For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know his HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

258) ASK CONSENT FOR DBS COLLECTION FROM 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 Ghana.
For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know whether you have HIV, I can provide you with 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 take the HIV test?

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

260) AGE:
CHECK COLUMN 7.

261) MARITAL STATUS:
CHECK COLUMN 8.

262) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

We ask you to allow the 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 tests might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (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?

263) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

264) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow the 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 tests might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

265) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

266) ADDITIONAL TESTS:

CHECK 263 AND 265:

IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

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

270) GO BACK TO 244 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.