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DEMOGRAPHIC AND HEALTH SURVEYS IN GUINEA - 2005 HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
REGION _____

URBAN/RURAL:

URBAN 1
RURAL 2

CONAKRY/CAPITAL NATURAL REGION/OTHER CITY/RURAL:

CONAKRY 1
CAPITAL REGION 2
OTHER CITY 3
RURAL 4

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

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

RESULT _____

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR 2005
NAME _____
RESULT _____

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____

TOTAL NO. OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____

LINE NO. OF RESPONDENTS TO HOUSEHOLD QUESTIONNAIRE _____

LANGUAGE OF QUESTIONNAIRE: FRENCH

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY _____

HOUSEHOLD SCHEDULE

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

1. LINE NUMBER:

LINE NO. _____

2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

NAME _____

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

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 CO-SPOUSE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DOESN'T KNOW

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

MALE 1
FEMALE 2

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

YES 1
NO 2

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

YES 1
NO 2

7. AGE: How old is (NAME)?

IN YEARS _____

ELIGIBILITY
8. CIRCLE LINE NUMBER OF ALL WOMEN BETWEEN 15-49 YEARS OLD.

ELIGIBILITY
9. CIRCLE LINE NUMBER OF ALL CHILDREN LESS THAN 6 YEARS OLD.
CHECK IF THE HOUSEHOLD WAS SELECTED FOR THE MEN'S SURVEY.

ELIGIBILITY:
9A. CIRCLE LINE NUMBER OF ALL MEN BETWEEN 15-59 YEARS OLD.
CHECK IF THE HOUSEHOLD WAS SELECTED FOR THE MEN'S SURVEY.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS FOR PERSONS UNDER 15 YEARS:

10. Is (NAME)'s natural mother alive?

YES 1
NO 2 (GO TO 12)
DOESN'T KNOW 8 (GO TO 12)

11. Does (NAME)'s natural mother live in this household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER. IF MOTHER NOT LISTED IN HOUSEHOLD, RECORD '00'.

MOTHER'S LINE NO._____

12. Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 14)
DOESN'T KNOW 8 (GO TO 14)

13. Does (NAME)'s natural father live in this household?
IF YES: What is his name?

RECORD FATHER'S LINE NUMBER. IF FATHER NOT LISTED IN HOUSEHOLD, RECORD '00'.

FATHER'S LINE NO._____

EDUCATION, IF 5 YEARS OR OLDER:

14. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

15. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

EDUCATION LEVEL _____
0 PRESCHOOL
1 PRIMARY
2 SECONDARY (1ST CYCLE)
3 SECONDARY (2ND CYCLE)
4 PROFESSIONAL A
5 PROFESSIONAL B
6 SUPERIOR
8 DOESN'T KNOW
GRADE ____
00 LESS THAN 1 YEAR COMPLETED
98 DOESN'T KNOW

EDUCATION, IF 5-24 YEARS:

16. Is (NAME) currently attending school?

YES 1 (GO TO 18)
NO 2

17. During the current school year, did (NAME) attend school at any time?

YES 1
NO 2 (GO TO 19)

18. During the current school year what level and grade (is/was) (NAME) attending?

EDUCATION LEVEL _____
0 PRESCHOOL
1 PRIMARY
2 SECONDARY (1ST CYCLE)
3 SECONDARY (2ND CYCLE)
4 PROFESSIONAL A
5 PROFESSIONAL B
6 SUPERIOR
8 DOESN'T KNOW
GRADE ____
00 LESS THAN 1 YEAR COMPLETED
98 DOESN'T KNOW

19. During the previous school year, did (NAME) attend any school at any time?

YES 1
NO 2 (GO TO NEXT LINE/PERSON)

20. During that school year, what level and grade did (NAME) attend?

EDUCATION LEVEL _____
0 PRESCHOOL
1 PRIMARY
2 SECONDARY (1ST CYCLE)
3 SECONDARY (2ND CYCLE)
4 PROFESSIONAL A
5 PROFESSIONAL B
6 SUPERIOR
8 DOESN'T KNOW
GRADE ____
00 LESS THAN 1 YEAR COMPLETED
98 DOESN'T KNOW

CHECK HERE IF ANOTHER SHEET IS USED _____

Just to make sure that I have a complete list:

1) Are there any other persons such as small children or infants that we have not included on the list?

YES (ADD TO TABLE)
NO

2) Are there any other people who may not be members of your family such as domestic workers or friends who usually live here?

YES (ADD TO TABLE)
NO

3) Did you have any guests, temporary visitors, or others who spent the night here last night and were not listed?

YES (ADD TO TABLE)
NO

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 23)
PIPED INTO YARD/PLOT 12 (GO TO 23)
TAP ELSEWHERE 13
OPEN WELL
OPEN WELL IN DWELLING 21 (GO TO 23)
IN YARD/PLOT 22 (GO TO 23)
OPEN WELL ELSEWHERE 23
COVERED WELL OR DRILLED SITE
PROTECTED WELL IN DWELLING 31 (GO TO 23)
IN YARD/PLOT 32 (GO TO 23)
PROTECTED WELL ELSEWHERE 33
DRILLED SITE 34
SURFACE WATER
CONVERTED SOURCE 41
NON-CONVERTED SOURCE 42
RIVER/STREAM 43
MARSH WATER/LAKE 44
DAM 45
RAINWATER 51 (GO TO 23)
TANKER TRUCK 61 (GO TO 23)
BOTTLED WATER 71 (GO TO 23)
OTHER (SPECIFY) _____ 96

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

MINUTES _____
ON PREMISES 996

23. What kind of toilet facilities does your household have?

FLUSH TOILET 11
PIT TOILET/LATRINE
UNCOVERED LATRINE 21
COVERED LATRINE 22
VENTILATED IMPROVED PIT LATRINE 23
NO FACILITY/BUSH/FIELD 31(GO TO 25)
OTHER (SPECIFY) _____ 96

24. Do you share this toilet facility with other households?

YES 1
NO 2

25. Does your household have:

Electricity?
A radio?
A television?
A telephone?
A refrigerator?
A portable stove/gas or electric stove?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
PORTABLE STOVE/GAS OR ELECTRIC STOVE
YES 1
NO 2

26. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
BOTTLED GAS 02 [note: This may be either LPG (liquefied petroleum gas)/natural gas]
BIOGAS 03
KEROSENE 04
CHARCOAL 05
WOOD 06
SAWDUST 07
OTHER (SPECIFY) _____ 96

27. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD/OTHER PLANT 21
FINISHED FLOOR
CEMENT 31
TILE 32
OTHER MODERN MATERIAL 33
OTHER (SPECIFY) _____ 96

28. Does any member of your household own:

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

BICYCLE
YES 1
NO 2
MOTORCYCLE OR MOTOR SCOOTER
YES 1
NO 2
CAR OR TRUCK
YES 1
NO 2

29. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 35)

29A. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS _____

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

OBSERVED 1
NOT OBSERVED 2

31. How long ago did your household obtain this mosquito net?

NUMBER OF MONTHS _____
3 YEARS OR MORE 96

32. How much did this net cost?

COST _____

FREE 99995
DOESN'T KNOW 99996

32A. When you got the net, was it treated with an insecticide to kill or repel mosquitoes?

YES 1
NO 2
UNSURE/DOESN'T KNOW 8

32B. Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

YES 1
NO 2 (GO TO 32D)
UNSURE/DOESN'T KNOW 8 (GO TO 32D)

32C. How much time has passed since the mosquito net was last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'.

MONTHS AGO _____

3 YEARS OR MORE 95
UNSURE/DOESN'T KNOW 98

32D. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 32F)
DOESN'T KNOW 8 (GO TO 32F)

32E. Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LIST UP TO 5 PEOPLE PER NET.

NAME _____
LINE NUMBER _____

32F. GO BACK TO QUESTION 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 32G. IF MORE THAN THREE NETS, USE AN ADDITIONAL QUESTIONNAIRE.

32G. CHECK 32B ALL COLUMNS

AT LEAST ONE 'YES' (GO TO 32H)
NO 'YES' (GO TO 35)

32H. What is the cost to saturate or re-saturate a mosquito net?

PRICE _____

FREE 99995
DOESN'T KNOW 99996

35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT USED FOR HOUSEHOLD NEEDS, THEN TEST THE SALT TO VERIFY THE PRESENCE OF IODINE.

NON-IODINE SALT 1
IODINE SALT 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (GIVE REASON) _____ 6

35A. CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES (GO TO 36)
NO (END OF HOUSEHOLD QUESTIONNAIRE)

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT

CHECK COLUMNS 8 AND 9 FROM HOUSEHOLD LISTING; RECORD THE LINE NUMBER, NAME, AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN BORN IN 2000 OR LATER.

FOR WOMEN AGE 15-49:

36. LINE NUMBER (FROM COL. 8 OF HOUSEHOLD LISTING):

LINE NO. _____

37. NAME (FROM COL. 2 OF HOUSEHOLD LISTING):

NAME ______

38. AGE (FROM COL. 7 OF HOUSEHOLD LISTING):

YEARS _____

FOR CHILDREN UNDER AGE 6:

36. LINE NUMBER (FROM COLUMN 9 OF HOUSEHOLD LISTING)

LINE NO. _____

37. NAME (FROM COLUMN 2 OF HOUSEHOLD LISTING):

NAME _____

38. AGE (FROM COLUMN 7 OF HOUSEHOLD LISTING)

AGE _____

39. What is (NAME)'s date of birth?

FOR THE CHILDREN NOT INCLUDED IN ANY OF THE 2 SECTIONS RELATING TO REPRODUCTION (ORPHANS, ADOPTED CHILDREN, ETC.) ASK THE DAY, THE MONTH, AND THE YEAR OF BIRTH. FOR ALL OTHER CHILDREN, COPY THE MONTH AND THE YEAR OF QUESTION 215 IN SECTION 2 OF THEIR MOTHER AND ASK THE DATE OF BIRTH.

DAY _____
MONTH _____
YEAR _____

WEIGHT AND HEIGHT MEASUREMENTS OF WOMEN 15-49:

40. WEIGHT (KILOGRAMS):

KG ______

41. HEIGHT (CENTIMETERS):

CM ______

43. RESULT:

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER

WEIGHT AND HEIGHT MEASUREMENTS OF CHILDREN BORN IN 2000 OR LATER:

40. WEIGHT (KILOGRAMS):

KG ______

41. HEIGHT (CENTIMETERS):

CM ______

42. MEASURED LYING DOWN OR STANDING UP:

LYING DOWN 1
STANDING UP 2

43. RESULT:

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEMS
6 OTHER

TICK HERE IF CONTINUATION SHEET USED _____

HEMOGLOBIN LEVEL OF WOMEN 15-49 YEARS:

44. CHECK COLUMN 38:

AGES 15-17 YEARS 1
AGES 18-49 YEARS 2 (GO TO 46)

45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

PARENT/RESPONSIBLE ADULT'S LINE NO. _____

46. READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT:
CIRCLE CODE (AND SIGN).

GRANTED 1 (SIGN) _____
REFUSED 2 (GO TO 49)

CONSENT STATEMENT:

As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in 2000 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. 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. The blood will be tested for anemia immediately, and the results told to you right away. The results will be kept strictly confidential.

May I now ask that you (and NAME OF CHILD(REN)) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

47. HEMOGLOBIN LEVEL (G/DL):

G/DL ______

48. CURRENTLY PREGNANT?

YES 1
NO/DOESN'T KNOW 2

49. RESULT:

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEM
6 OTHER

HEMOGLOBIN MEASUREMENT OF CHILDREN BORN IN 2000 OR LATER:

45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

PARENT/RESPONSIBLE ADULT'S LINE NO. ______

46. READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT:
CIRCLE CODE (AND SIGN).

GRANTED 1 (SIGN) _____
REFUSED 2 (GO TO 49)

CONSENT STATEMENT:

As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born in 2000 or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. 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. The blood will be tested for anemia immediately, and the results told to you right away. The results will be kept strictly confidential.

May I now ask that you (and NAME OF CHILD(REN)) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

47. HEMOGLOBIN LEVEL (G/DL):

G/DL _______

49. RESULT:

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEM
6 OTHER

HEMOGLOBIN MEASUREMENT OF MEN AGE 15-59 YEARS

CHECK COLUMNS 9A, 2, AND 7; RECORD THE LINE NUMBER, NAME, AND AGE OF ALL MEN AGE 15-59.

50. LINE NUMBER (FROM COL. 9A):

LINE NO. _____

51. NAME (FROM COL. 2):

NAME _____

52. AGE (FROM COL. 7):

YEARS______

53. CHECK COLUMN 52:

AGE 15-17 YEARS 1
AGE 18-59 YEARS 2 (GO TO 55)

54. LINE NUMBER OF PARENT/RESPONSIBLE ADULT
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

PARENT/RESPONSIBLE ADULT'S LINE NO. _____

55. READ CONSENT STATEMENT TO MAN/PARENT/RESPONSIBLE ADULT:
CIRCLE CODE (AND SIGN).

GRANTED 1 (SIGN) _____
REFUSED 2 (GO TO 57)

CONSENT STATEMENT:

As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. The blood will be tested for anemia immediately, and the results told to you right away. The results will be kept strictly confidential.

May I now ask that you participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

56. HEMOGLOBIN LEVEL (G/DL):

G/DL_____

57. RESULT:

1 MEASURED
2 NOT PRESENT
3 REFUSED
4 TECHNICAL PROBLEM
6 OTHER

TICK HERE IF CONTINUATION SHEET USED _____

58. CHECK COLUMNS 47, 48 (FOR WOMEN) AND 56 (FOR MEN):
NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW CUTOFF POINT.

THE CUTOFF POINT IS 9G/DL FOR PREGNANT WOMEN, AND 7G/DL FOR CHILDREN, FOR MEN, AND FOR WOMEN WHO ARE NOT PREGNANT (OR WHO DON'T KNOW IF THEY ARE PREGNANT).

ONE OR MORE: GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND GO TO 59.

NONE: GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND THIS IS THE END OF THE HOUSEHOLD QUESTIONNAIRE

59. We have detected a low hemoglobin level in (your blood/the blood of NAME OF CHILD/CHILDREN). This means that (you/NAME OF CHILD/CHILDREN) are/is severely anemic, which is a serious health problem. We recommend that you go to a health center as soon as possible for examination and treatment. GIVE RESPONDENT REFERENCE CARD FOR ANEMIA AND GO TO 60.

INFORMED CONSENT (HIV TEST)

INFORMED CONSENT FOR ADULT 18 YEARS OR OLDER:

In the survey, we are doing a study of HIV/AIDS among women aged 15-49 and men aged 15-59. You are aware, perhaps, that HIV is the virus that causes AIDS. AIDS is a serious illness, usually deadly. We are in the process of doing an HIV test to measure the severity of the AIDS problem in Guinea.

For the HIV test, we ask all the eligible women and men in the country to give a few drops of blood from a finger. To obtain the drops we use a sterile instrument made of new materials for one-time use. They have never been used before you, and they will not be used after.

The blood is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, I will give you a reference sheet for you to go to the Prevention and Voluntary Screening Center for a free test.

Do you have any questions?
Now, will you participate in the study? (GO TO COLUMN 67 AND CIRCLE THE APPROPRIATE CODE)

INFORMED CONSENT FOR YOUNG PEOPLE AGE 15-17:

1ST STAGE: ASK FOR INFORMED CONSENT OF PARENT/RESPONSIBLE ADULT:
The HIV/AIDS study includes young women and men starting at 15 years. For the HIV test of these young people aged 15-17, we ask their parents or a responsible adult to give their consent, and we also ask to get the consent of the young person.

We ask that the young person, (NAME), participate in the HIV by giving us a few drops of blood from a finger. To obtain these drops of blood we use sterile, non-reusable instruments made of new materials. They have never been used before you, and they will not be used after.

The blood is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, I will give (NAME OF YOUNG PERSON) a reference sheet for him/her to go to the Prevention and Voluntary Screening Center for a free test.

Now, can (NAME) participate in the study? (GO TO COLUMN 66 AND CIRCLE THE APPROPRIATE CODE)

2ND STAGE: INFORMED CONSENT OF YOUNG PERSON:
IF THE PARENT/RESPONSIBLE ADULT OF THE YOUNG PERSON ACCEPTS THAT HE/SHE PARTICIPATES IN A TEST, READ THE INFORMED CONSENT TO THE YOUNG PERSON.

In the survey, we are doing a study of HIV/AIDS among women aged 15-49 and men aged 15-59. You are aware, perhaps, that HIV is the virus that causes AIDS. AIDS is a serious illness, usually deadly. We are in the process of doing an HIV test to measure the severity of the AIDS problem in Guinea.

For the HIV test, we ask all the eligible women and men in the country to give a few drops of blood from a finger. To obtain the drops we use a sterile instrument made of new materials for one-time use. They have never been used before you, and they will not be used after.

The blood is then sent to a lab to be analyzed. No names will be revealed or tied to the result. As such, we cannot give you the results of the test. No one else will then know the results of your blood test. Meanwhile, I will give you a reference sheet for you to go to the Prevention and Voluntary Screening Center for a free test.

Do you have any questions?
Now, will you participate in the study? (GO TO COLUMN 67 AND CIRCLE THE APPROPRIATE CODE)

[DO NOT FORGET TO GIVE EACH ELIGIBLE PERSON A REFERENCE SHEET FOR THE VOLUNTARY FREE TEST.]

HIV TEST -WOMEN AND MEN

TOTAL NUMBER OF SAMPLES _____

CHECK COLUMNS 8 AND 9A IN THE HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER, THE NAME, THE SEX, AND THE AGE OF ALL WOMEN 15-49 AND MEN 15-59. THIS SHEET SHOULD BE DESTROYED AT THE OFFICE BEFORE THE RESULTS OF THE TEST ARE SENT, BASED ON THE DATA OF THE EDSG III (HEATH AND DEMOGRAPHIC SURVEY OF GUINEA).

60. LINE NUMBER (FROM COLUMN 8 OR COLUMN 9A):

LINE NO. ______

61. NAME (FROM COLUMN 2):

NAME _____

62. SEX (FROM COLUMN 4):

MALE 1
FEMALE 2

63. AGE (FROM COLUMN 7):

YEARS_____

64. CHECK THE AGE (FROM COLUMN 63):

AGE 15-17 YEARS 1
AGE 18 YEARS OR OLDER 2 (GO TO 67)

65. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:

PARENT/ RESPONSIBLE ADULT'S NO._____

66. READ THE CONSENT TO THE PARENT OR RESPONSIBLE ADULT.
CIRCLE THE CODE (AND SIGN).

AGREED 1 (SIGN) _____
REFUSED 2
NOT READ 3

67. READ THE CONSENT TO THE WOMAN/MAN OR THE YOUNG PERSON
CIRCLE THE CODE (AND SIGN).

AGREED 1 (SIGN) _____
REFUSED 2
NOT READ 3

68. RESULT

1 SAMPLING DONE
2 REFUSED
3 ABSENT
4 TECHNICAL PROBLEM
6 OTHER (SPECIFY) _____

69. BARCODE LABELS
PUT THE 1ST STICKER HERE. STICK THE 2ND STICKER ON THE FILTER PAPER OF THE SURVEYED PERSON AND THE 3RD ON THE SHEET THAT TRANSMITS THE SAMPLING

TICK HERE IF CONTINUATION SHEET USED _____