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NATIONAL FAMILY HEALTH SURVEY, INDIA 2015-2016 (NFHS-4)
BIOMARKER QUESTIONNAIRE [STATE NAME]

IDENTIFICATION:

STATE_____

DISTRICT_____

TEHSIL/TALUK_____

CITY/TOWN/VILLAGE_____

TYPE OF PSU

URBAN 1
RURAL 2

PSU NUMBER _______

STRUCTURE NUMBER _____

HOUSEHOLD NUMBER_____

NAME OF HOUSEHOLD HEAD_____

ADDRESS OF HOUSEHOLD_____

IS HOUSEHOLD SELECTED FOR THE STATE MODULE

YES 1
NO 2

HEALTH INVESTIGATOR VISITS:

FIRST VISIT
DATE__

NEXT VISIT
DATE__
TIME__

SECOND VISIT
DATE__

NEXT VISIT
DATE__
TIME__

THIRD VISIT
DATE__

FINAL VISIT
DAY__
MONTH__
YEAR__

TOTAL NUMBER OF VISITS____

LANGUAGE OF QUESTIONNAIRE

LANGUAGE CODES

01 = ASSAMESE
02 = BENGALI
03 = GUJARATI
04 = HINDI
05 = KANNADA
06 = KASHMIRI
07 = KONKANI
08 = MALAYALAM
09 = MANIPURI
10 = MARATHI
11 = NEPALI
12 = ORIYA
13 = PUNJABI
14 = SINDHI
15 = TAMIL
16 = TELUGU
17 = UDRU
18 = ENGLISH
19 = GARO
20 = KHASI
96 = OTHER (SPECIFY)_______

TOTAL NUMBER OF ELIGIBLE WOMEN__
TOTAL NUMBER OF ELIGIBLE CHILDREN__
TOTAL NUMBER OF ELIGIBLE MEN__

SUPERVISOR
NAME____
DATE___

HEALTH INVESTIGATOR
NAME___
DATE___

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

201) FROM THE LIST OF ELIGIBLE CHILDREN, RECORD THE NAME AND LINE NUMBER IN THE SAME ORDER THEY APPEAR.
IF MORE THAN SIX CHILDREN, USE AN ADDITIONAL QUESTIONNAIRE(S).

202) NAME
LINE NUMBER

NAME___
LINE NUMBER___

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

DAY__
MONTH__
YEAR__

204) CHECK 203:

CHILD BORN IN JANUARY 2011 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 303)

205) WEIGHT IN KILOGRAMS

KILOGRAMS___
NOT PRESENT 9994 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 303)
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CENTIMETERS___
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

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

0-5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 303)
OLDER 2

209) NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD

NAME___

210) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. We ask that children born in 2011 or later take part in anaemia 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 anaemia 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 anaemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
REFUSED 2
GRANTED (NO SIGNATURE) 3
__________(SIGN)

212) RECORD THE HAEMOGLOBIN LEVEL HERE AND IN THE ANAEMIA PAMPHLET.

G/DL____
REFUSED 995
OTHER 996

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 303.

WEIGHT, HEIGHT, BLOOD PRESSURE, BLOOD GLUCOSE, HAEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49

301) FROM THE LIST OF ELIGIBLE WOMEN, RECORD THE NAME, LINE NUMBER, AGE, AND MARITAL STATUS IN THE SAME ORDER THE APPEAR. WRITE THE NAME OF EACH WOMAN AT THE TOP OF THE FOLLOWING PAGES

302) NAME___

LINE NUMBER___

AGE___

MARITAL STATUS

NEVER MARRIED 1
OTHER 2

303) WEIGHT IN KILOGRAMS

KILOGRAMS___
NOT PRESENT 99994 (GO TO 303 FOR NEXT WOMAN OR, IF NO MORE WOMEN, GO TO 403)
REFUSED 99995
OTHER 99996

304) HEIGHT IN CENTIMETERS

CENTIMETERS___
REFUSED 9995
OTHER 9996

305) AGE:
CHECK 302.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 310)

306) MARITAL STATUS:
CHECK 302.

NEVER MARRIED 1
OTHER 2 (GO TO 310)

307) RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

NAME___

308) ASK FOR CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 307 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.
I would like to measure (NAME OF ADOLESCENT)’s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)’s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.
Will you allow me to measure (NAME OF ADOLESCENT)'s blood pressure?

309) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, TO GO 340)

310) ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.
I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 me to measure your blood pressure?

311) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 338)

312) Before taking you blood pressure, I would like to ask a few questions about things that may affect these measurements. Have you done any of the following within the past 30 minutes:

a) Eaten anything?
YES 1
NO 2
b) Had coffee, tea, cola, or other drink that has caffeine?
YES 1
NO 2
c) Smoked any tobacco product?
YES 1
NO 2
d) Used any other type of tobacco such as ghutka, pan masala with tobacco other chewing tobacco or snuff?
YES 1
NO 2

313) May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment.

ARM CIRCUMFERENCE (IN CENTIMETRES)___
MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETRES.

314) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.

SMALL: 17 CM - 22 CM 1
MEDIUM: 22 CM - 32 CM 2
LARGE: 32 CM - 42 CM 3

315) RECORD TIME OF FIRST BP READING

HOURS___ MINUTES___

316) TAKE THE FIRST BLOOD PRESSURE READING, RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE

SYSTOLIC____
DIASTOLIC____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996
(IF NOT MEASURED, GO TO 338)

317) Before this survey, has your blood pressure ever been checked?

YES 1
NO 2

318) Were you told on two or more different occasions by a doctor or health professional that you had hypertension or high blood pressure?

YES 1
NO 2

319) To lower your blood pressure, are you now taking a prescribed medicine?

YES 1
NO 2

320) CHECK THAT IT HAS BEEN AT LEAST FIVE MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT

321) May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 332)

322) RECORD TIME OF SECOND BP READING

HOURS___MINUTES___

323) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC____
DIASTOLIC____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHERS 996
(IF NOT MEASURED, GO TO 332)

324) CHECK THAT IT HAS BEEN AT LEAST FIVE MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT

325) May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 334)

326) RECORD TIME OF THIRD BP READING

HOURS___MINUTES___

327) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC____
DIASTOLIC____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHERS 996
(IF NOT MEASURED, GO TO 334)

328) RECORD THE SUM OF THE SYSTOLIC MEASURES FROM 323 AND 327.

SUM SYSTOLIC___

329) CALCULATE THE AVERAGE SYSTOLIC PRESSURES BY DIVIDING THE SUM IN 328 BY 2.

AVERAGE SYSTOLIC____
CIRCLE IN 336

330) RECORD THE SUM OF THE DIASTOLIC MEASURES FROM 323 AND 327.

SUM DIASTOLIC___

331) CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVIDING THE SUM IN 330 BY 2.

AVERAGE DIASTOLIC____
CIRCLE IN 336 AND SKIP TO 336

331A) IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE.

332) RECORD THE SYSTOLIC MEASURE FROM 316.

SYSTOLIC____
CIRCLE IN 336

333) RECORD THE DIASTOLIC MEASURE FROM 316.

DIASTOLIC____
CIRCLE IN 336 AND SKIP TO 336

333A) IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECOND SYSTOLIC AND DIASTOLIC NUMBERS HERE.

334) RECORD THE SYSTOLIC MEASURE FROM 323.

SYSTOLIC____
CIRCLE IN 336

335) RECORD THE DIASTOLIC MEASURE FROM 323.

DIASTOLIC____
CIRCLE IN 336

336) CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.

If AVERAGE SYSTOLIC is less than 120.
If AVERAGE DIASTOLIC IS:
Less than 80 = 1
Less than 85 = 2
85-89 = 3
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is less than 130.
If AVERAGE DIASTOLIC IS:
Less than 80 = 2
Less than 85 = 2
85-89 = 3
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is 130-139.
If AVERAGE DIASTOLIC IS:
Less than 80 = 3
Less than 85 = 3
85-89 = 3
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is 140-159.
If AVERAGE DIASTOLIC IS:
Less than 80 = 4
Less than 85 = 4
85-89 = 4
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is 160-179.
If AVERAGE DIASTOLIC IS:
Less than 80 = 5
Less than 85 = 5
85-89 = 5
90-99 = 5
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is greater than or equal to 180.
If AVERAGE DIASTOLIC IS:
Less than 80 = 6
Less than 85 = 6
85-89 = 6
90-99 = 6
100-109 = 6
Greater than or equal to 110 = 6

337) RECORD THE NUMBER YOU CIRCLED IN 336 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS.

If number circled in 336 is 1.
Respondent’s blood pressure category is: Normal (optimal)
Consult health provider to check blood pressure within: 1 year
If number circled in 336 is 2.
Respondent’s blood pressure category is: Normal (mildly high)
Consult health provider to check blood pressure within: 1 year
If number circled in 336 is 3.
Respondent’s blood pressure category is: Normal (moderately high)
Consult health provider to check blood pressure within: 2 months
If number circled in 336 is 4.
Respondent’s blood pressure category is: Abnormal (mildly elevated)
Consult health provider to check blood pressure within: 1 month
If number circled in 336 is 5.
Respondent’s blood pressure category is: Abnormal (moderately elevated)
Consult health provider to check blood pressure within: 1 week
If number circled in 336 is 6.
Respondent’s blood pressure category is: Abnormal (severely elevated)
Consult health provider to check blood pressure within: Immediately

338) AGE: CHECK 302.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 342)

339) MARITAL STATUS: CHECK 302.

NEVER MARRIED 1
OTHER 2 (GO TO 342)

340) ASK FOR CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 307 AS RESPONSBILE FOR NEVER MARRIED WOMEN AGE 15-17.
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. For the anaemia 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 anaemia 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.

Do you have any questions?
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 anaemia test?

341) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 347)

342) ASK CONSENT FOR ANAEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. For the anaemia 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 anaemia 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 anaemia test?

343) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
_________(SIGN)
(IF REFUSED, TO GO 345)

344) Are you pregnant now?

YES 1
NO 2
DK 8

345) AGE: CHECK 302.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 349)

346) MARITAL STATUS: CHECK 302.

NEVER MARRIED 1
OTHER 2 (GO TO 349)

347) ASK CONSENT FOR BLOOD GLUCOSE FROM PARENT/OTHER ADULT IDENTIFIED IN 307 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.
As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you and (NAME OF ADOLESCENT) with an explanation of the meaning of the blood sugar numbers. If (NAME OF ADOLESCENT)'S blood sugar is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having (NAME OF ADOLESCENT)'s blood sugar measured now.
Will you allow me to proceed to take (NAME OF ADOLESCENT)'s measurement?

348) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
________(SIGN)
(IF REFUSED, TO GO 353)

349) ASK CONSENT FOR BLOOD GLUCOSE FROM RESPONDENT.
As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you with an explanation of the meaning of your blood sugar numbers. If your blood sugar is high, we will suggest that you consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having your blood sugar measured now.
Will you allow me to proceed to take your measurement?

350) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
________(SIGN)
(IF REFUSED, GO TO 353)

351) When was the last time you had something to eat?

HOURS AGO___
IF LESS THAN 1 HOUR, RECORD '00'

352) When was the last time you had something to drink other than plain water?

HOURS AGO___
IF LESS THAN 1 HOUR, RECORD '00'

353) CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR STATE MODULE?

YES__(GO TO 354)
NO__ (GO TO 367)

354) AGE: CHECK 302.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 358)

355) MARITAL STATUS: CHECK 302.

NEVER MARRIED 1
OTHER 2 (GO TO 358)

356) ASK CONSENT FOR DBS COLLECTION FROM PARENT/ OTHER ADULT IDENTIFIED IN 307 AS RESPONSIBLE FOR NEVER MARRIED 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 India. 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 counselling 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?

357) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
________(SIGN)
(IF REFUSED, GO TO 367)

358) ASK FOR 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 India. 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 counselling 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?

359) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE)
________(SIGN)
(IF REFUSED, GO TO 367)

360) AGE: CHECK 302.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 364)

361) MARITAL STATUS: CHECK 302.

NEVER MARRIED 1
OTHER 2 (GO TO 364)

362) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 307 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.
We ask you to allow (NAME OF AGENCY) to store part of (NAME OF ADOLESCENT)'s 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?

363) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE)
________(SIGN)
(IF REFUSED, GO TO 366)

364) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.
We ask you to allow (NAME OF AGENCY) 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?

365) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE)
________(SIGN)
(IF REFUSED, GO TO 367)

366) ADDITIONAL TESTS
CHECK 363 AND 365: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

368) RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET.

G/DL____
REFUSED 995
OTHER 996
NOT TESTED 998

369) RECORD THE TIME OF THE BLOOD GLUCOSE TEST

HOURS____MINUTES____
NOT TESTED 9996

370) RECORD BLOOD GLUCOSRE IN MG/DL

MG/DL___
REFUSED 995
OTHER 996
NOT TESTED 998

371) BAR CODE LABEL

REFUSED 999994
NOT SELECTED 999995
OTHER 999996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRASNMITTAL FORM.

372) GO BACK TO 303 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 403.

WEIGHT, HEIGHT, BLOOD PRESSURE, BLOOD GLUCOSE, HAEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-54

401) CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR STATE MODULE?

YES__(FROM THE LIST OF ELIGIBLE MEN, RECORD THE NAME, LINE NUMBER, AGE, AND MARITAL STATUS IN THE SAME ORDER THEY APPEAR. WRITE THE NAME OF EACH MAN AT THE TOP OF THE FOLLOWING PAGES. IF THERE ARE MORE THAN THREE MEN, USE AN ADDITIONAL QUESTIONNAIRE(S).)
NO__ END INTERVIEW

402) NAME___

LINE NUMBER___

AGE___

MARITAL STATUS

NEVER MARRIED 1
OTHER 2

403) WEIGHT IN KILOGRAMS

KILOGRAMS___
NOT PRESENT 99994 (GO TO 303 FOR NEXT MAN OR, IF NO MORE MEN, END INTERVIEW.)
REFUSED 99995
OTHER 99996

404) HEIGHT IN CENTIMETERS

CENTIMETERS___
REFUSED 9995
OTHER 9996

405) AGE: CHECK 402.

15-17 YEARS 1
18-54 YEARS 2 (GO TO 410)

406) MARITAL STATUS: CHECK 402.

NEVER MARRIED 1
OTHER 2 (GO TO 410)

407) RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

NAME_____

408) ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/ OTHER ADULT IDENTIFIED IN 407 AS RESPONSIBLE FOR NEVER MARRIED MEN AGE 15-17.
I would like to measure (NAME OF ADOLESCENT)’s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)’s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 for (NAME OF ADOLESCENT) or you can say no. It is up to you to decide.
Will you allow me to measure (NAME OF ADOLESCENT)’s blood pressure?

409) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
__________(SIGN)
(IF REFUSED, GO TO 440)

410) ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.
I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 me to measure your blood pressure?

411) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
REFUSED 2
GRANTED (NO SIGNATURE) 3
__________(SIGN)
(IF REFUSED, GO TO 438)

412) Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements. Have you done any of the following within the past 30 minutes:

a) Eaten anything?
YES 1
NO 2
b) Had coffee, tea, cola, or other drink that has caffeine?
YES 1
NO 2
c) Smoked any tobacco product?
YES 1
NO 2
d) Used any other type of tobacco such as ghutka, pan masala with tobacco other chewing tobacco or snuff?
YES 1
NO 2

413) May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment.

ARM CIRCUMFERENCE (IN CENTIMETRES)____
MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETRES.

414) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF SIZE. CIRCLE THE CODE FOR THE CUFF SIZE.

SMALL: 17 CM - 22 CM 1
MEDIUM: 22 CM - 32 CM 2
LARGE: 32 CM - 42 CM 3

415) RECORD TIME OF FIRST BP READING

HOURS____MINUTES____

416) TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC____
DIASTOLIC____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHER 996
(IF NOT MEASURED, GO TO 438)

417) Before this survey, has your blood pressure ever been checked?

YES 1
NO 2

418) Were you told on two or more different occasions by a doctor or other health professional that you had hypertension or high blood pressure?

YES 1
NO 2

419) To lower your blood pressure, are you now taking a prescribed medicine?

YES 1
NO 2

420) CHECK THAT IS HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT

421) May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 432)

422) RECORD TIME OF SECOND BP READING

HOURS____MINUTES____

423) TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC____
DIASTOLIC____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHERS 996
(IF NOT MEASURED, GO TO 432)

424) CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT.

425) May I take your blood pressure at this time?

YES 1
NO 2 (GO TO 434)

426) RECORD TIME OF THIRD BP READING

HOURS____MINUTES____

427) TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

SYSTOLIC____
DIASTOLIC____
REFUSED 994
TECHNICAL PROBLEMS 995
OTHERS 996
(IF NOT MEASURED, GO TO 434)

428) RECORD THE SUM OF THE SYSTOLIC MEASURES FROM 423 AND 427.

SUM SYSTOLIC___

429) CALCULATE THE AVERAGE SYSTOLIC PRESSURES BY DIVIDING THE SUM IN 428 BY 2.

AVERAGE SYSTOLIC____
CIRCLE IN 436

430) RECORD THE SUM OF THE DIASTOLIC MEASURES FROM 423 AND 427.

SUM DIASTOLIC___

431) CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVIDING THE SUM IN 430 BY 2.

AVERAGE DIASTOLIC____
CIRCLE IN 436 AND SKIP TO 436

431A) IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE.

432) RECORD THE SYSTOLIC MEASURE FROM 416.

SYSTOLIC____
CIRCLE IN 436

433) RECORD THE DIASTOLIC MEASURE FROM 416.

DIASTOLIC____
CIRCLE IN 436 AND SKIP TO 436

433A) IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECOND SYSTOLIC AND DIASTOLIC NUMBERS HERE.

434) RECORD THE SYSTOLIC MEASURE FROM 423.

SYSTOLIC____
CIRCLE IN 436

435) RECORD THE DIASTOLIC MEASURE FROM 423.

DIASTOLIC____
CIRCLE IN 436

436) CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.

If AVERAGE SYSTOLIC is less than 120.
If AVERAGE DIASTOLIC IS:
Less than 80 = 1
Less than 85 = 2
85-89 = 3
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is less than 130.
If AVERAGE DIASTOLIC IS:
Less than 80 = 2
Less than 85 = 2
85-89 = 3
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is 130-139.
If AVERAGE DIASTOLIC IS:
Less than 80 = 3
Less than 85 = 3
85-89 = 3
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is 140-159.
If AVERAGE DIASTOLIC IS:
Less than 80 = 4
Less than 85 = 4
85-89 = 4
90-99 = 4
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is 160-179.
If AVERAGE DIASTOLIC IS:
Less than 80 = 5
Less than 85 = 5
85-89 = 5
90-99 = 5
100-109 = 5
Greater than or equal to 110 = 6
If AVERAGE SYSTOLIC is greater than or equal to 180.
If AVERAGE DIASTOLIC IS:
Less than 80 = 6
Less than 85 = 6
85-89 = 6
90-99 = 6
100-109 = 6
Greater than or equal to 110 = 6

437) RECORD THE NUMBER YOU CIRCLED IN 436 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS.

If number circled in 436 is 1.
Respondent’s blood pressure category is: Normal (optimal)
Consult health provider to check blood pressure within: 1 year
If number circled in 436 is 2.
Respondent’s blood pressure category is: Normal (mildly high)
Consult health provider to check blood pressure within: 1 year
If number circled in 436 is 3.
Respondent’s blood pressure category is: Normal (moderately high)
Consult health provider to check blood pressure within: 2 months
If number circled in 436 is 4.
Respondent’s blood pressure category is: Abnormal (mildly elevated)
Consult health provider to check blood pressure within: 1 month
If number circled in 436 is 5.
Respondent’s blood pressure category is: Abnormal (moderately elevated)
Consult health provider to check blood pressure within: 1 week
If number circled in 436 is 6.
Respondent’s blood pressure category is: Abnormal (severely elevated)
Consult health provider to check blood pressure within: Immediately

438) AGE: CHECK 402.

15-17 YEARS 1
18-54 YEARS 2 (GO TO 442)

439) MARITAL STATUS: CHECK 402.

NEVER MARRIED 1
OTHER 2 (GO TO 442)

440) ASK FOR CONSENT FOR THE ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 407 AS RESPONSIBLE FOR THE NEVER MARRIED MEN AGE 15-17.
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. For the anaemia 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 anaemia 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.
Do you have any questions?
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 anaemia test?

441) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, TO GO 446)

442) ASK CONSENT FOR ANAEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. For the anaemia 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 anaemia 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 anaemia test?

443) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, TO GO 446)

444) AGE: CHECK 402.

15-17 YEARS 1
18-54 YEARS 2

445) MARITAL STATUS: CHECK 402.

NEVER MARRIED 1
OTHER 2 (GO TO 448)

446) ASK FOR CONSENT FOR BLOOD GLUCOSE FROM PARENT/OTHER ADULT IDENTIFIED IN 407 AS RESPONSIBLE FOR NEVER MARRIED MEN AGE 15-17.
As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you and (NAME OF ADOLESCENT) with an explanation of the meaning of the blood sugar numbers. If (NAME OF ADOLESCENT)'S blood sugar is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having (NAME OF ADOLESCENT)'s blood sugar measured now.
Will you allow me to proceed to take (NAME OF ADOLESCENT)'s measurement?

447) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 453)

448) ASK CONSENT FOR BLOOD GLUCOSE FROM RESPONDENT.
As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you with an explanation of the meaning of your blood sugar numbers. If your blood sugar is high, we will suggest that you consult a health facility or doctor since we cannot provide any counselling, further testing or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having your blood sugar measured now.
Will you allow me to proceed to take your measurement?

449) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 453)

450) When was the last time you had something to eat?

HOURSE AGO____
IF LESS THAN 1 HOUR, RECORD '00'

451) When was the last time you had something to drink other than plain water?

HOURSE AGO____
IF LESS THAN 1 HOUR, RECORD '00'

453) AGE: CHECK 402.

15-17 YEARS 1
18-54 YEARS 2 (GO TO 457)

454) MARITAL STATUS: CHECK 402.

NEVER MARRIED 1
OTHER 2 (GO TO 457)

455) ASK CONSENT FOR DBS COLLECTION FROM PARENT/ OTHER ADULT IDENTIFIED IN 407 AS RESPONSIBLE FOR NEVER MARRIED 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 India. 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 counselling 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?

456) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 466)

457) 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 India. 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 counselling 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?

458) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 466)

459) AGE: CHECK 402.

15-17 YEARS 1
18-54 YEARS 2 (GO TO 463)

460) MARITAL STATUS: CHECK 402.

NEVER MARRIED 1
OTHER 2 (GO TO 463)

461) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 407 AS RESPONSIBLE FOR NEVER MARRIED MEN AGE 15-17.
We ask you to allow (NAME OF AGENCY) to store part of (NAME OF ADOLESCENT)'s 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?

462) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGNED) 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF REFUSED, GO TO 465)

463) ASK CONSENT FOR ADDITIONAL TESTING, FROM RESPONDENT.
We ask you to allow (NAME OF AGENCY) 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?

464) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
RESPONDENT REFUSED 2
GRANTED (NO SIGNATURE) 3
___________(SIGN)
(IF GRANTED, GO TO 466)

465) ADDITIONAL TESTS
CHECK 462 AND 464: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

467) RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET.

G/DL____
REFUSED 995
OTHER 996
NOT TESTED 998

468) RECORD THE TIME OF THE BLOOD GLUCOSE TEST

HOURS____MINUTES____
NOT TESTED 9996

469) RECORD BLOOD GLUCOSE IN MG/DL.

MG/DL____
REFUSED 995
OTHER 996
NOT TESTED 998

470) BAR CODE LABEL

REFUSED 999994
NOT SELECTED 999995
OTHER 999996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

471) GO BACK TO 403 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

HEALTH INVESTIGATOR'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS

COMMENTS ABOUT RESPONDENT: ______________________

COMMENTS ON SPECIFIC TESTS/QUESTIONS: __________________

ANY OTHER COMMENTS: ____________________

SUPERVISOR'S OBSERVATIONS: _______________

NAME OF SUPERVISOR: _________

DATE: ______________