IDENTIFICATION:

PLACE NAME ____

NAME OF HOUSEHOLD HEAD ____

EA NUMBER ____

HOUSEHOLD NUMBER ____

INTERVIEWER VISITS:

FIRST VISIT:
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT:
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

NEXT VISIT:
DATE ____
TIME ____

THIRD VISIT:
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

FINAL VISIT:
DAY ____
MONTH ____
YEAR 2014
INT. NUMBER ____
RESULT CODE**

TOTAL NUMBER OF VISITS ____

**RESULT CODES:

LANGUAGE OF QUESTIONNAIRE*** 2

LANGUAGE OF QUESTIONNAIRE*** ENGLISH

LANGUAGE OF INTERVIEW***

***LANGUAGE CODES:

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

201) FROM THE LIST OF ELIGIBLE CHILDREN, RECORD THE NAME AND LINE NUMBER IN QUESTION 202 IN THE SAME ORDER THEY APPEAR. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) CHILD'S NAME:
CHILD'S LINE NUMBER:

203) 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?

208A) RECORD MUAC IN CENTIMETERS:

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

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 all children born in 2009 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.

212) RECORD HAEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET:

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 216.

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

214) FROM THE LIST OF ELIGIBLE WOMEN, RECORD THE NAME, LINE NUMBER, AGE, AND MARITAL STATUS IN QUESTION 215 IN THE SAME ORDER THEY APPEAR. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) NAME:
LINE NUMBER:
AGE:
MARITAL STATUS:

216) WEIGHT IN KILOGRAMS:

217) HEIGHT IN CENTIMETERS:

218) AGE: CHECK 215

219) MARITAL STATUS: CHECK 215

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

221) ASK FOR CONSENT FOR ANAEMIA 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 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?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) ASK FOR 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?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

225) Are you pregnant?

226) AGE: CHECK 215

227) MARITAL STATUS: CHECK 215

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 Lesotho.

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 her with a list of [nearby] facilities offering counseling and testing for HIV.

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 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 Lesotho.

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.

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 215

233) MARITAL STATUS: CHECK 215

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 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?

235) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

236) 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?

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 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 245.

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

243) FROM THE LIST OF ELIGIBLE MEN, RECORD THE NAME, LINE NUMBER, AGE, AND MARITAL STATUS IN QUESTION 244 IN THE SAME ORDER THEY APPEAR. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

244) NAME:
LINE NUMBER:
AGE:
MARITAL STATUS:

245) WEIGHT IN KILOGRAMS:

246) HEIGHT IN CENTIMETERS:

247) AGE: CHECK 244

248) MARITAL STATUS: CHECK 244

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

250) ASK CONSENT FOR ANAEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION 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?

251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

252) 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?

253) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

254) AGE: CHECK 244

255) MARITAL STATUS: CHECK 244

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 Lesotho.

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

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 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 Lesotho.

For the HIV test, we need a few more 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. 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.

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 244

261) MARITAL STATUS: CHECK 244

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).

268) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

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 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.