IDENTIFICATION:

PLACE NAME ____

NAME OF HOUSEHOLD HEAD ____

EA NUMBER ____

HOUSEHOLD NUMBER ____

LESOTHO ECOLOGICAL ZONE

DISTRICT CODE ____

URBAN/RURAL

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:

TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

LANGUAGE OF QUESTIONNAIRE: ENGLISH 2

LANGUAGE OF QUESTIONNAIRE: ENGLISH 2

LANGUAGE OF INTERVIEW***

TRANSLATOR USED

SUPERVISOR

NAME ____
DATE ____

SECTION 1. RESPONDENT'S BACKGROUND:

INFORMED CONSENT

Hello. My name is _______________. I am with the Ministry of Health. We are conducting a survey about health all over the country. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions 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 the card that has already been given to your household.

SIGNATURE OF INTERVIEWER: ____ DATE: ____

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101) RECORD THE TIME

101B) During the interview I would like to measure your blood pressure. This will be done three times during the interview. This is a harmless procedure. It is used to find out if a person has high blood pressure. If it is 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 interview together with an explanation of the meaning of your blood pressure numbers. 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.

Do you have any questions about the blood pressure 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 the blood pressure measurement now. You can also decide at any time not to participate in the blood pressure measures.

Would you allow me to proceed to take your blood pressure measurement at this time?

SIGNATURE OF INTERVIEWER: ____
DATE: ____

RESPONDENT AGREES 1 (GO TO 101C)
RESPONDENT DOES NOT AGREE 2 (GO TO 102)

101C) 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?
b) Had coffee, tea, cola or other drink that has caffeine?
c) Smoked any tobacco product?

101D) May I begin the process of measuring your blood pressure?

BEFORE TAKING THE FIRST BLOOD PRESSURE READING, MEASURE THE CIRCUMFERENCE OF THE RESPONDENT'S ARM MIDWAY BETWEEN THE ELBOW AND THE SHOULDER. RECORD THE MEASUREMENT IN CENTIMETERS.

101E) USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE CUFF SIZE. RECORD THE CODE FOR CUFF SIZE

101F) TAKE THE FIRST BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

102) In what month and year were you born?

103) How old were you at your last birthday? COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104) Have you ever attended school?

105) What is the highest level of school you attended: primary, secondary, or higher?

106) What is the highest (standard/form/year) you completed at that level? IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

107) CHECK 105:

108) Now I would like you to read this sentence to me. SHOW CARD TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

109) CHECK 108:

110) Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

111) Do you listen to the radio at least once a week, less than once a week or not at all?

112) Do you watch television at least once a week, less than once a week or not at all?

113) What religion do you belong to?

IF CHRISTIAN: What church do you belong to?

115) In the last 12 months, how many times have you been away from home for one or more nights?

116) In the last 12 months, have you been away from home for more than one month at a time?

117) The last time you were away for more than a month, how many months were you away?

IF 12 MONTHS OR MORE, RECORD '95.'

118) Where did you go?

120) Why did you go there? PROBE: What was the main purpose of your trip?

121) CHECK 117

122) In the last 5 years, how many times have you been away from home for three or more months at a time?

123) The most recent time you were away from home for three or more months, where did you go?

124) Why did you go there? PROBE: What was the main purpose of your trip?

125) Including time you already mentioned, in the last 5 years, how many times have you been away from home for three or more months at a time?

SECTION 2. REPRODUCTION:

201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name. Have you ever fathered any children with any woman?

202) Do you have any sons or daughters that you have fathered who are now living with you?

203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'.

204) Do you have any sons or daughters that you have fathered who are alive but do not live with you?

205) How many sons are alive but do not live with you?
And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

206) Have you ever given fathered a son or a daughter who was born alive but later died? IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

207) How many boys have died?
And how many girls have died?
IF NONE, RECORD '00'.

208) SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.

209) CHECK 208:

210) Did all of the children you have fathered have the same biological mother?

211) In all, how many women have you fathered children with?

212) How old were you when your (first) child was born?

213) CHECK 203 AND 205:

214) How old is your (youngest) child?

215) CHECK 214:

216) What is the name of your (youngest) child?

WRITE NAME OF (YOUNGEST) CHILD

217) When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?

218) Were you ever present during any of those antenatal check-ups?

219) Was (NAME) born in a health facility?

220) When a child has diarrhoea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual, or nothing to drink at all?

SECTION 3. CONTRACEPTION:

301) Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.

Have you ever heard of (METHOD)?

302) In the last three months have you:

a) Heard about family planning on the radio?
b) Seen anything about family planning on the television?
c) Read about family planning in a newspaper or magazine?
d) Read about family planning on billboards, posters, or pamphlets?

303) In the last few months, have you discussed family planning with a health worker or health professional?

304) Now I would like to ask you about a woman's risk of pregnancy. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

305) Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?

306) I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.

a) Contraception is a woman's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.

307) CHECK 301 (07): KNOWS MALE CONDOM

308) Do you know of a place where a person can get male condoms?

309) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

310) If you wanted to, could you yourself get a male condom?

311) CHECK 301 (08): KNOWS FEMALE CONDOM

312) Do you know of a place where a person can get female condoms?

313) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

314) If you wanted to, could you yourself get a female condom?

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living together with a woman as if married?

402) Have you ever been married or lived together with a woman as if married?

403) What is your marital status now: are you widowed, divorced, or separated?

404) Is your (wife/partner) living with you now or is she staying elsewhere?

PROBE IF SHE IS STAYING ELSEWHERE: Elsewhere in Lesotho or outside of Lesotho?

404A) Does she stay there for work or another reason?

405) Do you have other wives or do you live with other women as if married?

406) Altogether, how many wives or live-in partners do you have?

407) CHECK 405:

ONE WIFE/PARTNER: Please tell me the name of (your wife/the woman you are living with as if married).

MORE THAN ONE WIFE/PARTNER: Please tell me the name of each of your wives or each woman you are living with as if married.

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.

IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

408) ASK 408 FOR EACH PERSON. How old was (NAME) on her last birthday?

409) CHECK 405:

410) Have you been married or lived with a woman only once or more than once?

411) In what month and year did you start living with your (wife/partner)?

411A) Now I would like to ask about your first (wife/partner). In what month and year did you start living with her?

412) How old were you when you first started living with her?

413) CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

414) Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues.

How old were you when you had sexual intercourse for the very first time?

415) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.

416) When was the last time you had sexual intercourse?

IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

417) When was the last time you had sexual intercourse with this person? [DO NOT ASK FOR LAST SEXUAL PARTNER]

418) The last time you had sexual intercourse (with this second/third person), was a condom used?

419) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

420) What was your relationship to this person with whom you had sexual intercourse?

IF GIRLFRIEND: Were you living together as if married?
IF YES, RECORD '2'.
IF NO, RECORD '3'.

421) CHECK 410:

422) CHECK 414:

423) How long ago did you first have sexual intercourse with this (second/third) person?

424) How many times during the last 12 months did you have sexual intercourse with this person?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, RECORD '95'.

425) How old is this person?

426) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

427) In total, with how many different people have you had sexual intercourse in the last 12 months?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS 95 OR MORE, RECORD '95'.

428) CHECK 420 (ALL COLUMNS):

429) CHECK 420 AND 418 (ALL COLUMNS):

430) In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

431) Have you ever paid anyone in exchange for having sexual intercourse?

432) The last time you paid someone in exchange for having sexual intercourse, was a condom used?

433) Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?

434) In total, with how many people have you had sexual intercourse in your lifetime?

IF NON-NUMERIC ANSWER PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

435) CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):

437) You told me that a condom was used the last time you had sex. From where did you obtain the condom the last time?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

438) The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

439) What method did you or your partner use?

PROBE: Did you or your partner use any other method to prevent pregnancy?

RECORD ALL MENTIONED.

SECTION 5. FERTILITY PREFERENCES

501) CHECK 401:

502) CHECK 439:

503) (Is your (wife/partner)/Are any of your (wives/partners)) currently pregnant?

504) Now I have some questions about the future. After the (child/children) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not to have any more children?

505) Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

506) CHECK 407:

507) CHECK 503:

WIFE/PARTNER NOT PREGNANT OR DON'T KNOW: How long would you like to wait from now before the birth of (a/another) child?

WIFE/PARTNER PREGNANT: After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

508) How long would you like to wait from now before the birth of (a/another) child?

509) CHECK 203 AND 205:

HAS LIVING CHILDREN: If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?

PROBE FOR A NUMERIC RESPONSE.

510) How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or a girl?

SECTION 6. EMPLOYMENT AND GENDER ROLES

600A) CHECK 101B:

600B) May I measure your blood pressure at this time?

RESPONDENT AGREES (RECORD OUTCOME OF BLOOD PRESSURE MEASUREMENT.)
RESPONDENT DOES NOT AGREE (RECORD 994)

601) Have you done any work in the last seven days?

602) Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, or any other such reason?

603) Have you done any work in the last 12 months?

604) What is your occupation, that is, what kind of work do you mainly do?

605) Do you usually work throughout the year, or do you work seasonally, or only once in a while?

606) Are you paid in cash or kind for this work or are you not paid at all?

606A) Where do you usually work? In your home community, elsewhere in Lesotho, or outside Lesotho?

606B) The last time you worked away from your home community, how long were you away from home?

607) CHECK 401:

608) CHECK 606):

609) Who usually decides how the money you earn will be used: you, your (wife/partner), or you and your (wife/partner) jointly?

610) Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly, or someone else?

611) Who usually makes decisions about making major household purchases?

612) Do you own this or any other house either alone or jointly with someone else?

613) Do you own any land either alone or jointly with someone else?

614) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

a) If she goes out without telling him?
b) If she neglects the children?
c) If she argues with him?
d) If she refuses to have sex with him?
e) If she burns the food?

SECTION 7. HIV/AIDSg

701) Now I would like to talk about something else. Have you ever heard of an illness called AIDS?

702) Can people reduce their chance of getting HIV by having just one uninfected sex partner who has no other sex partners?

703) Can people get HIV from mosquito bites?

704) Can people reduce their chance of getting HIV by using a condom every time they have sex?

705) Can people get HIV by sharing food with a person who has AIDS?

706) Can people get HIV because of witchcraft or other supernatural means?

707) Is it possible for a healthy-looking person to have HIV?

707A) Can AIDS be cured?

707B) What can cure AIDS? PROBE: Anything else?

708) Can the virus that causes AIDS be transmitted from a mother to her baby:

a) During pregnancy?
b) During delivery?
c) By breastfeeding?

709) CHECK 708:

710) Are there any special drugs that a doctor or nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby?

711) CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

712) I don't want to know the results, but have you ever been tested to see if you have HIV?

713) How many months ago was your most recent HIV test?

714) I don't want to know the results, but did you get the results of the test?

715) Where was the test done?

PROBE TO IDENTIFY TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

716) Do you know of a place where people can go to get tested for HIV?

717) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

717A) Some individuals choose not to go for HIV testing and counseling. In your opinion, why is this so? PROBE: Any other reason?

717B) CHECK 712:

717C) What is the main reason you have not been tested for HIV?

718) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

719) If a member of your family got infected with HIV, would you want it to remain a secret or not?

720) If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

721) In your opinion, if a female teacher has HIV but is not sick, should she be allowed to continue teaching in the school?

722) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

723) CHECK 701:

HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?

724) CHECK 414:

725) CHECK 723: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

726) Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

727) Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from you penis?

728) Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?

729) CHECK 726, 727, AND 728:

730) The last time you had (PROBLEM FROM 726/727/728), did you seek any kind of advice or treatment?

731) Where did you go? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

732) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

733) Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?

SECTION 8. OTHER HEALTH ISSUES

801A) Now I would like to ask you about something else. Since age 15, have you ever had the following symptoms:

a) Cough for two weeks or more?
b) Fever for two weeks or more?
c) Sweating at night?
d) Weight loss?

801B) CHECK 801A:

801C) Did you seek consultation or treatment for the symptoms?

801D) What is the main reason you did not seek treatment for the symptoms?

801E) The last time you had such symptoms, where did you first go for advice or treatment?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

801F) How soon after the symptom(s) appeared did you first seek consultation or treatment?

801G) Were you told by a doctor or a nurse that you had tuberculosis?

801H) Were you given any medicine to treat TB?

801I) How long were you told to take the medicine?

801J) Did you go anywhere else for advice or treatment after you were told that you had tuberculosis?

801K) Where did you go?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

801L) Have you ever heard of an illness called tuberculosis or TB?

802) How does tuberculosis spread from one person to another? PROBE: Any other ways?

RECORD ALL MENTIONED.

803) Can tuberculosis be cured?

804) If a member of your family got tuberculosis, would you want it to remain a secret or not?

804A) Would you be willing to work with someone who has been previously treated for tuberculosis?

804B) What signs or symptoms would lead you to think that a person has tuberculosis? PROBE: Any other signs or symptoms?

RECORD ALL MENTIONED.

804C) What do you think is the cause of tuberculosis? PROBE: Any other causes?

RECORD ALL MENTIONED.

805A) Some men are traditionally circumcised by a traditional practitioner, family member or friend. Are you traditionally circumcised?

805B) How old were you when you got traditionally circumcised?

805C) Some men are medically circumcised, that is the foreskin is completely removed from the penis by a health worker. Are you medically circumcised?

805D) How old were you when you got medically circumcised?

806) Now I would like to ask you some other questions relating to health matters. Have you had any injections for any reason in the last 12 months?

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

807) Among these injections, how many were administered by a doctor, a nurse, a dentist, or any other health worker?

IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

808) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

809) Do you currently smoke cigarettes, either manufactured or hand-rolled?

810) In the last 24 hours, how many cigarettes did you smoke?

811) Do you currently smoke or use any (other) type of tobacco?

812) What (other) type of tobacco do you currently smoke or use?

RECORD ALL MENTIONED.

812A) Now I want to talk about diabetes. Have you ever heard of an illness called diabetes?

812AA) What are symptoms of diabetes? PROBE: Any other symptoms?

RECORD ALL MENTIONED.

812B) Have you ever been told by a doctor or a nurse that you have diabetes?

812C) Are you taking medications for diabetes?

812D) How do you take the medicine?

812E) Now I want to talk about blood pressure. Before this survey, has your blood pressure ever been checked?

812F) When was the last time you had your blood pressure checked?

812G) Who took your blood pressure?

812H) Have you ever been told by a doctor or a nurse that you have high blood pressure?

812I) To lower your blood pressure, are you now:

a) Taking prescribed medicine?
b) Controlling you weight or losing weight?
c) Cutting down on salt in your diet?
d) Exercising?
e) Cutting down on alcohol consumption?
f) Stopping smoking?
g) Taking traditional medicine/herbs?

812J) Have you ever heard of a disease called breast cancer?

812K) Who can get breast cancer: women only, men only, or both men and women?

814) Are you covered by any health insurance?

815) What type of health insurance are you covered by?

RECORD ALL MENTIONED.

816) CHECK 101B;

817) May I measure your blood pressure at this time?

RESPONDENT AGREES (RECORD OUTCOME OF BLOOD PRESSURE MEASUREMENT.)
RESPONDENT DOES NOT AGREE (RECORD 994.)

818) RECORD THE TIME.

SECTION 9. AVERAGING BLOOD PRESSURE MEASURES

901) CHECK Q600B AND Q817:

902) RECORD AND CALCULATE THE AVERAGE OF THE SYSTOLIC AND DIASTOLIC BLOOD PRESSURE FROM Q600B AND Q817.

903) BLOOD PRESSURE MEASUREMENTS FROM Q600B:

904) BLOOD PRESSURE MEASUREMENTS FROM Q817:

905) RECORD THE SUM OF THE SYSTOLIC AND DIASTOLIC MEASURES.

906) CALCULATE THE AVERAGE SYSTOLIC AND DIASTOLIC BY DIVIDING THE SUM IN Q905 BY 2

907) CHECK Q817:

908) CHECK Q600B:

909) CHECK Q102F:

910) RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

911) USE THE TABLE BELOW TO DETERMINE THE CORRECT CODE TO RECORD ON THE BLOOD PRESSURE REPORT AND REFERRAL FORM. CIRCLE THE ROW IN WHICH THE VALUE FOR THE SYSTOLIC BLOOD PRESSURE FROM Q906 OR Q910 IS FOUND. CIRCLE THE COLUMN IN WHICH THE VALUE FOR THE DIASTOLIC BLOOD FROM Q906 OR Q910 IS FOUND. THE VALUE WHERE THE ROW AND COLUMN YOU HAVE CIRCLED INTERSECT IN THE TABLE WILL BE USED IN COMPLETING Q912.

912) RECORD THE NUMBER YOU RECORDED IN Q911 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE FINDINGS REPORT FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS HE/SHE MAY HAVE.

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

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

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT: ____

COMMENTS ON SPECIFIC QUESTIONS: ____

ANY OTHER COMMENTS: ____

SUPERVISOR'S OBSERVATIONS: ____
NAME OF SUPERVISOR: ____
DATE: ____