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MADAGASCAR DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE 2003

IDENTIFICATION

PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD UNIT NUMBER _____
REGION (FARITANY) _____
VILLAGE ____

URBAN/RURAL____

URBAN 1
RURAL 2

CITY ____

ANTANANARIVO 1
OTHER CITY 2
RURAL 3

HOUSEHOLD SELECTED FOR MEN'S SURVEY/ANEMIA SURVEY/SYPHILIS SURVEY?

YES 1
NO 2

HOUSEHOLD SELECTED FOR TETANUS/MEASLES TEST?

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 PERSON AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD
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 2003
INT. NUMBER ____
RESULT ____

TOTAL NUMBER OF VISITS _____

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

SUPERVISOR
NAME _______
DATE ______

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR ______
KEYED BY ______

HOUSEHOLD SCHEDULE

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

01. LINE NO. (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT)

_____

02. 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 ______

03. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household? SEE CODES BELOW.

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

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

MALE 1
FEMALE 2

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

YES 1
NO 2

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

YES 1
NO 2

07. AGE: How old is (NAME)?

AGE _____

ELIGIBILITY:
08. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

ELIGIBILITY:
08A. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

ELIGIBILITY:
09. CIRCLE LINE NUMBER OF ALL CHILDREN LESS THAN 6 YEARS OLD.

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF LESS THAN 15 YEARS:

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

YES 1
NO 2
DOESN'T KNOW 8

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

RECORD MOTHER'S LINE NUMBER.
RECORD '00' IF THE MOTHER IS NOT A MEMBER OF THE HOUSEHOLD

LINE NO. _____

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

YES 1
NO 2
DOESN'T KNOW 8

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

RECORD FATHER'S LINE NUMBER.
RECORD '00' IF THE FATHER IS NOT A MEMBER OF THE HOUSEHOLD

LINE NO. ______

EDUCATION IF AGE 5 YEARS OR OLDER:

14. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

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

EDUCATION LEVEL
PRIMARY 1
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
GRADE
0 LESS THAN ONE YEAR COMPLETED FOR ALL LEVELS
PRIMARY
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
MIDDLE SCHOOL
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
HIGH SCHOOL
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
8 DOESN'T KNOW
POST-SECONDARY
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

EDUCATION IF AGE 5-24 YEARS:

16. Is (NAME) currently attending school?
IF THE INTERVIEW IS DURING A SCHOOL VACATION: Did (NAME) attend school during the school year that has just finished?

YES 1 (GO TO 18)
NO 2

17. Has (NAME) attended school at any time during the current school year?
IF THE INTERVIEW IS DURING A SCHOOL VACATION: Did (NAME) ever attend school at any time during the school year that has just finished?

YES 1
NO 2 (GO TO 19)

18. During this school year, what level and grade is/was (NAME) attending?
IF THE INTERVIEW IS DURING A SCHOOL VACATION: During the school year that has just finished, what level and grade did (NAME) attend?

EDUCATION LEVEL
PRIMARY 1
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
GRADE
0 LESS THAN ONE YEAR COMPLETED FOR ALL LEVELS
PRIMARY
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
MIDDLE SCHOOL
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
HIGH SCHOOL
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
8 DOESN'T KNOW
POST-SECONDARY
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

19. Did (NAME) attend school at any time during the previous school year?

YES 1
NO 2 (GO TO NEXT LINE)

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

EDUCATION LEVEL
PRIMARY 1
MIDDLE SCHOOL 2
HIGH SCHOOL 3
POST-SECONDARY 4
GRADE
0 LESS THAN ONE YEAR COMPLETED FOR ALL LEVELS
PRIMARY
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
MIDDLE SCHOOL
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
8 DOESN'T KNOW
HIGH SCHOOL
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
8 DOESN'T KNOW
POST-SECONDARY
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

CHECK HERE IF ANOTHER SHEET WAS USED ____

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

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

YES (ADD TO TABLE)
NO

3) Are there any other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been 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 22A)
PIPED TO YARD/PLOT 12 (GO TO 22A)
PUBLIC TAP/STANDPIPE 13
OPEN TUBE WELL OR BOREHOLE
IN THE DWELLING 21 (GO TO 22A)
IN THE YARD/PLOT 22 (GO TO 22A)
PUBLIC 23
PROTECTED/COVERED WELL
IN THE DWELLING 31 (GO TO 22A)
IN THE YARD/PLOT 32 (GO TO 22A)
PUBLIC 33
SURFACE WATER
SPRING 41
RIVER 42
POND/LAKE 43
DAM 44
RAINWATER 51 (GO TO 22A)
TANKER TRUCK 61
BOTTLED WATER 71(GO TO 22A)
OTHER (SPECIFY) ________ 96

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

MINUTES ______
ON SITE 996

22A. What is the main source of water used by your household for other purposes such as dishwashing and other uses besides drinking?

PIPED WATER
PIPED INTO DWELLING 11
PIPED TO YARD/PLOT 12
PUBLIC TAP/STANDPIPE 13
OPEN TUBE WELL OR BOREHOLE
IN THE DWELLING 21
IN THE YARD/PLOT 22
PUBLIC 23
PROTECTED/COVERED WELL
IN THE DWELLING 31
IN THE YARD/PLOT 32
PUBLIC 33
SURFACE WATER
SPRING 41
RIVER 42
POND/LAKE 43
DAM 44
RAINWATER 51
TANKER TRUCK 61
BOTTLED WATER 71
OTHER (SPECIFY) _______ 96

22B. Have you ever heard of a water treatment product called "SUR'EAU"?

YES 1
NO 2 (GO TO 23)

22C. Where have you heard of "SUR'EAU "?

ON THE RADIO A
ON THE TELEVISION B
ON POSTERS C
ON BOTTLES FOR SALE D
T-SHIRTS/HATS E
"SUR'EAU" FILM/CINEMOBILE F
DOCTORS G
RELATIVES H
FRIENDS I
COMMUNITY VENDOR J
PSI VENDOR K
RETAIL SALES VENDOR L
OTHER (SPECIFY) _______ X

22D. Have you ever used the product "SUR'EAU" to treat your household's drinking water?

YES 1
NO 2

22E. Are you currently using the product "sur'eau" to treat your household's drinking water?

YES 1
NO 2

23. What kind of toilet facility do most members of your household use?

FLUSH TOILET 11
RUDIMENTARY PIT LATRINE 21
VENTILATED IMPROVED PIT LATRINE 22
HOLE/DITCH 23
NO TOILET/OUTSIDE 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?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

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

ELECTRICITY 01
NATURAL GAS 02
BIOGAS 03
KEROSENE 04
COAL, LIGNITE, PEAT 05
CHARCOAL 06
WOOD, STRAW 07
DUNG 08
OTHER (SPECIFY) ______ 96

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) _______ 96

28. Does any member of this household own:

A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A 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 33)

29A. Among these nets, is there a net by the brand "supermoustiquaire"?

YES 1
NO 2

30. CHECK COLUMNS 6 AND 7:
NUMBER OF CHILDREN UNDER THE AGE OF 5 THAT SLEPT IN THE HOUSEHOLD LAST NIGHT

NONE (GO TO 33)
ONE (GO TO 31)
TWO OR MORE (GO TO 32)

31. Last night, did (NAME) sleep under a mosquito net?

YES 1 (GO TO 33)
NO 2 (GO TO 33)

32. In terms of all the children under the age of 5 who slept in the household last night, did all of them sleep under a mosquito net, only some of them, or none of them?

ALL 1
SOME 2
NONE 3

33. In your household, where do you usually wash your hands?

IN THE DWELLING/YARD/LOT 1
ELSEWHERE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)

34. ASK TO SEE THE PLACE MOST OFTEN USED FOR HANDWASHING AND CHECK TO SEE IF THE FOLLOWING OBJECTS ARE FOUND THERE:

WATER/FAUCET
YES 1
NO 2
SOAP, ASH OR OTHER WASHING PRODUCT
YES 1
NO 2
BASIN
YES 1
NO 2

35. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION).
IF SALT IS NOT TESTED, GIVE REASON.

0 PPM (NO IODINE) 1
7 PPM 2
15 PPM 3
30 PPM 4
NO SALT IN HOUSEHOLD 5
SALT NOT TESTED (SPECIFY REASON) ______ 6

HEIGHT AND WEIGHT MEASUREMENT

CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

36. LINE NUMBER (FROM COLUMN 8)

LINE NO. _____

37. NAME (FROM COLUMN 2)

NAME ______

38. AGE (FROM COLUMN 7)

YEARS _____

39. What is (NAME'S) date of birth?
[FOR CHILDREN UNDER AGE 6 ONLY]

DAY ____
MONTH _____
YEAR _____

40. WEIGHT (KILOGRAMS)

KM ____

41. HEIGHT (CENTIMETERS)

CM ____

42. MEASURED LYING DOWN OR STANDING UP?
[FOR CHILDREN UNDER AGE 6 ONLY]

LYING 1
STANDING 2

43. RESULT:

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

TICK HERE IF CONTINUATION SHEET USED ____

INTERVIEWER'S/NURSE'S OBSERVATIONS

TO BE FILLED OUT AFTER COMPLETING THE QUESTIONNAIRE

IF THE QUESTIONNAIRE WAS NOT FILLED OUT, EXPLAIN _____

INTERVIEWER'S OBSERVATIONS _____
NAME OF THE INTERVIEWER _____
DATE _____

SUPERVISOR'S OBSERVATIONS _____
NAME OF SUPERVISOR ______
DATE _____

FIELD EDITOR'S OBSERVATIONS _____
NAME OF FIELD EDITOR _____
DATE _____


MADAGASCAR DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD BLOOD DRAW QUESTIONNAIRE 2003:

IDENTIFICATION

PLACE NAME _____
NAME OF HOUSEHOLD HEAD _____
CLUSTER NUMBER _____
HOUSEHOLD UNIT NUMBER _____
REGION (FARITANY) _____
VILLAGE _____

URBAN/RURAL? _____

URBAN 1
RURAL 2

BIG CITY/OTHER CITY/RURAL? _____

CAPITAL 1
OTHER CITY 2
RURAL 3

HOUSEHOLD SELECTED FOR MEN'S SURVEY, AND ANEMIA/SYPHILIS SURVEY?

YES 1
NO 2

HOUSEHOLD SELECTED FOR TETANUS/MEASLES TEST?

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 PERSON AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD
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 2003
INT. NUMBER ______
RESULT ______

TOTAL NUMBER OF VISITS _____

TOTAL ELIGIBLE CHILDREN _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _______
KEYED BY _________

CHECK COVER PAGE:

YES TO ANEMIA TEST
NO TO ANEMIA TEST (GO TO 201)

ANEMIA TEST FOR CHILDREN AGE 0-5 YEARS

BEFORE PROCEEDING WITH THE ANEMIA TEST FOR A CHILD, YOU MUST FIRST OBTAIN INFORMED CONSENT FROM A FAMILY MEMBER/ADULT RESPONSIBLE FOR THE CHILD.

As part of this survey, we would like to know anemia levels for children, women and men. Anemia is a serious health problem that is caused by poor nutrition. The results of this survey will help the government to put in place programs to treat and prevent anemia.

We would like all of your children or children within your care between the ages of 0-5 to participate in the anemia test by giving a few drops of blood from their finger. For this test, we use sterilized, individual instruments that are clean and risk-free. The blood will be analyzed using new equipment and the results will be given to you immediately after the blood draw. Results are confidential.

Do you have any questions?

We would like (NAME OF CHILD) to participate in the anemia test. You may accept or refuse, it is up to you to decide.

Now, will you allow (NAME OF CHILD) to participate in the anemia test?

RECORD. IF THE PARENT (OR OTHER ADULT) IN THE HOUSEHOLD ACCEPTS, CIRCLE '1' AND SIGN AT QUESTION 6. IF THE PARENT (OR OTHER ADULT) IN THE HOUSEHOLD REFUSES, CIRCLE '2', THEN SKIP TO QUESTION 12 AND RECORD THE FINAL RESULT '3' (REFUSED).

IF THE PARENT (OR OTHER ADULT) CONSENTED AND THE BLOOD WAS DRAWN, BUT THE HEMOGLOBIN LEVELS WERE NOT MEASURED, CIRCLE 996 (GO TO 12).

RECORD LINE NUMBER

____

1. CHECK COLUMN 9 IN THE HOUSEHOLD QUESTIONNAIRE. IN QUESTIONS 2-5 BELOW, RECORD NAME, SEX, AGE AND LINE NUMBER OF PARENT (OR OTHER RESPONSIBLE ADULT) FOR ALL CHILDREN AGE 0-5 YEARS. INFORMED CONSENT FOR ANEMIA TESTING FOR CHILDREN IS LOCATED ON THE OPPOSITE PAGE.

FOR QUESTION 5, IDENTIFY THE PARENT OR RESPONSIBLE ADULT OF THE CHILD(REN) TO WHOM YOU WILL ASK CONSENT FOR THE CHILD TO PARTICIPATE IN THE TEST. RECORD THEIR LINE NUMBER(S) FROM COLUMNS 8 OR 8A OF THE HOUSEHOLD QUESTIONNAIRE OR RECORD '00' IF THE PARENT OR DESIGNATED ADULT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

RECORD THE NAME, SEX AND AGE OF ALL CHILDREN 0-5 YEARS OLD. WRITE THE TOTAL NUMBER OF ELIGIBLE CHILDREN ON THE COVER PAGE OF THIS QUESTIONNAIRE.

2. NAME?

NAME _______

3. GENDER?

MALE 1
FEMALE 2

4. AGE?

AGE ______

5. RECORD THE LINE NUMBER OF THE PARENT/ADULT.
RECORD '00' IF THEY ARE NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

______

CONSENT FOR THE ANEMIA TEST:

6. RECORD THE RESULT OF PARENT/OTHER ADULT CONSENT FOR THE ANEMIA TEST:

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________ (GO TO 12)

HEMOGLOBIN LEVEL:

7. FOR EACH CHILD THAT WAS TESTED, RECORD THE TEST RESULTS IN QUESTION 7A. THEN PREPARE THE RESULTS SHEET TO GIVE TO THE PARENT (OR OTHER ADULT).

7A. RECORD HEMOGLOBIN LEVEL:

HEMOGLOBIN LEVEL _______
NOT MEASURED 996 (GO TO 12)
(SPECIFY) _____________

8. CHECK LEVEL:

1 LOWER THAN 7 G/DL (GO TO 9)
2 BETWEEN 7-10 G/DL (GO TO 10)
3 ABOVE 10 G/DL (GO TO 11)

9. The hemoglobin level we detected in (NAME'S) blood is too low. This signals that (NAME) has developed a severe case of anemia, which is a serious health issue. We would like to inform the nearest health center of (NAME'S) condition. This will help you to receive appropriate treatment for (NAME).

9A. Do you consent to transmitting the information about the level of hemoglobin in (NAME'S) blood to a doctor?

WAS INFORMED AND ACCEPTED 1 (GO TO 12)
WAS INFORMED BUT DID NOT ACCEPT 2 (GO TO 10A)

10. The hemoglobin level we detected in (NAME'S) blood signals that (NAME) has developed a moderate case of anemia. This signals that (NAME) was moderately anemic, which could develop into a serious health problem in the future if left untreated.

10A. Would you accept a letter of referral for (NAME) to see the doctor about his/her condition?

WAS INFORMED AND ACCEPTED 1 (GO TO 12)
WAS INFORMED BUT DID NOT ACCEPT 2 (GO TO 12)

11. The hemoglobin level detected in (NAME'S) blood is normal.

12. RECORD THE FINAL RESULT IN QUESTION 12A.

AFTER HAVING GONE BACK TO THE HOUSEHOLDS TO COMPLETE ALL FOLLOW-UP VISITS, CHECK AND RECORD THE FINAL RESULT OF THE ANEMIA BLOOD TEST FOR EACH CHILD. IF AN ELIGIBLE CHILD WAS NEVER PRESENT IN THE HOUSEHOLD OR IF NEITHER THE PARENT NOR ANY ADULT WAS PRESENT, RECORD '2' (ABSENT).

12A. RESULT OF BLOOD DRAW

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _______

13. AFTER HAVING GONE BACK TO THE HOUSEHOLDS TO COMPLETE ALL FOLLOW-UP VISITS, RECORD THE TOTAL NUMBER OF CHILDREN FOR WHOM THE ANEMIA TEST WAS COMPLETED (THAT IS, CODE '1' IN QUESTION 12A). _____

ANEMIA AND SYPHILIS TEST FOR ADULTS

INFORMED CONSENT FOR ANEMIA TEST:

As part of this survey, we would like to know anemia levels for children, women and men. Anemia is a serious health problem that is caused by poor nutrition and/or an infection. The results of this survey will help the government of Madagascar to put in place programs to treat and prevent anemia.

We would like you to participate in the anemia test by giving a few drops of blood from your finger. For this test, we use sterilized, individual instruments that are clean and risk-free. The blood will be analyzed using new equipment and the results will be given to you immediately after the blood draw. Results are confidential.

Do you have any questions?

We would like you to participate in the anemia test. You may accept or refuse, it is up to you to decide.

ASK CONSENT FROM A PARENT OR OTHER RESPONSIBLE ADULT FOR YOUTH AGE 15-17 YEARS: Now, will you allow (YOUTH 15-17 YEARS OLD) to participate in the anemia test? CIRCLE THE APPROPRIATE CODE IN QUESTION 107 AND SIGN.

ASK CONSENT FROM RESPONDENT AGE 18 YEARS OR OLDER AND FROM THE YOUTH AGE 15-17 YEARS WHOSE PARENT/ADULT GAVE CONSENT: Now, will you participate in the anemia test? CIRCLE THE APPROPRIATE CODE IN QUESTION 110 AND SIGN.

SYPHILIS TEST:

As part of this survey, we are also studying syphilis in men and women in Madagascar. Syphilis can cause serious health problems if it is left untreated. The results of this survey will help the government of Madagascar to put in place programs to treat and prevent syphilis.

We would like you to participate in this test. If you consent, we will first draw a few drops of blood from the same finger already pricked for the anemia test (or from a finger, IF THE RESPONDENT REFUSED THE ANEMIA TEST). We will determine the test result here in your home, if you have syphilis. If the test results shows that you do not have syphilis (negative result), we will know it right away.

If the test results show that you have syphilis (positive result), we will need to perform another test to confirm if you currently have syphilis or if you had it in the past. For this second test, we will draw some blood from a vein in your arm. This blood will be analyzed tonight and I will bring you your results tomorrow if you tell me when and where I may bring it to you. It is this result that will allow us to give you treatment if your test turns out to be positive.

Besides you, myself, the nurse and the lab technician that will analyze your blood, no one else will know the results of your syphilis test.

For these tests, we use sterilized and disposable instruments that are clean and completely risk-free.

Do you have any questions?

Now, will you take the syphilis test? You can accept or refuse. It is up to you to decide.

ASK CONSENT FROM A PARENT OR OTHER RESPONSIBLE ADULT FOR YOUTH AGE 15-17 YEARS: Now, will you allow (YOUTH 15-17 YEARS OLD) to participate in the syphilis test? CIRCLE THE APPROPRIATE CODE IN QUESTION 108 AND SIGN.

ASK CONSENT FROM RESPONDENT AGE 18 YEARS OR OLDER AND FROM THE YOUTH AGE 15-17 YEARS WHOSE PARENT/ADULT GAVE CONSENT: Now, will you participate in the syphilis test? CIRCLE THE APPROPRIATE CODE IN QUESTION 111 AND SIGN.

RECORD LINE NUMBER

LINE NO. ____

101. CHECK HOUSEHOLD QUESTIONNAIRE AND IDENTIFY ALL WOMEN AGE 15-49 AND ALL MEN 15-59 WHO ARE RESIDENTS OR WERE VISITORS THE NIGHT PRECEDING THE SURVEY.

RECORD THE VISIT NUMBER AT WHICH THE RESPONDENT WAS PRESENT FOR QUESTION 105 BELOW.

BEFORE PERFORMING THE ANEMIA AND SYPHILIS TESTS, YOU MUST OBTAIN THE CONSENT OF EACH RESPONDENT. IN THE CASE OF YOUTHS AGE 15-17 YEARS, YOU SHOULD FIRST OBTAIN CONSENT FROM A PARENT OR OTHER RESPONSIBLE ADULT IN THE HOUSEHOLD. THE INFORMED CONSENT FOR THE ANEMIA AND SYPHILIS TESTS, WHICH USE BLOOD FROM A PRICKED FINGER, IS LOCATED ON THE OPPOSITE PAGE, AND THE RESULTS ARE RECORDED IN QUESTIONS 107-112 BELOW.

RECORD THE NAME, SEX AND AGE OF EACH RESPONDENT ELIGIBLE FOR THE ANEMIA AND SYPHILIS TESTS.

WRITE THE NUMBER OF ELIGIBLE RESPONDENTS ON THE COVER PAGE OF THIS QUESTIONNAIRE.

102. NAME?

NAME _____

103. GENDER?

MALE 1
FEMALE 2

104. AGE?

AGE _____

105. CIRCLE THE VISIT NUMBER AT WHICH THE RESPONDENT WAS PRESENT FOR THE TEST.

FIRST VISIT
YES 1
NO 2
SECOND VISIT
YES 1
NO 2
THIRD VISIT
YES 1
NO 2

CONSENT FOR ANEMIA AND SYPHILIS TESTS:

106. CHECK 104:
AGE?

15-17 YEARS OLD 1 (GO TO 107)
18 OR OLDER 2 (GO TO 110)

107. RECORD CONSENT OF PARENT OR OTHER ADULT FOR THE BLOOD TEST FOR ANEMIA

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________

108. RECORD CONSENT OF PARENT OR OTHER ADULT FOR THE BLOOD TEST FOR SYPHILIS

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________

109. CHECK 107 AND 108:

PARENT/OTHER ADULT ACCEPTED ONE OR BOTH TESTS (GO TO 110)
REFUSED BOTH TESTS (GO TO 131)

110. RECORD CONSENT OF RESPONDENT FOR THE BLOOD TEST FOR ANEMIA

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________

111. RECORD CONSENT OF RESPONDENT FOR THE BLOOD TEST FOR SYPHILIS

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________

112. CHECK 110 AND 111:

ACCEPTED ONE OR BOTH TESTS (GO TO 113)
REFUSED BOTH TESTS (GO TO 131)

113. PREPARE THE MATERIALS AND EQUIPMENT NEEDED FOR THE TEST(S) TO WHICH THE RESPONDENT HAS CONSENTED. COMPLETE QUESTIONS 114, 121 AND 123 BEFORE PROCEEDING WITH THE TEST FOR THE RESPONDENT.

ANEMIA TEST:

114. CHECK 110:
RESPONDENT GAVE CONSENT FOR ANEMIA BLOOD TEST?

1 ACCEPTED
2 REFUSED (GO TO 121)

115. PROVIDED THAT THE RESPONDENT CONSENTED TO GIVE BLOOD FOR THE ANEMIA TEST, PROCEED WITH THE TAKING OF SEVERAL DROPS OF BLOOD FROM THE FINGER AND RECORD THE RESULTS IN QUESTION 116 BELOW.

FOR EACH RESPONDENT TESTED, RECORD THE RESULTS IN QUESTION 116, THEN PREPARE THE RESULTS SHEET TO GIVE TO THE RESPONDENT.

116. RECORD LEVEL OF HEMOGLOBIN

HEMOGLOBIN LEVEL _______

NOT MEASURED 996 (GO TO 121)
(SPECIFY) _______

117. CHECK LEVEL:

1 LOWER THAN 7 G/DL (GO TO 118)
2 BETWEEN 7-10 G/DL (GO TO 119)
3 ABOVE 10 G/DL (GO TO 120)

118. The hemoglobin level we detected in your blood is too low. This signals that you have developed a severe case of anemia, which is a serious health issue. We would like to inform the nearest health center of your condition. This will help you to receive appropriate treatment for your current health condition.

118A. Do you consent to transmitting the information about the level of hemoglobin in your blood to a doctor?

WAS INFORMED AND ACCEPTED 1 (GO TO 121)
WAS INFORMED BUT DID NOT ACCEPT 2 (GO TO 119A)

119. The hemoglobin level we detected in your blood signals that you have developed a moderate case of anemia. This signals that you were moderately anemic, which could develop into a serious health problem in the future if left untreated.

119A. Would you accept a letter of referral to see the doctor about your condition?

WAS INFORMED AND ACCEPTED 1 (GO TO 121)
WAS INFORMED BUT DID NOT ACCEPT 2 (GO TO 121)

120. The hemoglobin level detected in your blood is normal.

'ABBOTT DETERMINE' SYPHILIS TB TEST:

121. CHECK 111:
RESPONDENT GAVE CONSENT FOR SYPHILIS BLOOD TEST?

1 ACCEPTED (GO TO 122)
2 REFUSED (GO TO 131)

122. BEFORE STARTING THE TEST, ASSUMING THE RESPONDENT GAVE CONSENT TO GIVE BLOOD FOR THE SYPHILIS TEST, TAKE THE FIRST BARCODE LABEL IN THE FIRST AVAILABLE LINE ON THE LABEL SHEET AND ATTACH IT TO QUESTION 123. ATTACH THE SECOND BARCODE LABEL FROM THE SAME LINE ON THE ABBOTT TEST CARD YOU WILL USE FOR THE SYPHILIS TEST. CHECK THAT THE STICKER ON 123 AND THE STICKER ON THE ABBOTT CARD HAVE THE SAME BARCODE NUMBER.

123. CHECK 121. IF THE RESPONDENT HAS CONSENTED TO THE TEST, ATTACH THE FIRST BARCODE LABEL FROM A LINE.

ATTACH THE FIRST BARCODE LABEL FROM A LINE HERE.

124. RESULT OF BLOOD DRAW FROM FINGER PRICK FOR THE ABBOTT DETERMINE SYPHILIS TEST.

DRAWN 1
NOT DRAWN/PROBLEMS WITH DRAW (SPECIFY) ________ 2 (GO TO 131)

125. BEGIN THE SYPHILIS TEST USING THE RESPONDENT'S BLOOD DRAWN USING THE ABBOTT DETERMINE METHOD.

125A. AFTER HAVING PUT THE BLOOD ON THE ABBOTT CARD, RECORD THE TIME ON YOUR WATCH. THIS IS THE TEST'S START TIME.

HOURS ______
MINUTES _______

125B. WAIT 15 MINUTES.

125C. AFTER 15 MINUTES HAVE PASSED, RECORD THE TIME ON YOUR WATCH TO INDICATE THE TEST'S STOP TIME.

HOURS ______
MINUTES _______

125D. SUBTRACT THE TIME OF 125A FROM THAT OF 125C.

MINUTES _____

125E. IF THE NUMBER IN 125D IS 15 MINUTES OR MORE, READ THE RESULT OF THE SYPHILIS TEST ON THE ABBOTT CARD. IF THE NUMBER IN 125D IS LESS THAN 15 MINUTES, COMPLETE THE MINIMUM DURATION OF 15 MINUTES BEFORE READING THE RESULTS OF THE SYPHILIS TEST ON THE ABBOTT CARD.

126. RECORD THE RESULTS OF THE ABBOTT SYPHILIS TEST.

1 POSITIVE
2 NEGATIVE
3 UNDETERMINED

127. INFORM EACH RESPONDENT OF THEIR ABBOTT TEST RESULTS. FOR THOSE WHO HAVE A NEGATIVE RESULT, GO TO 131. FOR THOSE WHO HAVE A POSITIVE OR UNDETERMINED RESULT, IN 128-128A, ASK THEM FOR THEIR CONSENT FOR GIVING SOME BLOOD FROM A VEIN IN THE ARM FOR THE SYPHILIS CONFIRMATION TEST.

128. Given that the result of this test was positive, it is possible that you currently have syphilis. To be certain that you are presently infected so that we may give you treatment at home, we need to draw a small amount of blood from a vein in your arm to test it. The result will be given to you later today or tomorrow. The results of your tests are confidential. The decision to participate in this confirmation test in order to obtain treatment is up to you.

Do you have any questions?
Now, will you participate in this test?

128A. CONSENT FOR ARM BLOOD DRAW FOR RPR TEST

ACCEPTED 1 (SIGN) ________
REFUSED 2 (GO TO 131)
OTHER (SPECIFY) ________ 8 (GO TO 131)

129. BEFORE DRAWING THE RESPONDENT'S BLOOD, ATTACH THE BARCODE LABELS THAT CORRESPOND TO THE LABEL IN QUESTION 123 OF THIS QUESTIONNAIRE: THE THIRD BARCODE LABEL ON THE VACUTAINER TUBE; THE FOURTH ON THE CRYOGENIC TUBE; THE FIFTH ON THE RESULTS SHEET OF THE RPR TEST; AND THE SIXTH ON THE PLASMA TRANSMISSION SHEET FOR THE TPHA TEST. THEN, DRAW 5CC OF VEIN BLOOD INTO THE VACUTAINER TUBE AND RECORD THE DRAW RESULT IN QUESTION 130.

130. VEIN BLOOD DRAWN FOR THE RPR TEST.

DRAWN 1 (GO TO 132)
NOT DRAWN/PROBLEMS WITH DRAW (SPECIFY) ________ 2 (GO TO 131)

131. RETURN TO 102 FOR THE NEXT RESPONDENT.
IF NO MORE RESPONDENTS, CONTINUE TO 132.
RECORD LINE NUMBER.

132. CHECK 102-104 TO SEE IF THE NEXT RESPONDENT IN THE HOUSEHOLD IS AVAILABLE FOR THE BLOOD TEST FOR ANEMIA AND SYPHILIS.

IF THERE ARE NO MORE AVAILABLE RESPONDENTS, FOLLOW THE TRANSPORT INSTRUCTIONS FOR THE VACUTAINER TUBES CONTAINING BLOOD TO YOUR TEAM'S LAB TECHNICIAN. THE LAB TECHNICIAN PERFORMS THE RPR TEST AND REMOVES PART OF THE PLASMA IN THE CRYOGENIC TUBE THAT WAS LABELED FOR THE RESPONDENT. THIS PLASMA WILL BE THE OBJECT OF AN ADDITIONAL CONFIRMATION TEST AT THE PASTEUR INSTITUTE'S CENTRAL LAB.

ON SITE, THE LAB TECHNICIAN RECORDS ALL THE RESULTS OF THE RPR TEST ON THE RESPONDENT'S RPR TEST RESULTS SHEET. YOU WILL USE THIS RPR TEST RESULTS SHEET TO TRANSFER THE RESPONDENT'S TEST RESULTS INTO QUESTIONS 133-134 OF THE HOUSEHOLD BLOOD DRAW QUESTIONNAIRE.

RPR TEST RESULTS:

133. TRANSFER THE RPR TEST RESULTS FROM THE RESPONDENT'S RPR TEST RESULTS SHEET TO THE HOUSEHOLD BLOOD DRAW QUESTIONNAIRE. CHECK THE LINE NUMBER AND THE BARCODE LABEL FROM 123 AGAINST THE BARCODE LABEL ATTACHED TO THE RESPONDENT'S RESULTS SHEET TO ENSURE THAT THE RESPONDENT IS INDEED THE PERSON IN QUESTION.

INFORM EACH RESPONDENT THAT GAVE BLOOD OF THEIR RPR BLOOD TEST RESULTS. RECORD IN QUESTION 135 WHETHER OR NOT THE RESULTS WERE GIVEN TO THE RESPONDENT. IF THE RESULTS WERE NOT GIVEN TO THE RESPONDENT, EXPLAIN WHY IN QUESTION 135 AS WELL.

134. RECORD THE RPR TEST RESULT.

1 RPR REACTIVE
2 RPR NON-REACTIVE

135. INFORMED RESPONDENT OF RPR TEST RESULT.

YES 1
NO, ABSENT 2
NO, OTHER (SPECIFY) _____ 3

TREATMENT AND FOLLOW-UP CARE OF SYPHILIS:

136. CHECK 134: RECORD THE RESULTS OF THE RPR TEST A SECOND TIME IN 137. THEN, FOR THE RESPONDENTS WHOSE TEST RESULT IS REACTIVE, THAT IS TO SAY POSITIVE, OFFER TREATMENT AND FOLLOW-UP CARE.

137. RECORD THE RESULTS OF THE RPR TEST AGAIN, AS INDICATED IN 134.

1 RPR REACTIVE (GO TO 139)
2 RPR NON-REACTIVE (GO TO 138)

138. RETURN TO 133 FOR THE NEXT RESPONDENT. IF NO MORE RESPONDENTS, (GO TO 139).

139. Your RPR test results came back positive. This result indicates that you have syphilis, which can cause you serious health problems if you are not treated. The treatment consists of a penicillin shot or antibiotic pills.

We can provide immediate treatment here, in your home. Otherwise, if you prefer, we can give you the treatment in another location convenient to you in the area, or give you a letter of reference to get yourself treated at the nearest health facility. It is up to you to decide whether you prefer immediate treatment or you prefer to be referred.

Do you want to receive the treatment immediately? IF THE RESPONSE IS NO: Would you like to meet me at another location to receive the treatment or would you prefer to go to a health facility to receive the treatment?

RECORD THE RESPONSE IN QUESTION 139A. SIGN TO INDICATE THAT YOU HAVE GIVEN THE TREATMENT. IF THE RESPONDENT ACCEPTS IMMEDIATE TREATMENT, FIRST PROCEED TO ASK THE INVESTIGATION QUESTIONS FOR THE TREATMENT BEFORE GIVING ANY ANTIBIOTIC TREATMENT.

IF THE RESPONDENT WANTS TO BE TREATED IN ANOTHER LOCATION, DISCUSS THE PLACE AND TIME YOU CAN MEET THEM. IF YOU MUST MEET THEM IN ANOTHER LOCATION, YOU MUST ASK THE INVESTIGATION QUESTIONS FOR THE TREATMENT BEFORE ADMINISTERING ANY TREATMENT.

IF THE RESPONDENT WANTS A REFERRAL LETTER, PREPARE A LETTER OF REFERRAL AND GIVE IT TO THE RESPONDENT.

139A. CONSENT FOR TREATMENT/FOLLOW-UP CARE AT THE HOME

YES, AT THE HOUSE NOW 1 (SIGN) ________
YES, BUT PREFERS ANOTHER LOCATION 2
YES, BUT PREFERS LETTER OF REFERRAL 3 (GO TO 153)
NO, DOES NOT WANT TREATMENT/REFERRAL 4 (GO TO 153)

140. INFORM THE RESPONDENT OF THE POSSIBLE REACTIONS TO PENICILLIN AND ASK QUESTIONS ABOUT PREVIOUS REACTIONS FOLLOWING A PENICILLIN INJECTION.

For most people, the treatment is a penicillin injection. In rare cases, a person may be allergic to penicillin injections and present with itchy red skin and swelling of the lips, mouth or face. In very rare cases, a person may also have shortness of breath or even lose consciousness.

If you have never had these reactions, it is highly unlikely that you would have them today. However, just to be sure, I am going to ask you some questions about your past experiences with penicillin before I give you the treatment. In addition, I myself will stay in the area for at least two hours following the injection and you may contact me immediately, or contact anyone else in our team who is working in your area, for any allergic reaction that occurs after the penicillin injection.

141. To your knowledge, have you ever had a penicillin injection?

YES 1
NO/DOESN'T KNOW 2 (GO TO 143)

142. Have you ever had a reaction following these penicillin injections?

YES 1 (GO TO 147)
NO/DOESN'T KNOW 2

143. Have you ever received any other type of injection?

YES 1
NO/DOESN'T KNOW 2 (GO TO 145)

144. Have you ever had a reaction to these other injections?

YES 1 (GO TO 147)
NO/DOESN'T KNOW 2

145. ASK CONSENT FOR THE PENICILLIN INJECTION: I would like to give you a penicillin injection. You will only need one injection. However, if you prefer, I can give you antibiotic pills or a letter of referral to the nearest health center where you may receive treatment.

145A. Can I give the penicillin injection now?

YES 1 (SIGN) __________
NO, PREFERS PILLS 2 (GO TO 147)
NO, PREFERS REFERRAL 3 (GO TO 153)
NO, DOES NOT WANT TREATMENT/FOLLOW-UP CARE 4 (GO TO 153)

146. GIVE THE PENICILLIN INJECTION: It is very rare that you would have a reaction to penicillin. However, if you experience any symptoms of a reaction to penicillin, which are itchy red skin, swelling of the face, mouth or tongue or difficulty breathing, you should immediately contact me or any other member of my team that is working in your area, or go to a health clinic immediately. (GO TO 153)

147. ASK CONSENT FOR ANTIBIOTIC PILLS: Given it is possible that you may have a reaction to the penicillin injection, I would like to give you antibiotic pills, if you will accept them. But if you would rather, I can give you a letter of referral to the nearest health clinic in order to receive treatment there.

147A. May I have your consent to give you the pills?

YES 1 (SIGN) ________
NO, PREFERS LETTER OF REFERRAL 2 (GO TO 153)
NO, DOES NOT WANT TREATMENT/FOLLOW-UP CARE 3 (GO TO 153)

148. SEX?

MALE 1 (GO TO 150)
FEMALE 2

149. Are you currently pregnant?
[RECORD RESPONSE ACCORDING TO 226 ON THE WOMEN'S QUESTIONNAIRE.]

YES 1 (GO TO 151)
NO 2

150. GIVE DOXYCYCLIN PILLS AND SHOW HOW TO TAKE THEM. (GO TO 152)

151. GIVE ERYTHROMYCINE PILLS AND SHOW HOW TO TAKE THEM.

152. It is possible you may have a fever accompanied by headache and sore muscles in the 24 hours following treatment. This is a normal response to treatment. If you experience these symptoms, you may take aspirin or panadol if you like.

153. It is possible that this infection was transmitted to you by one or more sexual partners. As a result, it is very important to treat your partner today if he or she is available and does not belong to this household or another household in the survey.

FOR THESE PARTNERS WHO DO NOT BELONG TO A HOUSEHOLD BEING SURVEYED, TREATMENT WILL BE SOLELY BASED UPON THE PRESUMPTION OF INFECTION. THEY DO NOT NEED ADDITIONAL DIAGNOSTIC TESTING AS OF THE MOMENT A PARTNER HAS TESTED POSITIVE FOR SYPHILIS. ALSO, THE TREATMENT INFORMATION WILL NOT BE RECORDED IN THE QUESTIONNAIRE.
IF THE PARTNER IS NOT AVAILABLE OR IF THE RESPONDENT DOES NOT WANT YOU TO CONTACT THE PARTNER, OFFER A LETTER OF REFERRAL FOR THE PARTNER TO RECEIVE TREATMENT AT THE NEAREST HEALTH FACILITY.

154. CONSENT TO TREAT PARTNER?

YES 1 (GO TO 156)
NO 2

155. May I give you a letter to refer your partner to the nearest health facility?

YES 1
NO 2

156. RETURN TO 139 FOR THE NEXT RESPONDENT NEEDING TREATMENT OR FOLLOW-UP CARE. OR CHECK 127 FOR THE NEXT RESPONDENT FOR THE BLOOD TEST. IF NO MORE RESPONDENTS, (GO TO 157)

TREATMENT OF SEXUAL PARTNER AND RESULT:

157. CHECK 154 TO SEE IF THE RESPONDENT HAS CONSENTED TO YOU TREATING THEIR PARTNER (CODE 1 CIRCLED). IF PARTNER IS AVAILABLE AND WILLING TO BE TREATED, BEFORE ADMINISTERING TREATMENT CHECK WITH THE PARTNER ABOUT THE POSSIBILITY OF AN ALLERGIC REACTION TO PENICILLIN BY COMPLETING QUESTIONS 139-153 FOR THE PARTNERS IN AN APPROPRIATE FASHION. IF THERE ARE NO PARTNERS (GO TO 161).

158. TREAT THE PARTNER ACCORDING TO THE PROTOCOL IN QUESTIONS 139-153.

159. Did the partner receive treatment?

YES 1 (GO TO 161)
NO 2

160. REASON WHY THE TREATMENT WAS NOT ADMINISTERED TO PARTNER?

PARTNER REFUSED TREATMENT, BUT ACCEPTED REFERRAL 1
PARTNER REFUSED BOTH TREATMENT AND REFERRAL 2
PARTNER ABSENT 3

SUMMARY OF TEST RESULTS FOR RESPONDENTS OF THE HOUSEHOLD BLOOD DRAW QUESTIONNAIRE 2003:

161. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, CHECK AND RECORD THE FINAL RESULTS OF THE BLOOD DRAW FOR THE ANEMIA TEST AND SYPHILIS TEST FOR EACH RESPONDENT.

161A. RESULT CODE FOR ANEMIA TEST

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _____

161B. RESULT CODE FOR ABBOTT SYPHILIS TEST

1 TESTED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _____

161C. RESULT CODE FOR RPR SYPHILIS TEST

1 TESTED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _____

162. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF RESPONDENTS WHO COMPLETED THE ANEMIA TEST (THAT IS, WITH CODE '1' MARKED IN QUESTIONS 12A AND 161A).

ANEMIA ____

162A. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF RESPONDENTS WHO COMPLETED THE ABBOTT SYPHILIS TEST USING BLOOD DRAWN FROM A FINGER (THAT IS, WITH CODE '1' MARKED IN QUESTION 161B).

ABBOTT SYPHILIS ____

162B. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF RESPONDENTS WHO COMPLETED THE RPR SYPHILIS TEST USING BLOOD DRAWN FROM A VEIN (THAT IS, WITH CODE '1' MARKED IN QUESTION 161C).

RPR SYPHILIS ____

163. END OF HOUSEHOLD ANEMIA AND SYPHILIS TEST.

ANEMIA AND SYPHILIS TEST OBSERVATIONS

TO FILL OUT AFTER HAVING FINISHED THE TESTS

IF THE QUESTIONNAIRE WAS NOT COMPLETED, EXPLAIN _____

NURSE'S/LAB TECHNICIAN'S OBSERVATIONS______
NURSE'S NAME______
DATE ______

LAB TECHNICIAN'S OBSERVATIONS_______
LAB TECHNICIAN'S NAME ______
DATE______

SUPERVISOR'S OBSERVATIONS _______
SUPERVISOR'S NAME ______
DATE ______

TETANUS AND MEASLES TEST FOR CHILDREN AGE 0-5 YEARS

BEFORE PROCEEDING WITH THE TETANUS AND MEASLES TEST FOR A CHILD, YOU MUST FIRST OBTAIN INFORMED CONSENT FROM A PARENT/ADULT RESPONSIBLE FOR THE CHILD.

In this survey, we would like to know the level of vaccine protection children have against tetanus and measles infections. Tetanus and measles are very common illnesses for children in Madagascar. They are caused by a lack of vaccination in children and mothers during pregnancy. The results of this survey will help the government to implement adequate vaccination programs to prevent these illnesses in the children of Madagascar.

We would like all children age 0-5 years to participate in the tetanus and measles test by giving a few drops of blood from their finger or their heel if they are under 6 months old. For this test, we use sterilized and disposable instruments that are clean and risk-free. The blood will be analyzed in a central laboratory and your results will not be able to be shared with you. The results are confidential.

Do you have any questions?

We would like (CHILD'S NAME) to participate in the tetanus and measles test. You may accept or refuse, it is up to you.

Now, will you allow (CHILD'S NAME) to participate in the test?

RECORD. IF THE PARENT/ADULT IN THE HOUSEHOLD CONSENTS, CIRCLE '1' AND SIGN AT QUESTIONS 206 AND 207. IF THE PARENT/ADULT REFUSES, CIRCLE '2', THEN GO TO QUESTION 211 AND RECORD THE FINAL RESULT '3' (REFUSED).

FOR EACH CHILD THAT WILL BE TESTED, RECORD THE RESULT CODE IN QUESTIONS 211-211B.

RECORD LINE NUMBER:

LINE NUMBER _____

TETANUS AND MEASLES TEST FOR CHILDREN AGE 0-5 YEARS:

201. CHECK COLUMN 9 IN THE HOUSEHOLD QUESTIONNAIRE. IN QUESTIONS 202, 203, 204 AND 205 BELOW, RECORD NAME, SEX, AGE AND LINE NUMBER OF PARENT (OR OTHER RESPONSIBLE ADULT) FOR ALL CHILDREN AGE 0-5 YEARS. LIST ALL CHILDREN IN THE ORDER IN WHICH THEY APPEAR IN THE HOUSEHOLD QUESTIONNAIRE. INFORMED CONSENT FOR TETANUS AND MEASLES TESTING FOR CHILDREN IS LOCATED ON THE OPPOSITE PAGE.

FOR QUESTION 205, IDENTIFY THE PARENT OR RESPONSIBLE ADULT OF THE CHILD(REN) TO WHOM YOU WILL ASK CONSENT FOR THE CHILD TO PARTICIPATE IN THE TEST. RECORD THEIR LINE NUMBER(S) FROM COLUMNS 8 OR 8A OF THE HOUSEHOLD QUESTIONNAIRE OR RECORD '00' IF THE PARENT OR DESIGNATED ADULT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

RECORD THE NAME, SEX AND AGE OF ALL CHILDREN 0-5 YEARS OLD.

WRITE THE TOTAL NUMBER OF ELIGIBLE CHILDREN ON THE COVER PAGE OF THIS QUESTIONNAIRE.

202. NAME?

NAME _______

203. SEX?

MALE 1
FEMALE 2

204. AGE?

AGE ______

205. RECORD THE LINE NUMBER OF THE PARENT/ADULT OR RECORD '00' IF THEY ARE NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NUMBER ______

206. RECORD THE RESULT OF PARENT/OTHER ADULT CONSENT FOR THE TETANUS TEST:

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________

207. RECORD THE RESULT OF PARENT/OTHER ADULT CONSENT FOR THE MEASLES TEST:

ACCEPTED 1 (SIGN) _________
REFUSED 2 (SIGN) ________

208. CHECK 206 AND 207:

1 PARENT/ADULT CONSENTS TO ONE OR BOTH TESTS
2 REFUSED THE TWO TESTS (GO TO 211)

209. IF CONSENTED TO ONE OR BOTH TESTS, ATTACH THE FIRST BARCODE LABEL FROM A LINE.

ATTACH THE FIRST BARCODE LABEL FROM A LINE HERE. _____

210. PREPARE THE NECESSARY MATERIALS TO DRAW THE BLOOD FOR THE TETANUS AND MEASLES TEST.

ATTACH THE SECOND BARCODE LABEL FROM THE SAME LINE TO THE FILTER PAPER THAT YOU WILL USE FOR THE CHILD'S TETANUS TEST, AND THE THIRD BARCODE LABEL TO THE FILTER PAPER THAT YOU WILL USE FOR THE CHILD'S MEASLES TEST. THEN ATTACH THE FOURTH BARCODE LABEL TO THE TETANUS BLOOD DRAW TRANSMISSION SHEET AND THE FIFTH LABEL TO THE MEASLES BLOOD DRAW TRANSMISSION SHEET.

RESULTS SUMMARY FOR CHILDREN'S TETANUS AND MEASLES TEST FOR HOUSEHOLD BLOOD DRAW QUESTIONNAIRE 2003:

211. RECORD THE FINAL RESULTS IN QUESTIONS 211A AND 211B. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, CHECK AND RECORD THE FINAL RESULTS OF THE BLOOD DRAW FOR THE TETANUS AND MEASLES TEST FOR EACH CHILD.

211A. RESULT CODE FOR TETANUS TEST

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _____

211B. RESULT CODE FOR MEASLES TEST

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _____

212. RETURN TO 202 FOR THE NEXT CHILD. IF NO MORE CHILDREN, (GO TO 213).

213. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF CHILDREN FOR WHOM THE TETANUS TEST WAS COMPLETED (THAT IS, WITH CODE '1' MARKED IN QUESTION 211A).

TETANUS ____

214. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF CHILDREN FOR WHOM THE MEASLES TEST WAS COMPLETED (THAT IS, WITH CODE '1' MARKED IN QUESTION 211B).

MEASLES ____

TETANUS TEST FOR WOMEN

INFORMED CONSENT:

In this survey, we would like to know the level of vaccine protection women have against tetanus. Tetanus is a serious health problem that results from a lack of vaccination in mothers during pregnancy. The results of this survey will help the government to implement adequate vaccination programs to prevent these illnesses in the women and children of Madagascar.

We would like you to participate in the tetanus test by giving a few drops of blood from your finger. For this test, we use new, sterilized and disposable instruments that are clean and risk-free. The blood will be analyzed in a central laboratory and your results will not be able to be shared with you. The results are confidential.

Do you have any questions?

We would like you to participate in this tetanus test. You may accept or refuse, it is up to you.

ASK CONSENT FROM A PARENT OR OTHER RESPONSIBLE ADULT FOR YOUTH AGE 15-17 YEARS: Now, will you allow (YOUTH 15-17 YEARS OLD) to participate in the tetanus test? CIRCLE THE APPROPRIATE CODE IN QUESTION 306 AND SIGN.

ASK CONSENT FROM RESPONDENT AGE 18 YEARS OR OLDER AND FROM THE YOUTH AGE 15-17 YEARS WHOSE PARENT/ADULT GAVE CONSENT: Now, will you participate in the tetanus test? CIRCLE THE APPROPRIATE CODE IN QUESTION 307 AND SIGN.

RECORD LINE NUMBER.

LINE NUMBER _____

TETANUS TEST FOR WOMEN:

301. CHECK HOUSEHOLD QUESTIONNAIRE AND IDENTIFY ALL WOMEN AGE 15-49 WHO ARE RESIDENTS OR WERE VISITORS THE NIGHT PRECEDING THE SURVEY.

RECORD THE VISIT NUMBER AT WHICH THE RESPONDENT WAS PRESENT IN QUESTION 304 BELOW.

BEFORE PERFORMING THE TETANUS TEST, YOU MUST OBTAIN THE CONSENT OF EACH RESPONDENT. IN THE CASE OF YOUTHS AGE 15-17 YEARS, YOU SHOULD FIRST OBTAIN CONSENT FROM A PARENT OR OTHER RESPONSIBLE ADULT IN THE HOUSEHOLD. THE INFORMED CONSENT FOR THE TETANUS TEST, WHICH USES BLOOD FROM A PRICKED FINGER, IS LOCATED ON THE OPPOSITE PAGE, AND THE RESULTS ARE RECORDED IN QUESTIONS 306 AND 307 BELOW.

RECORD THE NAME AND AGE OF EACH WOMAN ELIGIBLE FOR THE TETANUS TEST.

WRITE THE NUMBER OF ELIGIBLE WOMEN ON THE COVER PAGE OF THIS QUESTIONNAIRE.

302. NAME?

NAME ______

303. AGE?

AGE ______

304. CIRCLE THE VISIT NUMBER AT WHICH THE RESPONDENT WAS PRESENT FOR THE TEST.

FIRST VISIT
YES 1
NO 2
SECOND VISIT
YES 1
NO 2
THIRD VISIT
YES 1
NO 2

CONSENT FOR WOMEN'S TETANUS TEST:

305. CHECK 303:
AGE?

15-17 YEARS OLD 1 (GO TO 306)
18 OR OLDER 2 (GO TO 307)

306. RECORD CONSENT OF PARENT OR OTHER ADULT FOR THE TETANUS TEST:

ACCEPTED 1 (SIGN) ______
REFUSED 2 (SIGN) ______ (GO TO 310)

307. RECORD CONSENT OF RESPONDENT FOR THE TETANUS TEST:

ACCEPTED 1 (SIGN) ______
REFUSED 2 (SIGN) ______ (GO TO 310)

308. CHECK 307 TO SEE IF CONSENTED TO TETANUS TEST. ATTACH THE FIRST BARCODE LABEL FROM A LINE.

ATTACH THE FIRST BARCODE LABEL FROM A LINE HERE.

309. PREPARE THE NECESSARY MATERIALS TO DRAW THE BLOOD FOR THE TETANUS TEST. ATTACH THE SECOND BARCODE LABEL FROM THE SAME LINE TO THE FILTER PAPER THAT YOU WILL USE FOR THE RESPONDENT'S DROPS OF BLOOD. THEN ATTACH THE THIRD BARCODE LABEL TO THE TETANUS BLOOD DRAW TRANSMISSION SHEET.

RESULTS SUMMARY FOR TESTS FOR HOUSEHOLD BLOOD DRAW QUESTIONNAIRE 2003:

310. RECORD THE FINAL RESULTS IN QUESTION 310A. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, CHECK AND RECORD THE FINAL RESULTS OF THE BLOOD DRAW FOR THE TETANUS TEST FOR EACH RESPONDENT.

310A. RESULT CODE FOR WOMEN'S TETANUS TEST

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER (SPECIFY) _____

311. RETURN TO 302 FOR THE NEXT RESPONDENT. IF NO MORE RESPONDENTS, (GO TO 312).

312. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF WOMEN AND CHILDREN FOR WHOM THE TETANUS TEST WAS COMPLETED (THAT IS, WITH CODE '1' MARKED IN QUESTIONS 211A AND 310A).

TETANUS ____

312A. AFTER HAVING COMPLETED ALL FOLLOW-UP VISITS TO THE HOUSEHOLD, RECORD THE TOTAL NUMBER OF CHILDREN FOR WHOM THE MEASLES TEST WAS COMPLETED (THAT IS, WITH CODE '1' MARKED IN QUESTION 211B).

MEASLES ____

313. END OF HOUSEHOLD TETANUS AND MEASLES TEST.

TETANUS AND MEASLES TEST OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING TESTS.

IF THE QUESTIONNAIRE WAS NOT FILLED OUT, EXPLAIN ____

NURSE'S/LAB TECHNICIAN'S OBSERVATIONS ______
NAME OF NURSE ______
DATE _____

SUPERVISOR'S OBSERVATIONS _______
NAME OF SUPERVISOR ______
DATE _____

FIELD EDITOR'S OBSERVATIONS ______
NAME OF FIELD EDITOR _______
DATE ______

[NOTE: The remainder of the Household Blood Draw Questionnaire is omitted from this translation of the original document. This includes the letters and forms concerning patient referrals and blood tests that do not constitute a part of the survey.]