IDENTIFICATION

PLACE NAME ______
NAME OF HOUSEHOLD HEAD ______
CLUSTER NUMBER ______
SEQUENTIAL NUMBER OF THE HOUSEHOLD WITHIN THE CLUSTER ______
BUILDING NUMBER ______
HOUSEHOLD UNIT NUMBER ______
REGION ______
VILLAGE ______

ANTANANARIVO/OTHER CITY/RURAL CITY?

HOUSEHOLD SELECTED FOR MEN'S SURVEY, BIOMARKERS, AND THE LONG VERSION OF THE WOMEN'S SURVEY?

INTERVIEWER VISITS

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

RESULT ______

NEXT VISIT
DATE ______
TIME ______

FINAL VISIT
DAY ______
MONTH ______
YEAR ______
INTERVIEWER NUMBER ______
RESULT ______

TOTAL NUMBER OF VISITS ______

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

SUPERVISOR
NAME ______
DATE ______

FIELD EDITOR
NAME ______
DATE ______

OFFICE EDITOR ______
KEYED BY ______

INTRODUCTION AND CONSENT

Hello. My name is _____ and I am working with The National Institute of Statistics. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete.

As part of the survey we would first like to ask some questions about your household. Whatever information you provide will be kept strictly confidential. Participation in this survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.

Do you have any questions to ask me about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER ______
DATE _____

HOUSEHOLD SCHEDULE

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

1. LINE NUMBER (THE NUMBER OF PERSONS LISTED BY THE RESPONDENT):

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

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK THE THREE QUESTIONS AT THE END OF THE TABLE TO ASSURE THAT THE LIST OF PERSONS IS COMPLETE. THEN ASK THE APPROPRIATE QUESTIONS FROM COLUMNS 5 TO 22 FOR EACH PERSON.

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

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

CHECK 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?

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?

3) Are there any other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

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

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

7. AGE: How old is (NAME)?

MARITAL STATUS. IF AGE 15 OR OLDER:

8. What is (NAME)'s current marital status?

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

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

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

BIRTH REGISTRATION, IF AGE 0-4 YEARS:

12. Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS. IF AGE 0-17 YEARS:

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

14. Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. IF NO: RECORD '00'.

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

16. Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NO: RECORD '00'.

EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:

17. Has (NAME) ever attended school?

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

RECENT/CURRENT EDUCATION. IF AGE 5-24 YEARS:

19. Did (NAME) attend school at any time during the 2008-2009 school year?

20. During this/that school year, what level and grade is/was (NAME) attending?

21. Did (NAME) attend school at any time during the previous school year, that is, 2007-2008?

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

HOUSEHOLD CHARACTERISTICS

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

102. What is the main source of water used by your household for other purposes such as cooking and hand washing?

103. Where is that water source located?

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

105. Who usually goes to this source to fetch the water for your household?

105A. In your opinion, what can someone do to make water safe to drink?
Anything else?
RECORD ALL MENTIONED.

106. Do you do anything to your water to make it safer to drink?

107. What do you usually do to make your water safer to drink?
Anything else?
RECORD ALL MENTIONED.

108. What kind of toilet facility do members of your household usually use?

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

110. How many households use this toilet facility?

111. Does your household have:

Electricity?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?

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

113. In this household, is food cooked on an open fire, an open stove, or a closed stove?

114. Does this fire/stove have a chimney, a hood, or neither of these?

115. Is the cooking usually done in the house, in a separate building, or outdoors?

116. Do you have a separate room which is used as a kitchen?

117. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

118. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

119. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

120. How many rooms in this household are used for sleeping?

121. Does any member of this household own:

A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?

122. Does any member of this household own any agricultural land?

123. How many hectares of agricultural land do members of this household own?

124. Does this household own any livestock, herds, other farm animals, or poultry?

125. How many of the following animals does this household own?
IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.

126. Does any member of this household have a bank account?

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

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

[REPEAT QUESTIONS 129-136 FOR EACH MOSQUITO NET]

129. ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD:
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRES.

130. How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.

131. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET:

132. When you got the net, was it treated with an insecticide to kill or repel mosquitos?

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

134. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'.

135. Did anyone sleep under this mosquito net last night?

136. Who slept under this mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. RECORD AS MANY PERSONS AS APPLICABLE FOR EACH NET.

137. GO BACK TO 129 FOR NET; OR, IF NO MORE NETS, SKIP TO 137A.

137A. In the last 12 months, has your household been affected by a natural disaster, such as a tornado, a flood, a drought, or locusts?

137B. What type of natural disaster?
PROBE: Any other natural disaster in the last 12 months?
RECORD ALL RESPONSES.

137C. In what way was your household affected?
Anything else?
RECORD ALL RESPONSES.

138. Where do members of your household usually wash their hands?

139. ASK TO SEE THE PLACE IN THE HOUSEHOLD MOST OFTEN USED FOR HAND WASHING AND VERIFY WHETHER THE FOLLOWING ITEMS ARE PRESENT:

140. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION).

141. CHECK THE FIRST PAGE:
IS THE HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, THE BIOMARKER SURVEY, AND THE LONG VERSION OF THE WOMEN'S SURVEY?

IDENTIFICATION

PLACE NAME ______
NAME OF HOUSEHOLD HEAD ______
CLUSTER NUMBER ______
SEQUENTIAL NUMBER OF THE HOUSEHOLD WITHIN THE CLUSTER ______
BUILDING NUMBER ______
HOUSEHOLD UNIT NUMBER ______
REGION ______
VILLAGE ______

ANTANANARIVO/OTHER CITY/RURAL?

INTERVIEWER VISITS

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

RESULT _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INTERVIEWER NUMBER _____
RESULT _____

TOTAL NUMBER OF VISITS _____

TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 0-5 _____
TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49_____
TOTAL NUMBER OF ELIGIBLE MEN AGE 15-59_____

SUPERVISOR
NAME _____
DATE _____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____
KEYED BY _____

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

101. CHECK COLUMN 11 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND AGE FOR ALL CHILDREN AGE 0-5 IN QUESTION 102 (BELOW). IF MORE THAN SIX CHILDREN USE AN ADDITIONAL QUESTIONNAIRE.

102. IN THE HOUSEHOLD QUESTIONNAIRE:

[REPEAT QUESTIONS 103-114 FOR EACH CHILD RECORDED IN 102]

103. What is (NAME)'s birth date?
IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

104. CHECK 103:
CHILD BORN IN JANUARY 2003 OR LATER?

105. WEIGHT IN KILOGRAMS:

106. HEIGHT IN CENTIMETERS:

107. MEASURED LYING DOWN OR STANDING UP?

108. RESULT OF WEIGHT AND HEIGHT MEASUREMENT:

109. CHECK 103:
IS CHILD AGE 0-5 MONTHS, I.E. WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

110. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR CHILD:
RECORD '00' IF NOT LISTED.

111. CONSENT STATEMENT FOR ANEMIA TEST FOR CHILDREN AGE 0-5 YEARS:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government in developing programs to prevent and treat anemia.
We request that all children born in 2003 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result is confidential.

Do you have any questions?
You can say 'Yes' to the test, or you can say 'No'. It is your decision.
Will you allow (NAME(S) OF CHILD(REN)) to participate in the anemia test?

CIRCLE THE APPROPRIATE CODE IN 111A AND SIGN.

111A. READ CONSENT STATEMENT FOR ANEMIA TEST TO PARENT/ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN:

112. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET:

113. RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT:

NEXT, FOR EACH CHILD TESTED, PREPARE A RESULTS SHEET AND GIVE IT TO THE PARENT (OR OTHER ADULT).

114. RETURN TO 103 IN THE NEXT COLUMN (IF NO MORE CHILDREN, GO TO 201)

CHECK HERE IF AN ADDITIONAL QUESTIONNAIRE WAS USED _____

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15-49 AND MEN AGE 15-59

201. CHECK COLUMNS 9 AND 10 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL WOMEN AGE 15-49 AND ALL MEN AGE 15-59 IN QUESTIONS 202 AND 203. IF THERE ARE MORE THAN FOUR ADULTS, USE AN ADDITIONAL QUESTIONNAIRE. A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN QUESTION 208 AND FOR THE ANEMIA TEST IN QUESTION 216.

[REPEAT QUESTIONS 202-332 FOR EACH WOMAN AGE 15-49 AND EACH MAN AGE 15-59]

202. LINE NUMBER (COLUMN 9 OR 10):

203. NAME (COLUMN 2):

204. RECORD AGE AND SEX OF ALL ELIGIBLE ADULTS:

205. WRITE THE NUMBER OF ELIGIBLE ADULTS ON THE COVER PAGE OF THIS QUESTIONNAIRE.

206. WEIGHT IN KILOGRAMS:

207. HEIGHT IN CENTIMETERS:

208. RESULT OF WEIGHT AND HEIGHT MEASUREMENT:

209. AGE AND SEX:
CHECK QUESTIONS 204 AND 205:

210. MARITAL STATUS:
CHECK COLUMN 8.

211. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF THE PERSON IS NOT LISTED.

212. FOR ADOLESCENTS AGE 15-17 YEARS:
ASK CONSENT FROM THE PARENT OR RESPONSIBLE ADULT FOR THE ANEMIA TEST.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government in developing programs to prevent and treat anemia. For this test, we need a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result told to you right away. The result is 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 your decision.
Now, will you allow (name of adolescent age 15-17 years) to take the anemia test?

CIRCLE THE APPROPRIATE CODE IN QUESTION 212A AND SIGN.

212A. READ ANEMIA TEST CONSENT STATEMENT TO THE PARENT OR ADULT IDENTIFIED IN QUESTION 211. (FOR ADOLESCENTS AGE 15-17 AND NEVER IN UNION):

212B. ASK CONSENT FROM ADULTS/YOUTHS FOR THE ANEMIA TEST:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government in developing programs to prevent and treat anemia.
For this test, we need a few drops of blood from a finger. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result told to you right away. The result is 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 your decision.
Now, will you agree to take the anemia test?

CIRCLE THE APPROPRIATE CODE IN QUESTION 212C AND SIGN.

212C. READ ANEMIA TEST CONSENT STATEMENT TO ADULT WOMAN AGE 18-49, ADULT MAN AGE 18-59, OR YOUTH:

213. SEX OF RESPONDENT:

214. CHECK 226 IN WOMEN'S QUESTIONNAIRE:
OR ASK: Are you pregnant?

215. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

216. RESULT OF HEMOGLOBIN TEST:

FOR EACH RESPONDENT TESTED, PREPARE THE ANEMIA PAMPHLET TO GIVE TO THE RESPONDENT (TO PARENT OR OTHER ADULT FOR ADOLESCENT'S AGE 15-17 YEARS).

217. CONTINUE TO 301 (SYPHILIS TEST).

CHECK HERE IF AN ADDITIONAL QUESTIONNAIRE WAS USED _____

SYPHILIS TEST - IDENTIFICATION AND CONSENT

301. CHECK 204 AND 205:
AGE AND SEX?

302. CHECK MARITAL STATUS:

303. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF THE PERSON IS NOT LISTED.

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

304. FOR ADOLESCENTS AGE 15-17 YEARS:
ASK CONSENT FROM THE PARENT OR RESPONSIBLE ADULT FOR THE SYPHILIS TEST.

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

We would like (NAME OF ADOLESCENT AGE 15-17 YEARS) 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 previously had or if you have syphilis. We will give you the test result immediately. For these tests, we use sterilized and disposable instruments that are clean and completely risk-free.

The result of (NAME)'s syphilis test is strictly confidential and will not be shared with anyone except you, (NAME), and our survey team. If the result of the test is positive, we will offer immediate treatment to (NAME). Additionally, we can also refer (NAME) to a health facility.

Do you have any questions?
Now, will you allow (NAME) to take the syphilis test?
You can accept or refuse the test for (NAME). It is up to you to decide.

CIRCLE THE APPROPRIATE CODE IN QUESTION 304A AND SIGN.

304A. READ SYPHILIS TEST CONSENT STATEMENT TO THE PARENT OR ADULT IDENTIFIED IN 303. (FOR ADOLESCENTS AGE 15-17 NEVER IN UNION):

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

304B. ASK CONSENT FROM ADULTS/YOUTHS FOR THE SYPHILIS TEST:

As part of this survey, we are studying syphilis in men and women in Madagascar. Syphilis can cause serious health problems if left untreated. The results of this survey will help the government of Madagascar to put in place programs for the prevention and treatment of 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 previously had or if you have syphilis. We will give you the test result immediately. For these tests, we use sterilized and disposable instruments that are clean and completely risk-free.

FOR ADULTS: The result of your syphilis test is strictly confidential and will not be shared with anyone except you and our survey team.

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

CIRCLE THE APPROPRIATE CODE IN QUESTION 304C AND SIGN.

304C. READ SYPHILIS TEST CONSENT STATEMENT TO ADULT WOMEN AGE 18-49, ADULT MEN AGE 18-59, OR YOUTH:

SYPHILIS TEST

305. DROPS OF BLOOD FROM THE FINGER DRAWN:

306. RESULT OF SYPHILIS TEST:
INFORM EACH RESPONDENT OF THE TEST RESULT.

306A. CHECK 301 AND 302:

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

307. FOR ADOLESCENTS AGE 15-17 YEARS:
ASK CONSENT FROM THE PARENT OR RESPONSIBLE ADULT TO DRAW BLOOD FROM THE VEINS.

Hello, my name is (NAME) and I work for the National Institute of Statistics. My colleague informed me of (ADOLESCENT)'s syphilis test result. (ADOLESCENT) has a positive test result. However, the test that we do only indicates that the illness is present and doesn't tell us if (ADOLESCENT) actually has syphilis. As a result, we would like to perform a second test to determine if (ADOLESCENT) actually has syphilis, or if (ADOLESCENT) had it in the past. For this second test, we will need to draw a vial of blood from the vein in (ADOLESCENT)'s arm. This second test will be done in a laboratory and no one will know (ADOLESCENT)'s test result because the vial will be labeled with only a number. (ADOLESCENT)'s name will not be written on the vial of blood and, therefore, we cannot provide you or (ADOLESCENT) with the result the test.

For this test, we will use sterilized instruments that are clean and risk-free.

Do you have any questions?
We would like (ADOLESCENT) to participate in this syphilis test. However, if you do not want this test done, that is your right and we will respect your decision.
Now, can you tell me if you will allow (ADOLESCENT) to take this syphilis test?

NAME OF NURSE ______
SIGNATURE ______

CIRCLE THE APPROPRIATE CODE IN QUESTION 307A AND SIGN.

307A. READ VEIN BLOOD DRAW CONSENT STATEMENT TO THE PARENT OR ADULT IDENTIFIED IN 303. (FOR ADOLESCENTS AGES 15-17 YEARS AND NEVER IN UNION).

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

307B. CONSENT FOR VEIN BLOOD DRAW FOR ADULTS/YOUTHS:

Hello, my name is (NAME) and I work for the National Institute of Statistics. My colleague informed me of your syphilis test result. You have a positive test result. However, the test that we do only indicates that the illness is present, and doesn't tell us if you actually have syphilis. As a result, we would like to perform a second test to determine if you actually have syphilis, or if you have had it in the past. For this second test, we will need to draw a vial of blood from the vein in your arm. This second test will be done in a laboratory and no one will know your test result because the vial will be labeled with only a number. Your name will not be written on the vial of blood and, therefore, we cannot provide you with the result the test. For this test, we will use sterilized instruments that are clean and risk-free.

Do you have any questions?
We would like your participation in this syphilis test. However, if you do not want this test done, that is your right and we will respect your decision.
Now, can you tell me if you will participate in this syphilis test?

NAME OF NURSE _____
SIGNATURE _____

CIRCLE THE APPROPRIATE CODE IN QUESTION 307C AND SIGN.

307C. READ VEIN BLOOD DRAW CONSENT STATEMENT TO ADULT WOMEN AGE 18-49, ADULT MEN AGE 18-59, OR YOUTH:

308. BEFORE DRAWING BLOOD, TAKE THE FIRST BARCODE LABEL IN THE FIRST AVAILABLE LINE ON THE LABEL SHEET AND ATTACH IT TO QUESTION 309.

309. ATTACH FIRST AVAILABLE BARCODE LABEL HERE

310. BLOOD FROM VEIN IN ARM DRAWN FOR THE RPR AND TPHA SYPHILIS TEST:

311. TAKE THE SECOND BARCODE LABEL FROM THE SAME AVAILABLE LINE ON THE LABEL SHEET AND ATTACH IT TO THE VIAL OF DRAWN BLOOD.

311A. CHECK 306:

311B. CHECK 301 AND 302:

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

312. FOR ADOLESCENTS AGE 15-17 YEARS:
ASK CONSENT FROM THE PARENT OR RESPONSIBLE ADULT FOR SYPHILIS TREATMENT.

(NAME OF ADOLESCENT AGE 15-17 YEARS)'s syphilis test came back positive. This result indicates that (NAME) may have syphilis, which can cause serious health problems for (NAME) if he/she is not treated. The treatment consists of a penicillin shot and antibiotic pills.

We can provide immediate treatment. Otherwise, if you prefer, we can refer (NAME) to a health facility. It is up to you to decide whether you prefer immediate treatment or you prefer that (NAME) is referred.

Do you want (NAME) to receive the treatment immediately, or do you want me to refer them to a health facility?

CIRCLE THE APPROPRIATE CODE IN 312A AND SIGN.

312A. CONSENT FROM RESPONSIBLE ADULT FOR TREATMENT/REFERRAL FOR TREATMENT OF SYPHILIS:

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

312B. CONSENT FROM ADULT/YOUTH FOR SYPHILIS TREATMENT:

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

We can provide immediate treatment. Otherwise, if you prefer, we can refer you to a 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, or do you want me to refer you to a health facility?

CIRCLE THE APPROPRIATE CODE IN 312C AND SIGN.

312C. READ THE SYPHILIS TREATMENT CONSENT STATEMENT TO ADULT WOMAN AGE 18-49, ADULT MAN AGE 18-59, OR YOUTH:

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

312D. FOR ADOLESCENTS AGE 15-17 YEARS:
ASK CONSENT FROM THE PARENT OF RESPONSIBLE ADULT FOR PENICILLIN INJECTION:

For most people, the treatment for syphilis is a Penicillin injection. I would like to give (NAME OF ADOLESCENT AGE 15-17 YEARS) a Penicillin injection. (NAME) will only need one injection. However, if you prefer, I can give antibiotic pills.

312E. Can I give the Penicillin injection now or do you prefer the pills?

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

312F. ASK CONSENT FOR PENICILLIN SHOT FROM ADULT/ADOLESCENT AGE 15-17 YEARS:

For most people, the treatment for syphilis is a 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.

312G. Can I give the Penicillin injection now or do you prefer the pills?

312H. SEX:

312I. Are you currently pregnant?

312J. GIVE CIPROFLOXACIN OR DOXYCYCLINE PILLS AND SHOW HOW TO TAKE THEM (GO TO 312L)

312K. GIVE CIPROFLOXACIN PILLS AND SHOW HOW TO TAKE THEM.

312L. During the first 24 hours after treatment, it's possible you may have a fever accompanied by headache and sore muscles. This is a normal response to treatment. If you experience these symptoms, you may take Aspirin or Panadol (Acetaminophen) if you would like. (GO TO 328)

313A. INFORM THE PARENT OR ADULT RESPONSIBLE FOR THE ADOLESCENT AGE 15-17 YEARS OF THE POSSIBLE REACTIONS TO PENICILLIN AND ASK QUESTIONS ABOUT PREVIOUS REACTIONS FOLLOWING A PENICILLIN INJECTION:

For most people, the treatment for syphilis 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 (NAME OF ADOLESCENT AGE 15-17 YEARS)'s has had these reactions, it is highly unlikely that he/she would have them today. However, just to be sure, I am going to ask you some questions about (NAME)'s past experiences with penicillin before I give (NAME) the treatment. After the penicillin injection, (NAME) must stay in the company of others for at least two hours, in case there is a reaction. 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 presents itself after the penicillin injection.

314. To your knowledge, has (NAME OF ADOLESCENT AGE 15-17 YEARS) ever had a penicillin injection?

315. Has (NAME OF ADOLESCENT AGE 15-17 YEARS) ever had a reaction following these penicillin injections?

316. Has (NAME OF ADOLESCENT AGE 15-17 YEARS) ever received any other type of injection?

317. Has (NAME OF ADOLESCENT AGE 15-17 YEARS) ever had a reaction to these other injections?

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

317A. INFORM THE ADULT/YOUTH OF THE POSSIBLE REACTIONS TO PENICILLIN AND ASK QUESTIONS ABOUT PREVIOUS REACTIONS FOLLOWING A PENICILLIN INJECTION:

For most people, the treatment for syphilis 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. After the penicillin injection, you must stay in the company of others for at least two hours, in case there is a reaction. 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 presents itself after the penicillin injection.

317B. To your knowledge, have you ever had a penicillin injection?

317C. Have you ever had a reaction following these penicillin injections?

317D. Have you ever received any other type of injection?

317E. Have you ever had a reaction to these other injections?

320. 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 328)

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

322A. ASK CONSENT FOR ANTIBIOTIC PILLS FROM ADULT/YOUTH (15-17 YEARS):

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.

322B. Would you like to receive the pills or do you prefer to be referred to the health clinic?

323. SEX:

324. Are you currently pregnant?

325. GIVE CIPROFLOXACIN OR DOXYCYCLINE PILLS AND SHOW HOW TO TAKE THEM (GO TO 327).

326. GIVE CIPROFLOXACIN PILLS AND SHOW HOW TO TAKE THEM.

327. During the first 24 hours after treatment, it's possible you may have a fever accompanied by headache and sore muscles. This is a normal response to treatment. If you experience these symptoms, you may take Aspirin or Panadol, if you would like.

[VERIFY THE PRESENCE OF OTHER PERSONS BEFORE CONTINUING. DO EVERYTHING YOU CAN TO ENSURE PRIVACY.]

[ASK FOR CONSENT FOR TREATMENT AGAINST SYPHILIS FOR PARTNER]

328. It is possible that your sexual partner(s) is/are also infected with syphilis. As a result, it is very important to treat your partner(s) today.

329. Would you like to inform your partner so that I may provide them with an immediate treatment?

331. TREAT THE PARTNER ACCORDING TO THE PROTOCOL IN QUESTIONS 311A-327.

332 RETURN TO 201 (WEIGHT/HEIGHT/ANEMIA TEST) FOR THE NEXT RESPONDENT. IF THERE ARE NO MORE RESPONDENTS, END OF THE BIOMARKER QUESTIONNAIRE.

OBSERVATIONS

TO FILL OUT AFTER HAVING FINISHED THE TESTS (IF THE QUESTIONNAIRE WAS NOT COMPLETED, EXPLAIN)

NURSE'S OBSERVATIONS ______
NURSE'S NAME ______
DATE ______

LAB TECHNICIAN'S OBSERVATIONS ______
LAB TECHNICIAN'S NAME ______
DATE ______

SUPERVISOR'S OBSERVATIONS ______
SUPERVISOR'S NAME ______
DATE _____