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DEMOGRAPHIC AND HEALTH SURVEY IN MALI-ADSM III, 2001 - HOUSEHOLD QUESTIONNAIRE

PLANNING AND STATISTICAL UNIT/M-HEALTH
NATIONAL DEPARTMENT OF STATISTICS AND INFORMATION
REPUBLIC OF MALI

IDENTIFICATION

PLACE NAME_____
COMMUNE_____
CLUSTER NUMBER______
NAME OF HEAD OF HOUSEHOLD AND HOUSEHOLD NUMBER______
REGION_____
VILLAGE ______

URBAN/RURAL?

URBAN 1
RURAL 2

BAMAKO, OTHER CITIES, OTHER VILLAGES, OR RURAL?

BAMAKO 1
OTHER CITIES 2
OTHER VILLAGES 3
RURAL 4

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

INTERVIEWER 1 (REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE____
DAY____
MONTH____
YEAR 2001
INTERVIEWER NAME____

RESULTS___

1 COMPLETED
2 NO MEMBER OF THE HOUSEHOLD AT HOME OR NO COMPETENT RESPONDENT AT THE TIME OF THE VISIT
3 HOUSEHOLD TOTALLY ABSENT FOR A LONG TIME
4 POSTPONED
5 REFUSED
6 EMPTY DWELLING OR NO DWELLING AT THE ADDRESS
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _____

NEXT VISIT
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH__
YEAR 2001
INTERVIEWER_____
RESULT_____

TOTAL NUMBER OF VISITS _____

TOTAL IN THE HOUSEHOLD_____
TOTAL ELIGIBLE WOMEN_____
TOTAL ELIGIBLE MEN_____

RESPONDENT'S LINE NUMBER_____

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____
KEYED BY_____

HOUSEHOLD SCHEDULE

We would now like information on the persons who usually live in your household and who are currently living with you.

1. LINE NUMBER

LINE NO. _____

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 slept here last night, starting with the head of the household.

NAME _____

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

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDSON OR GRANDDAUGHTER
06 FATHER OR MOTHER
07 FATHER-IN-LAW OR MOTHER-IN-LAW
08 BROTHER OR SISTER
09 CO-WIFE
10 OTHER RELATIVE
11 ADOPTED/FOSTER/STEPCHILD
12 NOT RELATED
98 DOESN'T KNOW

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

MALE 1
FEMALE 2

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

YES 1
NO 2

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

YES 1
NO 2

7. AGE: How old is (NAME)?

YEARS ____

8. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL WOMEN RESIDENTS OR VISITORS BETWEEN 15-49 YEARS.

9. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL MEN RESIDENTS OR VISITORS BETWEEN 15-59 YEARS.

9A. ELIGIBILITY: CIRCLE THE LINE NUMBER OF ALL THE CHILDREN RESIDENTS OR VISITORS LESS THAN 6 YEARS.

SURVIVORSHIP AND RESIDENCE OF PARENTS OF PERSONS UNDER 15 YEARS:

10. Is (NAME'S) biological mother still alive?

YES 1
NO 2
DOESN'T KNOW 8

11. IF ALIVE: Does the (NAME'S) biological mother live in the household?
IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER. RECORD '00' IF THE FATHER IS NOT MEMBERS OF THE HOUSEHOLD.

LINE NO. _____

12. Is (NAME'S) biological father still alive?

YES 1
NO 2
DOESN'T KNOW 8

13. IF ALIVE: Does the (NAME'S) biological father live in the household?
IF YES: What is his name?

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

LINE NO. _____

EDUCATION. IF 5 YEARS OR MORE:

14. Has (NAME) attended school?
FOR THE FIRST PERSON AGED 5 TO 17 YEARS, GO TO THE NEXT LINE OR COLUMN 20C.

YES 1
NO 2 (GO TO NEXT LINE)

15. What is the highest level of education attained by (NAME)? What is the last class completed by (NAME) at this level?

LEVEL OF EDUCATION ____
1 ELEMENTARY 1(FIRST CYCLE)
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
5 DOESN'T KNOW
GRADE ____
0 LESS THAN 1 YEAR COMPLETED
8 DOESN'T KNOW

EDUCATION. IF 5-24 YEARS OLD:

16. Does (NAME) currently attend school?

YES 1 (GO TO 18)
NO 2

17. Has (NAME) attended school during the current school at any time?

YES 1
NO 2 (GO TO 19)

18. During the current school year which level did (NAME) achieve and in which class?

LEVEL OF EDUCATION ____
1 ELEMENTARY 1(FIRST CYCLE)
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
5 DOESN'T KNOW
GRADE ____
0 LESS THAN 1 YEAR COMPLETED
8 DOESN'T KNOW

19. Did (NAME) attend school at any time during the previous school year?
FOR THE FIRST PERSON AGED 5 TO 17 YEARS, GO TO THE NEXT LINE OR COLUMN 20C.

YES 1
NO 2 (GO TO THE NEXT LINE)

20. During the current school year which level did (NAME) achieve and in which class?
FOR THE FIRST PERSON AGED 5 TO 17 YEARS, GO TO THE NEXT LINE OR COLUMN 20C.

LEVEL OF EDUCATION ____
1 ELEMENTARY 1(FIRST CYCLE)
2 ELEMENTARY 2(SECOND CYCLE)
3 SECONDARY (HIGH SCHOOL, TECHNICAL SCHOOL)
4 SUPERIOR
5 DOESN'T KNOW
GRADE ____
0 LESS THAN 1 YEAR COMPLETED
8 DOESN'T KNOW

MARK HERE IF ANOTHER SHEET WAS USED_____

Just to be sure that I have a complete list:

1) Are there other persons such as small children or infants that we have not recorded on the list?

YES 1 (WRITE EACH ONE IN THE TABLE)
NO 2

2) Are there other persons who maybe are not members of your family such as domestic workers, renters or friends who usually live here?

YES 1 (WRITE EACH ONE IN THE TABLE)
NO 2

3) Are there guests or temporary visitors who are at your household, or other persons who spent the last night here who were not listed?

YES 1 (WRITE EACH ONE IN THE TABLE)
NO 2

IF BETWEEN THE AGES OF 5 AND 17 YEARS:

20C. RECORD THE NAME OF EACH ELIGIBLE CHILD FOLLOWING THE CORRESPONDING LINE NUMBER

LINE NO. ____

20D. Who is the mother of the main person in charge of (NAME)?
RECORD THE LINE MOTHER/OR THIS PERSON'S LINE NUMBER

LINE NO. _____

20E. CHILD LABOR: Did (NAME) do any kind of work for someone who is not a member of this household last week?
IF YES: to be paid?

YES, PAID (IN MONEY OR IN KIND) 1
NO PAY 2
NO 3 (GO TO 20G)

20F. CHILD LABOR. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she work for someone who is not a member of the household?
IF MORE THAN ONE JOB, TAKE THE SUM OF ALL THE HOURS.

NO. OF HOURS ___ (GO TO 20H)

20G. During the last year did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: to be paid?

YES, PAID (IN MONEY OR IN KIND) 1
YES, UNPAID 2
NO 3

20H. Did (NAME) help with household work last week? For example: get groceries, cook, clean, get water, watch children, wash clothesÂ…?

YES 1
NO 2 (GO TO 20J)

20I. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she spend doing this household work?

NO. OF HOURS ____

20J. Did (NAME) do other work for the family last week (such as farm work, commerce, business,Â…) ?

GO TO THE NEXT LINE OR TO QUESTION 2 IF THERE IS NO ELIGIBLE CHILD FOR COLUMNS 20C TO 20K

YES 1
NO 2 (GO TO NEXT LINE)

20K. IF YES: Since last (DAY OF THE WEEK) about how many hours did he/she spend doing this work?

GO TO THE NEXT LINE OR TO QUESTION 2 IF THERE IS NO ELIGIBLE CHILD FOR COLUMNS 20C TO 20K

NO. OF HOURS ____

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

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

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

MINUTES ___
ON SITE 998

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

FLUSH 11
PIT/LATRINE
RUDIMENTARY 21
IMPROVED 22
NO FACILITY/BUSH/FIELD 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?
Radio?
Television?
Telephone?
Refrigerator?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

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

ELECTRICITY 01
BOTTLED GAS/NATURAL GAS 02
BIOGAS 03
KEROSENE/PETROL 04
CHARCOAL/LIGNITE (HARD FOSSIL CHARCOAL) 05
WOOD CHARCOAL 06
WOOD/STRAW 07
ANIMAL 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. Is there anyone in your household who owns:

A bicycle?
A scooter or motorcycle?
A car or truck?
A cart?
A plow?
A horse?
A camel?
A donkey?

BICYCLES?
YES 1
NO 2
SCOOTERS OR MOTORCYCLES?
YES 1
NO 2
CAR OR TRUCK?
YES 1
NO 2
CARTS?
YES 1
NO 2
PLOWS?
YES 1
NO 2
HORSES?
YES 1
NO 2
CAMELS?
YES 1
NO 2
DONKEYS?
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)

30. CHECK COLUMNS (6) AND (7):
NUMBER OF CHILDREN LESS THAN 5 YEARS WHO SLEPT IN THE HOUSEHOLD THE LAST NIGHT.

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

31. Did (NAME) sleep under a mosquito net last night?

YES 1
NO 2 (GO TO 33)

32. Among the children less than 5 years old who slept in the household last night, did they all sleep under a mosquito net, some of them, or none?

ALL 1
SOME 2
NONE 3

33. Where do members of your household most often wash their hands?

IN THE DWELLING/YARD/ON THE PLOT 1
SOMEWHERE ELSE 2 (GO TO 35)
NOWHERE 3 (GO TO 35)

34. ASK TO SEE THE PLACE MOST OFTEN USED FOR HAND WASHING AND CHECK TO SEE IF THE FOLLOWING OBJECTS ARE THERE.

WATER/FAUCET
YES 1
NO 2
SOAP, ASH OR OTHER CLEANING PRODUCT
YES 1
NO 2
WASHBOWL
YES 1
NO 2

35. Ask the respondent for a teaspoon of cooking salt, then test for iodide. Record the PPM (Proportion per million).

Test in the following order: iodate, iodide, alkaline.
Code '1' should only be used if the test is negative for all 3 reactions. If the test is positive for iodide or alkaline, circle code '6'.

0 PPM 1
1-25 PPM 2
26-50 PPM 3
51-75 PPM 4
76-100 PPM 5
1-75 PPM (IODINE/ALKALINE) 6
NO SALT IN HOUSEHOLD 8

WEIGHT AND HEIGHT AND HEMOGLOBIN MEASUREMENTS

CHECK COLUMNS (8) AND (9A), (2) AND (7) FROM THE HOUSEHOLD TABLE: RECORD THE LINE NUMBER, NAME AND AGE OF ALL OF THE WOMEN 15-49 AND OF ALL OF THE CHILDREN LESS THAN 6.

WOMEN 15-49:

36. LINE NUMBER FROM COLUMN (8):

LINE NO. _____

37. NAME FROM COL. (2):

NAME _____

38. AGE FROM COL. (7):

YEARS _____

WEIGHT AND HEIGHT OF WOMEN 15-49:

40. WEIGHT (KILOGRAMS):

KILOGRAMS _____

41. HEIGHT (CENTIMETERS):

CENTIMETERS_____

43. RESULT

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

CHILDREN LESS THAN 6:

36. LINE NUMBER OF COL. (9A):

LINE NO. _____

37. NAME FROM COL. (2):

NAME _____

38. AGE COL. (7):

YEARS _____

39. What is the birthdate of (NAME)?

DAY _____
MONTH _____
YEAR _____

WEIGHT AND HEIGHT OF CHILDREN BORN IN 1996 OR AFTER:

40. WEIGHT (KILOGRAMS):

KILOGRAMS _____

41. HEIGHT (CENTIMETERS):

CENTIMETERS _____

42. MEASURED LYING DOWN OR STANDING:

LYING 1
STANDING 2

43. RESULT:

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

43A. REGISTERED WITH THE STATE:

YES 1
NO 2
DOESN'T KNOW 8

CHECK HERE IF ANOTHER SHEET WAS USED _____

MEASUREMENT OF HEMOGLOBIN LEVEL OF WOMEN 15-49 YEARS:

44. CHECK COLUMN (38):

AGE 15-17 YEARS 1
AGE 18-49 YEARS 2 (GO TO 46)

45. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NO. _____

46. READ THE CONSENT STATEMENT TO THE WOMAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN)

CONSENTED 1 (SIGN) _____
REFUSED 2 (GO TO NEXT LINE)

47. HEMOGLOBIN LEVEL (G/DL):

G/DL _____

48. CURRENTLY PREGNANT:

YES 1
NO/DOESN'T KNOW 2

49. RESULT:

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

MEASUREMENT OF HEMOGLOBIN LEVEL OF CHILDREN BORN IN 1996 OR LATER:

45. LINE NUMBER OF THE PARENT/RESPONSIBLE ADULT.
RECORD '00' IF IT IS NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NO. _____

46. READ THE CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN).

CONSENTED 1 (SIGN) _____
REFUSED 2 (GO TO NEXT LINE)

47. HEMOGLOBIN LEVEL (G/DL)

G/DL _____

49. RESULT:

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

MEASUREMENT OF HEMOGLOBIN LEVEL OF MEN 15-59 YEARS:

CHECK COLUMNS (8), (9), (2) AND (7) OF THE HOUSEHOLD TABLE: RECORD THE LINE NUMBER, THE NAME AND AGE OF ALL MEN 15-59

49A. LINE NUMBER FROM COLUMN (9):

LINE NO. _____

49B. NAME FROM COL. (2):

NAME _____

49C. AGE FROM COL. (7):

YEARS_____

49D. CHECK COLUMN (49C):

AGE 15-17 YEARS 1
AGE 18-59 YEARS 2 (GO TO 49F)

49E. LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN THE HOUSEHOLD QUESTIONNAIRE.

LINE NO. _____

49F. READ THE CONSENT STATEMENT TO THE MAN/PARENT/RESPONSIBLE ADULT CIRCLE THE CODE (AND SIGN)

CONSENTED 1 (SIGN) ____
REFUSED 2 (GO TO NEXT LINE)

49G. HEMOGLOBIN LEVEL (G/DL)

G/DL _____

49H. RESULT

1 MEASURED
2 ABSENT
3 REFUSED
6 OTHER

MARK HERE IS ANOTHER SHEET WAS USED____

50. CHECK 47, 48 AND 49(G):
NUMBER OF USUAL RESIDENTS WHOSE HEMOGLOBIN IS BELOW THE CRITICAL THRESHOLD. THE CRITICAL THRESHOLD IS 7 G/DL.

ONE OR MORE: GIVE EVERY WOMAN/MAN/ADULT RESPONSIBLE TEST RESULTS AND GO TO 51. IF THERE IS MORE THAN ONE WOMAN OR CHILD WHO IS BELOW THE CRITICAL THRESHOLD, READ THE STATEMENT IN 51 TO EACH WOMAN WHO IS BELOW THE CRITICAL THRESHOLD AND TO EACH WOMAN/PARENT/RESPONSIBLE ADULT OF A CHILD WHO IS BELOW THE CRITICAL THRESHOLD.

NONE: GIVE EVERY WOMAN/MAN/ADULT RESPONSIBLE TEST RESULTS. END OF HOUSEHOLD QUESTIONNAIRE.

51. We have detected a low level of hemoglobin in (your blood/ the blood of NAME OF CHILD/CHILDREN). The means that (you/ NAME OF CHILD/CHILDREN) are severely anemic, this is a serious health problem. We wish to inform the doctor of ______ about (your condition /the condition of NAME OF CHILD/CHILDREN). This will help you to get the appropriate treatment for your condition Do you accept to have this information concerning the hemoglobin level of (your blood/ the blood of NAME OF CHILD/CHILDREN) given to the doctor?

WOMEN 18-49 AND MEN 18-59:

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD

NAME _____

ACCEPT THAT THE INFORMATION IS SHARED?

YES 1
NO 2

MEN AND WOMEN 15-17 AND CHILDREN LESS THAN 6 YEARS:

NAME OF THE PERSON WHO IS BELOW THE CRITICAL THRESHOLD:

NAME _____

NAME OF PARENT/RESPONSIBLE ADULT:

NAME _____

ACCEPT THAT THE INFORMATION IS SHARED?

YES 1
NO 2

CONSENT FOR HIV TESTING

CHECK COLUMNS (8) AND (9) OF THE HOUSEHOLD TABLE: RECORD THE LINE NUMBER, NAME, AGE AND MARITAL STATUS OF ALL THE WOMEN 15-49 YEARS AND ALL THE MEN 15-59 YEARS.

HIV TEST FOR WOMEN 15-49:

52. LINE NUMBER FROM COL. (8) OR COL (9):

LINE NO. _____

53. NAME FROM COL. (2):

NAME_____

54. MARITAL STATUS:

1 MARRIED
2 SINGLE
3 DIVORCED/WIDOWED/SEPARATED

55. AGE FROM COL. (7):

YEARS_____

56. CHECK COLUMN (55): AGE?

15-17 YEARS 1
18-49 YEARS 2 (GO TO 58)

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

LINE NO. ____

58. READ CONSENT STATEMENT TO THE WOMAN/MAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN).

AGREED 1 (SIGN) _____
REFUSED 2 (GO TO NEXT LINE)

59. RESULT:

1 TESTED
2 NOT TESTED
6 OTHER

HIV TEST FOR MEN 15-59:

52. LINE NUMBER FROM COL. (8) OR COL (9)

LINE NO. _____

53. NAME FROM COL. (2)

NAME _____

54. MARITAL STATUS:

1 MARRIED
2 SINGLE
3 DIVORCED/WIDOWED/SEPARATED

55. AGE FROM COL. (7):

YEARS_____

56. CHECK COLUMN (55): AGE?

15-17 YEARS 1
18-49 YEARS 2 (GO TO 58)

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

LINE NO. ____

58. READ CONSENT STATEMENT TO THE WOMAN/MAN/PARENT/RESPONSIBLE ADULT. CIRCLE THE CODE (AND SIGN).

AGREED 1 (SIGN) _____
REFUSED 2 (GO TO NEXT LINE)

59. RESULT:

1 TESTED
2 NOT TESTED
6 OTHER

MARK HERE IS ANOTHER SHEET WAS USED ____

VOLUNTARY CONSENT STATEMENT FOR ANEMIA AND HIV TESTS

Anemia test:

As part of this survey, we would like to know the level of anemia in women, men, and children. Anemia, which is due to poor nutrition, is a serious health problem. The results of this survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all of your children/children you care for) take an anemia test by giving a few drops of blood from a finger. For this test we use sterile, non-reusable instruments that are clean and risk-free. Blood will be analyzed with new equipment and the results will be given to you immediately. The results are confidential.

Do you have any questions?
May I request now that you (and all of your children/children you care for) take this anemia test? However, if you decide to refuse, know that you have this right and that we respect your decision.

Now, can you tell me if you (and all of your children/children you are for) accept to take this test?

FOR EACH PERSON, RETURN TO COLUMN (46) FOR WOMEN 15-49 AND CHILDREN BORN SINCE JANUARY 1996 AND TO COLUMN (49F) FOR MEN 15-59, ON THE LINE OF THE CORRESPONDING PERSON AND CIRCLE THE APPROPRIATE CODE. SIGN AND FOLLOW THE SKIP CODE.

HIV Test:

As part of this survey, we are doing a study of HIV/AIDS among women and men. HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. This survey will help the government develop programs to prevent this illness.

For the HIV test we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is no reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. No name will be linked to the result. Thus, we will not be able to tell you your test results. No else will know that result of the blood test either.

Do you have any questions?
Now, do you agree to take this HIV test? However, if you choose to refuse, know that you have the right and we will respect your decision.

Now, can you tell me if you agree to participate in the HIV test?

FOR EACH PERSON, RETURN TO COLUMN (58) AND THE LINE OF THE CORRESPONDING PERSON AND CIRCLE THE APPROPRIATE CODE. SIGN AND FOLLOW THE SKIP INSTRUCTIONS.

BE SURE TO GIVE EACH ELIGIBLE PERSON WHETHER OR NOT SHE/HE ACCEPTED THE HIV TEST, A CARD "ADVICE AND FREE HIV TESTS." TELL HIM/HER: "This card allows you to get free advice and HIV tests. If you would like to get tested, bring this card to the appropriate health facility. At this facility, information about HIV and ways to avoid it will be given to you. Also a few drops of blood will be taken which will allow you to know the results of your test. Do you have questions about this card and the place to go?"