IDENTIFICATION

PLACE NAME _________________________

NAME OF HOUSEHOLD HEAD __________________

DISTRICT _____________________

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

URBAN/RURAL __

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE ___

NAME AND LINE NUMBER OF MAN _________________ ___

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 CODE ____
RESULT _____

TOTAL NUMBER OF VISITS ___

LANGUAGE OF QUESTIONNAIRE***: 3

LANGUAGE OF INTERVIEW***: ___

NATIVE LANGUAGE OF RESPONDENT***: ___

WAS A TRANSLATOR USED?

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR____

KEYED BY____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND INFORMED CONSENT

INFORMED CONSENT

Hello. My name is _______________ and I am working with the National Statistical Office. The National Statistical Office, together with the Ministry of Health, is conducting a national survey about the health of women and children.
Your household is one that has been randomly selected out of all households in Malawi to be asked the questions in this survey. We would very much appreciate your participation in this survey.

I would like to ask you some questions related to health. This information will help the government to plan health services. The survey usually takes about 30 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey? May I begin the interview now?

Signature of interviewer: __________________
Date: ____________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101. RECORD THE TIME.

102. First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a city, in a town, or in the countryside?

103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

104. Just before you moved here, did you live in a city, in a town, or in the countryside?

105. In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?

106. In the last 12 months, have you been away from your home community for more than 1 month at a time?

107. In what month and year were you born?

108. How old were you at your last birthday?
COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT.

109. Have you ever attended school?

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

111. What is the highest (class/form/year) you completed at that level?

112. CHECK 110:

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

SENTENCES FOR LITERACY TEST (Q 113)

CHICHEWA
Makolo amakonda ana awo.
Ulimi ndi khama.
Mwana akuwerenga bukhu.
Ana amalimbikila kusukulu.

TUMBUKA
Bapapi wakutemwa wana wawo.
Kulima ndi ntchito yinonono.
Mwana wakuwerenga bukhu.
Wana wakulimbikira kusukulu.

ENGLISH
Parents love their children.
Farming is hard work.
The child is reading a book.
Children work hard at school.

YAO
Anangolo akusyanonyela wanachewawo.
Kulima kukusoseka kulimbichila
Mwanache akuwalanga buku.
Wanache akusyalimbichila sukulu.

114. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

115. CHECK 113:

116. Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?

117. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

118. Do you watch television almost every day, at least once a week, less than once a week or not at all?

119. Are you currently working?

120. Have you done any work in the last 12 months?

121. What have you been doing for most of the time over the last 12 months?

122. What is your occupation, that is, what kind of work do you mainly do?

123. CHECK 122:

124. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

125. During the last 12 months, how many months did you work?

126. Are you paid in cash or kind for this work, or are you not paid at all?

127. Who mainly decides how the money you earn will be used?

128. On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

129. What is your religion?

130. What is your tribe or ethnic group?

SECTION 2. REPRODUCTION

201. Now I would like to ask about any children you have had during your life. I am interested only in the children that are biologically yours. Have you ever fathered any children with any woman?

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

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

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

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

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

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

208. (In addition to the children that you have just told me about), do you have:
a) any other living sons or daughters who are biologically your children but who are not legally yours or do not have your last name?
b) any other sons or daughters who died who were biologically your children but who were not legally yours or did not have your last name?

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

210. CHECK 209:

211. Do the children that you have fathered all have the same biological mother?

212. In all, how many women have you fathered children with?

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

SECTION 3. CONTRACEPTION

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

CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY.
CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302 IF APPLICABLE.

301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK:
Have you ever heard of (METHOD)?

302. Have you ever used (METHOD)?

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

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

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401. Are you currently married or living with a woman?

402. Do you have one wife or more than one wife?
IF ONLY ONE WIFE, RECORD '01'.
IF MORE THAN ONE, ASK: How many wives do you currently have?

403. Are there any other women with whom you live as if married?

404. Are you living with one (other) woman or more than one (other) woman as if married?
IF ONLY ONE LIVE-IN PARTNER, RECORD '01'.
IF MORE THAN ONE, ASK: How many women are you living with as if married?

405. Apart from the woman/women you have already mentioned, do you currently have any other regular or occasional sexual partners?

406. Do you currently have any regular sexual partners, occasional sexual partners, or do you have no sexual partner at all?

407. Have you ever been married or lived with a woman?

408. What is your marital status now: are you widowed, divorced, or separated?

409. WRITE THE LINE NUMBERS FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE/PARTNER REPORTED IN QUESTIONS 402 AND 404 ONLY. IF A WIFE/PARTNER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, RECORD '00' IN THE LINE NUMBER BOXES. THE NUMBER OF LINES FILLED IN MUST BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS . (IF RESPONDENT HAS MORE THAN FIVE WIVES/PARTNERS USE ADDITIONAL QUESTIONNAIRE(S).)

410. CHECK: 402 AND 404

SUM OF 402 AND 404 = 1: Please tell me the name of your wife/partner.

SUM OF 402 AND 404 GREATER THAN 1: Please tell me the name of each (wife/partner that you live with as if married), starting with the one you lived with first.

410A. CHECK 410:

411. Have you been married or lived with a woman only once or more than once?

412. Have you ever been married to or lived as if married to any woman other than those you have just mentioned?

413. In total, how many women have you been married to or lived with as if married in your whole life?

414. CHECK 409 AND 411:

ONLY ONE WIFE/PARTNER AND 411 = 1: In what month and year did you start living with your wife/partner?

OTHER: Now we will talk about your first wife/partner. In what month and year did you start living with her?

415. How old were you when you started living with her?

416. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues. How old were you when you first had sexual intercourse with a woman (if ever)?

416A. CHECK 108:

416B. The first time you had sexual intercourse, was a condom used?

417. When was the last time you had sexual intercourse with a woman?
RECORD 'YEARS AGO' ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.

418. The last time you had sexual intercourse with a woman, was a condom used?

419. What was the main reason you used a condom on that occasion?

420. CHECK 302(02):

421. CHECK 419:

CONDOM USED TO PREVENT PREGNANCY (CODE '02' OR '03'): The last time you had sexual intercourse with a woman, did you or she do something else or use any other method besides a condom to avoid a pregnancy?

OTHER: The last time you had sexual intercourse with a woman, did you or she do something or use any method to avoid a pregnancy?

422. What method was used?
IF MORE THAN ONE METHOD USED, RECORD THE HIGHEST METHOD ON THE LIST.

424. What is your relationship to the woman with whom you last had sex?
IF WOMAN IS 'GIRLFRIEND' OR 'FIANCEE', ASK: Was your girlfriend/fiancée living with you when you last had sex with her?
IF YES, CIRCLE '01'. IF NO, CIRCLE '02'.

425. For how long (have you had/did you have) sexual relations with this woman?
IF ONLY HAD SEXUAL RELATIONS WITH THIS WOMAN ONCE, RECORD '01' DAYS.

426. Have you had sex with any other woman in the last 12 months?

427. The last time you had sexual intercourse with another woman, was a condom used?

428. What was the main reason you used a condom on that occasion?

430. CHECK 428:

CONDOM USED TO PREVENT PREGNANCY (CODE '02' OR '03'): The last time you had sexual intercourse with this woman, did you or she do something else or use any other method besides a condom to avoid a pregnancy?

OTHER: The last time you had sexual intercourse with this woman, did you or she do something or use any method to avoid a pregnancy?

431. What method was used?
IF MORE THAN ONE METHOD USED, RECORD THE HIGHEST METHOD ON THE LIST.

433. What is your relationship to this woman?
IF WOMAN IS 'GIRLFRIEND' OR 'FIANCEE', ASK: Was your girlfriend/fiancée living with you when you last had sex with her?
IF YES, CIRCLE '01'. IF NO, CIRCLE '02'.

434. For how long (have you had/did you have) sexual relations with this woman?
IF ONLY HAD SEXUAL RELATIONS WITH THIS WOMAN ONCE, RECORD '01' DAYS.

435. Other than these two women, have you had sex with any other woman in the last 12 months?

436. The last time you had sexual intercourse with this third woman, was a condom used?

437. What was the main reason you used a condom on that occasion?

438. CHECK 302(02):

439. CHECK 437:

CONDOM USED TO PREVENT PREGNANCY (CODE '02' OR '03'): The last time you had sexual intercourse with this third woman, did you or she do something else or use any other method besides a condom to avoid a pregnancy?

OTHER: The last time you had sexual intercourse with this third woman, did you or she do something or use any method to avoid a pregnancy?

440. What method was used?
IF MORE THAN ONE METHOD USED, RECORD THE HIGHEST METHOD ON THE LIST.

442. What is your relationship to this woman?
IF WOMAN IS 'GIRLFRIEND' OR 'FIANCEE', ASK: Was your girlfriend/fiancée living with you when you last had sex with her?
IF YES, CIRCLE '01'. IF NO, CIRCLE '02'.

443. For how long (have you had/did you have) sexual relations with this woman?
IF ONLY HAD SEXUAL RELATIONS WITH THIS WOMAN ONCE, RECORD '01' DAYS.

444. In total, with how many different women have you had sex in the last 12 months?

445. Have you ever paid for sex?

446. How long ago was the last time you paid for sex?

447. The last time that you paid for sex, was a condom used on that occasion?

448. Do you know of a place where a person can get condoms?

449. Where is that?
PROBE: Any other place?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
RECORD ALL PLACES MENTIONED.

450. If you wanted to, could you yourself get a condom?

451. CHECK 302(07), 416B, 418, 427, 436, AND 447:
USE OF CONDOMS

452. How old were you when you used a condom for the first time?

453. Why did you use a condom that first time?
PROBE: Any other reason?
RECORD ALL REASONS MENTIONED.

454. Have you ever experienced any problems with using condoms?
IF YES: What problems have you experienced?
PROBE: Any other problems?
RECORD ALL PROBLEMS MENTIONED.

455. Have you heard of a condom called 'Chishango'?

456. I will now read you some statements about condom use. Please tell me if you agree or disagree with each.

SECTION 5. FERTILITY PREFERENCES

501. CHECK 410:

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

503. CHECK 502:

YES, WIFE/WIVES/PREGNANT: Now I have some questions about the future. After the child(ren) your wife/wives/partner(s) is/are expecting now, would you like to have another child or would you prefer not to have any more children at all?

NO WIFE/PARTNER PREGNANT OR UNSURE: Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children at all?

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

505. CHECK 203 AND 205:

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

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

506. How many of these children would you like to be boys, how many would you like to be girls, and for how many would the sex not matter?

507. Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?

508. In the last few months have you heard about family planning:

509. In the last few months, have you listened to any of the following program series about family planning or health on the radio?

510. In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?

511. With whom? Anyone else?
RECORD ALL PERSONS MENTIONED.

512. In the last few months, have you discussed the practice of family planning with a health worker or health professional?

SECTION 6. PARTICIPATION IN HEALTH CARE

601. CHECK 209:

602. Please tell me the name and sex of your child (who was born most recently).

603. In what month and year was (NAME OF CHILD) born?

604. Is (NAME OF CHILD) still living?

605. How old was (NAME OF CHILD) when he/she died?
IF '1 YEAR', PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

606. CHECK 603:

607. What is the name of (NAME OF CHILD)'s mother?
WRITE THE CHILD'S MOTHER'S NAME AND HER LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE.
IF THE MOTHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE RECORD '00'

608. CHECK 606:

609. What is your relationship with (NAME OF CHILD)'s mother?

610. ASK QUESTIONS 610A-612 FIRST FOR PREGNANCY, THEN FOR DELIVERY, AND THEN FOR THE SIX WEEKS AFTER DELIVERY. ALL QUESTIONS REFER TO THE LAST BIRTH.

610A-610C. Now, think back to the time when (NAME OF CHILD'S MOTHER) was pregnant with (NAME OF CHILD).

PREGNANCY:

610A: Did (NAME OF CHILD'S MOTHER) receive any antenatal care from a doctor or any health care provider when she was pregnant with (NAME OF CHILD)?

DELIVERY:

610B: Did a doctor or any health care provider assist with the delivery of (NAME OF CHILD)?

SIX WEEKS AFTER DELIVERY:

610C: Did (NAME OF CHILD'S MOTHER) receive any care for herself from a doctor or any health care provider during the six weeks after this delivery?

611. Did you pay for this care?
IF YES ASK: Who mainly provided the money or goods or services to pay for this care?

612. What was the main reason (NAME OF CHILD'S MOTHER) did not receive any advice or care from a doctor or other health care provider during (pregnancy/ delivery/the six weeks after delivery)?

613. At any time while (NAME OF CHILD'S MOTHER) was pregnant with (NAME OF CHILD), did you yourself talk with a doctor or any other health care provider about the health of the mother or of the pregnancy?

614. CHECK 602 AND 604:

615. Does (NAME OF CHILD) live with you in your household?

616. In your household who usually decides what to do if (NAME OF CHILD) is ill?
RECORD ALL PERSONS MENTIONED.

616A. Have you yourself ever taken (NAME OF CHILD) to a health facility for care?

617. Now, I want to talk to you about pregnancy and the health of children. Sometimes a pregnancy can have complications that lead to miscarriage or even death. What are some of the signs and symptoms that indicate that a pregnancy may be in danger?
PROBE: Any other signs or symptoms?
RECORD ALL SIGNS AND SYMPTOMS MENTIONED.

618. When a child has diarrhea, should he/she be given less to drink than usual, about the same amount, or more than usual?

619. Have you ever heard of a special product called THANZI you can get for the treatment of diarrhea?

620. Now, please tell me about yourself. In the past 12 months, did you receive any injections?

620A. In the past 12 months, how many injections did you receive?

620B. Who gave you the injection the last time you got it?

621. Do you currently smoke cigarettes or use tobacco?
IF YES: What type of tobacco do you use?
RECORD ALL TYPES MENTIONED.

622. Do you drink alcohol?

622A. How often do you get drunk: very often, only sometimes, or never?

SECTION 7. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

702. Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

703. What can a person do? Anything else?
RECORD ALL WAYS MENTIONED.

704. Can people reduce their chances of getting the AIDS virus by having just one sex partner who is not infected and has no other partners?

705. Can a person get the AIDS virus from mosquito bites?

706. Can people reduce their chances of getting the AIDS virus by using a condom every time they have sex?

707. Can a person get the AIDS virus by sharing food with a person who has AIDS?

708. Can people reduce their chance of getting the AIDS virus by not having sex at all?

708A. Can people get the AIDS virus because of witchcraft or other supernatural means?

709. Is it possible for a healthy-looking person to have the AIDS virus?

710. Do you know someone personally who has the virus that causes AIDS or someone who died of AIDS?

711. Can the virus that causes AIDS be transmitted from a mother to a child?

712. Can the virus that causes AIDS be transmitted from a mother to her child...

712A. Are there any drugs that a woman infected with the AIDS virus can take to reduce the risk of transmission to the baby during pregnancy?

713. CHECK 401:

714. Have you ever talked with (your wife/the woman you are living with) about ways to prevent getting the virus that causes AIDS?
IF MORE THAN ONE WIFE/PARTNER, ASK ABOUT ANY OF HIS WIVES/PARTNERS.

715. In your opinion, is it acceptable or unacceptable for AIDS to be discussed:

715A. Would you buy fresh vegetables from a vendor who has the AIDS virus?

716. If a member of your family got infected with the virus that causes AIDS, would you fear disclosing their status?

717. If a member of your extended family such as a cousin died of AIDS and left orphaned children behind, would you be willing to take those children as part of your family?

718. If a female teacher has the AIDS virus, should she be allowed to continue teaching in the school?

718A. Should persons with the AIDS virus who work with other persons such as in a shop, office, or farm be allowed to continue their work or not?

718B. Are people who have AIDS immoral?

719. Should children age 12-14 years be taught about using a condom to avoid AIDS?

719A. Do you think that condoms are safe to use?

719B. Do you think that men and women who intend to marry should be tested for the AIDS virus before marriage?

719C. Have you heard any radio spots or messages with regard to HIV/AIDS in the last 30 days?

719D. Have you seen any TV spots or programs with regard to HIV/AIDS in the last 30 days?

719E. Have you read articles, messages or advertisements about HIV/AIDS in a magazine or newspaper in the last 30 days?

720. I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

720A. When was the last time you were tested?

720B. The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

720C. I don't want to know the results, but did you get the results of the test?

722. Do you know a place where you could go to get an AIDS test?

723. Where can you go for the test?

RECORD ONLY FIRST RESPONSE GIVEN.

723A. Where did you go for the test?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

724. Do you know the HIV status of any partner with whom you have had sex in the past year?

724A. Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

725. If a man has a sexually transmitted disease, what symptoms might he have? Any others?
RECORD ALL SYMPTOMS MENTIONED.

726. If a woman has a sexually transmitted disease, what symptoms might she have? Any others?
RECORD ALL SYMPTOMS MENTIONED.

727. CHECK 416:

727A. CHECK 724:

728. Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a sexually-transmitted disease?

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

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

731. CHECK 728/729/730:

732. The last time you had (PROBLEM(S) FROM 728/729/730), did you seek any kind of advice or treatment?

733. The last time you had (PROBLEM(S) FROM 728/729/730), did you do any of the following? Did you....

734. When you had (PROBLEM(S) FROM 728/729/730), did you inform the person(s) with whom you were having sex?

735. When you had (PROBLEM(S) FROM 728/729/730), did you do anything to avoid infecting your sexual partner(s)?

736. What did you do to avoid infecting your partner(s)? Did you....

737. Some men are circumcised. Are you circumcised?

SECTION 8. ATTITUDES TOWARDS GENDER ROLES

801. In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally:

802. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

802A. Sometimes a wife is annoyed or angered by things that her husband does. In your opinion, is a wife justified in hitting or beating her husband in the following situations:

803. When a wife knows her husband has a sexually transmitted disease, is she justified in asking that they use a condom?

804. Husbands and wives do not always agree on everything.
Please tell me if you think a wife is justified in refusing to have sex with her husband if...

805. Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to...

806. As far as you know, did your father ever hit your mother?

807. RECORD THE TIME.

SECTION 9. HIV TESTING

901. CHECK 108:

902. LINE NUMBER OF PARENT/RESPONSIBLE ADULT:
(FROM COLUMN 1 IN HOUSEHOLD SCHEDULE)
(IF PARENT OR RESPONSIBLE ADULT IS NOT IN HOUSEHOLD, WRITE '00')

903. READ THE CONSENT TO THE PARENT OR RESPONSIBLE ADULT.
CIRCLE CODE AND SIGN.

904. READ THE CONSENT TO THE MAN OR ADOLESCENT.
CIRCLE CODE AND SIGN.

905. RESULTS:

PASTE FIRST LABEL HERE
PASTE SECOND LABEL ON FILTER PAPER AND THE THIRD LABEL ON BLOOD SAMPLE TRANSMITTAL FORM

REQUEST FOR CONSENT FOR HIV TEST

We would like to ask you to participate in the HIV test by allowing us to collect a few drops of blood from your finger. As part of the survey, we are asking people all over the country to help find out how big the AIDS problem is in Malawi.

The test uses sterile, disposable instruments that are completely clean and safe. This blood will be tested later in the laboratory.
To ensure the confidentiality of this test result, no individual names will be attached to the blood sample; therefore, we will not be able to give you the result of your test and no one will be able to trace the test back to you.

However, if you want to know whether you have HIV, I can tell you where you can go to get tested.
You can go to a Voluntary Counseling and Testing (VCT) Centre where you will receive free counseling and confirmed HIV test results that same day.
We will provide you with a voucher for yourself, and a voucher for your partner, which either of you can use at the VCT Centre in the next 30 days.
With the voucher, there will be no charge for this service, and you will be reimbursed for your travel costs upon receiving the VCT services.
At this centre you will meet trained staff available to discuss with you all issues and matters regarding HIV/AIDS.
They will provide you with an HIV test and appropriate counseling.

Do you have any questions?

I hope you will agree to participate in the HIV testing. You can say yes or you can say no; it is up to you. However, if you agree, it will help the government to develop programs to fight the problem of HIV/AIDS in Malawi.

Will you agree to participate in the HIV test?

GO TO 904, CIRCLE THE APPROPRIATE CODE (AND SIGN).

IF RESPONDENT IS AGE 15-17:

ASK PARENT/GUARDIAN: Will you tell me if you will allow (NAME OF YOUTH) to participate in the HIV test? GO TO COLUMN 903, CIRCLE THE APPROPRIATE CODE (AND SIGN)).

IF PARENT/GUARDIAN AGREES, READ THE PRECEDING PARAGRAPHS TO YOUTH FOR HIS/HER CONSENT. GO TO COLUMN 904, CIRCLE THE APPROPRIATE CODE (AND SIGN).

*DON'T FORGET TO GIVE EACH ELIGIBLE PERSON TWO REFERRAL VOUCHERS FOR FREE HIV TESTS/TRAVEL EXPENSES TO VCT SITE.