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DEMOGRAPHIC AND HEALTH SURVEY-MALAWI
2010-HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME _________________________ ___

DISTRICT _____________________ ___

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

HOUSEHOLD SELECTED FOR MALE SURVEY, DOMESTIC VIOLENCE MODULE,
ANTHROPOMETRY, AND BLOOD WORK?

YES 1
NO 2

NAME OF HOUSEHOLD HEAD ___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT* _____________

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) ___________ 9

NEXT VISIT:
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INTERVIEWER CODE ____
RESULT* _____

TOTAL NUMBER OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN __

TOTAL ELIGIBLE MEN __

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __


LANGUAGE OF QUESTIONNAIRE**:

ENGLISH 4

LANGUAGE OF INTERVIEW**: ___

CHICHEWA 1
TUMBUKA 2
YAO 3
ENGLISH 4
OTHER (SPECIFY) __________________ 6

NATIVE LANGUAGE OF RESPONDENT***: ___

CHICHEWA 1
TUMBUKA 2
YAO 3
ENGLISH 4
OTHER (SPECIFY) __________________ 6

TRANSLATOR USED?

NOT AT ALL 1
SOMETIME 2
ALL THE TIME 3

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 Statistical Office.
We are conducting a national survey about various health issues.
We would very much appreciate your participation in this survey. This information will help the government to plan health services.
The survey usually takes between 15 and 30 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, and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, and 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.

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

HOUSEHOLD SCHEDULE

1) LINE NO.

LINE NUMBER____

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 QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON.

NAME__________

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

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
NIECE OR NEPHEW 09
CO-WIFE 10
ADOPTED/FOSTER/ STEPCHILD 11
OTHER RELATIVE 12
NOT RELATED 13
DON'T KNOW 98

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

MALE 1
FEMALE 2

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

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old was (NAME) at his/her last birthday?

IN YEARS __

MARITAL STATUS IF AGE 15 OR OLDER:

8) What is (NAME'S) current marital status?

MARRIED OR LIVING TOGETHER 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED AND NEVER LIVED TOGETHER 4

ELIGIBILITY:

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

10) CHECK COVER. CIRCLE LINE NUMBER OF ALL MEN AGE 15-54 IF HH SELECTED FOR MALE SURVEY, ANTHRO, AND BLOOD WORK.

11) CHECK COVER. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 IF HH SELECTED FOR MALE SURVEY, ANTHRO, AND BLOODWORK.

2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
NO

2B) 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

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

IF AGE 18-50 YEARS:

12) SICK PERSON: Has (NAME) been very sick for at least 3 months during the past 12 months, that is (NAME) was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

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

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

YES 1
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)

14) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.

LINE NUMBER___

15) IF MOTHER NOT LISTED IN HOUSEHOLD: Has (NAME)'s mother been very sick for at least 3 months during the past 12 months, that is she was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

16) Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 19)
DON'T KNOW 8 (GO TO 19)

17) Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

LINE NUMBER___

18) IF FATHER NOT LISTED IN HOUSEHOLD: Has (NAME)'s father been very sick for at least 3 months during the past 12 months, that is he was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

19) MOTHER AND/OR FATHER DEAD/SICK: CIRCLE LINE NUMBER IF CHILD'S MOTHER AND/OR FATHER HAS DIED (Q.13 OR 16=NO) OR BEEN SICK (Q.15 OR 18=YES).

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER:

23) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 29)

24) What is the highest level of school (NAME) has attended?
SEE CODES BELOW.
What is the highest class (NAME) completed at that level?
SEE CODES BELOW.

LEVEL __
PRESCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
CLASS __
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS:

25) Did (NAME) attend school at any time during the 2010 school year?
[USE THE 2009-2010 SCHOOL YEAR]

YES 1
NO 2 (GO TO 27)

26) During the 2010 school year, what level and class [is/was] (NAME) attending?
SEE CODES BELOW.
[USE THE 2009-2010 SCHOOL YEAR]

LEVEL __
PRESCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
CLASS __
DON'T KNOW 98

27) Did (NAME) attend school at any time during the 2009 school year?
[FOR PRIVATE SCHOOLS, USE THE 2008-2009 SCHOOL YEAR]

YES 1
NO 2 (GO TO 29)

28) During the 2009 school year, what level and class did (NAME) attend?
SEE CODES BELOW.
[FOR PRIVATE SCHOOLS, USE THE 2008-2009 SCHOOL YEAR]

LEVEL __
PRESCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
CLASS __
DON'T KNOW 98

BASIC MATERIAL NEEDS IF AGE 5-17 YEARS:

29) Does (NAME) have a blanket?

YES 1
NO 2
DON'T KNOW 8

30) Does (NAME) have a pair of shoes?

YES 1
NO 2
DON'T KNOW 8

31) Does (NAME) have at least two sets of clothes?

YES 1
NO 2
DON'T KNOW 8

32) How many meals did (NAME) eat yesterday?

NONE 0
1 MEAL 1
2 MEALS 2
3 OR MORE MEALS 3
DON'T KNOW 8

33. TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

CHECK COVER PAGE TO SEE IF HOUSEHOLD IS SELECTED FOR DOMESTIC VIOLENCE SECTION

HOUSEHOLD IS SELECTED FOR DV (*FOLLOW INSTRUCTIONS BELOW AND USE TABLE)
HOUSEHOLD IS NOT SELECTED FOR DV (GO TO 101)

LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE.
THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE.
THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX.
THIS IS THE NUMBER OF THE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
THEN, ENTER THE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE OF THE SELECTED WOMAN INTO THE BOXES AT THE BOTTOM OF THE KISH GRID.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.
FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE BOX ('2').
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07', THEN THE ELIGIBLE WOMAN FOR DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE ONE ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)

1 2 3 4 5 6 7 8
0 1 2 2 4 3 6 5 4
1 1 1 3 1 4 1 6 5
2 1 2 1 2 5 2 7 6
3 1 1 2 3 1 3 1 7
4 1 2 3 4 2 4 2 8
5 1 1 1 1 3 5 3 1
6 1 2 2 2 4 6 4 2
7 1 1 3 3 5 1 5 3
8 1 2 1 4 1 2 6 4
9 1 1 2 1 2 3 7 5

ENTER LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE ___

HOUSEHOLD CHARACTERISTICS

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED INTO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 106)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) ______ 96

103. Where is that water source located?

IN OWN YARD/PLOT 1 (GO TO 106)
ELSEWHERE 2

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

MINUTES ___
DON'T KNOW 998

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

ADULT WOMAN 1
ADULT MAN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) ____________ 6

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

YES 1
NO 2 (GO TO 108)
DON'T KNOW 8 (GO TO 108)

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

BOIL A
ADD BLEACH/CHLORINE/WATER GUARD B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ______________ X
DON'T KNOW Z

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

FLUSH TOILET 11
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 111)
OTHER (SPECIFY) ____________ 96

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

YES 1
NO 2 (GO TO 111)

110. How many households use this toilet facility, including your household?

NUMBER OF HOUSEHOLDS IF LESS THAN 10 ___
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

111. Does your household have:

Electricity?
YES 1
NO 2
Koloboyi?
YES 1
NO 2
A paraffin lamp other than a koloboyi?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A cellular phone?
YES 1
NO 2
A telephone (landline)?
YES 1
NO 2
A bed with a mattress?
YES 1
NO 2
A sofa set?
YES 1
NO 2
A table and chair(s)?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

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

ELECTRICITY 01 (GO TO 115)
LPG/NATURAL GAS 02 (GO TO 115)
BIOGAS 03 (GO TO 115)
KEROSENE 04 (GO TO 115)
COAL, LIGNITE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
ANIMAL DUNG 09
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 117)
OTHER (SPECIFY) ______ 96

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

OPEN FIRE 1
OPEN STOVE 2
CLOSED STOVE WITH CHIMNEY 3 (GO TO 115)
OTHER (SPECIFY) _____________ 6 (GO TO 115)

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

CHIMNEY 1
HOOD 2
NEITHER 3

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

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 117)
OUTDOORS 3 (GO TO 117)
OTHER (SPECIFY) ____________ 6 (GO TO 117)

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

YES 1
NO 2

117. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
BROKEN BRICKS 23
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) ______________ 96

118. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO/GRASS 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
IRON SHEETS 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY) ________________ 96

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

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO/TREE TRUNKS WITH MUD 21
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
REUSED WOOD 25
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BURNT BRICKS 33
UNBURNT BRICKS 34
CEMENT BLOCKS 35
WOOD PLANKS 36
OTHER (SPECIFY) ______________ 96

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

ROOMS ____

121. Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
A car or truck?
YES 1
NO 2
An oxcart?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 124)

123. How much agricultural land do members of this household own?
RECORD IN UNITS RESPONDENT USES.

ACRES 1 ___.___
HECTARES 2 ___.___
FOOTBALL PITCHES 3 ___.___
95 OR MORE ACRES/HECTARES/FOOTBALL PITCHES 9995
DON'T KNOW 9998

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

YES 1
NO 2 (GO TO 126)

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'.

Goats?
NUMBER OF GOATS ___
Pigs?
NUMBER OF PIGS ___
Cattle?
NUMBER OF CATTLE ___
Sheep?
NUMBER OF SHEEP ___
Poultry (chickens, ducks, pigeons)?
NUMBER OF POULTRY ___
Other? (SPECIFY) _______________
OTHER ___

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

YES 1
NO 2

126A. At any time in the past 12 months, has anyone come into your house to spray the interior walls of your dwelling against mosquitoes?

YES 1
NO 2 (GO TO 127)
DON'T KNOW 8 (GO TO 127)

126B. How many months ago was the house sprayed?
IF LESS THAN 1 MONTH AGO, RECORD '00'

MONTHS ___

126C. Who sprayed the house?

ARMY/POLICE 1
OTHER GOVERNMENT WORKER/PROGRAMME 2
PRIVATE COMPANY 3
OTHER (SPECIFY) ____________ 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 138)

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

NUMBER OF NETS ___


129. ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

OBSERVED 1
NOT OBSERVED 2

129A. OBSERVE (OR ASK ABOUT) THE CONDITION OF THE MOSQUITO NET: DOES THE NET HAVE HOLES IN IT (HOLES THE SIZE OF THE TIP OF YOUR THUMB OR LARGER)?

YES 1
NO 2

129B. OBSERVE (OR ASK) THE COLOR OF THE MOSQUITO NET.

GREEN 1
DARK BLUE 2
LIGHT BLUE 3
WHITE 4
OTHER 6

129C. OBSERVE (OR ASK) THE SHAPE OF THE MOSQUITO NET.

CONICAL 1
RECTANGLE 2

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

MONTHS AGO ___
MORE THAN 36 MONTHS AGO 95
NOT SURE 98

130B. Is this net a long-lasting net, retreatable, or an untreated net?
OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

ITN/LONG-LASTING NET:

DURANET (GREEN, SQUARE)
OLYSNET (LIGHT BLUE, SQUARE)
LIFENET (WHITE, SQUARE)
PERMANET (GREEN, SQUARE)

CONVENTIONAL NETS: CAN BE RETREATABLE OR UNTREATED

SAFI NET (DARK BLUE, CONICAL)
THERE ARE OTHER BRANDS

BE AWARE THAT MANY BRANDS MAY EXIST AND BE DISTRIBUTED BY DIFFERENT ORGANIZATIONS.

ITN/LONG-LASTING NET
DURANET 11 (GO TO 135)
OLYSNET 12 (GO TO 135)
LIFENET 13 (GO TO 135)
PERMANET 14 (GO TO 135)
OTHER/DON'T KNOW BRAND 16 (GO TO 135)
RETREATABLE NET
SAFI NET 21 (GO TO 133)
OTHER/DON'T KNOW BRAND 26 (GO TO 133)
UNTREATED NET
SAFI NET 31
OTHER/DON'T KNOW BRAND 36
OTHER (SPECIFY) __________ 41
DON'T KNOW BRAND 98

130C. When you received this net, did it come with a treatment kit?

YES 1
NO 2
NOT SURE 8

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

YES 1
NO 2 (GO TO 135)
NOT SURE 8 (GO TO 135)

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

MONTHS AGO ___
MORE THAN 24 MONTHS AGO 95
NOT SURE 98

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

YES 1
NO 2 (GO TO 137)
NOT SURE 8 (GO TO 137)

136. Who slept under this mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME ____________
LINE NUMBER __

137. GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138.

138. What color of mosquito net do you prefer?

BLUE 1
GREEN 2
WHITE 3
OTHER (SPECIFY) ______________ 6
DON'T KNOW/NO PREFERENCE 8

139. What shape of mosquito net do you prefer?

CONICAL 1
RECTANGULAR 2
DON'T KNOW/NO PREFERENCE 8

139A. Please show me where members of your household most often wash their hands.

OBSERVED 1
NO SPECIFIC PLACE 2 (GO TO 140)
NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

139B. OBSERVATION ONLY: CHECK AVAILABILITY OF WATER AT THE SPECIFIC PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

139C. OBSERVATION ONLY: CHECK AVAILABILITY OF SOAP AT THE SPECIFIC PLACE FOR HANDWASHING.
CIRCLE ALL THAT APPLY.

SOAP OR DETERGENT (BAR, LIQUID, POWDER OR PASTE) A
ASH/MUD/SAND B
NONE Y

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

0 PPM (NO IODINE) 1
BELOW 15 PPM 2
15 PPM AND ABOVE 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED (SPECIFY REASON) _____________ 6

SUPPORT FOR SICK PEOPLE

201. CHECK QUESTIONS 7 AND 12 IN THE HOUSEHOLD SCHEDULE:

NUMBER OF SICK PEOPLE AGE 18-59____
AT LEAST ONE (GO TO 202)
NONE (GO TO 301)

202. ENTER IN QUESTION 203 THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-59, BEGINNING WITH THE FIRST SICK PERSON LISTED IN QUESTION 12 IN THE HOUSEHOLD SCHEDULE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

READ THE INTRODUCTION THAT FOLLOWS. THEN ASK QUESTIONS 204-211 AS APPROPRIATE FOR EACH OF THE PERSONS AGE 18-59 REPORTED AS HAVING BEEN VERY SICK.

You told me that in your household one (some) of the members of your household has(ve) been very sick for at least three of the past 12 months. We are interested in learning about the care and support that may have been received for [that/each of those persons].
First I would like to ask you about any formal, organized help or support that your household may have been given for [that/each of those] person(s) for which you did not have to pay.
By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

203. NAME AND LINE NUMBER FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE

NAME _____________
LINE NO. __

204. Now I would like to ask you about any support you received for (NAME).
In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

YES 1
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)

205. Did your household receive any of this medical support at least once a month while (NAME) was sick?

YES 1
NO 2
DON'T KNOW 8

206. In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, for which you did not have to pay?

YES 1
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)

207. Did your household receive any emotional or psychological support in the past 30 days?

YES 1
NO 2
DON'T KNOW 8

208. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

YES 1
NO 2 (GO TO 210)
DON'T KNOW 8 (GO TO 210)

209. Did your household receive any of this material support in the past 30 days?

YES 1
NO 2
DON'T KNOW 8

210. In the last 12 months, has your household received any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

YES 1
NO 2 (GO TO 301)
DON'T KNOW 8 (GO TO301)

211. Did your household receive any of this social support in the past 30 days?

YES 1
NO 2
DON'T KNOW 8

PERSONS WHO HAVE DIED

301. Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has any usual member of your household died in the last 12 months?

YES 1
NO 2 (GO TO 401)
DON'T KNOW 8 (GO TO 401)

302. How many household members died in the last 12 months?

NUMBER OF DEATHS __

303. ASK 304-308 AS APPROPRIATE FOR EACH PERSON WHO DIED. IF THERE WERE MORE THAN 3 DEATHS, USE ADDITIONAL QUESTIONNAIRE(S).

304. What was the name of the person who died (most recently/before him/her)?

NAME ___________________

305. Was (NAME) male or female?

MALE 1
FEMALE 2

306. How old was (NAME) when (he/she) died?

AGE _____

307. CHECK 306:
AGE OF PERSON AT DEATH

LESS THAN 18/OVER 60 YEARS (GO TO 401)
18-59 (GO TO 308)

308. Was (NAME) very sick for at least three of the 12 months before (he/she) died, that is (NAME) was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

401. CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE:
ANY CHILD AGE 0-17?

AT LEAST ONE CHILD AGE 0-17 (GO TO 402)
NO CHILD AGE 0-17 (GO TO 501)

402. CHECK COLUMN 12 IN THE HOUSEHOLD SCHEDULE:
ANY SICK ADULT AGE 18-59 WHO IS VERY SICK?

NO SICK ADULT AGE 18-59 (GO TO 403)
AT LEAST ONE SICK ADULT AGE 18-59 (GO TO 406. CHECK QUESTION 7
IN THE HOUSEHOLD SCHEDULE AND LIST THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL PERSONS AGE 0-17 YEARS.)

403. CHECK 306 IN THE PREVIOUS SECTION:
ANY ADULT AGE 18-59 WHO DIED IN PAST 12 MONTHS?

NO ADULT DEATH AGE 18-59 IN 306 (GO TO 404)
AT LEAST ONE ADULT DEATH AGE 18-59 IN 306 (GO TO 406. CHECK QUESTION 7 IN THE HOUSEHOLD SCHEDULE AND LIST THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL PERSONS AGE 0-17 YEARS.)

404. CHECK COLUMN 19 IN THE HOUSEHOLD SCHEDULE:
ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND IS VERY SICK?

AT LEAST ONE CHILD WHOSE MOTHER AND/OR FATHER HAS DIED/IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND HAS BEEN VERY SICK (GO TO 405)
NO CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR IS NOT LISTED IN HOUSEHOLD SCHEDULE AND HAS BEEN VERY SICK (GO TO 501)

405. RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AGE 0-17 FOR ALL CHILDREN WHO ARE IDENTIFIED IN COLUMN 19 AS HAVING A MOTHER AND/OR FATHER WHO HAS DIED OR HAS BEEN VERY SICK.

406. NAME FROM COLUMN 2
LINE NUMBER FROM COLUMN 1
AGE FROM COLUMN 7

NAME ___________
LINE NO. ___
AGE ___

407. I would like to ask you about any formal, organized help or support for children that your household may have received for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

408. Now I would like to ask you about the support your household received for (NAME).
In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

YES 1
NO 2
DON'T KNOW 8

409. In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support,
which you received at home and for which you did not have to pay?

YES 1
NO 2 (GO TO 411)
DON'T KNOW 8 (GO TO 411)

410. Did your household receive any of this emotional or psychological support in the past 3 months?

YES 1
NO 2
DON'T KNOW 8

411. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

YES 1
NO 2 (GO TO 413)
DON'T KNOW 8 (GO TO 413)

412. Did your household receive any of this material support in the past 3 months?

YES 1
NO 2
DON'T KNOW 8

413. In the last 12 months, has your household received any social support for (NAME) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

YES 1
NO 2 (GO TO 415)
DON'T KNOW 8 (GO TO 415)

414. Did your household receive any of this social support in the past 3 months?

YES 1
NO 2
DON'T KNOW 8

415. CHECK 406:
AGE OF CHILD

AGE 0-4 (GO TO 417)
AGE 5-17 (GO TO 416)

416. In the last 12 months, has your household received any support for (NAME'S) schooling, such as allowance, free admission, books or supplies, for which you did not have to pay?

YES 1
NO 2 (GO TO 417)
DON'T KNOW 8 (GO TO 417)

416A. What type of assistance did you receive for (NAME'S) schooling?
PROBE: Anything else?
RECORD ALL MENTIONED.

MONEY FOR SCHOOL FEES A
OTHER MONEY B
UNIFORM C
NOTEBOOKS D
OTHER X

417. GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.

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

501. CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502.
IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

502. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NUMBER ___
NAME ___________

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

DAY __
MONTH __
YEAR __

504. CHECK 503:
CHILD BORN IN JANUARY 2005 OR LATER?

YES 1
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 515)

505. WEIGHT IN KILOGRAMS

KILOGRAMS ___.___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

506. HEIGHT IN CENTIMETERS

CENTIMETERS ___.___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

507. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

509. CHECK 503:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

0-5 MONTHS 1 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 515)
OLDER 2 (GO TO 510)

510. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1)
RECORD '00' IF NOT LISTED.

LINE NUMBER ___

511. READ CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD.

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 to develop programs to prevent and treat anemia.

We request that all children born in 2005 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 will be kept strictly 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 up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

511A. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______________
REFUSED 2 (SIGN) ______________

512. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

G/DL ___.___
NOT PRESENT 994
REFUSED 995
OTHER 996

514. GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

515. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 516. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

516. LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

LINE NUMBER ___
NAME ___________

517. WEIGHT IN KILOGRAMS

KILOGRAMS ___.___
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

518. HEIGHT IN CENTIMETERS

CENTIMETERS ___.___
NOT PRESENT 9994 (GO TO 527)
REFUSED 9995
OTHER 9996

520. AGE: CHECK COLUMN 7.

15-17 YEARS 1 (GO TO 521)
18-49 YEARS 2 (GO TO 523C)

521. MARITAL STATUS: CHECK COLUMN 8.

CODE 4 (NEVER IN UNION) 1 (GO TO 522)
OTHER 2 (GO TO 523C)

522. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT __

523A. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 522 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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 to develop programs to prevent and treat anemia.
For the anemia testing, we will 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 results told to you right away. The result will be kept strictly 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 up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

523B. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____(GO TO 525A)

523C. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.

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 to develop programs to prevent and treat anemia.
For the anemia testing, we will 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 results told to you right away. The result will be kept strictly 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 up to you to decide.
Will you take the anemia test?

523D. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______________
RESPONDENT REFUSED 2 (SIGN) _____________ (GO TO 524A)

524. PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

524A. CHECK 520 AND 521

520 = 0 AND 521 = 1 1 (GO TO 525A)
OTHER 2 (GO TO 525C)

525A. ASK CONSENT FOR HIV TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 522 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Malawi.

For the HIV test, we need a few more drops of blood from a finger.
Again 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.

No names will be attached so we will not be able to tell (NAME OF ADOLESCENT) the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either.
If (NAME OF ADOLESCENT) wants to know whether she has HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

525B. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _______(GO TO 526)

525C. HIV STATUS DISCLOSURE: CHECK WOMAN'S QUESTIONNAIRE: 1317

POSITIVE 1 (GO TO 525E)
NEGATIVE 2 (GO TO 525E)
UNDETERMINED 3 (GO TO 525D)
REFUSED TO ANSWER 4 (GO TO 525D)
BLANK 6 (GO TO 525D)

525D. ASK CONSENT FOR HIV TEST FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Malawi.

For the HIV test, we need a few more drops of blood from a finger.
Again 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.
If you want to know whether you have HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test? (GO TO 525F)

525E. ASK CONSENT FOR HIV TEST FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take an HIV test. I know that you already told me/my colleague the result of your last test for the AIDS virus. However, it is important for everyone in the survey to participate in the test, even those who already told us their results, to see how big the AIDS problem is in Malawi.

For the HIV test, we need a few more drops of blood from a finger.
Again 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.

If you want to be retested and receive the result or to receive advice and counseling, I can provide you with a list of nearby facilities offering counseling and testing for HIV.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

525F. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME, ENTER YOUR INTERVIEWER CODE.

GRANTED 1 (SIGN) ______________
RESPONDENT REFUSED 2 (SIGN) ______________ (GO TO 526)
INTERVIEWER CODE____

525G. CHECK 520 AND 521

520 = 0 AND 521 = 1 1
OTHER 2 (GO TO 525K)

525H. ASK CONSENT FOR FUTURE TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 522 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other information attached that could identify (NAME OF ADOLESCENT).
You do not have to agree.
If you do not want the blood sample stored for later use, (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for later testing or research?

525J. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) _______
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _____(GO TO 525M)

525K. ASK CONSENT FOR FUTURE TESTING FROM RESPONDENT.

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other information attached that could identify you.
You do not have to agree.
If you do not want the blood sample stored for later use, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for later testing or research?

525L. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______________
RESPONDENT REFUSED 2 (SIGN) ______________ (GO TO 526)

525M. ADDITIONAL TESTS

CHECK 525J AND 525L:
IF CONSENT HAS NOT BEEN GRANTED WRITE 'NO ADDITIONAL TEST' ON THE FILTER PAPER.

526. CHECK 523B/523D AND 525B/525F AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

527. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL ___.___
NOT PRESENT 994
REFUSED 995
OTHER 996

529. BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.

BARCODE

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

530. GO BACK TO 517 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, GO TO 531.

HIV TESTING FOR MEN AGE 15-54

531. CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 532. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

532. LINE NUMBER (COLUMN 10)
NAME (COLUMN 2)

LINE NUMBER ___
NAME ___________

533. RECORD WHETHER RESPONDENT IS PRESENT OR NOT.

RESPONDENT PRESENT 1
RESPONDENT NOT PRESENT 2 (GO TO 544)

536. AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-54 YEARS 2 (GO TO 540C)

537. MARITAL STATUS: CHECK COLUMN 8.

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 540C)

538. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT __

540A. ASK CONSENT FOR HIV TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 538 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Malawi.

For the HIV test, we need a few more drops of blood from a finger.
Again 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either.
If (NAME OF ADOLESCENT) wants to know whether he has HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

540B. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ______ (GO TO 544)

540C. HIV STATUS DISCLOSURE:
CHECK MAN'S QUESTIONNAIRE 907.

POSITIVE 1 (GO TO 540E)
NEGATIVE 2 (GO TO 540E)
UNDETERMINED 3 (GO TO 540D)
REFUSED TO ANSWER 4 (GO TO 540D)
BLANK 6 (GO TO 540D)

540D. ASK CONSENT FOR HIV TEST FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Malawi.

For the HIV test, we need a few more drops of blood from a finger.
Again 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.
If you want to know whether you have HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test? (GO TO 540F)

540E. ASK CONSENT FOR HIV TEST FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take an HIV test. I know that you already told me/my colleague the result of your last test for the AIDS virus. It is important for everyone in the survey to participate in the test, even those who already told us their results, to see how big the AIDS problem is in Malawi.

For the HIV test, we need a few more drops of blood from a finger.
Again 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.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.

If you want to be retested and receive the result or to receive advice and counseling, I can provide you with a list of nearby facilities offering counseling and testing for HIV.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

540F. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME. ENTER YOUR INTERVIEWER CODE.

GRANTED 1 (SIGN) ______________
RESPONDENT REFUSED 2 (SIGN) ______________ (GO TO 544)
INTERVIEWER CODE____

540G. CHECK 536 AND 537

536 = 1 AND 537 = 1 1 (GO TO 540H)
OTHER 2 (GO TO 540K)

540H. ASK CONSENT FOR FUTURE TESTING FROM PARENT/OTHER ADULT
IDENTIFIED IN 538 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other information attached that could identify (NAME OF ADOLESCENT).
You do not have to agree.
If you do not want the blood sample stored for later use, (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for later testing or research?

540J. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2(SIGN) _____(GO TO 540M)

540K. ASK CONSENT FOR FUTURE TESTING FROM RESPONDENT.

We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other information attached that could identify you.
You do not have to agree.
If you do not want the blood sample stored for later use, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for later testing or research?

540L. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ______________ (GO TO 541)
RESPONDENT REFUSED 2 (SIGN) ______________

540M. ADDITIONAL TESTS

CHECK 540J AND 540L:
IF CONSENT HAS NOT BEEN GRANTED WRITE 'NO ADDITIONAL TEST' ON THE FILTER PAPER.

541. CHECK 540B/540F TO VERIFY THAT CONSENT FOR HIV TEST HAS BEEN GRANTED. PREPARE EQUIPMENT AND SUPPLIES FOR THE HIV TEST AND PROCEED WITH THE TEST.

544. BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.

BARCODE

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

545. GO BACK TO 536 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE MEN, END INTERVIEW.