IDENTIFICATION

PLACE NAME _________________________ ___

DISTRICT _____________________ ___

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

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

NAME OF HOUSEHOLD HEAD ___

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 __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN __

TOTAL ELIGIBLE MEN __

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

LANGUAGE OF QUESTIONNAIRE**:

LANGUAGE OF INTERVIEW**: ___

NATIVE LANGUAGE OF RESPONDENT***: ___

TRANSLATOR USED?

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.

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.

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

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

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

6) Did (NAME) stay here last night?

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

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.

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?

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?

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

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?

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

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

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'.

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?

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

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'.

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?

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?

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.

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]

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

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

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]

BASIC MATERIAL NEEDS IF AGE 5-17 YEARS:

29) Does (NAME) have a blanket?

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

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

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

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

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

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?

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?

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

107. What do you usually do to make the 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, including your household?

111. Does your household have:

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:

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

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

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?

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?

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

126C. Who sprayed the house?

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 NETS, RECORD '7'.

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

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)?

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

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

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

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:

CONVENTIONAL NETS: CAN BE RETREATABLE OR UNTREATED

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

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

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

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.

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?

139. What shape of mosquito net do you prefer?

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

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

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

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

SUPPORT FOR SICK PEOPLE

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

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

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?

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

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?

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

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?

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

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?

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

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?

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

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)?

305. Was (NAME) male or female?

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

307. CHECK 306:
AGE OF PERSON AT DEATH

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?

SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

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

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

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

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?

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

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?

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?

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

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?

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

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?

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

415. CHECK 406:
AGE OF CHILD

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?

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

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

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?

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

505. WEIGHT IN KILOGRAMS

506. HEIGHT IN CENTIMETERS

507. MEASURED LYING DOWN OR STANDING UP?

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

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

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.

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

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)

517. WEIGHT IN KILOGRAMS

518. HEIGHT IN CENTIMETERS

520. AGE: CHECK COLUMN 7.

521. MARITAL STATUS: CHECK COLUMN 8.

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

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.

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.

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

524A. CHECK 520 AND 521

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.

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

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.

525G. CHECK 520 AND 521

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.

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.

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

529. BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE.

BARCODE

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)

533. RECORD WHETHER RESPONDENT IS PRESENT OR NOT.

536. AGE: CHECK COLUMN 7.

537. MARITAL STATUS: CHECK COLUMN 8.

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

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.

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

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.

540G. CHECK 536 AND 537

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.

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.

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

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.