IDENTIFICATION
NAME OF PLACE ______

CLUSTER NUMBER_____

CONCESSION NUMBER_____

FIRST AND LAST NAME OF HEAD OF HOUSEHOLD______

HOUSEHOLD NUMBER_______

REGION______

URBAN/RURAL _____

NIAMEY/REGIONAL ADMINISTRATIVE CENTER/OTHER CITY/RURAL____

UNICEF INTERVENTION ZONE______

HOUSEHOLD SELECTED FOR MEN'S SURVEY______

HEIGHT/WEIGHT MEASUREMENT, HEMOGLOBIN AND HIV TEST, SALT SAMPLE (LABORATORY)?

MEN'S SURVEY_____

INTERVIEWER VISITS

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

NEXT VISIT________
DATE_________
TIME_______

FINAL VISIT
DAY_______
MONTH_______
YEAR 2012
NAME________
RESULT*__________

RESULT CODES*:

TOTAL NO. OF VISITS_________

TOTAL PERSONS IN HOUSEHOLD________
TOTAL ELIGIBLE WOMEN__________
TOTAL ELIGIBLE MEN_________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE________

SUPERVISOR________
NAME_______
DATE_______

FIELD EDITOR________
NAME_______
DATE________

OFFICE EDITOR_______

KEYED BY__________

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Office of Statistics. We are conducting a survey about health all over Niger. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take between 1 hour and 1 hour and 30 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you 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.

Do you have any questions?
May I begin the interview?

SIGNATURE OF INTERVIEWER____________________
DATE______

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.

TICK HERE IF CONTINUATION SHEET USED _____

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) In addition, are there any other people who many 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?

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20A FOR EACH PERSON.

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

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

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

6) Did (name) stay here last night?

7) AGE: How old is (name)?
IF 95 OR MORE, RECORD 95.

IF AGE 10 OR OLDER:

8) MARITAL STATUS: What is (name)'s current marital status?

9) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) IF HOUSEHOLD SELECTED FOR MEN'S SURVEY.
CIRCLE LINE NUMBER OF ALL MEN 15-49
IF NOT, LEAVE COLUMN BLANK

11) IF HOUSEHOLD SELECTED FOR MEN'S SURVEY
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
IF NOT, LEAVE COLUMN BLANK

LINE NO._________

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

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

13) 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.

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

15) Does (NAME)'s natural father 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.

IF AGE 5 YEARS OR OLDER:

16) EVER ATTENDED SCHOOL: Has (NAME) ever attended school?

17) What is the highest level of school (NAME) has attended?

What is the highest grade (NAME) completed at that level?

IF AGE 7-24 YEARS:

17a) CURRENT/RECENT SCHOOL ATTENDANCE: Did (name) attend school at any time during the current (2011-2012) school year?

17b) During this/that school year (2011-2012), what level and grad (is/was) (NAME) attending?

17c) What is the main reason for which (name) did not go to school?

18) Did (NAME) attend school at any time during the (2010-2011) school year?

19) During this/that school year (2010-2011), what level and grade (is/was) (NAME) attending?

IF AGE 0-4 YEARS:

20) BIRTH REGISTRATION: Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

20a) REASONS FOR NOT REGISTERING: Why was (NAME)'s birth not registered/declared?

IF MORE THAN ONE REASON, RECORD THE MAIN ONE.

CARE OF CHILDREN AGE 4-6 YEARS AND WORK OF CHILDREN AGE 5-14 YEARS

21) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 4 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

RECORD THE NAME OF EACH CHILD BETWEEN 4 AND 14 YEARS OLD FROM HIS/HER LINE NUMBER IN THE HOUSEHOLD SCHEDULE

21a) CARE FOR CHILDREN BETWEEN 4 AND 6 YEARS: During the 2011-2012 school year, did (NAME) go to an establishment outside of the home such as a nursery school, day care, community center or other?

21b) What type of establishment did he/she go to?

21c) Since when has he/she gone to this establishment?

Now I would like to ask you some questions on the type of work that children in your household did last week.

22a) IF AGE 5-14 YEARS:

Since last week, did (NAME) do any work for anyone who is not a member of this household?

IF YES: Was he/she paid?

22b) IF YES:

Since the last (day of the week), approximately how many hours did he/she work for someone who is not a member of this household?

IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

22c) In the last week, did (name) go get water or wood for the household?

22d) Since the last (day of the week), approximately how many hours did he/she spend getting water or wood for the household?

22e) In the last week, did (name) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?

22f) Since last (day of the week), approximately how many hours did he/she spend doing work for his/her family or him/herself?

22g) In the last week, did (name) do any household chores, such as shopping, cooking, cleaning, taking care of children, washing clothes??

22h) Since last (day of the week), approximately how many hours did he/she spend doing these household chores?

DISCIPLINE OF CHILD

23) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 4 AND 14 YEARS OLD LIVING IN THIS HOUSEHOLD:

TABLE 1: CHILDREN AGE 2-14 YEARS ELIGIBLE FOR QUESTIONS REGARDING DISCIPLINE

RECORD EACH CHILD AGE 2-14 YEARS BELOW IN THE SAME ORDER FROM THE HOUSEHOLD REGISTRATION SHEET. DO NOT INCLUDE MEMBERS OF THE HOUSEHOLD WHOSE AGE IS OUTSIDE OF 2-14 YEARS.

RECORD THE LINE NUMBER, NAME, SEX AND AGE FOR EACH CHILD.

THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS IN THE SPACE PROVIDED (23F)

23a. RANK NUMBER

23b. LINE NUMBER FROM (1)

23c. FIRST NAME FROM (2)

23d) SEX FROM (4)

23e) AGE FROM (7)

23f. TOTAL NUMBER OF CHILDREN AGE 2-14 YEARS_________

IF THERE IS ONLY ONE CHILD AGE 2-14 YEARS IN THE HOUSEHOLD, SKIP TABLE 2 AND GO TO 23H; RECORD 1 AND CONTINUE TO 23I.

TABLE 2: RANDOM SELECTION OF THE CHILD FOR QUESTIONS ON DISCIPLINE

USE TABLE 2 TO SELECT A CHILD BETWEEN 2 AND 14 YEARS IF, IN THE HOUSEHOLD, THERE ARE MORE THAN ONE CHILD IN THIS AGE GROUP.

CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE. THIS IS THE LINE NUMBER THAT YOU MUST GO TO IN THE TABLE BELOW.

CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN (2-14 YEARS) IN 23F BELOW. THIS IS THE COLUMN NUMBER YOU SHOULD USE.

FIND THE SPACE WHERE THE LINE AND COLUMN MEET AND CIRCLE THE NUMBER BELONGING IN THE SPACE. THIS IS THE RANK NUMBER OF THE CHILD 23A TO WHOM YOU SHOULD ASK THE QUESTIONS.

23G. LAST DIGIT FROM HOUSEHOLD NUMBER
0-9

TOTAL NUMBER OF ELIGIBLE CHILDREN IN THE HOUSEHOLD (23f)
1 - 8+

23H. RECORD THE RANK NUMBER OF THE SELECTED CHILD_____

23I RECORD THE FIRST NAME AND LINE NUMBER OF THE CHILD SELECTED FOR THE MODULE BASED ON 23C AND 23B, ACCORDING TO THE RANK NUMBER FROM 23H

FIRST NAME______
LINE NUMBER_______

23J) Adults use certain methods to teach child how to behave well or to treat behavioral problems. I will read you a list of methods that are used and I'd like you to tell me if you or someone else in your household has used one of these methods with (NAME) in the last month.

23J1) Revoking privileges, not allowing (NAME) to do something that he/she likes or not allowing him/her to leave the house

23J2) Explain to (NAME) why his/her behavior is not acceptable

23J3) Shake him/her

23J4) Yell at him/her

23J5) Give him/her something else to do

23J6) Spank him/her, hit him/her, or slap him/hers buttock with bare hands

23J7) Hit him/her on the buttock or other body part with something like a belt, a hairbrush, stick, or other hard object

23J8) Call him/her an idiot, lazy, or a similar word

23J9) Hit or slap him/her on the face, head, or ears

23J10) Hit him/her on the hands, arms, or legs

23J11) Beat him/her with an object
PROBE IF NECESSARY:
Hit as hard as possible without stopping

23K) Do you think that to properly raise and educate (NAME), you must punish him/her physically or psychologically?

HOUSEHOLD FEATURES

102) What is the main source of drinking water for members of your household?

103) Where is the water source located?

103A) Who generally goes to retrieve water?

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

105) Do you do anything to the water to make it safer to drink?

106) What do you usually do to make the water safer to drink?
ANYTHING ELSE?

RECORD ALL MENTIONED

106a) CHECK 106:

106a1) Have you ever heard of a product called Aquatabs?

106a2) What are Aquatabs?

106b) You said that the water your household drinks comes mainly from (source from q 102). Has that water source been interrupted or has there been a shortage of water from this source in the last two weeks?

106c) Do these interruptions or shortages occur every day, several day s a week, a few days a week, or rarely?

106d) In the last two weeks, how many days have you had interruptions or shortages of water that affected your household?

107) What kind of toilet facility do members of your household usually use?

108) Do you share this toilet facility with other households?

109) How many households use this toilet facility?

109a) What is the main method of evacuation for your household's waste?

109b) What is the main method of evacuation for your household's used water?

110) Does your household have:

111) What type of fuel does your household mainly use for cooking?

111a) How much time does it take to get to the place where you usually get wood, get the wood, and come back?

112) Is the cooking usually done in the house, in a separate building, or outdoors?

113) Do you have a separate room which is used as a kitchen?

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

115) MAIN MATERIAL OF ROOF
RECORD OBSERVATION

116) MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION

117) How many rooms in this household are used for sleeping?

118) Does any member of your household own:

119) Does any member of this household own any agricultural land?

120) How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950

121) Does this household own any livestock, herds, other farm animals, or poultry?

122) How many of the following animals does this household own?

IF NONE, ENTER 00
IF 95 OR MORE, ENTER 95
IF UNKNOWN, ENTER 98

123) Does any member of this household have a bank account?

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

125) Who sprayed the dwelling?

126) Does your household have any mosquito nets that can be used while sleeping?

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

128) ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
ASK THE FOLLOWING QUESTIONS FOR EACH NET. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

129) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00

130a) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

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

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

134) Did anyone sleep under this mosquito net last night?

135) Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 140

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

141) In the last three years, has there been any event that affected life in your household?

142) What was the main event for your household?

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

201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202 ACCORDING TO LINE NUMBER ORDER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11

NAME FROM COLUMN 2

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF CHILD'S BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth day?

204) CHECK 203:
Child born in January 2007 or later?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

208) CHECK 203:
IS THE CHILD'S AGE 0-5 MONTHS, I.E. WAS THE CHILD BORN IN THE MONTH OF INTERVIEW OR THE FIVE PREVIOUS MONTHS?

208a) CHECK FOR PRESENCE OF BILATERAL EDEMA ON FEET

CHECKED:

209) LINE NUMBER FROM PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD 00 IF NOT LISTED.

210) ASK CONSENT FOR THE ANEMIA TEST FROM THE PARENT/OTHER ADULT IDENTIFIED IN 209 AS 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 ask that all children born in 2007 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take 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 will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member 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 take the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TEST FOR WOMEN 15-49

214) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN FROM QUESTION 215. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

215) LINE NUMBER FROM COLUMN 9

NAME FROM COLUMN 2

216) WEIGHT IN KILOGRAMS

217) HEIGHT IN CENTIMETERS

218) AGE: CHECK COLUMN 7

219) MARITAL STATUS: CHECK COLUMN 8

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

221) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 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 test, we need a few drops of blood from a finger. The equipment used to take 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 will be told to you and to (name of adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

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

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) 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 test, we need a few drops of blood from a finger. The equipment used to take 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 will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

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

224) CIRCLE APPROPRIATE CODE AND SIGN

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

226) AGE: CHECK COLUMN 7

227) MARITAL STATUS: CHECK COLUMN 8

228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 220 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 Niger.

For the HIV test, we need a few drops of blood from a finger. The equipment used to take 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 the results of (name of adolescent's) test either. If (name of adolescent) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you that you can use at any of these facilities.

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?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

230) ASK CONSENT FOR DBS COLLECTION 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 Niger.

For the HIV test, we need a few drops of blood from a finger. The equipment used to take 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 you HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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

Will you take in the HIV test?

231) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.

239) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

241) BAR CODE LABEL

PUT THE 1ST BAR CODE HERE__________

242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 243.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

243) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

244) LINE NUMBER FROM COLUMN 10

NAME FROM COLUMN 2

247) AGE: CHECK COLUMN 7

248) MARITAL STATUS: CHECK COLUMN 8

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

250) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN 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 few drops of blood from a finger. The equipment used to take 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 will be told to you and (name of adolescent) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

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

251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

252) 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 few drops of blood from a finger. The equipment used to take 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 will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member 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 in the anemia test?

253) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

254) AGE: CHECK COLUMN 7

255) MARITAL STATUS: CHECK COLUMN 8

256) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 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 Niger.

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take 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 his HIV status, I can provide him with a list of [nearby] facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

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?

257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

258) ASK CONSENT FOR DBS COLLECTION 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 Niger.

For the HIV test, we need a few more drops of blood from a finger. The equipment used to take 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 you HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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?

259) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME AND ENTER YOUR INTERVIEWER NUMBER.

267) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

268) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

269) BAR CODE LABEL

PUT THE 1ST BAR CODE HERE

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

270) GO BACK TO 247 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.