MINECOFIN / REPUBLIC OF RWANDA
DEPARTMENT OF STATISTICS

IDENTIFICATION

PLACE NAME_____
NAME HOUSEHOLD HEAD____
PROVINCE ______
DISTRICT______
CLUSTER NUMBER _____
STRUCTURE NUMBER ______
HOUSEHOLD NUMBER _______

URBAN/RURAL _________

KIGALI CITY / OTHER TOWNS/ RURAL ____

HOUSEHOLD SELECTED FOR MALE INTERVIEW, HOUSEHOLD RELATIONS (SECTION X WOMEN)/HIV/ANEMIA TEST/ANTHROPOMETRIC MEASUREMENTS

HOUSEHOLD NOT SELECTED FOR MALE INTERVIEW, ETC.

INTERVIEWER VISITS

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

*RESULT CODES:

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE___
HOUR ____

FINAL VISIT
DAY __
MONTH ___
YEAR _200_
CODE ___
RESULT __

TOTAL NUMBER OF VISTS ___

TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___

LINE NO. OF RESP. TO HOUSEHOLD QUEST. ___

TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___

LINE NO. OF RESP. TO HOUSEHOLD QUEST. ___

TEAM LEADER
NAME ____
DATE ____

FIELD CONTROLLER
NAME ____
DATE ____

OFFICE EDITOR ____
KEYED BY ____

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

(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.

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

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

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

(6) Did (NAME) stay here last night?

(7) AGE
How old is (NAME)?
IF LESS THAN ONE YEAR, RECORD '00'
IF 95 YEARS OR MORE RECORD '95'.

(7a) CHRONIC ILLNESS
IF AGE 18-59 YEARS IF COL(5) = 2GO TO COL (8)
Has (NAME) been very ill for at least 3 months in the last 12 months? By 'very sick' I mean has (NAME) been too sick to work or to carry out his/her normal activities at home?

ELIGIBILITY

(8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

CHECK IF THE HOUSEHOLD IS SELECTED FOR MALE INTERVIEW:

(9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

(9a) CIRCLE LINE NUMBER OF ALL MALES AGED 15-59 (9a)

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 18 YEARS OLD**

(10) Is (NAME)'s natural mother alive? IF NO OR DK, GO TO Q 12

IF ALIVE

(11) Does (NAME)'s natural mother live in this house-hold?
IF YES: What is her name?
RECORD MOTHER'S LINE NUBMER THEN GO TO Q 12

(11A) (IF MOTHER DOES NOT LIVE IN HOUSEHOLD)
Has (NAME)'s mother been very sick for at least three months during the past 12 months? By very sick, I mean that she was too sick to work or do normal activities around the house for at least three of the past 12 months.

(12) Is (NAME)'s natural father alive? IF NO OR DK, GO TO Q 13B.

IF ALIVE

(13) Does (NAME)'s natural father live in this house-hold? IF YES: What is his name? RECORD FATHER'S LINE NUMBER THEN GO TO Q 13B.

(13A) (IF FATHER DOES NOT LIVE IN HOUSEHOLD)
Has (NAME)'s father been very sick for at least three months during the past 12 months? By very sick, I mean that he was too sick to work or do normal activities around the house for at least three of the past 12 months

IF AGED 0-4 YEARS
BIRTH REGISTRATION

(13B) Does [NAME] have a birth certificate?
IF YES GO TO Q14

(13C) Was the birth of [NAME] declared with the vital statistics office?

**Q.10 TO Q.13A
THESE QUESTIONS CONCERN BIOLOGICAL PARENTS OF THE CHILD.
IN Q.11 AND Q.13, RECORD '00' IF THE PARENTS ARE NOT MEMBERS OF THE HOUSEHOLD.

EDUCATION

IF AGE 3 YEARS OR OLDER IF AGE 3-24 YEARS

(14) Has (NAME) ever attended school

(15) What is the highest level of school (NAME) has attended?*** What is the highest grade (NAME) completed at that level?*** (15)

(16) Is (NAME) currently attending school?

(17) During the current school year (2005), did (NAME) attend school at any time? (17)

IF AGE 3-24 YEARS

(18) During the current school year (2005), what level and grade [is/was] (NAME) attending?***

(19) During the previous school year (2003-2004), did (NAME) attend school at any time?

(20) During the school year (2003-2004), what level and grade did (NAME) attend ?***

TICK HERE IF CONTINUATION SHEET USED _____

Just to make sure that I have a complete listing:

1) Are there any other persons such as small children or infants that we have not listed?

2) In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?

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

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

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

23. What kind of toilet facilities does your household have?

24. Do you share these facilities with other households?

25. Does your household have:

Electricity?
A radio?
A television?
A telephone?
A refrigerator?

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

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

28. Does any member of your household own:

A bicycle?
A motorcycle or motor scooter?
A car or truck?
A mobile telephone?

Now I would like to ask you some questions concerning the mosquito nets.

29. Does your household have any bednets that can be used while sleeping?

29A. How many mosquito nets does your household have?

Q. 30- Q. 32E ARE ASKED OF NETS 1-4 SEPARATELY.

30. ASK RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 4 NETS, USE AN ADDITIONAL QUESTIONNAIRE.

31. How long ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH REGISTER '00'

31A. CHECK Q. 31
BEDNET OBTAINED WITHIN THE LAST 6 MONTHS.

31B. How or from where did you get your mosquito net?

31C. How much did you pay for this mosquito net?

32. OBSERVE OR ASK THE BRAND OF MOSQUITO NET.

*1 "Permanent" is a pretreated net that does not require any further treatment.
*2 "Pretreated" is a net that has been pretreated, but requires further treatment after 6-12 months.

32A. Since you got the mosquito net, was it treated with a liquid to repel mosquitoes or bugs?

32B. Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs?

32C. How long ago was the net last soaked or dipped?
IF LESS THAN 1 MONTH, RECORD '00'.

32D. Did anyone sleep under this mosquito net last night?

32E. Who slept under this mosquito net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

32F. GO BACK TO 30 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 35. IF THERE ARE MORE THAN 4, USE AN ADDITIONAL QUESTIONNAIRE.

35. ASK THE RESPONDENT FOR A TEASPOONFUL OF SALT NORMALLY USED IN THE HOUSEHOLD, THEN TEST THE SALT TO VERIFY THE PRÉSENCE OF IODINE.
RECORD RESULTS IN PPM (PARTS PER MILLION).

C1. SUPPORT FOR CHRONICALLY ILL PERSONS.

101. CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE:
NUMBER OF SICK PEOPLE AGE 18-59 ___

102. ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH SICK HOUSEHOLD MEMBER AGE 18-59, BEGINNING WITH THE FIRST SICK MEMBER LISTED IN THE HOUSEHOLD SCHEDULE. ASK THE QUESTIONS ABOUT ALL OF THESE PEOPLE.
IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

103. RECORD LINE NUMBER AND NAME OF THE SICK MEMBER IN THE HOUSEHOLD SCHEDULE

104. You said to me that in your household, (NAME OF EACH SICK PERSON TO Q103) was very sick during at least 3 months during the last 12 months.
I would like to ask you questions in connection with any type of assistance or organized support that your household could have received for [ this/any of these ] patient(s) and for which you did not pay.
By assistance or organized support, I want to say a help or I want to say a help or support provided by somebody who works for a program, that it is governmental, private sector, religious, a charity organization or a Community based program.

105. Now I would like to ask you some questions about the help or support that your household may have received from anyone besides your relatives, friends or neighbors because of (NAME)'s illness.
In the last 12 months, has your household received any medical care for (NAME) for which you did not have to pay?

106. Your household received any of these supports at least once per month when (name) was ill?

107. In the last 12 months, has your household received any companionship, emotional or spiritual support in your home, because of (NAME)'s situation, for which you did not have to pay?

108. Did your household receive this support during the last 30 days?

109. In the last 12 months. Did your household receive material support for (NAME) like clothing food or financial support for which you did not have to pay?

110. Did your household receive this support in the last 30 days?

111. In the last 12 months. Did your household receive any social because of (NAME)'s illness like household work training of caregiver or assistance for legal service for which you did not have to pay?

112. Did your household receive this support in the last 30 days

113. In the last 30 days, has [NAME] had severe pain, mild pain, or no pain at all?

114. When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time or not at all?

115. In the last 30 days, did (NAME) suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Did (NAME) suffer severely or mildly?

116. Was (NAME) able to reduce or stop the (nausea/coughing/ diarrhea/constipation) most of the time, some of the time, or not at all?

117. RETURN TO 105 FOR THE NEXT COLUMN OR IF THERE ARE SICK PEOPLE. GO TO 201.

C2. SUPPORT FOR PERSONS WHO HAVE DIED

201. Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has anyone who lived in this household died in the last 12 months

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

203. POSE 204-221 FOR EACH PERSON, ONE AFTER ANOTHER. IF MORE THAN 3, USE ADDITIONAL QUESTIONNAIRE.

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

205. Was (NAME) male or female?

206. How old was (NAME) when (s)he died?

207. Was (NAME) very sick for at least three of the 12 months before s(he)died?
By very sick, I want to say too sick to work or to ensure normal activities the house for 3 months in the last 12 months?

208. CHECK 206: AGE OF DEAD PERSON

209. I would like to ask you questions in connection with any type of assistance or organized support that your household could have received for [ NAME ] before his death and for which you did not pay.
By assistance or organized support I want to say help or support provided by somebody who works for a program, that it is governmental, of the private sector, religious, charity organization or a Community based program.

210. In the last 12 months, has your household received any medical care for (NAME) for which you did not have to pay?

211. Your household received any of these supports during the last 30 days preceding the death of (NAME)?

212. In the last 12 months, has your household received any companionship, emotional or spiritual support in you home, because of (NAME)'s situation, for which you did not have to pay?

213. Your household received any of these supports during the last 30 days preceding the death of (NAME)?

214. In the last 12 months. Did your household recieve material support for (NAME) like clothing food or financial support for which you did not have to pay?

215. Your household received any of these supports during the last 30 days preceding the death of (NAME)?

216. In the last 12 months. Did your household receive any social assistance because of (NAME)'s illness like household work training of caregiver or assistance for legal service for which you did not have to pay?

217. Your household received any of these supports during the last 30 days preceding the death of (NAME)?

218. In the 30 days before (NAME) died, did he/she have severe pain, mild pain, or no pain at all?

219. When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

220. In the 30 days before (NAME) died, did he/she suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Did (NAME) suffer severely or mildly?

221. Was (NAME) able to reduce or stop the (nausea/coughing/ diarrhea/constipation) most of the time, some of the time or not at all?

222. RETURN TO 204 FOR THE NEXT COLUMN OR THERE ARE MORE PERSONS WHO DIED, GO TO 301.

C3. SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

301. CHECK COLUMN 7 OF THE HOUSEHOLD SCHEDULE: IS THERE A CHILD OF 0-17 YRS?

302. CHECK COLUMN 7 OF THE HOUSEHOLD SCHEDULE: IS THERE AN ADULT OF 18-59 YRS?

303. VERIFY COLUMN 7A OF THE HOUSEHOLD SCHEDULE: IS THERE AN ADULT OF 18-59 YRS WHO IS SICK?

304. VERIFY 206 IN SECTION C2: IS THERE AN ADULT OF 18-59 YRS WHO DIED DURING THE LAST 12 MONTHS?

305. CHECK COLUMN 10 AND 12 IN THE HOUSEHOLD SCHEDULE: MOTHER OR FATHER ALIVE?

306. CHECK COLUMNS 11A AND 13A IN THE HOUSEHOLD SCHEDULE: MOTHER OR FATHER VERY SICK?

307 MAKE THE LIST OF ALL THE CHILDREN OF 0-17 YRS IN THE HOUSEHOLD

IF YOU HAVE TO REGISTER MORE THAN 8 CHILDREN, USE AN ADDITIONAL QUESTIONNAIRE.

308. REGISTER THE LINE NUMBER AND NAME OF EACH LISTED CHILD IN Q.307, STARTING WITH THE FIRST CHILD IN THE LIST.
ASK THE QUESTIONS ABOUT EACH ONE OF THESE CHILDREN.
IF THERE ARE MORE THAN 8 CHILDREN, USE AN ADDITIONALQUESTIONNAIRE.

309. LINE NUMBER AND NAME IN 307.

310. I would like to ask you questions in connection with any type of assistance or organized support that your household could have received for [NAME OF EACH CHILD IN 309 ] and for which you did not pay.
By assistance or organized support, I want to say help or support provided by somebody who works for a program, that it is governmental, of the private sector, religious, charity organization or a Community based program.

311. I would like to now ask you questions about the support that your household received for (NAME).
During the last 12 months did your receive medical support for (NAME) for which did not have to pay?

312. In the last 12 months, has your household received any counseling from a trained counselor because of (NAME)'s situation, for which you did not have to pay?

313. Did your household receive this support during the last 3 months?

314. In the last 12 months, has your household received any clothing, food or financial support because of (NAME)'s situation for which you did not have to pay?

315. Did your household receive this support during the last 3 months?

316. In the last 12 months, has your household received any help with household work or childcare, training of caregiver because of (NAME)'s situation for which you did not have to pay?

317. Did your household receive this support during the last 3 months?

318. VERIFY 307:
AGE OF CHILD

319. In the last 12 months, has your household received any help with school fees or school related expenses for (NAME) for which you did not have to pay?

320. RETURN TO 311 FOR THE NEXT COLUMN; IF THERE ARE NOMORE CHILDREN,
CONTINUE WITH INDIVIDUAL INTERVIEW OF THE ELIGIBLE PERSON.

Q. 35A CHECK THE COVER PAGE OF THIS QUESTIONNAIRE. USE THIS TABLE ONLY IF THE HOUSEHOLD WAS SELECTED FOR QUESTIONS IN SECTION 10, « RELATIONS IN THE HOUSEHOLD ».

IF THERE IS ONLY ONE ELEGIBLE WOMAN IN THE HOUSEHOLD: In the first line (row) of the table below, write the name, age and line number of the eligible woman (see Column (8) of the Household Schedule) : this woman is selected to be interviewed with questions in Section 11 «Relations in the Household».

IF THERE ARE SEVERAL ELEGIBLE WOMEN IN THE HOUSEHOLD: In the table below, write the name, the age and the line number of all eligible women (see Column (8) of the Household Questionnaire), beginning with the oldest and ending with the youngest.

Note the last digit of the household structure number recorded on the cover page of the questionnaire and circle that number on the first line of the table below.

Descend down this column of this number until you reach the line of the last woman recorded.
Circle the number that is at the intersection between the column descended and the line of the last woman recorded.

The number you circled (1, 2, 3 etc.) at this intersection tells you the order of the woman selected for Section 11 of the Women's Questionnaire (the 1st, 2nd, 3rd, etc?).

In the household schedule, circle the LINE NUMBER of the woman selected.

ANTHROPOMETRY AND CHILD'S HEMOGLOBIN SCHEDULE

CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

WOMEN 15-49/CHILDREN UNDER AGE 6

(36) LINE NO. FROM COL. (9)

(37) NAME FROM COL. (2)

(38) AGE FROM COL. (7)

(39) What is (NAME)'s date of birth?* (ONLY FOR CHILDREN AGE 6)

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49/CHILDREN BORN IN 1999 OR LATER

(40) WEIGHT (KILOGRAMS)

(41) HEIGHT (CENTIMETERS)

(42) MEASURED LYRIND DOWN OR STANDING UP (ONLY FOR CHILDREN AGE 6)

(43) RESULT

TICK HERE IF CONTINUATION SHEET IS USED: ___

CHECK COLUMNS (8) AND (9): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN UNDER AGE 6.

* FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY (SECTION 2), SUCH AS ORPHANS, ADOPTED CHILDREN, ETC.), ASK DAY, MONTH AND YEAR OF BIRTH. FOR ALL OTHER CHILDREN, COPY MONTH AND YEAR FROM Q.215 IN MOTHER'S BIRTH HISTORY (SECTION 2) AND ASK DAY OF BIRTH.

INFORMED CONSENT STATEMENT FOR ANEMIA
As part of this survey, we are studying anemia among women, men and children under age 6 years. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.

We request that you (and all children born since 1999) participate in the anemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be taken with new equipment and the results of the test will be given to you immediately after. These results will be kept confidential.

Now I would like to ask that you (and NAME OF CHILD[REN]) agree to participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test done.

CONTINUE TO COLUMN (45) AND CIRCLE THE APPROPRIATE CODE.

HEMOGLOBIN MEASUREMENT OF WOMEN 15-49

(44) LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

(45) READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT*
CIRCLE CODE (AND SIGN)

(46) HEMOGLOBIN LEVEL (G/DL)

(47) RESULT

Informed Consent Statements
HIV testing

INFORMED CONSENT STATEMENT FOR HIV TESTING ADULTS AGE 18 OR OLDER

As part of this survey, we are studying HIV/AIDS among women age 15 to 49 years and men age 15-59 years. As you may know, HIV is the virus that causes AIDS, and AIDS is a serious illness that often leads to death. We are conducting a test to measure the extent of the disease in Cameroon. The results from the survey will assist the government in developing programs for preventing HIV and AIDS.

We request that you participate in the HIV testing part of this survey by permitting us to take a few drops of blood from your finger. Only disposable, sterile instruments that are clean and completely safe will be used.

The blood sample will be sent directly to a laboratory to be analyzed. To ensure confidentiality, your name will not be attached to the blood sample. The results will be completely anonymous and for this reason we cannot provide you with results of the test. However, we will give you a coupon for a free test at a Voluntary Counseling and Testing center in case you want to know your HIV status.

Do you have any questions about this?
Now I would like you to please tell me if you agree to participate in the HIV test?

CONTINUE TO COLUMN (67) AND CIRCLE THE APPROPRIATE CODE.

INFORMED CONSENT STATEMENTS FOR HIV TESTING
YOUNG MEN AND WOMEN AGE 15-17 YEARS

1st step: First ask the consent of the parent or responsible adult:
The study of HIV/AIDS includes young women and men starting at age 15. For HIV testing of young men and women ages 15 to 17 years we ask that the parent or a responsible adult provides their consent, as well as the eligible young man or woman.

We request that the young man/woman, [NAME], participate in the HIV testing part of this survey by permitting us to use a few drops of blood from his/her finger. Only disposable, sterile instruments that are clean and completely safe will be used.

The blood sample will be sent directly to a laboratory to be analyzed. To ensure confidentiality, no name or personally identifying information will be attached to the blood sample. The results will be completely anonymous and for this reason we cannot provide results of the test.However, we will give you a coupon for a free test at a Voluntary Counseling and Testing center in case you want to know your HIV status.

Now I would like you to please tell me if you agree that [NAME] participates in the HIV test ?

CONTINUE TO COLUMN (66) AND CIRCLE THE APPROPRIATE CODE.

2nd step: Consent of the young man/woman:
IF THE PARENT OR RESPONSIBLE ADULT AGREES THAT THE YOUNG PERSON BE TESTED, THEN READ THE CONSENT TO THE YOUNG PERSON.

As part of this survey, we are studying HIV/AIDS among women age 15 to 49 years and men age 15-59 years. As you may know, HIV is the virus that causes AIDS, and AIDS is a serious illness that often leads to death. We are conducting test to measure the extent of the disease in Cameroon. The results from the survey will assist the government in developing programs for preventing HIV and AIDS.

We request that you participate in the HIV testing part of this survey by permitting us to use a few drops of blood from your finger. Only disposable, sterile instruments that are clean and completely safe will be used.

The blood sample will be sent directly to a laboratory to be analyzed. To ensure confidentiality, your name will not be attached to the blood sample. The results will be completely anonymous and for this reason we cannot provide you with results of the test. However, we will give you a coupon for a free test at a Voluntary Counseling and Testing center in case you want to know your HIV status.

Do you have any questions about this?
Now I would like you to please tell me if you agree to participate in the HIV test?

CONTINUE TO COLUMN (67) AND CIRCLE THE APPROPRIATE CODE.

* DON'T FORGET TO GIVE EACH ELIGIBLE PERSON A REFERENCE FORM FOR A FREE HIV TEST.

ADULT HIV AND HEMOGLOBIN SCHEDULE

Number of blood samples: _______

CHECK COLUMNS (8) AND (9a) FROM HOUSEHOLD SCHEDULE: RECORD THE LINE NUMBER, NAME, SEX AND AGE OF ALL WOMEN AGE 15-49 AND ALL MEN AGE 15-59 YEARS. THIS FORM MUST BE DESTROYED BEFORE THE RESULTS OF THE TEST ARE LINKED TO THE RDHS DATABASE.

(48) LINE NUMBER FROM COLUMN (8) OR COLUMN (9a)

(49) NAME FROM COL.(2)

(50) SEX FROM COL. (4)

(51) AGE FROM COL.(7) CHECK AGE IN COLUMN

(52) CHECK AGE IN COLUMN (51)

(53) LINE NUMBER OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSE-HOLD SCHEDULE

READ THE CONSENT TO THE PARENT OR RESPONSIBLE ADULT CIRCLE CODE (AND SIGN)

(54a) CONSENT FOR ANEMIA TESTING

(54b) CONSENT FOR HIV TESTING

READ THE CONSENT TO THE RESPONDENT CIRCLE CODE (AND SIGN)
If 54a - 1, READ CONSENT IN 55a.
IF 54b - 1, READ CONSENT IN 55b.
IF 55a AND 55b DO NOT EQUAL 1, GO TO 58.

(55a) CONSENT FOR ANEMIA TESTING

(55b) CONSENT FOR HIV TESTING

(56) HEMOGLOBIN LEVEL (G/DL)

(57) (FOR WOMEN) CURRENTLY PREGNANT

(58) ANEMIA RESULT

(59) HIV RESULT

(60) PLACE BAR CODES
5 DROPS of blood:
First drop is wiped away;
Second, third, fourth drops are collected for HIV;
Fifth (last) drop is collected for anemia.

TICK HERE IF ANOTHER SEET IS USED _____

61. CHECK QUESTIONS 46 (FOR CHILDREN) AND 56/57 (FOR ADULTS):
NUMBER OF HOUSEHOLD MEMBERS FOR WHICH THE LEVEL OF HEMOGLOBIN IS BELOW THE CUT-OFF POINTS:
LESS THAN 7G/DL FOR CHILDREN, FOR MEN, AND FOR WOMEN WHO ARE NOT PREGNANT (OR WHO DO NOT KNOW IF THEY ARE PREGNANT); LESS THAN 9G/DL FOR PREGNANT WOMEN.

62. The results of the test show that (your blood/the blood of NAME OF CHILD/CHILDREN) has a very low level of hemoglobin.

This indicates the (you/NAME OF CHILD/CHILDREN) are severely anemic, which is a serious health problem.

We recommend that you visit a health facility as soon as possible to be examined and obtain the proper treatment.

GIVE THE ADULT THE REFERENCE FORM FOR ANEMIA AND CONTINUE TO Q. 60.