NATIONAL INSTITUTE OF STATISTICS
IDENTIFICATION

PROVINCE____

DISTRICT____

SECTOR____

NAME OF HOUSEHOLD HEAD____

CLUSTER NUMBER____

HOUSEHOLD STRUCTURE NUMBER____

HOUSEHOLD NUMBER____

HOUSEHOLD SELECTED FOR ANTHROPOMETRY, ANEMIA/MALARIA FOR CHILDREN AND WOMEN:

HOUSEHOLD SELECTED FOR MALE SURVEY AND HIV TESTING FOR ADULTS:

HOUSEHOLD SELECTED FOR HIV TESTING FOR CHILDREN:

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE FOR WOMEN:

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE FOR MEN:

INTERVIEWER VISITS:

FIRST VISIT
DATE____
INTERVIEWER'S NAME____
RESULT

NEXT VISIT:
DATE____
TIME____

SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT

NEXT VISIT:
DATE____
TIME____

THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT

FINAL VISIT
DAY____
MONTH____
YEAR____
INT. NUMBER____
RESULT____

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD___

TOTAL ELIGIBLE WOMEN___

TOTAL ELIGIBLE MEN___

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

SUPERVISOR____
NAME____

FIELD EDITOR____
NAME____

OFFICE EDITOR____

KEYED BY____

INTRODUCTION AND CONSENT

Hello. My name is _________________________. I am working with National Institute of Statistics of Rwanda. We are conducting a survey about health all over Rwanda. 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 will usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of the 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.

In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION.

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

SIGNATURE OF INTERVIEWER: _________________________ DATE: _______________

HOUSEHOLD SCHEDULE

1) 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 5-23 FOR EACH PERSON.

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?

3) RELATIONSHIP TO HEAD OF HOUSEHOLD

What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

CODES FOR QUESTION 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

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 95 OR MORE, RECORD 95'.

IF AGE 15 OR OLDER:
8) MARITAL STATUS:
What is (NAME'S) current marital status?

ELIGIBILITY:

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

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

11A) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-14

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 usually live in this household or was he a guest here last night? IF YES: What is his name? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

IF AGE 3 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

16) 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?
SEE CODES BELOW.

CODES FOR QUESTIONS 17 AND 19: EDUCATION

LEVEL ____

GRADE ____

IF AGE 3-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school at any time during the (2014 - 2015/2014/2015) school year?

19) During this/that school year, what level and grade [is/was] (NAME) attending?
SEE CODES BELOW.

LEVEL ____

GRADE ____

IF AGE 0-4 YEARS:

BIRTH REGISTRATION:

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

INSURANCE:

21) Is (NAME) covered by any health insurance?

22) What is (NAME)'s main type of health insurance?
CODES FOR QUESTION 22:

IF AGE 7 OR MORE YEARS:

23) Does (NAME) currently smoke?

HOUSEHOLD CHARACTERISTICS

101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

102) 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?

104A) What is the distance from your home to that water source?

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) Is the water this household uses for drinking stored?

106B) ASK TO SEE THE CONTAINER(S) IN WHICH WATER IS STORED. RECORD OBSERVATION.

106C) How many times per week does your household wash these containers?

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 (including this household) use this toilet facility?

109A) CLEANLINESS OF THE TOILET FACILITY
RECORD OBSERVATION.

110) Does your household have:

Electricity?
A radio?
A television?
A mobile phone?
A non-mobile telephone?
A refrigerator?
A computer?

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

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 THE 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 this household own:

A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat without a motor?
A boat with a motor?

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 '95.0'

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'.

Cows (traditional)?
Milk cows (modern)?
Bulls?
Goats?
Sheep?
Chickens?
Pigs?
Rabbits?
Horses, donkeys, or mules?

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

123A) CHECK 21:

123E) Does your household plan to obtain health insurance for members that are currently not covered?

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 ALL THE NETS IN THE HOUSEHOLD.

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

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

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'.

133A) How did you obtain the net?

133B) OBSERVE CONDITION OF MOSQUITO NET: DOES IT HAVE HOLES THAT ARE EQUAL TO OR LARGER THAN THE TIP OF YOUR THUMB?

133C) OBSERVE OR ASK THE SHAPE OF THE MOSQUITO NET.

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

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

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137) Please show me where members of your household most often wash their hands.

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE SPECIFIC PLACE FOR HANDWASHING.

139) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.

141m) CHECK THE COVER PAGE OF THIS QUESTIONNAIRE. USE THIS TABLE ONLY IF THE HOUSEHOLD WAS SELECTED FOR MALE DOMESTIC VIOLENCE.

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD STRUCTURE NUMBER ON THE COVER PAGE. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE. CHECK THE TOTAL NUMBER OF ELIGIBLE MEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE. FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE ELIGIBLE MAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS. THEN, GO TO COLUMN (10) IN THE HOUSEHOLD SCHEDULE AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED ELIGIBLE MAN AND RECORD THIS HOUSEHOLD LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

FOR EXAMPLE, IF THE HOUSEHOLD STRUCTURE NUMBER IS '716', GO TO COLUMN 6 AND CIRCLE THE COLUMN NUMBER ('6'). IF THERE ARE TWO ELIGIBLE MEN IN THE HOUSEHOLD, GO TO ROW 2 AND CIRCLE THE ROW NUMBER ('2'). DRAW LINES FROM COLUMN 6 AND ROW 2 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT ('1'). THIS MEANS YOU HAVE TO SELECT THE FIRST ELIGIBLE MAN. SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE TWO ELIGIBLE MEN ARE '02' AND '03'; THEN THE ELIGIBLE MAN FOR THE HOUSEHOLD RELATIONS QUESTIONS IS THE FIRST ELIGIBLE MAN, I.E., THE MAN WITH HOUSEHOLD LINE NUMBER '02'. PUT A '*' NEXT TO THIS MAN'S LINE NUMBER IN COLUMN (10) OF THE HOUSEHOLD SCHEDULE AND ALSO ENTER THE TWO DIGIT LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

141w) CHECK THE COVER PAGE OF THIS QUESTIONNAIRE. USE THIS TABLE ONLY IF THE HOUSEHOLD WAS SELECTED FOR FEMALE DOMESTIC VIOLENCE.

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD STRUCTURE NUMBER ON THE COVER PAGE. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE. FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE ELIGIBLE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS. THEN, GO TO COLUMN (9) IN THE HOUSEHOLD SCHEDULE AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED ELIGIBLE WOMAN AND RECORD THIS HOUSEHOLD LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

FOR EXAMPLE, IF THE HOUSEHOLD STRUCTURE NUMBER IS '716', GO TO COLUMN 6 AND CIRCLE THE COLUMN NUMBER ('6'). IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO ROW 3 AND CIRCLE THE ROW NUMBER ('3'). DRAW LINES FROM COLUMN 6 AND ROW 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT ('3'). THIS MEANS YOU HAVE TO SELECT THE THIRD ELIGIBLE WOMAN. SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE WOMEN ARE '02', '3', AND '07'; THEN THE ELIGIBLE WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS IS THE THIRD ELIGIBLE WOMAN, I.E., THE WOMAN WITH HOUSEHOLD LINE NUMBER '07'. PUT A '*' NEXT TO THIS WOMAN'S LINE NUMBER IN COLUMN (9) OF THE HOUSEHOLD SCHEDULE AND ALSO ENTER THE TWO DIGIT LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENTS, AND MALARIA TESTING FOR CHILDREN AGE 0-5

CHECK HOUSEHOLD COVER PAGE TO SEE IF HOUSEHOLD IS SELECTED FOR ANTHROPOMETRY, ANEMIA, AND MALARIA FOR CHILDREN (0-5) AND WOMEN (15-49).

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

202) LINE NUMBER FROM COLUMN 11:
NAME FROM COLUMN 2:

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

204) CHECK 203: CHILD BORN IN JANUARY 2009 OR LATER?

205) WEIGHT IN KILOGRAMS:

206) HEIGHT IN CENTIMETERS:

207) MEASURED LYING DOWN OR STANDING UP?

207A) EDEMA OF BOTH FEET:

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

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

210) READ ANEMIA CONSENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

211) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

212) READ MALARIA CONSENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

212A) RECORD RESULT CODE OF MALARIA TEST

212B) BAR CODE LABEL:
PUT THE 2ND BAR CODE ON THE SLIDE AND THE 3RD ON TRANSMITTAL FORM.

212C) RESULT OF MALARIA TEST:

212D) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD. ASK ABOUT ANY TREATMENT THE CHILD HAS ALREADY RECEIVED.

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.

CONSENT STATEMENT FOR ANEMIA TEST:

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 2009 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 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/NAMES OF CHILDREN) to participate in the anemia test?

CONSENT STATEMENT FOR MALARIA TEST:

As part of this survey, we are asking that children all over the country take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will help the government to develop programs to prevent malaria.

We request that all children born in 2009 or later participate in the malaria 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 malaria immediately and the result will be told to you right away. The result will be kept confidential.

Do you have any questions about the malaria test?

You can say yes to the test or you can say no. It is up to you to decide.
Will you allow (NAME(S) of CHILD(REN) to participate in the malaria test?

TREATMENT FOR CHILDREN AND WOMEN WITH POSITIVE MALARIA TESTS:

IF MALARIA TEST IS POSITIVE: The malaria test shows that (your child/you) has malaria. We can give you free medicine. The medicine is called ACT. ACT is very effective and in a few days it should get rid of the fever and other symptoms.

BEFORE PROVIDING ACT, FIRST ASK IF THE CHILD OR WOMAN IS ALREADY TAKING OTHER DRUGS AND IF SO, ASK TO SEE THEM. IF SHE/HE IS ALREADY TAKING ACT, CHECK ON THE DOSE ALREADY AVAILABLE. BE CAREFUL NOT TO OVER TREAT.

You do not have to (give the child/take) the medicine. This is up to you. Please tell me whether you accept the medicine or not.

TREATMENT WITH ACT:
ARTHEMETER (20MG )+ LUMEFANTRINE (120MG)
A 3-day treatment schedule with a total of 6 doses is recommended as below

WEIGHT (IN KG): 05.0-14.9 KG
TREATMENT: One tablet as an initial dose, 1 tablet again after 8 hours and then 1 tablet twice daily (morning and evening) for the following two days (total course of 6 tablets).

WEIGHT (IN KG): 15.0-24.9 KG
TREATMENT: Two tablets as an initial dose, 2 tablets again after 8 hours and then 2 tablets twice daily (morning and evening) for the following two days (total course of 12 tablets).

WEIGHT (IN KG): 25.0-34.9 KG
TREATMENT: Three tablets as an initial dose, 3 tablets again after 8 hours and then 3 tablets twice daily (morning and evening) for the following two days (total course of 18 tablets).

WEIGHT (IN KG): 35 KG AND ABOVE
TREATMENT: Four tablets as a single initial dose, 4 tablets again after 8 hours and then 4 tablets twice daily (morning and evening) for the following two days (total course of 24 tablets).

WEIGHT, HEIGHT MEASUREMENT, HEMOGLOBIN MEASUREMENTS, AND MALARIA TESTING FOR WOMEN AGE 15-49

CHECK HOUSEHOLD COVER PAGE TO SEE IF HOUSEHOLD IS SELECTED FOR ANTHROPOMETRY, ANEMIA, AND MALARIA FOR CHILDREN (0-5) AND WOMEN (15-49)

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

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 ADULT RESPONSIBLE 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 testing, we will 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 (NAME OF ADOLESCENT) 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 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 testing, we will 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 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?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

224A) AGE: CHECK 218.

224B) MARITAL STATUS: CHECK 219.

224C) LINE NUMBER FROM COLUMN 9:
NAME FROM COLUMN 2:

224D) ASK CONSENT FOR MALARIA 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 a Malaria test. Malaria is a serious health problem that is caused by a parasite transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent and treat Malaria. For the Malaria testing, we will 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 Malaria 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 members 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 Malaria test?

224E) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

224F) ASK CONSENT FOR MALARIA TEST FROM RESPONDENT.

As part of this survey, we are asking people all over the country to take a Malaria test. Malaria is a serious health problem that is caused by a parasite transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent and treat Malaria. For the Malaria testing, we will 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 Malaria 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 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 Malaria test?

224G) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

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

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

227) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

228) RECORD RESULT CODE OF MALARIA RAPID TEST:

229) RESULT OF MALARIA RAPID TEST:

230) RECORD RESULT CODE OF BLOOD SLIDE COLLECTION:

231) BAR CODE LABEL:

232) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN,
[#transcriber note: survey text is cut off from this point]

HIV TESTING FOR WOMEN AGE 15-49

CHECK HOUSEHOLD COVER PAGE TO SEE IF SELECTED FOR MALE SURVEY AND HIV TESTING FOR ADULTS

301) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 302. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

302) LINE NUMBER FROM COLUMN 9:
NAME FROM COLUMN 2:

303) AGE: CHECK COLUMN 7.

304) MARITAL STATUS: CHECK COLUMN 8.

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

306) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 305 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 Rwanda.

For the HIV test, we need a few (more) drops of blood from a finger. Again 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 her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her 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?

307) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

308) 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 Rwanda.

For the HIV test, we need a (few) more drops of blood from a finger. Again 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 whether you have HIV, I can provide you with 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?

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

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

311) RECORD RESULT CODE OF DBS COLLECTION:

312) BAR CODE LABEL:

313) GO BACK TO 303 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 343.

WEIGHT, HEIGHT MEASUREMENT AND HIV TESTING FOR MEN AGE 15-59

CHECK HOUSEHOLD COVER PAGE TO SEE IF SELECTED FOR MALE SURVEY AND HIV TESTING FOR ADULTS.

343) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 344. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

344) LINE NUMBER FROM COLUMN 10:
NAME FROM COLUMN 2:

345) WEIGHT IN KILOGRAMS:

346) HEIGHT IN CENTIMETERS:

347) AGE: CHECK COLUMN 7.

348) MARITAL STATUS: CHECK COLUMN 8.

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

356) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 349 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 Rwanda.
For the HIV test, we need a few (more) drops of blood from a finger. Again 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 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 HIV test?

357) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

358) 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 Rwanda.

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. 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?

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

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

369) BAR CODE LABEL.

370) GO BACK TO 345 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, GO TO 401.

HIV TESTING FOR CHILDREN AGE 0-14

CHECK HOUSEHOLD COVER PAGE TO SEE IF SELECTED FOR HIV TESTING FOR CHILDREN (0-14)

401) CHECK COLUMN 11A IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-14 YEARS IN QUESTION 402. IF MORE THAN NINE CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

402) LINE NUMBER FROM COLUMN 11A:
NAME FROM COLUMN 2:

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

404) CHECK 403: CHILD BORN IN JANUARY 2000 OR LATER?

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

406) READ HIV CONSENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

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

408) RECORD RESULT CODE OF DBS COLLECTION:

409) BAR CODE LABEL

410) GO BACK TO 403 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO THE NEXT HOUSEHOLD.

CONSENT STATEMENT FOR HIV TEST

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 Rwanda.

We ask that all children born in 2000 or later take part in HIV 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. 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 CHILD)'s test results either. If you want to know (NAME OF CHILD)'s 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 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 CHILD/NAMES OF CHILDREN) to participate in the HIV test? [#transcriber note: survey form asks for child(ren) to participate in anemia test, but it is presumed to mean HIV test]