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RWANDA DEMOGRAPHIC AND HEALTH SURVEYS 2014-15
HOUSEHOLD QUESTIONNAIRE

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:

YES 1
NO 2

HOUSEHOLD SELECTED FOR MALE SURVEY AND HIV TESTING FOR ADULTS:

YES 1
NO 2

HOUSEHOLD SELECTED FOR HIV TESTING FOR CHILDREN:

YES 1
NO 2

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE FOR WOMEN:

YES 1
NO 2

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE FOR MEN:

YES 1
NO 2

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____

*RESULT CODES

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

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: _______________

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

HOUSEHOLD SCHEDULE

1) LINE NUMBER:

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.

NAME ____

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?

YES (ADD TO TABLE)
NO

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

YES (ADD TO TABLE)
NO

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

YES (ADD TO TABLE)
NO

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

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

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

MALE 1
FEMALE 2

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

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

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

AGE IN YEARS___

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

MARRIED 1
LIVING TOGETHER 2
DIVORCED 3
SEPARATED 4
WIDOWED 5
NEVER-MARRIED AND NEVER LIVED TOGETHER 6

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?

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

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'.

LINE NUMBER___

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

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

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'.

LINE NUMBER___

IF AGE 3 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20)

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 ____

1 PRIMARY
2 POST-PRIMARY/VOCATIONAL
3 SECONDARY
4 TERTIARY
6 PRE-PRIMARY
8 DON'T KNOW

GRADE ____

00 LESS THAN 1 YEAR COMPLETED (USE '00' FOR Q. 17 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 19)
98 DON'T KNOW

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?

YES 1
NO 2 (GO TO 20)

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

LEVEL ____

1 PRIMARY
2 POST-PRIMARY/VOCATIONAL
3 SECONDARY
4 TERTIARY
6 PRE-PRIMARY
8 DON'T KNOW

GRADE ____

98 DON'T KNOW

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?

HAS CERTIFICATE 1
REGISTERED 2
NEITHER 3
DON'T KNOW 8

INSURANCE:

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

YES 1
NO 2 (GO TO 23)
DON'T KNOW 8 (GO TO 23)

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

1 MUTUELLE / COMMUNITY HEALTH
2 RAMA
3 MMI
4 PRIVATE/COMMERCIAL
5 OTHER
8 DON'T KNOW

IF AGE 7 OR MORE YEARS:

23) Does (NAME) currently smoke?

YES 1
NO 2
DON'T KNOW 8

HOUSEHOLD CHARACTERISTICS

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

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAPS/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) __________ 96

103) Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES________
DON'T KNOW 998

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

LESS THAN 200M 1
200M - 500M 2
MORE THAN 500M 3
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 106A)
DON'T KNOW 8 (GO TO 106A)

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

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

106A) Is the water this household uses for drinking stored?

YES 1
NO 2 (GO TO 107)
DON'T KNOW 8 (GO TO 107)

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

JERRY CAN 1
POT 2
BOTTLE 3
COOKING POT 4
OTHER (SPECIFY) __________ 6
NOT AVAILABLE TO BE OBSERVED 8

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

NO. OF TIMES PER WEEK IF LESS THAN 7_____
7 OR MORE TIMES PER WEEK 7
DON'T KNOW 8

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER (SPECIFY) __________ 96

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

YES 1
NO 2 (GO TO 109A)

109) How many households (including this household) use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10______
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

109A) CLEANLINESS OF THE TOILET FACILITY
RECORD OBSERVATION.

TOILET'S PLATE FORM IS DRY AND CLEAN A
TOILET'S PLATE FORM IS WITH URINE OR EXCRETA B
TOILET'S PLATE FORM IS WITH FLIES C

110) Does your household have:

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

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
COMPUTER
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) __________ 96

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

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFY) _________ 6 (GO TO 114)

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

YES 1
NO 2

114) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

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

115) MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF/LEAF 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT/PLASTIC 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
METAL/IRON SHEET 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY) __________ 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) __________ 96

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

ROOMS______

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?

WATCH
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BOAT WITHOUT MOTOR
YES 1
NO 2
BOAT WITH MOTOR
YES 1
NO 2

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

YES 1
NO 2 (GO TO 121)

120) How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '95.0'

HECTARES______
95 OR MORE HECTARES 95.0
DON'T KNOW 99.8

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

YES 1
NO 2 (GO TO 123)

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?

COWS____
MILK COWS____
BULLS____
GOATS____
SHEEP____
CHICKENS____
PIGS____
RABBITS____
HORSES/DONKEYS/MULES____

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

YES 1
NO 2

123A) CHECK 21:

AT LEAST ONE "NO" (GO TO 123E)
ALL "YES" (GO TO 126)

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 137)

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

NUMBER OF NETS______

128) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.

NET OBSERVED 1
NET NOT OBSERVED 2

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

MONTHS AGO____
MORE THAN 36 MONTHS AGO 95
NOT SURE 98

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.

TUZANET: LONG-LASTING INSECTICIDE-TREATED NET (LLIN)

PERMENET/OLYSET/NET PROTECT 11 (GO TO 133A)
OTHER LLIN DON'T KNOW BRAND 16 (GO TO 133A)

'PRETREATED' NET BUT NOT PERMANENT 22 (GO TO 132)

OTHER 96
DON'T KNOW BRAND 98

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

YES 1
NO 2
NOT SURE 8

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

YES 1
NO 2 (GO TO 133A)
NOT SURE 8 (GO TO 133A)

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

MONTHS AGO____
MORE THAN 24 MONTHS AGO 95
NOT SURE 98

133A) How did you obtain the net?

DURING IMMUNIZATION OF CHILDREN 11
DURING IMMUNIZATION CAMPAIGN 12
DURING ANC VISIT 13
FROM A COMMUNITY HEALTH WORKER 14
FROM PHARMACY 15
FROM SHOP 16
HOUSEHOLD HEALTH PROGRAM 17
OTHER (SPECIFY) _________ 96

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

YES 1
NO 2

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

CONICAL 1
RECTANGLE 2

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

YES 1
NO 2 (GO TO 136)
NOT SURE (GO TO 136)

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

NAME______________
LINE NO.______

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.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

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

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

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

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

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) _______________ 6

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.

HOUSEHOLD LINE NUMBER OF MAN SELECTED FOR DOMESTIC VIOLENCE MODULE ________

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.

HOUSEHOLD LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE____ ____

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:

LINE NUMBER______
NAME__________

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?

DAY____
MONTH____
YEAR________

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

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)

205) WEIGHT IN KILOGRAMS:

KG.____.____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS:

CM.____.___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

207A) EDEMA OF BOTH FEET:

YES 1
NO 2

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

0-5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)
OLDER 2

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

LINE NUMBER______

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

GRANTED (SIGN) __________ 1
REFUSED (SIGN) __________ 2

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

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

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

GRANTED (SIGN) __________ 1
REFUSED (SIGN) __________ 2

212A) RECORD RESULT CODE OF MALARIA TEST

TESTED 1
NOT PRESENT 2 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)
REFUSED 3 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)
OTHER 6 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)

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

PUT THE 1ST BAR CODE HERE.

212C) RESULT OF MALARIA TEST:

POSITIVE 1
NEGATIVE 2 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)
OTHER 6 (GO TO 203 FOR NEXT CHILD OR IF NO MORE CHILDREN, GO TO 214)

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.

ACCEPTED MEDICINE (SIGN) __________ 1
REFUSED 2
ALREADY HAS ACT 3
NOT ELIGIBLE 4
OTHER 6

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:

LINE NUMBER______
NAME_______________

216) WEIGHT IN KILOGRAMS:

KG.______.____
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217) HEIGHT IN CENTIMETERS:

CM.______.____
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

218) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 223)

219) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 223)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT______

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.

GRANTED 1 (SIGN) __________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 224D)

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.

GRANTED 1 (SIGN) _______________
RESPONDENT REFUSED 2 (SIGN) _______________

224A) AGE: CHECK 218.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 224F)

224B) MARITAL STATUS: CHECK 219.

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 224F)

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

LINE NUMBER______
NAME______________

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) _________ (GO TO 226)

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.

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

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

YES 1
NO 2
DON'T KNOW 8

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.

G/DL______.____
NOT PRESENT 994
REFUSED 995
OTHER 996

228) RECORD RESULT CODE OF MALARIA RAPID TEST:

TESTED 1
NOT PRESENT 2 (GO TO 231)
REFUSED 3 (GO TO 231)
OTHER 6 (GO TO 231)

229) RESULT OF MALARIA RAPID TEST:

POSITIVE 1
NEGATIVE 2
OTHER 6

230) RECORD RESULT CODE OF BLOOD SLIDE COLLECTION:

COLLECTED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

231) BAR CODE LABEL:

PUT THE 1ST BAR CODE LABEL HERE.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE ON THE BLOOD SLIDE FOR MALARIA TEST AND THE 3RD ON THE TRANSMITTAL FORM.

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:

LINE NUMBER______
NAME_______________

303) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 308)

304) MARITAL STATUS: CHECK COLUMN 8.

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 308)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT______

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.

GRANTED 1 (SIGN) __________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) __________ (GO TO 310)

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.

GRANTED 1 (SIGN) _______________
RESPONDENT REFUSED 2 (SIGN) ____________ (GO TO 310)
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:

COLLECTED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

312) BAR CODE LABEL:

PUT THE 1ST BAR CODE LABEL HERE.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

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:

LINE NUMBER______
NAME______________

345) WEIGHT IN KILOGRAMS:

KG.______.____
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

346) HEIGHT IN CENTIMETERS:

CM._____.__
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

347) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 358)

348) MARITAL STATUS: CHECK COLUMN 8.

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 358)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT______

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.

GRANTED 1 (SIGN) ___________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ___________ (GO TO 367)

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.

GRANTED 1 (SIGN) ___________
RESPONDENT REFUSED 2 (SIGN) ____________ (GO TO 367)
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.

PUT THE 1ST BAR CODE LABEL HERE.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

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:

LINE NUMBER______
NAME_______________

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?

DAY____
MONTH____
YEAR______

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

YES 1
NO 2 (GO TO 403 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO THE NEXT HOUSEHOLD)

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

LINE NUMBER______

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

GRANTED 1 (SIGN) _______________
REFUSED 2 (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:

COLLECTED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

409) BAR CODE LABEL

PUT THE 1ST BAR CODE HERE
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

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]