IDENTIFICATION

PLACE NAME _____
NAME OF HEAD OF HOUSEHOLD _____
HOUSEHOLD NUMBER _____
CONCESSION NUMBER _____
CLUSTER NUMBER _____
REGION _____
DEPARTMENT _____
HEALTH DISTRICT _____

URBAN OR RURAL:

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL:

HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE?

INTERVIEWER VISITS

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

RESULT* _____

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR 201____
INT. NUMBER _____
RESULT CODE*_____

TOTAL NO. OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____
KEYED BY______

INTRODUCTION AND CONSENT:
Hello. My name is _______. I am working with the National Institute of Statistics and Demography. We are conducting a survey about health all over Senegal. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take 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 our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

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?

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 THE APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

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

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

TICK HERE IF CONTINUATION SHEET USED _____

Just to make sure that I have a complete listing:

2A) 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?

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

6. RESIDENCE: Did (NAME) stay here last night?

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

MARITAL STATUS. IF AGE 15 OR OLDER:

8. What is (NAME)'s current marital status?

ELIGIBILITY:
9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

ELIGIBILITY:
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 IF THE HOUSEHOLD IS SELECTED FOR THE MEN'S QUESTIONNAIRE.

ELIGIBILITY:
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

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

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 last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:

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?

CURRENT/RECENT SCHOOL ATTENDANCE. IF AGE 5-24 YEARS:

18. Did (NAME) attend school at any time during the (2009-2010) school year?

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

PREVIOUS SCHOOL ATTENDANCE, IF AGE 5-24 YEARS:

19A. During the previous school year 2009-2010, did (NAME) attend school at any time?

19B. During the previous school year, what level and grade was (NAME) attending?

BIRTH REGISTRATION, IF AGE 0-4 YEARS:

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

20D. CHILDCARE FOR CHILDREN AGE 3-5 YEARS: During this school year, did (NAME) go to childcare outside of school like nursery school, a national childcare program [note: the document uses here the official name of the program, "Case des Tout Petits"], a community center, or other?

20E. Where did (NAME) go?
RECORD THE APPROPRIATE CODE.

20F. For how many years?
RECORD THE APPROPRIATE CODE.

WORK FOR CHILDREN AGE 5-17 YEARS:

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

20G. Since (DAY OF THE WEEK), did (NAME) do any work for anyone who is not a member of this household?
IF YES: What is he/she paid?

20H. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she work for someone who is not a member of this household?
IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

20I. Since (DAY OF THE WEEK), did (NAME) do any household chores?
For example: shopping, cooking, cleaning, getting water, taking care of children, washing clothes??

20J. IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?
IF MORE THAN ONE JOB, ADD UP ALL THE HOURS.

20K. Since (DAY OF THE WEEK), did (NAME) do any (other) work for the family (on the farm, in a shop, in a business)?

20L. IF YES: Since (DAY OF THE WEEK), approximately how many hours did he/she spend doing this work?
ADD UP ALL THE HOURS.

HOUSEHOLD CHARACTERISTIC

101A. What is the occupation status of the dwelling for your household?

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

103. Where is the water source located?

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

104A. Who usually goes to the water source to bring water to your household?

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.

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

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

109. How many households use this toilet facility?

110. Does your household have:

Electricity?
A radio?
A television?
A TV5 antenna?
A subscription to Canal?
A non-mobile telephone?
A mobile telephone?
A washing machine?
A refrigerator?
A portable stove/gas or electric stove?
An improved fireplace?
A CD/DVD player?
An air conditioner?
A computer?
Internet at home?

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

111A. What type of lighting does your household mainly use?

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 your household own:

A bicycle?
A motorcycle or motor scooter?
A personal car?
A commercial car or truck?
A cart?
A plow?
A canoe or fishing nets?

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

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

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

122. How many of the following animals does this household own?
IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'.

Milk cows or bulls?
Camels?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Chickens?

123. Does any member of this household have an account in a bank or in another financial institution (savings and credit union, savings bank)?

123A. Does any member of your household participate in a tontine?

123B. Does anyone smoke in your household?
Would you say daily, weekly, monthly, less than monthly, or never?

123C. In the last 6 months, have you heard any messages about malaria prevention?

123D. What was in these messages?

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

125. Who sprayed the dwelling?

125A. Are the windows of your living space equipped with wire netting to keep mosquitoes from entering?

125B. Are the doors of your living space equipped with wire netting or curtains to keep mosquitoes from entering?

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

127. How many mosquito nets does your household have?
IF 25 OR MORE NETS, RECORD '25'.

127A. Do you use the mosquito nets outside of the bedrooms: for example, in the yard, under trees?

127B. Do members of your household always sleep under mosquito nets year round?

127C. Why don't members of your household always sleep under mosquito nets year round?

127D. Why do you not have any mosquito nets in your household?

[ASK QUESTIONS 128-136 FOR ALL MOSQUITO NETS]

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

128A. OBSERVE OR ASK THE SHAPE OF THE MOSQUITO NET.

128B. OBSERVE OR ASK THE SIZE OF THE MOSQUITO NET.

129. How many months ago did your household get the mosquito net?

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

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

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

133. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'. IF MORE THAN 2 YEARS, RECORD THE NUMBER OF MONTHS.

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

135. Who slept under the mosquito net last night?
RECORD THE PERSONS' LINE NUMBER FROM THE HOUSEHOLD SCHEDULE. RECORD ALL PERSONS WHO SLEPT UNDER EACH MOSQUITO NET LAST NIGHT.

136A. In the last 12 months, for how many months did a member of your household sleep under this mosquito net?

136B. Was this mosquito net made in a factory or was it made by a tailor?

136C. CHECK 134:

136D. Why didn't anyone sleep under this mosquito net last night?
IF SEVERAL REASONS ARE MENTIONED, ASK AND RECORD THE MAIN REASON.

136E. Where did you get this mosquito net?

136F. How was this mosquito net acquired?

136G. How much money did you pay to get this mosquito net?
RECORD IN CFA FRANCS.

136H. CHECK 130 AND 132:
MIILDA OR OTHER TYPE OF MOSQUITO NET [NOTE: ACRONYM STANDS FOR A LONG-LASTING MOSQUITO NET WITH INSECTICIDE]
[Note: The original text had the two words as I transcribed them, MIILDA and MILDA, in their respective places. These questions were not on the standard questionnaire. Internet searches show that both terms are related to malaria prevention in French-speaking countries.]

136I-a. Was this mosquito net washed since you acquired it?

136I-b. Was this mosquito net washed since it was last soaked?

136J. How many times was this mosquito net washed in the last 12 months?

136K. How many months ago was this mosquito net last washed?
IF 12 MONTHS OR MORE, RECORD '12'.

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 PLACE FOR HAND WASHING.

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 AND RECORD IN PPM (PARTS PER MILLION).

140A. In the last three years, has your household been subjected to any traumatic event or shock?

140B. What was the main traumatic event or shock in this household?

WEIGHT, HEIGHT, HEMOGLOBIN, AND PARASITEMIA/ANEMIA TESTS FOR CHILDREN AGE 0-5

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 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202. LINE NUMBER FROM COLUMN 10 AND 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 2005 OR LATER?

205. WEIGHT IN KILOGRAMS:

206. HEIGHT IN CENTIMETERS:

207. MEASURE LYING DOWN OR STANDING UP?

208. CHECK 203:
IS THE 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. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2005 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.

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

211. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

211A. ASK CONSENT FOR PARASITEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD:

As part of this survey, we are asking children under 6 years old all over the country to take a test to see if they have malaria. Malaria is a serious health problem that is caused by a parasite transmitted from mosquito bites. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2005 or later take part in malaria testing in this survey and give a few drops of blood from a finger (or a heel if the child is less than 6 months old). 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. A portion of the blood drops will be transported to the Laboratory for confirmation. The result will be kept strictly 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 OF CHILD) to participate in the malaria test?

211B. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

[PERFORM EACH TEST FOR EACH CHILD FOR WHOM YOU OBTAINED CONSENT IN 211 AND 211B]

212. RECORD THE HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET:

212A. RECORD IF THE CHILD WAS TESTED FOR PARASITEMIA PALUDAL:

212B. RECORD THE RESULT CODE OF THE MALARIA TEST:

212C. READ THE INFORMATION FOR MALARIA TREATMENT AND THE CONSENT OF THE PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD:

212D. ATTACH 1ST BAR CODE HERE.
ATTACH A BAR CODE ON EACH OF THE 2 STRIPES.
ATTACH ONE ON THE PARASITEMIA PALUDAL TEST (TDR).
ATTACH THE 5TH ON THE SAMPLE TRANSMISSION FORM.

213. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

TREATMENT OF CHILDREN WITH A POSITIVE PARASITEMIA PALUDAL TEST:

IF THE PARASITEMIA PALUDAL TEST IS POSITIVE: The diagnostic test for malaria shows that your child has malaria. We can offer you free medicine. This medicine is called ACT. ACT is very effective and should eliminate the fever and other symptoms in a few days. ACT is also very safe.

However, with all medications, there are side effects, and this medication might have some. The most common side effects are dizziness, fatigue, loss of appetite, palpitations. ACT should not be taken by people who have a serious heart problem or severe malaria (for example, cerebral malaria) or who have problem regulating body salt levels.

ASK IF THE MOTHER IS AWARE OF THE CHILD HAVING ANY OF THESE PROBLEMS. IF YES, DO NOT OFFER THEM ACT. EXPLAIN THE RISKS OF MALARIA AND REFER THE CHILD TO THE CLOSEST HEALTH ESTABLISHMENT.

You don't have to give the medicine to your child. It is your choice. Please tell me if you will take the medicine or not?

TREATMENT WITH ACT (FALCIMON):

WEIGHT (IN KG) -- APPROXIMATE AGE:

YOU ALSO MUST TELL THE PARENT/ADULT RESPONSIBLE FOR CHILD: If (NAME OF CHILD) has any of the following symptoms, you must immediately take him/her to a health care professional to receive care:

High fever
Convulsions, coma
Rapid breathing or difficulty breathing
Not able to drink or nurse
Gets sicker or doesn't improve in 2 days

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TEST FOR WOMEN AGE 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 RESPONSIBLE ADULT FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

221. ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE 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 member of our survey team.

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

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 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:

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

226. AGE:
CHECK COLUMN 7.

227. MARITAL STATUS:
CHECK COLUMN 8.

228. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN 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 Senegal

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know 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?

229. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

230. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (country).

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know her HIV status, I can provide a list of (nearby) facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (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?

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

232. AGE:
CHECK COLUMN 7.

233. MARITAL STATUS:
CHECK COLUMN 8.

234. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

235. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

236. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

237. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

238. ADDITIONAL TESTS:
CHECK 235 AND 237: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

240. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

241. BAR CODE LABEL.
PUT THE 1ST BAR CODE HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

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

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

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

244. LINE NUMBER FROM COLUMN 10.
NAME FROM COLUMN 2.

245. WEIGHT IN KILOGRAMS:

246. HEIGHT IN CENTIMETERS:

247. AGE:
CHECK COLUMN 7.

248. MARITAL STATUS:
CHECK COLUMN 8.

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

250. ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than 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 participate in the anemia test?

251. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

252. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT:

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than 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 in the anemia test?

253. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

254. AGE:
CHECK COLUMN 7.

255. MARITAL STATUS:
CHECK COLUMN 8.

256. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Senegal.

For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give him a voucher for free services that can be used at any of these facilities.

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

257. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

258. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in (NAME OF COUNTRY).

For the HIV test, we need a few more drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know your HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

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

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

260. AGE:
CHECK COLUMN 247.

261. MARITAL STATUS:
CHECK COLUMN 248.

262. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

263. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

264. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:

We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional test might be done.

The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

265. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME:

266. ADDITIONAL TESTS: CHECK 263 AND 265:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

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

268. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET:

269. BAR CODE LABEL:
PUT THE 1ST BAR CODE HERE. PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

270. GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.