Republic of Senegal
Ministry of the Economy, Finance, and Planning
Ministry of Health and Social Action

ICF International

IDENTIFICATION

PLACE NAME ______

NAME AND NUMBER OF HEAD OF HOUSEHOLD _____

PLOT NUMBER ______

CLUSTER NUMBER ____

REGION ____

DEPARTMENT ____

HEALTH DISTRICT____

URBAN/RURAL

DAKAR/REGIONAL CAPITAL/OTHER CITY/RURAL

Household selected for men's survey?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER'S NAME ______

FINAL VISIT:
DAY ____
MONTH ___
YEAR ____

NEXT VISIT:
DATE _____
TIME ____

TOTAL NUMBER OF VISITS _____

TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW*

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

LANGUAGE CODES:

SUPERVISOR:
NAME ______
NUMBER_____
DATE _____

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

101) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

102) CHECK LINE NUMBER FROM COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE.

103) IF MOTHER WAS INTERVIEWED, COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER WAS NOT INTERVIEWED, ASK: What is (name)'s date of birth?

104) CHECK 103:
CHILD BORN 2012-2017?

105) Weight in kilograms

106) Height in centimeters
IF UNDER 2 YEARS OLD, MEASURE THE CHILD LYING DOWN, OTHERWISE, STANDING UP

107) Measured lying down or standing up?

108) MEASURER: ENTER YOUR INTERVIEWER NUMBER

101) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

102) CHECK LINE NUMBER FROM COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE

109) CHECK 103: If child age 0-5 months, i.e. was child born in month of interview or five previous months?

110) Line number from parent/other adult responsible for the child
RECORD '00' IF NOT LISTED.

111) Ask consent for anemia test from parent/other adult

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 and set up programs to prevent and treat anemia. We ask that all children born in 2012 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

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

Will you allow (name of child) to participate in the anemia test?

112) Circle the appropriate code and sign your name.

112a) Ask for consent for the malaria test from the parent/other adult identified in 209 as responsible for child.

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

We ask that all children born in 2012 or later take part in malaria 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. (We will use the blood from the anemia test).

The blood will be tested for malaria immediately, and the result will be told to you right away. A few drops will be preserved on a slide or two and sent to a lab to be tested. You will not receive the results of the lab test. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

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

Will you allow (name of child) to participate in the malaria test?

112b) Circle the appropriate code and sign your name.

112c) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

112d) Bar code label for malaria test

113) Record hemoglobin level here and in anemia pamphlet.

113a) Record TDR malaria result code

113b) Record TDR malaria result code here and in anemia and malaria pamphlet.

113c) CHECK 216:

113d) Reference declaration for severe anemia

The anemia diagnostic test show that (name of child) has severe anemia. You child is seriously ill and must be taken to a health care establishment immediately (GO TO 114)

113e) Did (name) suffer from any of the following illness or present one or more of the following symptoms?

113f) CHECK 221:
Is a code A-H circled?

113g) CHECK 216: HEMOGLOBIN LEVEL

113h) Reference declaration for serious malaria

The diagnostic test for malaria shows that (name of child) has malaria. You child has the symptoms of serious malaria. The antimalarial drugs that I have will not help your child, and I cannot give him/her treatment. You child is seriously ill and must be taken to a health care establishment immediately (GO TO 113N)

113i) In the last two weeks, has (name) taken or is (name) taking CTA given to him/her by a doctor or health care establishment to treat malaria?
CHECK BY ASKING TO SEE TREATMENT

113j) Reference declaration for children already taking CTA drug.

You told me that (name of child) already received CTA for malaria. I cannot give you extra CTA. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of CTA, you must bring the child to the closest health care establishment for further testing (GO TO 113N)

113k) Read information for malaria treatment and the declaration of consent to the parents or other adult responsible for the child.
The malaria test shows that your child has malaria. We can give you free drugs. The drug is called CTA. CTA is very effective and in a few days, he/she will not have a fever or any other symptoms. You are not obligated to give the drug to the child. It is up to you to decide. Please tell me, do you accept the drug or not?

113l) CIRCLE THE APPROPRIATE CODE AND SIGN

113m) Treatment for children with positive malaria test

CHILD LESS THAN ONE YEAR OLD OR LESS THAN 8 KGS.

25 mg tablet of Artesunate and 67.5 mg of Amodiaquine (Rose striped brochure)

CHILD AGE 1-5 YEARS OR 8-17 KGS.

50 mg tablet of Artesunate and 135 mg of Amodiaquine

Tell the parents/adult responsible for child: If (name) has a high fever, difficulty or rapid breathing, if he/she cannot drink or breastfeed, if his/her condition worsens or if he/she doesn't get better in two days, you must take him/her to a health professional for treatment immediately.

113n) Record the result code of the malaria treatment or of the reference sheet

114) GO BACK TO QUESTION 103 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN ON THE NEXT PAGE; IF THERE ARE NO MORE CHILDREN, GO TO 201.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR WOMEN AGE 15-49

201) CHECK COLUMN 9 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AND MARITAL STATUS FOR ALL WOMEN ELIGIBLE FOR QUESTIONS 202, 203, AND 204. IF MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

202) CHECK HOUSEHOLD QUESTIONNAIRE:

203) CHECK HOUSEHOLD QUESTIONNAIRE:

204) CHECK HOUSEHOLD QUESTIONNAIRE:

210) Ask for consent 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.

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?

211) CIRCLE THE CODE AND SIGN YOUR NAME.

211a) CHECK 226 IN WOMEN'S QUESTIONNAIRE OR ASK: Are you pregnant?

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

212) 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. The HIV testing is being done to see how many people have HIV.

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 if you have HIV, 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 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 give blood for the HIV testing?

213) Circle the code, sign your name, and enter your interviewer number.

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

214) Ask consent for additional testing.

We ask you to allow the laboratory to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

215) CIRCLE AND SIGN YOUR NAME.

216) Record the line number of the parent/other adult responsible for the adolescent.
Line number of the parent/other adult responsible for the adolescent.
(RECORD '00' IF NOT LISTED)

217) Ask for consent for anemia test from parent/other adult.

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 minor) 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 minor) to take the anemia test?

218) CIRCLE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

219) Ask for 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 and (name of parent/responsible adult) 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?

220) CIRCLE AND SIGN YOUR NAME.

220a) CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: are you pregnant?

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

221) Ask for consent for DBS collection from parent/adult

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. The HIV testing is being done to see how many people have HIV.

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 the results of (name of minor)'s test either. If (name of minor) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services 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 minor) to take the HIV test?

222) CIRCLE THE APPROPRIATE CODE, SIGN, AND RECORD YOUR INTERVIEWER NUMBER

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

223) Ask consent for DBS collection from minor 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. The HIV testing is being done to see how many people have HIV.

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 the results of your test either. If you want to know if you have HIV, 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 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 give blood for the HIV testing?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL; TESTING

225) Ask for consent for additional testing from parent/adult

We ask you to allow the laboratory to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could identify (name of minor). You do not have to agree. If you do not want the blood sample stored for additional testing, (name of minor) can still participate in the HIV testing in this survey.

Will you allow us to keep the blood sample for additional testing?

226) CIRCLE THE CODE AND SIGN YOUR NAME

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

227) Ask consent for additional testing from minor respondent.
We ask you to allow the laboratory to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

228) CIRCLE THE CODE AND SIGN YOUR NAME.

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

230) ADDITIONAL TESTS

IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 226 and 228: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

231) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

232) Place bar code stickers here

233) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 301.

HEMOGLOBIN AND HIV TEST FOR MEN AGE 15-59

301) CHECK COLUMN 10 OF THE HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AND MARITAL STATUS FOR ALL MEN ELIGIBLE FOR QUESTIONS 302, 303, AND 304. IF MORE THAN 3 MEN, USE ADDITIONAL QUESTIONNAIRE(S).

302) CHECK HOUSEHOLD QUESTIONNAIRE:

303) CHECK HOUSEHOLD QUESTIONNAIRE:

304) CHECK HOUSEHOLD SCHEDULE:

ADULT RESPONDENT CONSENT FOR ANEMIA TEST

310) Ask for consent 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.

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?

311) CIRCLE THE CODE AND SIGN YOUR NAME.

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

312) 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. The HIV testing is being done to see how many people have HIV.

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 if you have HIV, 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 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 give blood for the HIV testing?

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

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

314) Ask consent for additional testing.
We ask you to allow the laboratory to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

315) CIRCLE AND SIGN YOUR NAME.

316) Record the line number of the parent/other adult responsible for the adolescent.
Line number of the parent/other adult responsible for the adolescent.
(RECORD '00' IF NOT LISTED)

317) Ask consent for anemia test from parent/adult

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 and set up programs to prevent and treat anemia.

For the anemia testing, we will need 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 and (name of minor) right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.

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

Will you allow (name of minor) to participate in the anemia test?

318) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

319) Ask for 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 and (name of parent/responsible adult) 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?

320) CIRCLE THE CODE AND SIGN YOUR NAME.

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

321) Ask for consent for DBS collection from parent/adult

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. The HIV test is being done in this survey to understand how many people have contracted the virus.

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 the results of (name of minor)'s test either. If (name of minor)' want sot know his 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 minor) to take the HIV test?

322) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER THE INTERVIEWER NUMBER

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

323) Ask consent for DBS collection from minor 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. The HIV test is being done in this survey to understand how many people have contracted the virus.

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 the results of your test either. If you want to know if you have HIV, 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 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 give blood for the HIV testing?

324) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

325) Ask for consent for additional testing from parent/adult

We ask you to allow the laboratory to store part of the blood sample at the laboratory for additional testing or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could identify (name of minor). You do not have to agree. If you do not want the blood sample stored for additional testing, (name of minor) can still participate in the HIV testing in this survey.

Will you allow us to keep the blood sample for additional testing?

326) CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

327) Ask consent for additional testing from minor respondent.
We ask you to allow the laboratory to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.

The blood sample will not have any name or other data attached that could easily 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 for additional testing?

328) CIRCLE THE CODE AND SIGN YOUR NAME.

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

330) ADDITIONAL TESTS

IF ADULT RESPONDENT, CHECK 315; IF MINOR RESPONDENT, CHECK 315; IF MINOR RESPONDENT, CHECK 326 AND 328: IF CONSENT HAS BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

331) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

332) PLACE BAR CODE STICKERS HERE

333) GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, END INTERVIEW.

INTERVIEWER OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING BIOMARKERS.

SUPERVISOR'S OBSERVATIONS

EDITOR'S OBSERVATIONS