Ministry of Planning, of Development and of Territory Organization (MPDAT)
General Office of Statistics and of National Accounting (DGSCN)

IDENTIFICATION

NAME OF PREFECTURE __________

NAME OF LOCATION __________

NAME OF HEAD OF HOUSEHOLD __________

CLUSTER NUMBER ______

HOUSEHOLD NUMBER ______

REGION ____

URBAN/RURAL

HOUSEHOLD SELECTED FOR MEN'S QUESTIONNAIRE, ANTHROPOMETRIC MEASUREMENTS, ANEMIA, MALARIA AND HIV TEST

INTERVIEWER VISITS

DATE __________

INTERVIEWER'S NAME __________

RESULT

NEXT VISIT:

FINAL VISIT:

TOTAL NUMBER OF VISITS_________

TOTAL PERSONS IN HOUSEHOLD ____

TOTAL ELIGIBLE WOMEN ____

TOTAL ELIGIBLE MEN ____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

SUPERVISOR

FIELD EDITOR

OFFICE EDITOR ____

KEYED BY ____

INTRODUCTION AND CONSENT

Hello. My name is __________. I am working for the General Office of Statistics and of National Accounting. We are conducting a survey about health. This study is lead for the MPDAT, to better understand the health of the Togolese population. The information we collect will help the government improve health services on a national level and we hope on a local level, which will benefit your community. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 30 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team, who are not allowed to divulge any of the information gathered during these interviews. There is no risk to taking this survey. You don't have to be in the survey, and there is no penalty if you refuse. However, we hope you will agree to participate since your participation is very importance for the success of the study.

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 General Office of Statistics and of National Accounting with the following number: 90-27-12-46.

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

SIGNATURE OF INTERVIEWER __________
DATE __________

RECORD THE TIME

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.

2A) Just to make sure that I have a complete listing: Are there any other persons such as small children or infants that we have not listed?

2B) In addition, are there any other people who many 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?

THEN ASK 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?

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

IF LESS THAN ONE YEAR, RECORD 00.
IF 95 OR MORE, RECORD 95.

IF AGE 12 OR OLDER:

8) MARITAL STATUS: What is (NAME)'s current marital status?

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY

11) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY

TICK HERE IF CONTINUATION SHEET USED __

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

12) Is (NAME)'s natural mother alive?

13) Does (NAME)'s natural mother usually live in this household or was she a guest last night?

IF YES: What is her name?

RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD 00.

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

15) Does (NAME)'s natural father usually live in this household or was he a guest last night?

IF YES: What is his name?

RECORD FATHER'S LINE NUMBER.
IF NO, RECORD 00.

IF AGE 3 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

17) What is the highest level of school (NAME) has attended?

What is the highest grade (NAME) completed at that level?

IF AGE 3-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the current (2013-2014) school year?

19) During this/that school year (2013-2014), what level and grade (is/was) (NAME) attending?

HOUSEHOLD CHARACTERISTICS

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

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

103) Where is the water source located?

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

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

106) What do you usually do to make the water safer to drink?
Anything else?

RECORD ALL MENTIONED

106A) How do you usually store drinking water in your household?

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:

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

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

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

114) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION

115) MAIN MATERIAL OF 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:

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, RECORD '00'.
IF 95 OR MORE, RECORD '95'.
IF UNKNOWN, RECORD '98'.

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

123a) Does any member of this household have a tontine?

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

127) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD 7.

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

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

IF LESS THAN ONE MONTH AGO, RECORD 00

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

IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT

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

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

133) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD 00.

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

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 HANDWASHING.

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

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

SELECTION TABLE FOR CHILDREN'S WORK AND FOR DISCIPLINE OF CHILD

141) CHECK COLUMN (5) AND (7): NUMBER OF CHILDREN BETWEEN 1 AND 17 YEARS OLD LIVING IN THIS HOUSEHOLD:

TABLE 1: ELIGIBLE CHILDREN AGE 1-17

RECORD EACH CHILD AGE 1-17 FROM THE HOUSEHOLD TABLE IN THE TABLE BELOW, ORDERED BASED ON THEIR LINE NUMBER (Q 1) FROM THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS WHO ARE NOT AGE 1-17. RECORD THE LINE NUMBER, NAME, SEX AND AGE OF EACH CHILD, THEN RECORD THE TOTAL NUMBER OF CHILDREN AGE 1-17 IN THE RESERVED SPACE.

142) RANK NUMBER

143) LINE NUMBER FROM Q. 1

144) NAME FROM Q. 2

145) SEX FROM Q. 4

146) AGE FROM Q. 7

147) TOTAL NUMBER OF CHILDREN AGE 1-17

TABLE 2: RANDOM SELECTION

USE THIS TABLE TO SELECT ONE CHILDREN AGE 1-17, IF THERE IS MORE THAN ONE IN THE HOUSEHOLD.

A) CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER FROM THE COVER PAGE.
B) THIS IS THE LINE NUMBER THAT YOU MUST GO TO IN THE TABLE BELOW.
C) CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN IN Q.147.
D) THIS IS THE COLUMN NUMBER YOU SHOULD USE.
E) FIND THE SPACE WHERE THE LINE AND COLUMN MEET AND CIRCLE THAT NUMBER.
F) THIS IS THE RANK NUMBER OF THE CHILD WHO WILL BE SELECTED (1ST, 2ND, 3RD, ETC).

EXAMPLE:
THE HOUSEHOLD NUMBER IS 6, SO PICK LINE 6.
THERE ARE 3 ELIGIBLE CHILDREN IN THIS HOUSEHOLD, SELECT COLUMN 3.
THE SPACE AT THE INTERSECTION OF LINE 6 AND COLUMN 3 CONTAINS THE NUMBER 2: THE 2ND ELIGIBLE CHILD LISTED IN THE HOUSEHOLD SCHEDULE WILL BE SELECTED. IF THE LINE NUMBER OF 3 ELIGIBLE CHILDREN IS 07, 11, AND 16, THE CHILD SELECTED IS THE 2ND CHILD LISTED, MEANING THE ONE WITH LINE NUMBER 11.

148) LAST DIGIT IN HOUSEHOLD NUMBER

TOTAL NUMBER OF ELIGIBLE CHILDREN IN HOUSEHOLD

149) RECORD THE RANK NUMBER (Q. 142), LINE NUMBER (Q. 143), NAME (Q. 144) AND AGE (Q. 146) OF THE CHILD SELECTED.

IF ONLY ONE CHILD, RECORD 0 FOR THE RANK NUMBER

CHILD LABOR

150) CHECK 149:

151) Now I would like to ask you some questions on the type of work that children in your household can do.

Since last (DAY OF WEEK OF INTERVIEW), did (NAME) do any of the following activities, even if only for one hour?

IF NO, PROBE:
Please include any type of activity that (NAME) might have done like regular or temporary employment, for his own business or for an employer, or as an unpaid family worker in the household or in a family business.

152) CHECK 151 A-D:

153) Since last (DAY OF WEEK OF INTERVIEW), approximately how many hours total did (NAME) work on this activity/these activities?

154) Does this activity/do these activities require carrying heavy loads?

155) Does this activity/do these activities require working with dangerous tools (knives, etc) or big machines?

156) In this work, is (NAME) exposed to dust/smoke or gas?

157) In this work, is (NAME) exposed to cold, heat, or excessive humidity?

158) In this work, is (NAME) exposed to loud noises or vibrations?

159) In this work, is (NAME) exposed to working at high heights?

160) In this work, is (NAME) exposed to chemical products (pesticides, glues, etc.) or to explosives?

161) In this work, is (NAME) exposed to other things, behaviors, or conditions that are bad for his/her health or safety?

162) Since last (DAY OF WEEK OF INTERVIEW), did (NAME) fetch water or firewood for the household?

163) In total, since last (DAY OF WEEK OF INTERVIEW), how many hours did (NAME) spend fetching water or firewood for the household?

164) Since last (DAY OF WEEK OF INTERVIEW), did (NAME) do any of the following tasks for the household?

165) CHECK 164 A-G:

166) Since last (DAY OF WEEK OF INTERVIEW), about how many hours in total did (NAME) spend doing these activities?

CHILD DISCIPLINE

167) CHECK 149:

168) RECORD THE NAME OF CHILD SELECTED AND HIS/HER LINE NUMBER (Q. 149)

Adults use certain methods to teach child how to behave well or correctly. I will read you a list of methods that are used and I'd like you to tell me if you or someone else in your household has used one of these methods with (NAME OF CHILD FROM Q. 168) in the last month.

169) In the last month, did you or someone in your household revoke privileges, not allow (NAME OF CHILD FROM Q. 168) to do something that he/she likes or now allow him/her to leave the house

170) In the last month, did you or someone in your household explain to (NAME OF CHILD FROM Q. 168) why his/her behavior is not acceptable

171) In the last month, did you or someone in your household shake (NAME OF CHILD FROM Q. 168)?

172) In the last month, did you or someone in your household yell or scream at (NAME OF CHILD FROM Q. 168)?

173) In the last month, did you or someone in your household give (NAME OF CHILD FROM Q. 168) something else to do?

174) In the last month, did you or someone in your household hit or spank (NAME OF CHILD FROM Q. 168) on his/her buttocks with hands?

175) In the last month, did you or someone in your household hit (NAME OF CHILD FROM Q. 168) on his/her buttocks or elsewhere on his/her body with someone like a belt, a whip, a stick, or another hard object?

176) In the last month, did you or someone in your household call (NAME OF CHILD FROM Q. 168) an idiot, lazy, ugly or a similar word?

177) In the last month, did you or someone in your household slap or hit (NAME OF CHILD FROM Q. 168) on the face, head, or ears?

178) In the last month, did you or someone in your household slap or hit (NAME OF CHILD FROM Q. 168) on the hands, arms or legs?

179) In the last month, did you or someone in your household beat (NAME OF CHILD FROM Q. 168), that is, hitting as hard as possible without stopping?

180) Do you think that to properly raise and educate (NAME), you must punish him/her physically?

190) Selection table for women for domestic violence module

ONE WOMAN PER HOUSEHOLD WILL BE SURVEYED FOR THIS SECTION: THE FOLLOWING TABLE ALLOWS YOU TO RANDOMLY SELECT THIS WOMAN FROM THE HOUSEHOLD.

1- IF THERE IS ONLY ONE ELIGIBLE WOMAN IN THE HOUSEHOLD
This woman will be selected for the "domestic violence" section of the woman's questionnaire.

2-IF THERE ARE SEVERAL ELIGIBLE WOMEN IN THE HOUSEHOLD
a) Take the last digit from the household number recorded on the cover page
b) Use this figure as the line number to pick from.
c) Check the total number of eligible women from column 9 of the household schedule.
d) Use this figure as the column number to pick from.
e) Find the space that corresponds to the intersection of that line and column and circle the number.
f) This number corresponds to the woman who will be selected for "domestic violence": the 1st, 2nd, 3rd woman, etc.
g) From the household schedule, transcribe in q 191 the line number (column 1) and the name (column 2) of the woman selected.

EXAMPLE:
The household structure number is 36: Select line 6
There are 3 eligible women in this household, (line number 02, 04, and 07), select column 3.
The intersecting space of line 6 and column 3 is 2: the 2nd eligible woman listed in the household schedule will be selected.
If the line number of the 3 eligible women are 02, 04, and 07, the woman selected is the 2nd woman listed, meaning the one with line number 04.

LAST DIGIT OF HOUSEHOLD NUMBER

TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD

191) RECORD THE LINE NUMBER (COLUMN 1) AND THE NAME (COLUMN 2) OF THE SELECTED WOMAN

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

200) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANTHROPOMETRY, ANEMIA AND HIV TEST?

201) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND THE NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202 ACCORDING TO LINE NUMBER ORDER. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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

204) CHECK 203: CHILD BORN IN JANUARY 2008 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

IF 2 YEARS OR UNDER, MEASURE THE CHILD LYING DOWN, OTHERWISE STANDING UP.

207) MEASURED LYING DOWN OR STANDING UP?

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

209) LINE NUMBER FROM 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 2008 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 take the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212) ASK CONSENT FOR MALARIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

We are asking all of the children in this country to participate in a malaria test. Malaria a serious health problem caused by a parasite transmitted from a mosquito bite. This survey will assist the government to develop programs to prevent and treat anemia.

We ask that all children born in 2008 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. (We use the blood from the same needle prick as for the anemia test)

The blood will be tested for malaria immediately, and the result will be told to you right away. Some drops will be saved on one or more slides and sent to a laboratory to be tested. You will not find out 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 take the anemia test?

213) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

214) PREPARE THE INSTRUMENTS NECESSARY ONLY FOR THE TEST(S) FOR WHICH CONSENT WAS OBTAINED AND PROCEED WITH THE TEST(S).

215) BAR CODE STICKER FOR MALARIA TEST
PUT FIRST BAR CODE HERE

PUT THE 2ND BAR CODE STICKER ON THE TDR [RAPID DIAGNOSTIC TEST], THE 3RD ON THE SLIDE, AND THE 4TH ON THE TRANSMISSION SHEET

216) RECORD THE HEMOGLOBIN LEVEL HERE AND ON THE ANEMIA AND MALARIA BROCHURE

217) RECORD THE RESULT CODE FROM THE MALARIA TDR [RAPID DIAGNOSTIC TEST] HERE

218) RECORD THE RESULT CODE FROM THE MALARIA TDR [RAPID DIAGNOSTIC TEST] HERE AND ON THE ANEMIA AND MALARIA BROCHURE.

219) CHECK 216:
HEMOGLOBIN LEVEL

220) 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 232

221) Did (NAME) suffer from any of the following illness or present one or more of the following symptoms?

Extreme weakness?
Heart problems?
Loss of consciousness?
Rapid or difficulty breathing?
Convulsions?
Abnormal bleeding?
Jaundice/yellow skin?
Dark urine?

IF NONE OF THE ABOVE SYMPTOMS, CIRCLE CODE Y

222) CHECK 221: IS A CODE A-H CIRCLED

223) CHECK 216: HEMOGLOBIN LEVEL

224) 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 231

225) In the last two weeks, has (NAME) taken or is (NAME) taking ACT given to him/her by a doctor, health care establishment, or fieldworker to treat malaria?

CHECK BY ASKING TO SEE THE TREATMENT

226) REFERENCE DECLARATION FOR CHILDREN ALREADY TAKING CTA DRUG.
You told me that (NAME OF CHILD) already received ACT for malaria. I cannot give you extra ACT. However, the test shows that he/she has malaria. If your child had a fever in the two days after the last dose of ACT, you must bring the child to the closest health care establishment for further testing.

GO TO 231

227) 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 ACT. ACT 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?

228) CIRCLE THE APPROPRIATE CODE AND SIGN.

230) 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 (Pink striped brochure)

Child age 1-5 years or 8-17 Kgs: 50 mg tablet of Artesunate and 135 mg of Amodiaquine (Purple striped brochure)

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.

231) RECORD THE RESULT CODE OF THE MALARIA TREATMENT OR OF THE REFERENCE SHEET

232) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE 1ST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE CHILDREN, GO TO 240.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TEST FOR WOMEN 15-49

240) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 241. (IF THERE ARE MORE THAN 3 WOMEN, USE ADDITIONAL QUESTIONNAIRES)

241) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

242) WEIGHT IN KILOGRAMS

243) HEIGHT IN CENTIMETERS

244) AGE: CHECK COLUMN 7

245) MARITAL STATUS: CHECK COLUMN 8

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

247) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 246 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 test, we 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 to (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 take the anemia test?

248) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

249) 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 test, we 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 member of our survey team.

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

250) CIRCLE APPROPRIATE CODE AND SIGN

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

252) AGE: CHECK COLUMN 7

253) MARITAL STATUS: CHECK COLUMN 8

254) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER RESPONSIBLE ADULT IDENTIFIED IN 246 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 Togo.

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 ADOLESCENT'S) test 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 you a voucher for free services for you 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?

255) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

256) 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 Togo.

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 you 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, or you can say no to the test. It is up to you to decide.

Will you take in the HIV test?

257) CIRCLE APPROPRIATE CODE, SIGN AND RECORD YOUR INTERVIEWER CODE.

258) AGE: CHECK COLUMN 7

259) MARITAL STATUS: CHECK COLUMN 8

260) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 246 AS RESPONSIBLE FOR NEVER IN UNION WOMAN AGE 15-17.

We ask you to allow the 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?

261) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

262) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow 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?

263) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

264) ADDITIONAL TESTS

CHECK 261 AND 263: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

266) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

267) 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.

268) GO BACK TO 241 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 269.

HEMOGLOBIN MEASUREMENT AND HIV TEST FOR MEN AGE 15-59

269) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 270. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

270) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

271) AGE: CHECK COLUMN 7

272) MARITAL STATUS: CHECK COLUMN 8

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

274) ASK FOR CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 273 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 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?

275) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

276) 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 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 take in the anemia test?

277) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

278) AGE: CHECK COLUMN 7

279) MARITAL STATUS: CHECK COLUMN 8

280) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 273 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 Togo.

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

281) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

282) 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 Togo.

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 you 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?

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

284) AGE: CHECK COLUMN 271

285) MARITAL STATUS: CHECK COLUMN 272

286) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 273 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

We ask you to allow the 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?

287) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

288) ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow the 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?

289) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

290) ADDITIONAL TESTS

CHECK 287 AND 289: IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

292) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

293) 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.

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