IDENTIFICATION

LOCALITY NAME _________________

NAME OF HOUSEHOLD HEAD __________________

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

PROVINCE ___

URBAN/RURAL

LUSAKA/OTHER CITY/TOWN/VILLAGE

IS THIS HOUSEHOLD SELECTED FOR SYPHILIS TESTING?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT*____

RESULT* ______________

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INT. NUMBER ___
RESULT* ____

TOTAL NUMBER OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN __

TOTAL ELIGIBLE MEN __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR____

KEYED BY____

INTRODUCTION AND CONSENT

Hello. My name is ________ and I am working with the Ministry of Health in collaboration with Central Statistical Office (CSO). We are conducting a national survey that asks about various health issues. We would very much appreciate your participation in this survey. The interview usually takes between 30 and 60 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

As part of this survey we would first ask some questions about your household. All of the answers you give will be confidential.

Participation in this survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.

Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.

If you have any questions, you may contact the ZDHS Survey Coordinator at __________. This person will only be available for a limited time.
GIVE INFORMATION TO RESPONDENT.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ___________ Date: ___________

HOUSEHOLD SCHEDULE

(1) LINE NO.

(2) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 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?

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

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

(7) AGE: How old is (NAME)?

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

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

(9A) ELIGIBILITY: CIRCLE LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE QUESTIONS IN Q.33.

(10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59.

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

TICK HERE IF CONTINUATION SHEET USED ___

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

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

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

(12) SICK PERSON, IF AGE 15-59 YEARS: Has (NAME) been very sick for at least 3 months during the past 12 months, that is (NAME) was too sick to work or do normal activities?

(13) SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS: Is (NAME)'s natural mother alive?

(14) 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'.

(15) IF MOTHER NOT LISTED IN HOUSEHOLD: Has (NAME)'s mother been very sick for at least 3 months during the past 12 months, that is she was too sick to work or do normal activities?

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

(17) 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'.

(18) IF FATHER NOT LISTED IN HOUSEHOLD: Has (NAME)'s father been very sick for at least 3 months during the past 12 months, that is he was too sick to work or do normal activities?

(19) MOTHER AND/OR FATHER DEAD/SICK: CIRCLE LINE NUMBER IF CHILD'S MOTHER AND/OR FATHER HAS DIED (Q.13 OR 16 = NO) OR BEEN SICK (Q.12, Q.15 OR 18 =YES).

(19A) YEAR OF MOTHER'S AND/OR FATHER'S DEATH: IF CHILD'S MOTHER HAS DIED, ASK YEAR OF DEATH AND RECORD IN THE BOXES. IF CHILD'S FATHER HAS DIED, ASK YEAR OF DEATH AND RECORD IN THE BOXES.

(20) BOTH PARENTS ALIVE: IF YES TO Q.13 AND Q.16 (BOTH ALIVE), CIRCLE '1'. FOR ALL OTHER CASES, CIRCLE '2'.

(21) BROTHERS AND SISTERS IF AGE 0-17 YEARS: Does (NAME) have any brothers or sisters under age 18 who have the same mother and the same father?

(22) Do any of these brothers and sisters age under age 18 not live in this household?

(23) EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER: Has (NAME) ever attended school?

(24) What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?

(25) CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS: Did (NAME) attend school at any time during the (2007) school year?

(26) During this/that school year, what level and grade [is/was] (NAME) attending?

(27) Did (NAME) attend school at any time during the previous school year, that is, (2006)?

(28) During that school year, what level and grade did (NAME) attend?

(29) BASIC MATERIAL NEEDS IF AGE 5-17 YEARS: Does (NAME) have a blanket?

(30) Does (NAME) have a pair of shoes?

(31) Does (NAME) have at least two sets of clothes?

(32) BIRTH REGISTRATION IF AGE 0-4 YEARS: Does (NAME) have a birth certificate? IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

33. LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS NUMBER IS USED TO IDENTIFY WHETHER THE FIRST ('1'), SECOND ('2'), THIRD ('3'), ETC. ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
CIRCLE THE LINE NUMBER FOR THIS WOMAN IN COLUMN 9A.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.
FIND THE BOX WHERE ROW '6' AND COLUMN '3' MEET. THE NUMBER IN THAT BOX ('2') INDICATES THAT THE SECOND ELIGIBLE WOMAN IN THE HOUSEHOLD LISTING SHOULD BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07'. THE WOMAN TO BE ASKED THE DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE WOMAN ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN HOUSEHOLD (COLUMN)
1 2 3 4 5 6 7 8
0 1 2 2 4 3 6 5 4
1 1 1 3 1 4 1 6 5
2 1 2 1 2 5 2 7 6
3 1 1 2 3 1 3 1 7
4 1 2 3 4 2 4 2 8
5 1 1 1 1 3 5 3 1
6 1 2 2 2 4 6 4 2
7 1 1 3 3 5 1 5 3
8 1 2 1 4 1 2 6 4
9 1 1 2 1 2 3 7 5

HOUSEHOLD CHARACTERISTICS

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

102. What is the main source of water used by your household for other purposes such as cooking and handwashing?

103. Where is that water source located?

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

105. Who usually goes to this source to fetch the water for your your household?

106. Do you do anything to the water to make it safer to drink?

107. What do you usually do to make the water safer to drink? Anything else?
CIRCLE ALL MENTIONED.

108A. How do you store your drinking water?

108B. Have you ever seen or heard of a product called Clorin - a liquid that is sold in a bottle and can be used to make water safer to drink?

108C. Where have you seen or heard messages about Clorin? Any other?
CIRCLE ALL MENTIONED.

108D. Is your household water currently treated with Clorin from a bottle?

108E. What kind of toilet facility do members of your household usually use?

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

110. How many households use this toilet facility?

111. Does your household have:

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

113. In this household, is food cooked on an open fire, an open stove or a closed stove?

114. Does this (fire/stove) have a chimney, a hood, or neither of these?

115. Is the cooking usually done in the house, in a separate building, or outdoors?

116. Do you have a separate room which is used as a kitchen?

117. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

118. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

119. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

120. How many rooms in this household are used for sleeping?

121. Does any member of this household own:

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

123. How much of agricultural land do members of this household own?

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

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

126. Does any member of this household have a bank account?

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

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

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

129A. Where did you get this net from?

130. How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.

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

132. When you got the net, was it treated with an insecticide to kill or repel mosquitos?

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

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

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

136. Who slept under this mosquito net last night?
RECORD THE PERSON'SLINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

137. GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137A.

137A. In the last twelve months, has your house been sprayed to kill mosquitoes?

137B. Who sprayed?

138. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE (POTASIUM IODATE).
RECORD PPM (PARTS PER MILLION)

SUPPORT FOR SICK PEOPLE

201. CHECK QUESTIONS 7 AND 12 IN THE HOUSEHOLD SCHEDULE:
NUMBER OF SICK PEOPLE AGE 15-59

202. ENTER IN QUESTION 203 THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 15-59, BEGINNING WITH THE FIRST SICK PERSON LISTED IN QUESTION 12 IN THE HOUSEHOLD SCHEDULE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

READ THE INTRODUCTION THAT FOLLOWS. THEN ASK QUESTIONS 204-215 AS APPROPRIATE FOR EACH OF THE PERSONS AGE 15-59 REPORTED AS HAVING BEEN VERY SICK.

You told me that in your household one (some) of the members of your household has(ve) been very sick for at least three of the past 12 months. We are interested in learning about the care and support that may have been received for [that/each of those persons].
First I would like to ask you about any formal, organized help or support that your household may have been given for [that/ each of those] person(s) for which you did not have to pay.
By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

203. NAME AND LINE NUMBER FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE

204. Now I would like to ask you about any support you received for (NAME). In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

205. Did your household receive any of these medical support at least once a month while (NAME) was sick?

206. In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, for which you did not have to pay?

207. Did your household receive any of this emotional or psychological support in the past 30 days?

208. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

209. Did your household receive any of this material support in the past 30 days?

210. In the last 12 months, has your household received any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

211. Did your household receive any of this social support in the past 30 days?

212A. ASK SICK PERSON OR CARETAKER: Now I would like to ask about health problems (NAME) may have recently had. In the last 30 days, has (NAME) had severe pain, mild pain, or no pain at all?

212B. ASK SICK PERSON OR CARETAKER: In the last 30 days, has (NAME) been bed ridden?

213. ASK SICK PERSON OR CARETAKER: When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

214. ASK SICK PERSON OR CARETAKER: In the last 30 days, did (NAME) suffer from nausea, coughing, diarrhea, or constipation?

214A. ASK SICK PERSON OR CARETAKER: Was this problem (were any of these problems) ever severe?

215. ASK SICK PERSON OR CARETAKER: Was (NAME) able to reduce or stop this (these) problem(s) most of the time, some of the time, or not at all?

216. GO BACK TO 204 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE SICK PEOPLE, GO TO 301.

SUPPORT FOR PERSONS WHO HAVE DIED

301. Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has any usual member of your household died in the last 12 months?

302. How many household members died in the last 12 months?

303. ASK 304-322 AS APPROPRIATE FOR EACH PERSON WHO DIED. IF THERE WERE MORE THAN 3 DEATHS, USE ADDITIONAL QUESTIONNAIRE(S).

304. What was the name of the person who died (most recently/before him/her)?

305. Was (NAME) male or female?

306. How old was (NAME) when (he/she) died?

307. CHECK 306:
AGE OF PERSON AT DEATH

308. Was (NAME) very sick for at least three of the 12 months before (he/she) died, that is (NAME) was too sick to work or do normal activities?

309. I would like to ask you about any formal, organized help or support that your household may have received for [NAME] before (he/she) died, for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

310. In the last 12 months, did your household receive any medical supplies for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

311. Did your household receive any of this medical support at least once a month while (NAME) was sick?

312. In the last 12 months, did your household receive any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did not have to pay?

313. Did your household receive any of these emotional or psychological support in the last 30 days before (NAME)'s death?

314. In the last 12 months, did your household receive any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

315. Did your household receive any of this material support in the last 30 days before (NAME)'s death?

316. In the last 12 months, did your household receive any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

317. Did your household receive any of this social support in the last 30 days before (NAME)'s death?

318. Now I would like to ask about the health problems (NAME) may have had. In the 30 days before (NAME) died, did he/she have severe pain, mild pain, or no pain at all?

319. When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

320. In the 30 days before (NAME) died, did he/she suffer from nausea, coughing, diarrhea, or constipation?

320A. Was this problem (were any of these problems) severe?

321. Was (NAME) able to reduce or stop the problems he/she had most of the time, some of the time or not at all?

322. GO BACK TO 304 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE DEATHS, GO TO 401.

SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

401. CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE:
ANY CHILD AGE 0-17?

402. CHECK COLUMN 12 IN THE HOUSEHOLD SCHEDULE:
ANY SICK ADULT AGE 15-59 WHO IS VERY SICK?

403. CHECK 306 IN THE PREVIOUS SECTION:
ANY ADULT AGE 15-59 WHO DIED IN PAST 12 MONTHS?

404. CHECK COLUMN 19 IN THE HOUSEHOLD SCHEDULE:
ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND IS VERY SICK?

405. RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AGE 0-17 FOR ALL CHILDREN WHO ARE IDENTIFIED IN COLUMN 19 AS HAVING A MOTHER AND/OR FATHER WHO HAS DIED OR HAS BEEN VERY SICK FOR AT LEAST THREE MONTHS.

406. NAME FROM COLUMN 2
LINE NUMBER FROM COLUMN 1
AGE FROM COLUMN 7

407. I would like to ask you about any formal, organized help or support for children that your household may have received for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

408. Now I would like to ask you about the support your household received for (NAME).
In the last 12 months, has your household received any medical support for (NAME), such as
medical care, supplies or medicine, for which you did not have to pay?

409. In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support,
which you received at home and for which you did not have to pay?

410. Did your household receive any of this emotional or psychological support in the past 3 months?

411. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

412. Did your household receive any of this material support in the past 3 months?

413. In the last 12 months, has your household received any social support for (NAME) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

414. Did your household receive any of this social support in the past 3 months?

415. CHECK 406:
AGE OF CHILD

416. In the last 12 months, has your household received any support for (NAME'S) schooling, such as allowance, free admission, books or supplies, for which you did not have to pay?

417. GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5

501. CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

CHECK COLUMN 11 IN THE HOUSEHOLD SCHEDULE:
ANY CHILD 0-5?

502. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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

504. CHECK 503:
CHILD BORN IN JANUARY 2002 OR LATER?

505. WEIGHT IN KILOGRAMS

506. HEIGHT IN CENTIMETERS.
FOR CHILDREN AGED 24 MONTHS AND BELOW, MEASURE HEIGHT IN LYING POSITION

507. MEASURED LYING DOWN OR STANDING UP?

508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

509. GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST
COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

TICK HERE IF CONTINUED IN ANOTHER QUESTIONNAIRE. ___

WEIGHT AND HEIGHT MEASUREMENT, HIV AND SYPHILIS TESTING FOR WOMEN AGE 15-49

515. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 516. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME FOR THE HIV TEST PROCEDURE MUST BE RECORDED IN 527 FOR EACH ELIGIBLE WOMAN.

516. LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

517. WEIGHT IN KILOGRAMS

518. HEIGHT IN CENTIMETERS

519. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

520. AGE: CHECK COLUMN 7.

521. MARITAL STATUS: CHECK COLUMN 8.

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

523. PREGNANT STATUS ASK:
Are you pregnant?

524. READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

525. CHECK 524 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
A FINAL OUTCOME FOR THE HIV TEST PROCEDURE MUST BE RECORDED IN FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

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

527. OUTCOME OF HIV TEST PROCEDURE

528. CHECK 527:
SAMPLE COLLECTED?

CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH FEMALE RESPONDENT. CIRCLE CODE '1' IN FIELD 524 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-MARRIED WOMEN AGE 15-17 YEARS, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 524 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we are asking people all over the country to give a few drops of blood for 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 Zambia.

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

No name will be attached so we will not be able to tell you the test results. No one else will be able to know the test results either.

If you want to know whether you have HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?

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

Will you (NAME OF ADOLESCENT) take the HIV test?

529. CHECK 527:
OUTCOME OF HIV TEST

530. READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

531. ADDITIONAL TESTS: CHECK 530:

IF CONSENT HAS NOT BEEN GRANTED WRITE 'NO ADDITIONAL TEST' ON THE FILTER PAPER.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 530 IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF SHE REFUSES.

FOR NEVER-MARRIED WOMEN AGE 15-17 YEARS, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 530 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow the Ministry of Health and Central Statistical Office to store part of the blood sample at the laboratory to be used for testing or research in the future. At this time we are not certain about what tests might be done.

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

532. READ THE SYPHILIS TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

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

534. OUTCOME OF SYPHILIS TEST PROCEDURE

535. CHECK 534:
OUTCOME OF SYPHILIS TEST

CONSENT STATEMENT FOR SYPHILIS TEST

READ CONSENT STATEMENT TO EACH FEMALE RESPONDENT. CIRCLE CODE '1' IN 532 IF RESPONDENT CONSENTS TO THE SYPHILIS TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-MARRIED WOMEN AGE 15-17 YEARS, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 532 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we are asking people all over the country to give a small amount of blood for a syphilis test. Syphilis can cause serious problems if it is not treated. The results from this survey will help the government to develop programs to prevent and treat syphilis.

For the syphilis test, we need a small amount of blood from your arm. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested tonight and if you want to know the test result, I will be back tomorrow to give you the result if you tell me when you will be here. If the test shows you have syphilis, we would provide free treatment for you and your partner(s) at home or at the nearest health center. No one will know the results except for you and me.

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 (NAME OF ADOLESCENT) take the syphilis test?

Will you and (NAME OF ADOLESCENT) want to know the test result and to be treated if (NAME OF ADOLESCENT) has syphilis?

HIV AND SYPHILIS TESTING FOR MEN AGE 15-59

536. CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 537. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

537. LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

538. AGE: CHECK COLUMN 7.

539. MARITAL STATUS: CHECK COLUMN 8.

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

541. READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 540 BEFORE ASKING RESPONDENT'S CONSENT.

542. CHECK 541 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
A FINAL OUTCOME FOR THE HIV TEST PROCEDURE MUST BE RECORDED IN 544 FOR EACH ELIGIBLE MAN EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

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

544. OUTCOME OF HIV TEST PROCEDURE

545. CHECK 527:
SAMPLE COLLECTED?

CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH MALE RESPONDENT. CIRCLE CODE '1' IN 541 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-MARRIED MEN AGE 15-17 YEARS, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 540) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 541 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we are asking people all over the country to give a few drops of blood for 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 Zambia.

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

No name will be attached so we will not be able to tell you the test results. No one else will be able to know the test results either.

If you want to know whether you have HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?

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

Will you (NAME OF ADOLESCENT) take the HIV test?

546. CHECK 544:
OUTCOME OF HIV TEST

547. READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS WITH LEFT OVER BLOOD. FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 540 BEFORE ASKING RESPONDENT'S CONSENT.

548. ADDITIONAL TESTS: CHECK 547:
IF CONSENT HAS NOT BEEN GRANTED WRITE 'NO ADDITIONAL TEST' ON THE FILTER PAPER.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 547 IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF HE REFUSES.

FOR NEVER-MARRIED MEN AGE 15-17 YEARS, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 540) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 547 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow the Ministry of Health and Central Statistical Office to store part of the blood sample at the laboratory to be used for testing or research in the future. At this time we are not certain about what tests might be done.

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

549. READ THE SYPHILIS TEST CONSENT STATEMENT. FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 540 BEFORE ASKING RESPONDENT'S CONSENT.

550. BAR CODE LABEL

551. OUTCOME OF SYPHILIS TEST PROCEDURE

552. CHECK 550:
OUTCOME OF SYPHILIS TEST

CONSENT STATEMENT FOR SYPHILIS TEST

READ CONSENT STATEMENT TO EACH MALE RESPONDENT. CIRCLE CODE '1' IN 549 IF RESPONDENT CONSENTS TO THE SYPHILIS TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-MARRIED MEN AGE 15-17 YEARS, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 540) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 549 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we are asking people all over the country to give a small amount of blood for a syphilis test. Syphilis can cause serious problems if it is not treated. The results from this survey will help the government to develop programs to prevent and treat syphilis.

For the syphilis test, we need a small amount of blood from your arm. The equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested tonight and if you want to know the test result, I will be back tomorrow to give you the result if you tell me when you will be here. If the test shows you have syphilis, we would provide free treatment for you and your partner(s) at home or at the nearest health center. No one will know the results except for you and me.

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 (NAME OF ADOLESCENT) take the syphilis test?

Will you and (NAME OF ADOLESCENT) want to know the test result and to be treated if (NAME OF ADOLESCENT) has syphilis?