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DEMOGRAPHIC AND HEALTH SURVEYS – ZAMBIA 2007 - HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

LOCALITY NAME _________________

NAME OF HOUSEHOLD HEAD __________________

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

PROVINCE ___

URBAN/RURAL

URBAN = 1
RURAL = 2

LUSAKA/OTHER CITY/TOWN/VILLAGE

LUSAKA = 1
OTHER CITY = 2
TOWN = 3
VILLAGE = 4 ___

IS THIS HOUSEHOLD SELECTED FOR SYPHILIS TESTING?

YES = 1
NO = 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER’S NAME _______________
RESULT____

RESULT* ______________

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

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: ___________

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

HOUSEHOLD SCHEDULE

(1) LINE NO.

LINE NUMBER____

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

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

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON.

NAME__________

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

01 = HEAD
02 = WIFE OR HUSBAND
03 = SON OR DAUGHTER
04 = SON-IN-LAW OR DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = NIECE/NEPHEW BY BLOOD
10 = NIECE/NEPHEW BY MARRIAGE
11 = OTHER RELATIVE
12 = ADOPTED/FOSTER/ STEPCHILD
13 = NOT RELATED
98 = DON’T KNOW

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

MALE 1
FEMALE 2

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

YES 1
NO 2

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

YES 1
NO 2

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

IN YEARS __

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

1 = MARRIED
2 = LIVING TOGETHER
3 = DIVORCED
4 = SEPARATED
5 = WIDOWED
6 = NEVER MARRIED

(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?

YES (ADD TO TABLE)
NO

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

YES (ADD TO TABLE)
NO

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

YES (ADD TO TABLE)
NO

(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?

YES 1
NO 2
DON'T KNOW 8

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

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

(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’.

LINE NUMBER_____

(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?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 19)
DON'T KNOW 8 (GO TO 19)

(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’.

LINE NUMBER_____

(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?

YES 1
NO 2
DON'T KNOW 8

(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.

YEAR____

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

1 (GO TO 23)
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?

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

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 29)

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

LEVEL ___
0 = NURSERY/KINDERGARTEN
1 = PRIMARY
2 = SECONDARY
3 = HIGHER
8 = DON’T KNOW
GRADE ___
00 = LESS THAN 1 YEAR COMPLETED
98 = DON’T KNOW

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

YES 1
NO 2 (GO TO 27)

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

LEVEL ___
0 = NURSERY/KINDERGARTEN
1 = PRIMARY
2 = SECONDARY
3 = HIGHER
8 = DON’T KNOW
GRADE ___
98 = DON’T KNOW

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

YES 1
NO 2 (GO TO 29)

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

LEVEL ___
0 = NURSERY/KINDERGARTEN
1 = PRIMARY
2 = SECONDARY
3 = HIGHER
8 = DON’T KNOW
GRADE ___
98 = DON’T KNOW

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

(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?

1 = HAS CERTIFICATE
2 = REGISTERED
3 = NEITHER
8 = DON’T KNOW

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?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
COMMUNAL TAP 13 (GO TO 103)
WATER FROM OPEN WELL
OPEN WELL IN YARD/PLOT 21 (GO TO 103)
OPEN PUBLIC WELL/BOREHOLE 32 (GO TO 103)
COVERED WELL/BOREHOLE
PROTECTED WELL/BOREHOLE IN YARD/PLOT 42 (GO TO 103)
PROTECTED PUBLIC WELL 51
SURFACE WATER
SPRING 71 (GO TO 103)
RIVER/STREAM 72 (GO TO 103)
POND/LAKE/DAM 73 (GO TO 103)
RAINWATER 81 (GO TO 103)
TANKER TRUCK 91
CART WITH SMALL TANK 92
BOTTLED WATER 93
OTHER (SPECIFY) __________ 96 (GO TO 103)

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
COMMUNAL TAP 13
WATER FROM OPEN WELL
OPEN WELL IN YARD/PLOT 21
OPEN PUBLIC WELL/BOREHOLE 32
COVERED WELL/BOREHOLE
PROTECTED WELL/BOREHOLE IN YARD/PLOT 42
PROTECTED PUBLIC WELL 51
SURFACE WATER
SPRING 71
RIVER/STREAM 72
POND/LAKE/DAM 73
RAINWATER 81
TANKER TRUCK 91
CART WITH SMALL TANK 92
BOTTLED WATER 93
OTHER (SPECIFY) __________ 96

103. Where is that water source located?

IN OWN DWELLING 1 (GO TO 106)
IN OWN YARD/PLOT 2 (GO TO 106)
ELSEWHERE 3

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

MINUTES _____

ON PREMISES 996
DON’T KNOW 998

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

ADULT WOMAN/WOMEN 1
ADULT MAN/MEN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) _________ 6

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

YES 1
NO 2 (GO TO 108A)
DON’T KNOW 8 (GO TO 108A)

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

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

108A. How do you store your drinking water?

CLOSED CONTAINER/JERRY CAN 1
OPEN CONTAINER/BUCKET 2
OTHER (SPECIFY) ____________ 6

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?

YES 1
NO 2 (GO TO 108E)

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

RADIO A
TELEVISION B
SHOP C
LEAFLETS/BOOKLETS D
POSTER E
COMMUNITY-BASED AGENT F
OTHER (SPECIFY) ______________ X

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

YES 1
NO 2

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON’T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/ OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 111)
OTHER (SPECIFY) __________ 96

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

YES 1
NO 2 (GO TO 111)

110. How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 ___

10 OR MORE HOUSEHOLDS 95
DON’T KNOW 98

111. Does your household have:

Electricity?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
A bed?
A Chair?
A Table?
A Cupboard?
A Sofa?
A Clock?
A fan?
A sewing machine?
A Cassette player?
A plough?
A grain grinder?
A VCR/DVD?
A tractor?
A vehicle?
A Hammer mill?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2

NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
BED
YES 1
NO 2
CHAIR
YES 1
NO 2
TABLE
YES 1
NO 2
CUPBOARD
YES 1
NO 2
SOFA
YES 1
NO 2
CLOCK
YES 1
NO 2
FAN
YES 1
NO 2
SEWING MACHINE
YES 1
NO 2
CASSETTE PLAYER
YES 1
NO 2
PLOUGH
YES 1
NO 2
GRAIN GRINDER
YES 1
NO 2
VCR/DVD
YES 1
NO 2
TRACTOR
YES 1
NO 2
VEHICLE
YES 1
NO 2
HAMMER MILL
YES 1
NO 2

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

ELECTRICITY 01 (GO TO 115)
SOLAR POWER 02 (GO TO 115)
LIQUID PROPANE GAS (LPG) 03 (GO TO 115)
NATURAL GAS 04 (GO TO 115)
BIOGAS 05 (GO TO 115)
KEROSENE 06
COAL, LIGNITE 07
CHARCOAL 08
WOOD 09
STRAW/SHRUBS/GRASS 10
AGRICULTURAL CROP 11
ANIMAL DUNG 12
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 117)
OTHER (SPECIFY) ______________ 96

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

OPEN FIRE 1
OPEN STOVE/BRAZIER 2
CLOSED STOVE WITH CHIMNEY 3 (
OTHER (SPECIFY) ___________ 6 (GO TO 115)

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

CHIMNEY 1
HOOD 2
NEITHER 3

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

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 117)
OUTDOORS 3 (GO TO 117)
OTHER (SPECIFY) _________ 6 (GO TO 117)

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

YES 1
NO 2

117. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR

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

118. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
METAL/IRON SHEETS 31
WOOD 32
CALAMINE/CEMENT FIBER (ASBESTORS) 33
CERAMIC TILES/HARVEY TILES 34
CEMENT 35
ROOFING SHINGLES 36
MUD TILES 37
OTHER (SPECIFY) ______ 96

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

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

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

ROOMS ___

121. Does any member of this household own:

A watch?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?
A banana boat?

WATCH
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BOAT WITH MOTOR
YES 1
NO 2
BANANA BOAT
YES 1
NO 2

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

YES 1
NO 2 (GO TO 124)

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

LIMA 1 __
ACRES 2 __
HECTARES 3 __

95 OR MORE HECTARES 995
DON’T KNOW 998

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

YES 1
NO 2 (GO TO 126)

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’.

Traditional cattle?
Dairy cattle?
Beef cattle?
Horses, donkeys, or mules?
Goats?
Sheep?
Pigs?
Chickens?
Other Poultry?
Other Livestock?

Traditional cattle?
TRADITIONAL __
Dairy cattle?
DAIRY __
Beef cattle?
BEEF __
Horses, donkeys, or mules?
HORSES/DONKEYS/MULES __
Goats?
GOATS __
Sheep?
SHEEP __
Pigs?
PIGS __

Chickens?
CHICKENS__
Other poultry?
OTHER POULTRY __
Other livestock?
OTHER LIVESTOCK __

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 137A)

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

NUMBER OF NETS ___

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

OBSERVED 1
NOT OBSERVED 2
OTHER (SPECIFY) __________ 6

129A. Where did you get this net from?

ANC 1
COMMERCIAL SHOP 2
HEALTH CENTRE 3
COMMUNITY BASED AGENT 4
OTHER (SPECIFY)____ 6

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

MONTHS AGO __

37 OR MORE MONTHS AGO 95
NOT SURE 98

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

‘PERMANET’ NET
PermaNET 11 (GO TO 135)
OLICET 12 (GO TO 135)
OTHER/DON'T KNOW BRAND 16 (GO TO 135)
‘PRETREATED’ NET
K-0NET 21 (GO TO 133)
SAFENITE 22 (GO TO 133)
OTHER/DON'T KNOW BRAND 26 (GO TO 133)
OTHER (SPECIFY) ___________ 31
DON'T KNOW BRAND 98

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

YES 1
NO 2
NOT SURE 8

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

YES 1
NO 2 (GO TO 135)
NOT SURE 8 (GO TO 135)

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

MONTHS AGO __

25 OR MORE MONTHS AGO 95
NOT SURE 98

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

YES 1
NO 2 (GO TO 137)
NOT SURE 8 (GO TO 137)

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

NAME _____________
LINE NO. __

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?

YES 1
NO 2 (GO TO 138)

137B. Who sprayed?

MINISTRY OF HEALTH (e.g NMCC) A
COUNCIL B
MINES C
SELF D
OTHER (SPECIFY) _____________ X

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

0 PPM (NO IODINE) 1
25 PPM 2
50 PPM 3
75 PPM AND ABOVE 4
NO SALT IN HH 5
SALT NOT TESTED (SPECIFY REASON) ____________ 6

SUPPORT FOR SICK PEOPLE

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

AT LEAST ONE (GO TO 202)
NONE (GO TO 301)

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

NAME _____________
LINE NO. __

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?

YES 1
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 210)
DON'T KNOW 8 (GO TO 210)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 212A)
DON'T KNOW 8 (GO TO 212A)

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

YES 1
NO 2
DON'T KNOW 8

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?

SEVERE 1
MILD 2
NOT AT ALL 3 (GO TO 214)

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

YES 1
NO 2
DON'T KNOW 8

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?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

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

YES 1
NO 2 (GO TO 216)

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

YES 1
NO 2

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?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

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?

YES 1
NO 2 (GO TO 401)
DONT KNOW 8 (GO TO 401)

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

NUMBER OF DEATHS __

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)?

NAME___________________

305. Was (NAME) male or female?

MALE 1
FEMALE 2


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

AGE _____

307. CHECK 306:
AGE OF PERSON AT DEATH

LESS THAN 15 YEARS OLD (GO TO 318)
OVER 60 YEARS OLD (GO TO 318)
15-59 (GO TO 308)

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?

YES 1
NO 2 (GO TO 318)
DON'T KNOW 8 (GO TO 318)

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?

YES 1
NO 2 (GO TO 312)
DON'T KNOW 8 (GO TO 312)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 314)
DON'T KNOW 8 (GO TO 314)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 316)
DON'T KNOW 8 (GO TO 316)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 318)
DON'T KNOW 8 (GO TO 318)

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

YES 1
NO 2
DON'T KNOW 8

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?

SEVERE 1
MILD 2
NOT AT ALL 3 (GO TO 320)

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?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

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

YES 1
NO 2 (GO TO 322)

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

YES 1
NO 2

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?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

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?

AT LEAST ONE CHILD AGE 0-17 (GO TO 402)
NO CHILD AGE 0-17 (GO TO 501)

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

NO SICK ADULT AGE 15-59 (GO TO 403)
AT LEAST ONE SICK ADULT AGE 15-59 (GO TO 406. CHECK QUESTION 7
IN THE HOUSEHOLD SCHEDULE AND LIST THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL PERSONS AGE 0-17 YEARS.)

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

NO ADULT DEATH AGE 15-59 IN 306 (GO TO 404)
AT LEAST ONE ADULT DEATH AGE 15-59 IN 306 (GO TO 406. CHECK QUESTION 7 IN THE HOUSEHOLD SCHEDULE AND LIST THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL PERSONS AGE 0-17 YEARS.)

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?

AT LEAST ONE CHILD WHOSE MOTHER AND/OR FATHER HAS DIED/IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND HAS BEEN VERY SICK (GO TO 405)
NO CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR IS NOT LISTED IN HOUSEHOLD SCHEDULE AND HAS BEEN VERY SICK (GO TO 501)

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

NAME ___________
LINE NO. ___
AGE ___

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?

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 411)
DON'T KNOW 8 (GO TO 411)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 413)
DON'T KNOW 8 (GO TO 413)

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2 (GO TO 415)
DON'T KNOW 8 (GO TO 415)

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

YES 1
NO 2
DON'T KNOW 8

415. CHECK 406:
AGE OF CHILD

AGE 0-4 (GO TO 417)
AGE 5-17 (GO TO 416)

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?

YES 1
NO 2
DON'T KNOW 8

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?

AT LEAST ONE CHILD 0-5 (GO TO 502)
NO CHILD AGE 0-5 (GO TO 515)

502. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NO. ___
NAME ___________

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.

DAY __
MONTH __
YEAR __

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

YES 1
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 515)

505. WEIGHT IN KILOGRAMS

KG. ___.___

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

CM. ___.___

507. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY) ______________ 6

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)

LINE NO. ___
NAME ___________

517. WEIGHT IN KILOGRAMS

KG. __.__

518. HEIGHT IN CENTIMETERS

CM. __.__

519. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER (SPECIFY) ____________ 6

520. AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-49 YEARS 2 (GO TO 523)

521. MARITAL STATUS: CHECK COLUMN 8.

CODE 6 (NEVER IN UNION) 1
OTHER 2 (GO TO 523)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT __

523. PREGNANT STATUS ASK:
Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________
RESPONDENT REFUSED 3 (SIGN) ________

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

BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6

528. CHECK 527:
SAMPLE COLLECTED?

FILTER PAPER 1
NO SAMPLE 2

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

BLOOD TAKEN (GO TO 530)
BLOOD NOT TAKEN (GO TO NEXT WOMAN)

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________
RESPONDENT REFUSED 3 (SIGN) ________

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________
RESPONDENT REFUSED 3 (SIGN) ________

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

BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6

535. CHECK 534:
OUTCOME OF SYPHILIS TEST

BLOOD TAKEN (GO TO 536)
BLOOD NOT TAKEN (GO TO NEXT WOMAN)

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)

LINE NUMBER ___
NAME ___________

538. AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-59 YEARS 2 (GO TO 541)

539. MARITAL STATUS: CHECK COLUMN 8.

CODE 6 (NEVER IN UNION) 1
OTHER _______________ 6 (GO TO 541)

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

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT __

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________
RESPONDENT REFUSED 3 (SIGN) ________

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

BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6

545. CHECK 527:
SAMPLE COLLECTED?

FILTER PAPER 1
NO SAMPLE 2

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

BLOOD TAKEN (GO TO 547)
BLOOD NOT TAKEN (GO TO NEXT MAN)

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________
RESPONDENT REFUSED 3 (SIGN) ________

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.

GRANTED 1 (SIGN) ________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ________
RESPONDENT REFUSED 3 (SIGN) ________

550. 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.

551. OUTCOME OF SYPHILIS TEST PROCEDURE

BLOOD TAKEN 1
NOT PRESENT 2
REFUSED 3
OTHER 6

552. CHECK 550:
OUTCOME OF SYPHILIS TEST

BLOOD TAKEN
BLOOD NOT TAKEN (GO TO NEXT MAN)

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?