LOCALITY NAME____________
NAME OF HOUSEHOLD HEAD___________
CLUSTER NUMBER________________
HOUSEHOLD NUMBER____________
PROVINCE_____________
URBAN 2
OTHER CITY 2
TOWN 3
VILLAGE 4
DATE________
DAY______
MONTH_____
YEAR_______
INTERVIEWER NAME________
RESULTS________
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) __________________ 9
NEXT VISIT:
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
BEMBA 02
KAONDE 03
LOZI 04
LUNDA 05
LUVALE 06
NYANJA 07
TONGA 08
OTHER 09
NATIVE LANGUAGE OF RESPONDENT_______
BEMBA 02
KAONDE 03
LOZI 04
LUNDA 05
LUVALE 06
NYANJA 07
TONGA 08
OTHER 09
NO 2
NAME______
DATE_______
FIELD EDITOR
NAME_________
DATE____________
OFFICER EDITOR_____
KEYED BY______
Hello. My name is____________. I am working with the Ministry of Health in collaboration with Central Statistical Office (CSO). We are conducting a survey about health all over Zambia. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 20 to 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. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop at any time.
In case you need more information about the survey, you may contact the person listed on this card.
GIVE CARD WITH CONTACT INFORMATION
Do you have any questions?
Date: _______
May I begin the interview now?
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED. . . . 2 END
Now we would like some information about the people who usually live in your household or who are staying with you now.
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 LISTING IS COMPLETE.
Just to make sure that I have a complete listing:
2A) Are there any other persons such as small children or infants that we have not listed?
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?
NO
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 CO-WIFE
04 SON OR DAUGHTER
05 SON-IN-LAW OR DAUGHTER-IN-LAW
06 GRANDCHILD
07 PARENT
08 PARENT-IN-LAW
09 BROTHER OR SISTER
10 NIECE/NEPHEW BY BLOOD
11 NIECE/NEPHEW BY MARRIAGE
12 OTHER RELATIVE
13 ADOPTED/FOSTER/STEPCHILD
14 NOT RELATED
98 DON'T KNOW
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (Name) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
7. AGE: How old is (Name)?
IF 95 OR MORE RECORD '95'
8. MARITAL STATUS IF AGE 15 OR OLDER: What is (NAME)'s current marital status?
2 DIVORCED
3 SEPARATED
4 WIDOWED
5 NEVER-MARRIED
9. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49________
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59____________
11. CIRCLE NUMBER OF ALL CHILDREN AGE 0-5___________
12. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Is (Name)'s natural mother alive?
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)
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?
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)
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
16. EVER ATTENDED SCHOOL: Has (NAME) ever attended school?
NO 2 (NEXT LINE)
17. What is the highest level of school (NAME) has attended?
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW
98 DON'T KNOW
17a. What is the highest grade (NAME) completed at that level?
98 DON'T KNOW
18. CURRENT/RECENT SCHOOL ATTENDANCE: Did (NAME) attend school at any time during the 2013 school year?
NO 2 (NEXT LINE)
19. During this/that school year, what level and grade [is/was] (NAME) attending?
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW
20. BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
2 REGISTERED
3 NEITHER
8 DON'T KNOW
Q21. TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS
LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.
LINE NUMBER OF SELECTED WOMEN __ __
NAME OF SELECTED WOMAN______________________
LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER (COLUMN)
TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 9
Rows of numbers 1 through 8, 1 number in each column, follows.
SECTION 1: HOUSEHOLD CHARACTERISTICS:
101. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5
102. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) _________________ 96
103. Where is that water source located?
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
ON PREMISES 996
DON'T KNOW 998
105. Do you do anything to the water to make it safer to drink?
NO 2 (GO TO 106A)
DON'T KNOW 8 (GO TO 106A)
106. What do you usually do to make the water safer to drink?
RECORD ALL MENTIONED
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
106A. How do you store your drinking water?
OPEN CONTAINER/BUCKET 2
DOES NOT STORE WATER 3
OTHER (SPECIFY)__________________ 6
107. What kind of toilet facility do members of your household usually use?
FLUSH TO SPECIFIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER (SPECIFY) ______________ 96
108. Do you share this toilet facility with other households?
NO 2 (GO TO 110)
109. How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
110. Does your household have?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
111. What type of fuel does your household mainly use for cooking?
SOLAR POWER 02
LIQUID PROPANE GAS (LPG) 03
NATURAL GAS 04
BIOGAS 05
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 114)
OTHER (SPECIFY)________________ 96
112. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFY)_________ 6 (GO TO 114)
113. Do you have a separate room which is used as a kitchen?
NO 2
114. MAIN MATERIAL OF THE FLOOR: RECORD OBSERVATION
DUNG 12
PALM/BAMBOO/LEEDS 22
VINYL (PVC) OR ASPHALT STRIPS 32
CERAMIC/TERRAZZO TILES 33
CONCRETE CEMENT 34
CARPET 35
115. MAIN MATERIAL OF THE ROOF: RECORD OBSERVATION
THATCH/PALM LEAF 12
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBRE (ASBESTOS) 33
CERAMIC TILES/HARVEY TILES 34
CEMENT 35
ROOFING SHINGLES 36
MUD TILES 37
116. MAIN MATERIAL OF THE EXTERIOR WALLS: RECORD OBSERVATION
CANE/PALM/TRUNKS 12
MUD 13
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
REUSED WOOD 25
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS 35
117. How many rooms in this household are used for sleeping?
118. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
119. Does any member of this household own any agricultural land?
NO 2 (GO TO 121)
120. How much lima, acres, or hectares of agricultural land do members of this household own?
ACRES 2__ __.__
HECTARES 3__ __.__
95 OR MORE HECTARES 995
DON'T KNOW 998
121. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 123)
122. How many of the following animals does this household own?
IF NONE, ENTER '00'
IF MORE, THAN 95, ENTER '95'
IF UNKNOWN, ENTER '98'
123. Does any member of this household have a bank account?
NO 2
124. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (GO TO 126)
DON'T KNOW (GO TO 126)
125. Who sprayed the dwelling?
PRIVATE COMPANY B
NON GOVERNMENTAL ORGANISATION (NGO) C
OTHER (SPECIFY) ____________x
DON'T KNOW Y
126. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 136)
127. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'
Questions 128 through 135 ask for NETS 1-3:
128. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S)
NOT OBSERVED 2
129. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
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
OLICET 12
OTHER/DK BRAND 16 (SKIP TO 133)
DK BRAND 98
131. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (GO TO 133)
NOT SURE (GO TO 133)
132. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
133. Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 135)
NOT SURE 8 (GO TO 135)
134. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE
135. GO BACK TO 128 FOR NEXT NET; IF NO MORE NETS, GO TO 136
136. Please show me where members of your household most often wash their hands.
NOT OBSERVED: NOT IN DWELLING/YARD/PLOT 2 (GO TO 139)
NOT OBSERVED: NO PERMISSION TO SEE 3 (GO TO 139)
NOT OBSERVED: OTHER REASON 4 (GO TO 139)
137. OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE OF HANDWASHING.
WATER IS NOT AVAILABLE 2
138. OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.
ASH, MUD, SAND B
NONE C
139. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON)_____________6
SECTION 2: WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5
201. CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
ASK QUESTIONS 202- 208 FOR CHILDREN 1-6:
202.
203. IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?
204. CHECK 203: CHILD BORN IN JANUARY 2008 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 209)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207. MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
NOT MEASURED 3
208. GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 209.
WEIGHT, HEIGHT, AND HIV TESTING FOR WOMEN AGE 15-49
209. CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 210. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
ASK QUESTIONS 211 TO 251B FOR WOMEN 1-3
210.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
18-49 YEAR 2 (GO TO 220)
214. MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 220)
215. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
216. ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/ OTHER ADULT IDENTIFIED IN 215 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 Zambia.
For the HIV test, we need a few drops of blood from a finger. The blood will be collected on a paper card. 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. I will provide her with a list of [nearby] facilities offering counselling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to give blood on a paper card for the HIV test?
217. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 252)
SIGN______________________________
218. ASK FOR CONSENT FOR RAPID HIV TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 215 RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
If you want (NAME OF ADOLESCENT) to know her HIV status, I can do a rapid test for her and I can tell her the result. The rapid test is simple and accurate. It takes about 30 minutes.
For the HIV test, we need a few (more) drops of blood from a finger. The blood will be from the same finger prick used to collected blood on the card. 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. I will use two tests to determine the HIV result. I will tell her the result of the tests.
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 give blood for the HIV rapid test?
219. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
SIGN_______________________
220. 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 Zambia.
For the HIV test, we need a few drops of blood from a finger. The blood will be collected on a paper card. 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. I will provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services that can be used at any of these facilities.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you give blood on a paper card for the HIV test?
221. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (IF REFUSED, GO TO 252)
SIGN_______________________
222. CHECK 219: PARENTAL CONSENT FOR RAPID HIV TEST
CODE 2 2 (GO TO 227)
223. ASK CONSENT FOR RAPID HIV TEST FROM RESPONDENT
If you want to know your HIV status, I can do a rapid test and I can tell you the result. The rapid test is simple and accurate. It takes about 30 minutes.
For the HIV test, we need a few (more) drops of blood from a finger. The blood will be from the same finger prick used to collected blood on the card. 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. I will use the two tests to determine the HIV result. I will tell you the result of the tests right away.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you give blood for the rapid HIV test?
224. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2
SIGN__________________________
18-49 2 (GO TO 229)
226. MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 229)
227. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 215 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
We ask you to allow the Ministry of Health to store part of the blood sample on the card at the laboratory for additional tests or research. It is likely that the samples will be used for additional HIV testing in a laboratory. We are not certain about what other additional tests might have been 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 for additional testing?
228. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 231)
SIGN______________
229. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT
We ask you to allow the Ministry of Health to store part of the blood sample on the card at the laboratory for additional tests or research. It is likely that the samples will be used for additional HIV testing in a laboratory. We are not certain about what other additional tests 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?
230. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (IF REFUSED, GO TO 232)
SIGN______________
CHECK 228 AND 230: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
232. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH VCT AND TEST(S).
233. BAR CODE LABEL FOR FILTER PAPER. PUT THE 2ND BAR CODE LABEL ON THE RESPONDENTS FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
234. RECORD THE RESULT CODE OF THE HOME-BASED HIV TESTING
NOT PRESENT 2 (GO TO 252)
PARENT REFUSED 3 (GO TO 252)
RESPONDENT REFUSED 4 (GO TO 252)
OTHER 6 (GO TO 252)
235. RECORD RESULT OF THE DETERMINE HIV RDT
UNIGOLD NON-REACTIVE 2
INVALID 3
OTHER 6
235A. RECORD RESULT OF UNIGOLD HIV RDT
UNIGOLD NON-REACTIVE 2
INVALID 3
OTHER 6
236. CHECK 235: DETERMINE RESULT
ANY OTHER CODE 2
236A. CHECK 235A: UNIGOLD RESULT
ANY OTHER CODE 2 (GO TO 252)
18-49 YEARS 2 (GO TO 241)
238. MARITAL STATUS: CHECK COLUMN 8
OTHER 2 (GO TO 252)
239. ASK FOR CONSENT FOR VENOUS BLOOD COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 215 RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.
We would like to collect more blood from (NAME OF ADOLESCENT) to do additional testing. The additional tests will see how many CD4 cells (NAME OF ADOLESCENT) has. CD4 cells help a person stay healthy. We will use the same blood in a central laboratory to test for new HIV infections.
If you agree, we would like to draw a little bit of blood from (NAME OF ADOLESCENT)'s arm. We will take about a teaspoon of blood. 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 to the tests. We will return to the household to tell (NAME OF ADOLESCENT) the CD4 test results. No one will be able to know (NAME OF ADOLESCENT)'s test results.
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 give blood from her arm for the tests?
240. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
SIGN_________________________
241. ASK CONSENT FO R VENOUS BLOOD COLLECTION FROM RESPONDENT
We would like to collect more blood from you to do additional testing. The additional tests will see how many CD4 cells (NAME OF ADOLESCENT) has. CD4 cells help a person stay healthy. We will use the same blood in a central laboratory to test for new HIV infections.
If you agree, we would like to draw a little bit of blood from your arm. We will take about a teaspoon of blood. 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 to the tests. We will return to the household to tell you the CD4 test results. No one will be able to know (NAME OF ADOLESCENT)'s test results.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you give blood from her arm for the tests?
246. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED GO TO 249)
SIGN______________________________
247. ASK 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 tests 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 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?
248. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (IF REFUSED, GO TO 250)
SIGN________________________________
CHECK 246 AND 248:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE TRANSMITTAL FORM.
250. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE VENOUS BLOOD COLLECTION IF CONSENT HAS BEEN OBTAINED AND PROCEED.
251. BAR CODE LABEL FOR BLOOD TUBE
PUT THE 5TH BAR CODE LABEL ON THE RESPONDENT'S BLOOD TUBE AND THE 6TH ON THE TRANSMITTAL FORM. PUT THE 7TH LABEL ON THE CD4 RESULT FORM.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
251A. RECORD THE DATE OF THE VENOUS BLOOD COLLECTION
251B. RECORD THE TIME OF THE VENOUS BLOOD COLLECTION
MINUTES______________
252. GO BACK TO 211 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ANY ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 253.
253. CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 254. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
254. LINE NUMBER FROM COLUMN 10
18-59 YEARS 2 (GO TO 264)
258. MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 264)
259. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
260. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 259 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 Zambia.
For the HIV test, we need a few drops of blood from a finger. The blood will be collected on a paper card. 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 results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. I will 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 give blood on a paper card for the HIV test?
261. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 296)
SIGN____________________
262. If you want (NAME OF ADOLESCENT) to know his HIV status, I can do a rapid test for him and I can tell him the result. The rapid test is simple and accurate. It takes about 30 minutes.
For the HIV test, we need a few (more) drops of blood from a finger. The blood will be from the same finger prick used to collected blood on the card. 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. I will use two tests to determine the HIV result. I will tell him the result of this tests.
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 give blood for the HIV rapid test?
263. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
SIGN______________
264. 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 Zambia.
For the HIV test, we need a few drops of blood from a finger. The blood will be collected on a paper card. 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 results. No one else will be able to know your test results either. I will provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services that can be used at any of these facilities.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you give blood on a paper card for the HIV test?
265. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (IF REFUSED, GO TO 296)
SIGN___________________
266. CHECK 263: PARENTAL CONSENT FOR RAPID HIV TEST
CODE 2 (GO TO 271)
267. ASK CONSENT FOR RAPID HIV TEST FROM RESPONDENT
If you want to know your HIV status, I can do a rapid test for you and I can tell you the result. The rapid test is simple and accurate. It takes about 30 minutes.
For the HIV test, we need a few (more) drops of blood from a finger. The blood will be from the same finger prick used to collected blood on the card. 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. I will use two tests to determine the HIV result. I will tell you the result of the tests right away.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you give blood for the HIV rapid test?
268. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2
SIGN_________________
18-59 YEARS 2 (GO TO 273)
270. MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 273)
271. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 259 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 on the card at the laboratory for additional tests or research. It is likely that the samples will be used for additional HIV testing in a laboratory. We are not certain about what other tests 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?
272. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 275)
SIGN_____________________________
273. We ask you to allow the Ministry of Health to store part of the blood sample on the card at the laboratory for additional tests or research. It is likely that the samples will be used for additional HIV testing in a laboratory. We are not certain about what other tests 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?
274. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2
SIGN_______________
CHECK 272 AND 274:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
276. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH VCT AND TEST(S).
277. BAR CODE LABEL FOR FILTER PAPER
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
278. RECORD THE RESULT CODE OF THE HOME-BASED HIV TESTING
NOT PRESENT 2 (GO TO 296)
PARENT REFUSED 3 (GO TO 296)
RESPONDENT REFUSED 4 (GO TO 296)
OTHER 6 (GO TO 296)
279. RECORD THE RESULT OF THE DETERMINE HIV PLOT
DETERMINE NON-REACTIVE 2
INVALID 3
OTHER 6
279A. RECORD RESULT OF THE UNIGOLD HIV RDT
UNIGOLD NON-REACTIVE 2
INVALID 3
OTHER 6
280. CHECK 279: DETERMINE RESULT
ANY OTHER CODE 2
280A. CHECK 279A: UNIGOLD RESULT
ANY OTHER CODE 2 (GO TO 296)
18-59 YEARS 2 (GO TO 285)
282. MARITAL STATUS: CHECK COLUMN 8.
OTHER 2 (GO TO 285)
283. ASK CONSENT FOR VENOUS BLOOD COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 259 RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.
We would like to collect more blood from (NAME OF ADOLESCENT) to do additional testing. The additional tests will see how many CD4 cells (NAME OF ADOLESCENT) has. CD4 cells help a person stay healthy. We will use the same blood in a central laboratory to test for new HIV infections.
If you agree, we would like to draw a little bit of blood from (NAME OF ADOLESCENT)'s arm. We will take about a teaspoon of blood. 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 to the tests. We will return to the household to tell (NAME OF ADOLESCENT) the CD4 test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results.
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 give blood from his arm for the tests?
284. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 296)
SIGN______________________
285. ASK FOR CONSENT FOR VENOUS BLOOD COLLECTION FROM RESPONDENT
We would like to collect more blood from you to do additional testing. The additional tests will see how many CD4 cells you have. CD4 cells help a person stay healthy. We will use the same blood in a central laboratory to test for new HIV infections.
If you agree, we would like to draw a little bit of blood from your arm. We will take about a teaspoon of blood. 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 to the tests. We will return to the household to tell you the CD4 test results. No one else will be able to know your test results.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you give blood from his arm for the tests?
286. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (IF REFUSED, GO TO 296)
SIGN__________________________
18-59 YEARS 2 (GO TO 291)
288. MARITAL STATUS CHECK COLUMN 8.
OTHER 2 (GO TO 291)
289. ASK FOR CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 259 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 tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do 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 of this survey. Will you allow us to keep the blood sample stored for additional testing?
290. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 293)
SIGN____________________________________
291. 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 tests 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?
292. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2
SIGN_______________________
CHECK 290 AND 292:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE TRANSMITTAL FORM.
294. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE VENOUS BLOOD COLLECTION IF CONSENT HAS BEEN OBTAINED AND PROCEED.
295. BAR CODE LABEL FOR BLOOD TUBE.
PUT THE 5th BAR CODE LABEL ON THE RESPONDENT'S BLOOD TUBE AND THE 6th ON THE TRANSMITTAL FORM. PUT THE 7th LABEL ON THE CD4 RESULT FORM.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
295A. RECORD THE DATE OF THE VENOUS BLOOD COLLECTION
295B. RECORD THE TIME OF THE VENOUS BLOOD COLLECTION
MINUTES___________
296. GO BACK TO 257 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.