FORMATTING DATE: 09 Jun 2015
ENGLISH LANGUAGE: 23 Oct 2014
2018 ZAMBIA DEMOGRAPHIC AND HEALTH SURVEY
BIOMARKER QUESTIONNAIRE
ZAMBIA MINISTRY OF HEALTH / CENTRAL STATISTICAL OFFICE
IDENTIFICATION
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
FIELDWORKER VISITS
DATE
FIELDWORKER'S NAME
NEXT VISIT
TIME
FINAL VISIT
MONTH
YEAR
TOTAL NUMBER OF VISITS
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN
LANGUAGE OF QUESTIONNAIRE** 01 ENGLISH
LANGUAGE OF INTERVIEW**
NATIVE LANGUAGE OF RESPONDENT**
NO 2
02 BEMBA
03 KAONDE
04 LOZI
05 LUNDA
06 LUVALE
07 NYANJA
08 TONGA
DATE________
WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5
101. CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.
NAME_________
NAME_________
NAME_________
103. IF MOTHER INTERVIEWED: COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED ASK:
What is (NAME)'s date of birth?
MONTH________
YEAR________
104. CHECK 103: CHILD BORN IN 2013-2018?
NO 2 (SKIP TO 114)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994 (SKIP TO 108)
REFUSED 9995 (SKIP TO 108)
OTHER 9996 (SKIP TO 108)
107. MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
OLDER 2
110. LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR THE CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.
(RECORD '00' IF NOT LISTED)
111. ASK CONSENT FOR ANEMIA TEST FROM PARENT / OTHER ADULT.
As part of this survey, we are asking people all over the country to take an anemia test.
Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. We ask that all children born in 2013 or later take part in the anemia testing and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
112. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)____________
REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)____________
NOT PRESENT / OTHER 3 (SKIP TO 114)
113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
REFUSED 995
OTHER 996
114. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.
##NOTE: QUESTIONS 102-114 REPEATED FOR CHILDREN 4-6
HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49
201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 208, AND 209. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9.
NAME_________
NAME________
NAME________
208. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-49 YEARS 2 (SKIP TO 210)
209. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NAME FROM COLUMN 2.
NAME________
210. ASK CONSENT FOR ANEMIA TEST.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
211. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)________
RESPONDENT REFUSED 2 (SKIP TO 212)
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)________
NOT PRESENT / OTHER 3 (SKIP TO 212)
211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
ADULT RESPONDENT CONSENT FOR DBS COLLECTION
212. ASK CONSENT FOR DBS COLLECTION.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few (more) 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 we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
213. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER ID)________
RESPONDENT REFUSED 2 (SKIP TO 216)
(SIGN AND ENTER YOUR FIELDWORKER ID)________
NOT PRESENT / OTHER 3 (SKIP TO 216)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
214. ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other information 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?
215. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)_______
RESPONDENT REFUSED 2
(SIGN)_______
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
214. ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other information 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?
215. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)________
RESPONDENT REFUSED 2
(SIGN)________
ADULT RESPONDENT CONSENT FOR RDT TESTING
216. ASK CONSENT FOR HIV RDT TEST.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
217. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN, ENTER YOUR FIELDWORKER NUMBER, AND SKIP TO 239)_______
RESPONDENT REFUSED 2
(SIGN, ENTER YOUR FIELDWORKER NUMBER, AND SKIP TO 239)_______
NOT PRESENT / OTHER 3 (SKIP TO 239)
218. RECORD LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
(RECORD '00' IF NOT LISTED)
PARENTAL / RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
219. ASK CONSENT FOR ANEMIA TEST FROM PARENT / ADULT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from (NAME OF MINOR)'s finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF MINOR) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
220. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
NOT PRESENT / OTHER 3
PARENTAL / RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
221. ASK CONSENT FOR DBS COLLECTION FROM PARENT / ADULT.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few (more) 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 we take the blood. No names will be written on the paper card so we will not be able to tell you the results of (NAME OF MINOR)'s test. No one else will be able to know (NAME OF MINOR)'s test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood on a paper card for HIV testing in a laboratory?
222. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SKIP TO 225)
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
NOT PRESENT / OTHER 3 (SKIP TO 225)
PARENTAL / RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
223. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT / ADULT.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
224. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)__________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN)__________
PARENTAL / RESPONSIBLE ADULT CONSENT FOR RDT TESTING
225. ASK CONSENT FOR RDT TEST FROM PARENT / ADULT.
If you want (NAME OF MINOR) to know her HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give (NAME OF MINOR) a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
226. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)___________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)___________
NOT PRESENT / OTHER 3
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
227. CHECK 220: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 230)
228. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT / RESPONSIBLE ADULT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
229. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)_________
MINOR RESPONDENT REFUSED 2 (SKIP TO 230)
(SIGN)________
NOT PRESENT / OTHER 3 (SKIP TO 230)
229A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
230. CHECK 222: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 236)
231. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few (more) 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 we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood on a paper card for HIV testing in a laboratory?
232. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN)_______
MINOR RESPONDENT REFUSED 2 (SKIP TO 236)
(SIGN)_______
NOT PRESENT / OTHER 3 (SKIP TO 236)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
233. CHECK 224: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 236)
234. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR 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. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
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?
235. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)________
MINOR RESPONDENT REFUSED 2
(SIGN)________
MINOR RESPONDENT CONSENT FOR RDT TEST
236. CHECK 226: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 239)
237. ASK CONSENT FOR RDT TEST FROM MINOR RESPONDENT.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
238. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN)________
MINOR RESPONDENT REFUSED 2
(SIGN)________
NOT PRESENT / OTHER 3
239. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
240. ADDITIONAL TESTS.
IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 224 AND 235.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
241. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
243. RECORD THE RESULT OF THE "DETERMINE HIV RDT" HERE.
NEGATIVE 2 (SKIP TO 246)
NOT PRESENT 3 (SKIP TO 248)
REFUSED 4 (SKIP TO 248)
OTHER 5 (SKIP TO 248)
244. RECORD THE RESULT OF THE "UNIGOLD HIV RDT" HERE.
NEGATIVE 2 (SKIP TO 247)
NOT PRESENT 3 (SKIP TO 248)
REFUSED 4 (SKIP TO 248)
OTHER 5 (SKIP TO 248)
245. IF 243 AND 244 ARE POSITIVE, RESPONDENT IS HIV POSITIVE:
INFORM SURVEY PARTICIPANT ABOUT POSITIVE HIV STATUS AND PROVIDE POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV CARE AND TREATMENT SERVICES ARE AVAILABLE.
246. IF 243 IS NEGATIVE, RESPONDENT IS HIV NEGATIVE:
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING.
SKIP TO 248
247. IF 243 IS POSITIVE AND 244 IS NEGATIVE, RESPONDENT'S HIV STATUS IS INDETERMINATE:
INFORM THE RESPONDENT OF INDETERMINATE TEST RESULT, AND CONDUCT POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, RECOMMEND THAT RESPONDENT IS RETESTED WITHIN 14 DAYS AND PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV TESTING CAN BE CONDUCTED.
248. WHILE TESTING THIS PERSON, WAS ANY RDT INVALID / DID ANY RDT FAIL TO RUN, THAT IS, THE CONTROL BAND DID NOT APPEAR?
NO 2 (SKIP TO 251)
249. RECORD NUMBER OF INVALID RESULTS USING "DETERMINE HIV RDT".
250. RECORD NUMBER OF INVALID RESULTS USING "UNIGOLD HIV RDT" HERE.
251. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.
301. CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 308, AND 309.
IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
302. CHECK HOUSEHOLD QUESTIONNAIRE:
LINE NUMBER FROM COLUMN 10.
NAME FROM COLUMN 2.
NAME________
NAME________
NAME________
308. CHECK HOUSEHOLD QUESTONNAIRE COLUMN 7 (AGE):
18-59 YEARS 2 (SKIP TO 310)
309. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NAME FROM COLUMN 2.
NAME_________
ADULT RESPONDENT CONSENT FOR DBS COLLECTION
310. ASK CONSENT FOR DBS COLLECTION.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, 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 we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood on a paper card for HIV testing in a laboratory?
311. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)________
RESPONDENT REFUSED 2 (SKIP TO 314)
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)________
NOT PRESENT / OTHER 3 (SKIP TO 314)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
312. ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research.
These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
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?
313. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)_______
RESPONDENT REFUSED 2
(SIGN)_______
ADULT RESPONDENT CONSENT FOR RDT TEST
314. ASK CONSENT FOR RDT TEST.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the rapid HIV testing?
315. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN, ENTER YOUR FIELDWORKER NUMBER, AND SKIP TO 332)__________
RESPONDENT REFUSED 2
(SIGN, ENTER YOUR FIELDWORKER NUMBER, AND SKIP TO 332)__________
NOT PRESENT / OTHER 3 (SKIP TO 332)
316. RECORD LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
(RECORD '00' IF NOT LISTED)
PARENT / RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
317. ASK CONSENT FOR DBS COLLECTION FROM PARENT / ADULT.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, 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 we take the blood. No names will be written on the paper card so we will not be able to tell you the results of (NAME OF MINOR)'s test. No one else will be able to know (NAME OF MINOR)'s test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood on a paper card for HIV testing in a laboratory?
318. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SKIP TO 321)
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
NOT PRESENT / OTHER 3 (SKIP TO 321)
PARENTAL / RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
319. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT / ADULT.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
320. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)___________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN)____________
PARENTAL / RESPONSIBLE ADULT CONSENT FOR RDT TEST
321. ASK CONSENT FOR RDT TEST FROM PARENT / ADULT.
If you want (NAME OF MINOR) to know his HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give (NAME OF MINOR) a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the rapid HIV test?
322. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2
(SIGN AND ENTER YOUR FIELDWORKER NUMBER)__________
NOT PRESENT / OTHER 3
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
323. CHECK 318: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 329)
324. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, 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 we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood on a paper card for HIV testing in a laboratory?
325. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)_________
MINOR RESPONDENT REFUSED 2 (SKIP TO 329)
(SIGN)_________
NOT PRESENT / OTHER 3 (SKIP TO 329)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
326. CHECK 320: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 329)
327. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR 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. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
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 an 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?
328. CIRCLE THE CODE AND SIGN YOUR NAME.
(SIGN)_________
MINOR RESPONDENT REFUSED 2
(SIGN)_________
MINOR RESPONDENT CONSENT FOR RDT TEST
329. CHECK 322: WAS CONSENT GRANTED?
NO OR NOT ASKED (SKIP TO 332)
330. ASK CONSENT FOR RDT TEST FROM MINOR RESPONDENT.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the rapid HIV testing?
331. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
(SIGN)_________
MINOR RESPONDENT REFUSED 2
(SIGN)_________
NOT PRESENT / OTHER 3
332. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
333. ADDITIONAL TESTS.
IF ADULT RESPONDENT, CHECK 313; IF MINOR RESPONDENT, CHECK 320 AND 328.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
334. PLACE BAR CODE LABEL.
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
335. RECORD THE RESULT OF THE "DETERMINE HIV RDT" HERE.
NEGATIVE 2 (SKIP TO 338)
NOT PRESENT 3 (SKIP TO 340)
REFUSED 4 (SKIP TO 340)
OTHER 5 (SKIP TO 340)
336. RECORD THE RESULT OF THE "UNIGOLD HIV RDT" HERE.
NEGATIVE 2 (SKIP TO 339)
NOT PRESENT 3 (SKIP TO 340)
REFUSED 4 (SKIP TO 340)
OTHER 5 (SKIP TO 340)
337. IF 335 AND 336 ARE POSITIVE, RESPONDENT IS HIV POSITIVE:
INFORM SURVEY PARTICIPANT ABOUT POSITIVE HIV STATUS AND PROVIDE POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV CARE AND TREATMENT SERVICES ARE AVAILABLE.
338. IF 335 IS NEGATIVE, RESPONDENT IS HIV NEGATIVE:
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING.
SKIP TO 340
339. IF 335 IS POSITIVE AND 336 IS NEGATIVE, RESPONDENT'S HIV STATUS IS INDETERMINE:
INFORM THE RESPONDENT OF INDETERMINATE TEST RESULT, AND CONDUCT POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, RECOMMEND THAT RESPONDENT IS RETESTED WITHIN 14 DAYS AND PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV TESTING CAN BE CONDUCTED.
340. WHILE TESTING THIS PERSON, WAS ANY RDT INVALID / DID ANY RDT FAIL TO RUN, THAT IS, THE CONTROL BAND DID NOT APPEAR?
NO 2 (SKIP TO 343)
341. RECORD NUMBER OF INVALID RESULTS USING "DETERMINE HIV RDT"
342. RECORD NUMBER OF INVALID RESULTS USING "UNIGOLD HIV RDT" HERE.
343. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
SUPERVISOR'S OBSERVATIONS
EDITOR'S OBSERVATIONS