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2010 DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE (ENGLISH)

ZIMBABWE

ZIMSTAT

IDENTIFICATION

PLACE NAME

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

INTERVIEWER VISITS:

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT*

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT*

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT*

TOTAL NUMBER OF VISITS

*RESULT CODES

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT 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)_________


TOTAL PERSONS IN HOUSEHOLD___

TOTAL ELIGIBLE WOMEN___

TOTAL ELIGIBLE MEN___

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME

FIELD EDITOR
NAME

OFFICE EDITOR

KEYED BY

Introduction and Consent

Hello. My name is ______________________________. I am working with the Central Statistical Office/ZIMSTAT. We are conducting a survey about health all over Zimbabwe. 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 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than the members of our survey team. It's up to if you want 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 the interview 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?
May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________________________ DATE:______________

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

HOUSEHOLD SCHEDULE

1) LINE NO.

2) USUAL RESIDENTS AND VISITORS

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

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 who stayed here last night, who have not been listed?

YES (ADD TO TABLE)
NO

3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF 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 = OTHER RELATIVE
10 = ADOPTED/FOSTER/STEPCHILD
11 = NOT RELATED
98 = DON'T KNOW

4) SEX
Is (NAME) male or female

MALE 1
FEMALE 2

RESIDENCE

5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

AGE IN YEARS___

IF AGE 15 OR OLDER

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

MARRIED OR LIVING TOGETHER 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER-MARRIED AND NEVER LIVED TOGETHER 4

ELIGIBILITY

9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

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

YES 1
NO 2 (GO TO 14)
DON'T KNOW (GO TO 14)

13) Does (NAMES)'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___

14) Is name's natural father alive?

YES 1
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'.

LINE NUMBER___

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (name) ever attended school?

YES 1
NO 2 (GO TO NEXT LINE)

17) What is the highest level of school (NAME) has attended? SEE CODES BELOW.
What is this highest grade (NAME) completed at that level? SEE CODES BELOW.

CODES FOR Qs. 17 AND 19: EDUCATION

LEVEL

0 = PRE-SCHOOL
1 = PRIMARY
2 = SECONDARY
3 = HIGHER
8 = DON'T KNOW

GRADE

00 = LESS THAN 1 YEAR COMPLETED (USE '00' FOR Q. 17 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 19)
98 = DON'T KNOW
LEVEL
GRADE

IF AGE 5-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

18) Did (NAME) attend school at any time during the 2010 school year?

YES 1
NO 2 (GO TO NEXT LINE)

19) During this/that year, what level and grade [is/was] (NAME) attending? SEE CODES.

LEVEL
GRADE

IF AGE 0-4 YEARS

BIRTH REGISTRATION

20) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the Births and Deaths Registry?

HAS CERTIFICATE 1
REGISTERED 2
NEITHER 3
DON'T KNOW 8

SELECTION OF RESPONDENT FOR SECTION ON HOUSEHOLD RELATIONS

21. ONLY ONE WOMAN PER HOUSEHOLD SHOULD BE SELECTED FOR HR MODULE.

USE THE TABLE BELOW TO SELECT THE WOMAN IN THIS HOUSEHOLD TO BE INTERVIEWED WITH HR MODULE.

HOUSEHOLD LINE NUMBER ___
NAME ___

GO TO COLUMN 9 IN THE HOUSEHOLD SCHEDULE AND WRITE 'HR' NEXT TO THE LINE NUMBER OF THE WOMAN.

HOW TO USE THE TABLE FOR SELECTION OF RESPONDENT FOR HR MODULE

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE ON THE COVER SHEET. THIS IS THE NUMBER OF THE ROW YOU SHOULD CIRCLE. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD CIRCLE.

FIND THE BOX [IN THE TABLE BELOW] WHERE THE CIRCLED ROW AND THE CIRCLED 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 HOUSEHOLD RELATIONS QUESTIONS. GO TO COLUMN 9 OF THE HOUSEHOLD SCHEDULE AND PUT A 'HR' NEXT TO THE LINE NUMBER OF THE SELECTED ELIGIBLE WOMAN. RECORD HER NAME AND LINE NUMBER IN THE SPACE PROVIDED ABOVE.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS 3716, GO TO ROW 6 AND CIRCLE THE ROW NUMBER ('6'). IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN 3 AND CIRCLE THE COLUMN NUMBER ('3'). DRAW LINES FROM ROW 6 AND COLUMN 3, FIND THE BOX WHERE THE TWO LINES MEET, AND CIRCLE THE NUMBER IN IT ('2'). THIS MEANS THAT YOU HAVE TO SELECT THE SECOND ELIGIBLE WOMAN. SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE WOMEN ARE '02', '03', AND '07'. THEN THE ELIGIBLE WOMEN FOR THE HOUSEHOLD RELATIONS QUESTIONS IS THE SECOND ONE, I.E., THE WOMAN WITH THE HOUSEHOLD LINE NUMBER '03'. PUT A 'HR' NEXT TO THIS WOMAN'S LINE NUMBER IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE AND ALSO ENTER THE TWO DIGIT LINE NUMBER AND THE WOMAN'S NAME IN THE SPACE PROVIDED AT THE TOP OF THIS PAGE.

TABLE FOR SELECTION OF RESPONDENTS FOR HOUSEHOLD RELATIONS MODULE:

HEADER FOR LEFT-HAND COLUMN: "LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)" (VALUES 0-9 BELOW THIS)

HEADER FOR TOP ROW OF TABLE: TOTAL NUMBER OF ELIGIBLE WOMEN 15-49 IN THE HOUSEHOLD (COLUMN)

COLUMNS WITH 1'S, 2'S, 3'S, 4'S, 5'S, 6'S, 7'S, AND 8'S FILL THE CELLS OF THE TABLE.

HOUSEHOLD CHARACTERISTICS

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

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN ONCE A MONTH 4
NEVER 5

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13

TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
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 DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT (GO TO 105)
ELSEWHERE 3

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

MINUTES___
DON'T KNOW 998

105) Do you do anything to the water to make it safer to drink? IF YES, PROBE: Always or sometimes?

YES, ALWAYS 1
YES, SOMETIMES 2
NO 3 (GO TO 107)
DON'T KNOW 8 (GO TO 107)

106) What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE 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

107) What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET SYSTEM
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 (VIP)/BLAIR TOILET 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 14
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER (SPECIFY) 96

108) Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 110)

109) How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10____
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110) Does your dwelling unit/household have:

Electricity that is connected?
YES 1
NO 2
A battery or generator for power?
YES 1
NO 2
A solar panel for power?
YES 1
NO 2
A radio in working condition?
YES 1
NO 2
A television in working condition?
YES 1
NO 2
A mobile telephone in working condition?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator in working condition?
YES 1
NO 2
A computer in working condition?
YES 1
NO 2

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

ELECTRICITY 01
LIQUID PROPANE GAS (LPG) 02
NATURAL GAS 03
BIOGAS 04
PARAFFIN/KEROSENE 05
JELLY 06
COAL, LIGNITE 07
CHARCOAL 08
WOOD 09
STRAW/SHRUBS/GRASS 10
MAIZE/AGRICULTURAL CROP WASTE 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 THE HOUSE 1
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?

YES 1
NO 2

114) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

NATURAL ROOFING
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOORS
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96

115) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
WOOD PLANKS 23
FINISHED ROOFING
METAL 31
WOOD 32
ASBESTOS 33
TILES 34
CEMENT 35
OTHER (SPECIFY) 96

116) MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

NATURAL WALLS
CANE/TRUNKS 12
MUD 13
RUDIMENTARY WALLS
STONE WITH MUD 22
PLYWOOD 24
CARTON 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) 96

117) How many rooms in this household are used for sleeping?

ROOMS____

118) Does any member of this household own:

A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A tractor?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2
A wheelbarrow?
YES 1
NO 2

119) Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 121)

120) How many acres of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.

ACRES___
95 OR MORE ACRES 950
DON'T KNOW 998

121) Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 123)

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

Cattle?
__
Horses?
__
Donkeys or mules?
__
Goats?
__
Sheep?
__
Chicken or other poultry?
__
Rabbits?
__
Pigs?
__

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

YES 1
NO 2

124) At any time in the past 12 months, has anyone come to your dwelling to spray the interior walls and outside eaves against mosquitos?

YES 1
NO 2 (GO TO 126)
DON'T KNOW 8 (GO TO 126)

125) Who sprayed the dwelling?

GOVERNMENT WORKER PROGRAM/PROGRAM PRIVATE COMPANY A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) X
DON'T KNOW Y

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

YES 1
NO 2 (GO TO 137)

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

NUMBER OF NETS___

128) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 6 NETS, USE ADDITIONALL QUESTIONNAIRE(S).

NET OBSERVED 1
NET NOT OBSERVED 2

129) How many months did you household get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00'.

MONTHS AGO___
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.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
OLYSET 11 (GO TO 134)
PERMANET 12 (GO TO 134)
OTHER/ DON'T KNOW BRAND 16 (GO TO 134)
'PRETREATED' NET
KO TAB123 21 (GO TO 132)
IRONET 22 (GO TO 132)
OTHER/DON'T KNOW BRAND 26 (GO TO 132)
OTHER BRAND 96
DON'T KNOW BRAND 98

131) When you got the net, was it already soaked or dipped in a liquid to kill or repel mosquitos?

YES 1
NO 2
NOT SURE 8

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

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

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

MONTHS AGO___
MORE THAN 24 MONTHS AGO 95
NOT SURE 98

134) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 136)
NOT SURE 8 (GO TO 136)

135) Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME___
LINE NO.___

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137) Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 140)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 140)
NOT OBSERVED, OTHER REASON 4 (GO TO 140)

138) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE Y

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

IODINE PRESENT 1
NO IODINE 2
NO SALT IN THE HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON)___ 6

BIOMARKER DATA COLLECTION FORM

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

CLUSTER NUMBER___

HOUSEHOLD NUMBER___

NAME OF HOUSEHOLD HEAD:___

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202.

IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11

NAME FROM COLUMN 2

LINE NUMBER__
NAME__

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?

DAY
MONTH
YEAR

204) CHECK 203:

CHILD BORN IN JANURARY 2005 OR LATER?
YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214.)

205) WEIGHT IN KILOGRAMS

KILOGRAMS___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206) HEIGHT IN CENTIMETERS

CENTIMETERS___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207) MEASURED LYING DOWN OR STANDING?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

208) CHECK 203:

IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?
0-5 MONTHS 1 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214.)
OLDER 2

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE).

RECORD '00' IF NOT LISTED.

LINE NUMBER___

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

PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT FORM.

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

CONSENT FORM SIGNED 1 (SIGN NAME)
REFUSED 2

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

G/DL___
NOT PRESENT 994
REFUSED 995
OTHER 996

213) 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 214.

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

CLUSTER NUMBER___

HOUSEHOLD NUMBER___

NAME OF HOUSEHOLD HEAD___

214) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215.

IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) LINE NUMBER FROM COLUMN 9

NAME FROM COLUMN 2

LINE NUMBER___
NAME___

216) WEIGHT IN KILOGRAMS

KILOGRAMS___
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217) HEIGHT IN CENTIMETERS

CENTIMETERS___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

218) AGE: CHECK COLUMN 7

15-17 YEARS 1
18-49 YEARS 2 (GO TO 229.)

219) MARITAL STATUS: CHECK COLUMN 8.

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 229)

220) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE).

RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT

221) ASK CONSENT FOR ANEMIA, DBS COLLECTION AND ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR ADOLESCENT AND FROM ADOLESCENT.

PROVIDE PARENT/RESPONSIBLE ADULT AND ADOLESCENT WITH PARENTAL CONSENT AND ADOLESCENT ASSENT FORM
.

ANEMIA TEST

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 225)
SIGN___

223) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID ADOLESCENT GRANT CONSENT?
CONSENT FORM SIGNED 1
ADOLESCENT 2 (GO TO 225)
SIGN___

LINE NUMBER FROM COLUMN 9

NAME FROM COLUMN 2

LINE NUMBER___
NAME___

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

YES 1
NO 2
DON'T KNOW 8

DBS COLLECTION FOR HIV TESTING

225) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARRENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 235)

SIGN___

226) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER

DID ADOLESCENT GRANT CONSENT?
CONSENT FORM SIGNED 1
ADOLESCENT 2

SIGN___
INTERVIEWER NUMBER___

ADDITIONAL TESTING
227) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2

SIGN___

(IF REFUSED, WRITE 'NO ADDITIONAL TEST' ON THE FILTER PAPER. GO TO 235.)

228) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2

SIGN___

(IF REFUSED, WRITE 'NO ADDITIONAL TEST' ON THE FILTER PAPER. GO TO 235.)

229) ASK CONSENT FOR ANEMIA TEST, DBS COLLECTION AND ADDITIONAL TESTING FROM RESPONDENT.

PROVIDE ADULT CONSENT FORM.

LINE NUMBER FROM COLUMN 9

NAME FROM COLUMN 2

LINE NUMBER___
NAME___

ANEMIA TEST

230) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID RESPONDENT GRANT CONSENT?
CONSENT FORM SIGNED 1
RESPONDENT REFUSED 2 (GO TO 232)

SIGN___

231) PREGNANCY STATUS: CHECK IN 226 IN WOMEN'S QUESTIONNAIRE OR ASK: Are you pregnant?

YES 1
NO 2
DON'T KNOW 8

DBS COLLECTION FOR HIV TESTING

232) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME AND ENTER YOUR INTERVIEWER NUMBER

DID RESPONDENT GRANT CONSENT?
CONSENT FORM SIGNED 1
RESPONDENT REFUSED 2 (GO TO 235)

SIGN___
INTERVIEWER NUMBER___

ADDITIONAL TESTING

233) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

CONSENT FORM SIGNED 1
RESPONDENT REFUSED 2

SIGN___

234) ADDITIONAL TESTS

CHECK 233:

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

235) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT FORMS HAVE BEEN SIGNED AND PROCEED WITH THE TEST(S)

236) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL___

NOT PRESENT 994
REFUSED 995
OTHER 996

237) BAR CODE LABEL

(PUT THE 1ST BAR CODE LABEL HERE)

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.

238) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 243.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-54

CLUSTER NUMBER___

HOUSEHOLD NUMBER___

NAME OF HOUSEHOLD HEAD___

243) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244.

IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

244) LINE NUMBER FROM COLUMN 10

NAME FROM COLUMN 2

LINE NUMBER___
NAME___

245) WEIGHT IN KILOGRAMS

KILOGRAMS___
NOT PRESENT 99994
REFUSED 99995
OTHER 99996

246) HEIGHT IN CENTIMETERS

CENTIMETERS___
NOT PRESENT 9994
REFUSED 9995
OTHER 9996

247) AGE: CHECK COLUMN 7.

15-17 YEARS 1
18-54 YEARS 2 (GO TO 257)

248) MARITAL STATUS: CHECK COLUMN 8

CODE 4 (NEVER IN UNION) 1
OTHER 2 (GO TO 257)

249) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE).

RECORD '00' IF NOT LISTED.

LINE NUMBER OF PARENT OR OTHER RESPONSIBLE ADULT

250) ASK CONSENT FOR ANEMIA TEST, DBS COLLECTION AND ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR ADOLESCENT AND FROM ADOLESCENT.

PROVIDE PARENT/RESPONSIBLE ADULT AND ADOLESCENT WITH PARENTAL CONSENT AND ADOLESCENT ASSENT FORM.

ANEMIA TEST

251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSES 2 (GO TO 253)

SIGN___

252) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID ADOLESCENT GRANT CONSENT?
CONSENT FORM SIGNED 1
ADOLESCENT REFUSED 2

SIGN___

LINE NUMBER FROM COLUMN 10

NAME FROM COLUMN 2

LINE NUMBER__
NAME__

DBS COLLECTION FOR HIV TESTING

253) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (GO TO 262)

SIGN___

254) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER

DID ADOLESCENT GRANT CONSENT?
CONSENT FORM SIGNED 1
ADOLESCENT REFUSED 2

SIGN___

INTERVIEWER NUMBER___

ADDITIONAL TESTING

255) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID PARENT/OTHER RESPONSIBLE ADULT GRANT CONSENT?
CONSENT FORM SIGNED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2

SIGN___

(IF REFUSED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER. GO TO 262.)

256) CIRCLE THR APPROPRIATE CODE AND SIGN YOUR NAME.

DID ADOLESCENT GRANT CONSENT?
CONSENT FORM SIGNED 1
ADOLESCENT REFUSED 2

SIGN___

(IF REFUSED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER. GO TO 262.)

257) ASK CONSENT FOR ANEMIA TEST, DBS COLLECTION AND ADDITIONAL TESTING FROM RESPONDENT.

PROVIDE ADULT CONSENT FORM.

LINE NUMBER FROM COLUMN 10

NAME FROM COLUMN 2

LINE NUMBER___
NAME___

ANEMIA TEST

258) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

DID RESPONDENT GRANT CONSENT?
CONSENT FORM SIGNED 1
RESPONDENT 2

SIGN___

DBS COLLECTION FOR HIV TESTING

259) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER

DID RESPONDENT GRANT CONSENT?
CONSENT FORM SIGNED 1
RESPONDENT REFUSED 2

SIGN___

INTERVIEWER NUMBER___

ADDITIONAL TESTING

260) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

DID RESPONDENT GRANT CONSENT?
CONSENT FORM SIGNED 1
RESPONDENT 2

SIGN___

261) ADDITIONAL TESTS

CHECK 260: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

262) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT FORMS HAVE BEEN SIGNED AND PROCEED WITH THE TEST(S).

263) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

G/DL___
NOT PRESENT 994
REFUSED 995
OTHER 996

264) BAR CODE LABEL

(PUT THE 1ST BAR CODE LABEL HERE)

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.

265) GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

ADULT CONSENT FORM

ANAEMIA TESTING
PURPOSE
As part of the survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. The purpose of the anaemia testing is to establish the size of this problem in Zimbabwe. You are one of several thousand men, women and children selected at random as a possible participant in this study.

PROCEDURES AND DURATION
If you decide to have an anaemia test, you will undergo a finger prick in which a few drops of blood will be collected. The blood will be tested for anaemia immediately, and the result told to you right away.

RISKS AND DISCOMFORTS
The risks associated with procedure, including the risks to pregnant women, are minimal. 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. You will experience a slight pain during the finger prick.

BENEFITS
We cannot offer you any direct benefits from the testing. However, if we find that the test results indicate that medical attention is required, we will refer you to the nearest health facility.

CONFIDENTIALITY
If you indicate your willingness to be tested for anaemia by signing this document, any information that is obtained in connection with this study that can be identified with you will remain confidential and will not be disclosed to anyone other than members of our survey team.

VOLUNTARY PARTICIPATION
You can say yes to the test or you can say no. If you decide not to be tested, your decision will not affect your future relations with the Ministry of Health and Child Welfare, its personnel, and associated hospitals or with the Zimbabwe National Statistics Agency.

QUESTIONS
Before you sign this form, please ask any questions on any aspect of the anaemia testing that is unclear to you. You may take as much time as necessary to think it over.

AUTHORIZATION
You are making a decision whether or not to be tested for anaemia. Your signature indicates that you have understood the information provided above, have had all your questions answered, and have decided to participate.

Name of respondent (please print)___
Date/Time___

Signature of respondent or legally authorized representative___

HIV TESTING
PURPOSE
As part of this survey, we are asking people all over the country to provide a blood sample for HIV testing. HIV is the virus that causes AIDS. AIDS is a very serious health problem that has affected a lot of people in Zimbabwe. The purpose of the HIV testing is to find out how big this problem in Zimbabwe. You are one of several thousand men and women selected at random as a possible participant in providing a blood sample that will be used for HIV testing.

PROCEDURES AND DURATION
If you decide to provide a blood sample for HIV testing, you will undergo a finger prick in which a few drops of blood will be collected on a card. The HIV test will be done in the
National Microbiology Reference Laboratory in Harare. Because the card used to collect your blood will be labeled using a code and not your name, no one will be able to know your HIV test results. We will not be able to tell you the results of the test.

RISKS AND DISCOMFORTS
The risks associated with procedure, including the risks to pregnant women, are minimal. 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. You will experience a slight pain during the finger prick.

BENEFITS
We cannot offer you any direct benefits from the testing. However, the results of the survey will assist in planning HIV/AIDS programs in Zimbabwe.

CONFIDENTIALITY
If you are willing to provide a blood sample for HIV testing, the results will not be linked to you and will be strictly confidential. You are assured of this confidentiality through provisions of the Census and Statistics Act Chapter 10:29.

VOLUNTARY PARTICIPATION
You can say yes or no to having your blood collected and tested for HIV. If you decide not to give a sample for HIV testing, your decision will not affect your future relations with the Ministry of Health and Child Welfare, its personnel, and associated hospitals or with the Zimbabwe National Statistics Agency.

QUESTIONS
Before you sign this form, please ask any questions on any aspect of the blood sample collection that is unclear to you. You may take as much time as necessary to think it over.

AUTHORIZATION
You are making a decision whether or not to provide a blood sample for HIV testing. Your signature indicates that you have understood the information provided above, have had
all your questions answered, and have decided to participate.

Name of respondent (please print)___
Date/Time___

Signature of respondent or legally authorized representative___

ADDITIONAL TESTING

PURPOSE
As part of the survey, we are asking you to allow the National Microbiology Reference Laboratory to store part of the blood sample collected for HIV testing for additional testing or research. We are not certain about what additional tests might be done.

PROCEDURES AND DURATION
If you decide to participate, any blood collected for HIV testing that remains following the study will be stored for additional testing at the National Microbiology Reference Laboratory in Harare for up to five years. The blood sample will not have any name or other data attached to it that could identify you. The results of the additional tests will not be returned to you.

BENEFITS
We cannot offer you any direct benefits from the testing.

CONFIDENTIALITY
If you are willing for your blood sample to be stored and used for additional testing, the results of any tests will not be linked to you and will remain strictly confidential. You are ensured of this confidentiality through provisions of the Census and Statistics Act Chapter 10:29.

VOLUNTARY PARTICIPATION
You can say yes or no to having your blood stored for additional testing. If you decide not to allow your blood sample to be stored for additional testing, your decision will not affect your future relations with the Ministry of Health and Child Welfare, its personnel, and associated hospitals or with the Zimbabwe National Statistics Agency.

QUESTIONS
Before you sign this form, please ask any questions on any aspect of the storage of the blood sample for additional testing that is unclear to you. You may take as much time as necessary to think it over.

AUTHORIZATION
You are making a decision whether or not to allow your blood sample to be stored and used for additional testing or research. Your signature indicates that you have understood the information provided above, have had all your questions answered, and have decided to participate.

Name of respondent (please print)___
Date/Time___

Signature of respondent or legally authorized representative___

YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP. If you have any questions concerning this study or consent form beyond those answered by the investigator, including questions about the research, your rights as a research subject or research-related injuries; or if you feel that you have been treated unfairly and would like to talk to someone other than a member of the research team, please feel free to contact ZIMSTAT officials Mr. Washington Mapeta (telephone: 793967) or Mr. Godfrey Matsinde (telephone: 794757), or the Medical Research Council of Zimbabwe (telephone: 791792 or 791193).

PARENTAL CONSENT AND ADOLESCENT ASSENT FORM

ANAEMIA TESTING

PURPOSE
As part of the survey, we are asking people all over the country to take an anaemia test. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. The purpose of the anaemia testing is to establish the size of this problem in Zimbabwe. Your child is one of several thousand men, women and children selected at random as a possible participant in this study.

PROCEDURES AND DURATION
If you decide to allow your child to have an anaemia test, your child will undergo a finger prick in which a few drops of blood will be collected. The blood will be tested for anaemia immediately, and the result told to you right away.

RISKS AND DISCOMFORTS
The risks associated with procedure are minimal. 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. Your child will experience a slight pain during the finger prick.

BENEFITS
We cannot offer you or your child any direct benefits from the testing. However, if we find that the test results indicate that medical attention is required, we will refer you and your child to the nearest health facility.

CONFIDENTIALITY
If you indicate your willingness for your child to be tested for anaemia by signing this document, any information that is obtained in connection with this study that can be identified with you will remain confidential and will not be disclosed to anyone other than members of our survey team.

VOLUNTARY PARTICIPATION
You can say yes to the test or you can say no. If you decide not to allow your child to be tested, your decision will not affect your child’s future relations with the Ministry of Health and Child Welfare, its personnel, and associated hospitals or with the Zimbabwe National Statistics Agency.

QUESTIONS
Before you sign this form, please ask any questions on any aspect of the anaemia testing that is unclear to you. You may take as much time as necessary to think it over.

AUTHORIZATION
You are making a decision whether or not to allow your child to be tested for anaemia. Your signature indicates that you have understood the information provided above, have had all your questions answered, and have decided to allow your child to participate.

Name of child (please print)___
Date/Time

Name of parent (please print)

Signature of parent or legally authorized representative___

Relationship to child___

For children 15-17 years old:
My participation in this research study is voluntary. Ihave read and understood the above information, asked any questions which I may have and have agreed to participate. I will be given a copy of this form to keep.

Signature of child___

HIV TESTING (CHILDREN AGE 15-17 ONLY)

PURPOSE
As part of this survey, we are asking people all over thecountry to provide a blood sample that will be used for HIV testing. HIV is the virus that causes AIDS. AIDS is a very serious health problem that has affected a lot of people in Zimbabwe. The purpose of the HIV testing is to find out how big this problem in Zimbabwe. Your child is one of several thousand men and women selected at random as a possible participant in providing a blood sample that will be used for HIV testing.

PROCEDURES AND DURATION
If you decide to allow your child to provide a blood sample for HIV testing, your child will undergo a finger prick in which a few drops of blood will be collected on a card. The HIV test will be done in the National Microbiology Reference Laboratory in Harare. Because the card used to collect your child’s blood will be labeled using a code and not your child’s name, no one will be able to know your child’s HIV test results. We will not be able to tell you the results of your child’s test.

RISKS AND DISCOMFORTS
The risks associated with procedure, including the risks to pregnant women, are minimal. 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. Your child will experience a slight pain during the finger prick.

BENEFITS
We cannot offer you or your child any direct benefits from the testing. However, the results of the survey will assist in planning HIV/AIDS programs in Zimbabwe.

CONFIDENTIALITY
If you are willing for your child to provide a blood sample for HIV testing, the results will not be linked to your child and will be strictly confidential. Your child is assured of this confidentiality through provisions of the Census and Statistics Act Chapter 10:29.

VOLUNTARY PARTICIPATION
You can say yes or no to having your child’s blood collected and tested for HIV. If you decide not to allow your child to give a sample for HIV testing, your decision will not affect your child’s future relations with the Ministry of Health and Child Welfare, its personnel, and associated hospitals or with the Zimbabwe National Statistics Agency.

QUESTIONS
Before you sign this form, please ask any questions on any aspect of the blood sample collection that is unclear to you. You may take as much time as necessary to think it over.

AUTHORIZATION
You are making a decision whether or not to allow your child to provide a blood sample for HIV testing. Your signature indicates that you have understood the information provided above, have had all your questions answered, and have decided to participate.

Name of child (please print)___
Date/Time

Name of parent (please print)

Signature of parent or legally authorized representative___

Relationship to child___

For children 15-17 years old:
My participation in this research study is voluntary. Ihave read and understood the above information, asked any questions which I may have and have agreed to participate. I will be given a copy of this form to keep.

Signature of child___

ADDITIONAL TESTING (CHILDREN AGE 15-17 ONLY)

PURPOSE
As part of the survey, we are asking you to allow the National Microbiology Reference Laboratory to store part of the blood sample collected from your child for HIV testing for additional testing or research. We are not certain about what additional tests might be done.

PROCEDURES AND DURATION
If you decide to allow your child to participate, any blood collected for HIV testing that remains following the study will be stored for additional testing at the National Microbiology Reference Laboratory in Harare for up to five years. The blood sample will not have any name or other data attached to it that could identify your child. The results of the additional tests will not be returned to you or your child.

BENEFITS
We cannot offer your child any direct benefits from the testing.

CONFIDENTIALITY
If you are willing for your child’s blood sample to be stored and used for additional testing, the results of any tests will not be linked to your child and will remain strictly confidential. Your child is ensured of this confidentiality through provisions of the Census and Statistics Act Chapter 10:29.

VOLUNTARY PARTICIPATION
You can say yes or no to having your child’s blood stored for additional testing. If you decide not to allow your child’s blood sample to be stored for additional testing, your decision will not affect your child’s future relations with the Ministry of Health and Child Welfare, its personnel, and associated hospitals or with the Zimbabwe National Statistics Agency.

QUESTIONS
Before you sign this form, please ask any questions on any aspect of the storage of the blood sample for additional testing that is unclear to you. You may take as much time as necessary to think it over.

AUTHORIZATION
You are making a decision whether or not to allow your child’s blood sample to be stored and used for additional testing or research. Your signature indicates that you have understood the information provided above, have had all your questions answered, and have decided to allow your child to participate.

Name of child (please print)___
Date/Time

Name of parent (please print)

Signature of parent or legally authorized representative___

Relationship to child___

For children 15-17 years old:
My participation in this research study is voluntary. Ihave read and understood the above information, asked any questions which I may have and have agreed to participate. I will be given a copy of this form to keep.

Signature of child___

YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP. If you have any questions concerning this study or consent form beyond those answered by the investigator, including questions about the research, your rights as a research subject or research-related injuries; or if you feel that you have been treated unfairly and would like to talk to someone other than a member of the research team, please feel free to contact ZIMSTAT officials Mr. Washington Mapeta (telephone: 793967) or Mr. Godfrey Matsinde (telephone: 794757), or the
Medical Research Council of Zimbabwe (telephone: 791792 or 791193).