NAME OF ASSISTANT _____
ASSISTANT CODE _____

NAME OF ASSISTANT _____
ASSISTANT CODE:

NAME OF ASSISTANT____

NAME OF ASSISTANT______

ASSISTANT'S RELATIONSHIP TO CHILD____

*CODES: IF THE ASSISTANT IS A TEAM MEMBER, RECORD HIS/HER CODE, OTHERWISE USE THE FOLLOWING CODES: MOTHER (190); OTHER MEMBERS OF THE HOUSEHOLD (191); OTHER PERSONS (192).

NAME OF ASSISTANT: ___________

NAME OF ASSISTANT_______

215) NAME OF MEASURER/TESTER __ __
NAME OF ASSISTANT __ __

* CONSENT STATEMENT
As part of this survey, we are studying anemia among women, children and adolescents. 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 request that you (and all children under age 6, and all male and never married female adolescents aged 10-19) to participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.

May I now ask that you (and NAME OF CHILD[REN]/ADOLESCENT) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

IN THE HEPATITIS C TESTING SUBSAMPLE (GO TO 301)
NOT IN THE HEPATITIS C TESTING SUBSAMPLE (GO TO 401)

TICK IF AN ADDITIONAL HOUSEHOLD QUESTIONNAIRE USED ____

Name of Measurer __________
Name of Assistant __________

NAME OF ASSISTANT

ASSISTANT CODE ____

NAME OF ASSISTANT: ___________