Survey Text

Angola 2015 Ethiopia 2011 Liberia 2007 Senegal 2017
Burkina Faso 2010 Ethiopia 2016 Liberia 2013 South Africa 2016
Burundi 2010 Ghana 2014 Malawi 2010 Togo 2013
Burundi 2016 Guinea 2012 Malawi 2016 Zambia 2007
Cameroon 2011 Guinea 2018 Mali 2006 Zambia 2013
Chad 2014 India 2005 Mali 2012 Zambia 2018
Congo (Democratic Republic) 2007 India 2015 Namibia 2013 Zimbabwe 2005
Congo (Democratic Republic) 2013 Kenya 2008 Niger 2012 Zimbabwe 2015
Cote d'Ivoire 2011 Lesotho 2009 Rwanda 2010
Eswatini (Swaziland) 2006 Lesotho 2014 Rwanda 2014
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Angola 2015
Survey form view entire document:  text 
206) RECORD THE CODE, SIGN YOUR NAME AND ENTER YOUR FIELDWORKER NUMBER

GRANTED 1 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) ____
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR FIELDWORKER NUMBER) ____(IF REFUSED GO TO 221)
NOT PRESENT/OTHER 3 (GO TO 221)

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Burkina Faso 2010
Survey form view entire document:  text 
228. (12) ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As a 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 (COUNTRY).

For the HIV test, we need a few (more) 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 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. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of (nearby) facilities offering counseling 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 take the HIV test?

229. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
PARENT/OTHER ADULT RESPONSIBLE REFUSED 2 (GO TO 239)

(SIGN) _____________


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Burundi 2010
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426) (6)

CHECK 425:

SP/FANSIDAR TAKEN FOR MALARIA PREVENTION.

CODE 'A' CIRCLED____
CODE 'A' NOT CIRCLED___ (GO TO 430)

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Burundi 2016
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226) Are you pregnant now?

YES 1
NO 2 (GO TO 230)
UNSURE 8 (GO TO 230)

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Cameroon 2011
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CONSENT DECLARATION FOR HIV TEST

READ THE CONSENT STATEMENT TO EACH RESPONDENT. RECORD CODE '1' IN 806 IF RESPONDENT ACCEPTS THE HIV TEST AND CODE '3' IF SHE REFUSES.
FOR WOMEN BETWEEN 15 AND 17NEVER IN A UNION, ASK FOR THE CONSENT OF THE PARENT/ ADULT IDENTIFIED IN 805 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE '2' IN 806 IF THE PARENTS REFUSE. ONLY PERFORM THE TEST IF BOTH CONSENTS, THAT OF THE PARENT/ADULT AND THE ADOLESCENT RESPONDENT, HAVE BEEN RECEIVED.

As part of this survey, we are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious health problem. This test will assist the government to measure the severity of the problem of AIDS in Cameroun.

For this test, we 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 each test.

No name will be attached to the blood samples and we will not be able to tell you the results. No one else will be able to know (NAME OF ADOLESCENT) results either. If you would like to know if you have HIV, I can give you a list of the (closest) facilities that offer tests and counseling for HIV. I would also give you a coupon for free services in these facilities for you (and for your partner if you would like).

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 participate in the HIV test?
Do you agree to participate in the HIV test?


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Chad 2014

No questionnaire text is available for this sample.


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Congo (Democratic Republic) 2007
Survey form view entire document:  text 
525 READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

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

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Congo (Democratic Republic) 2013
Survey form view entire document:  text 
228. (12) ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As a 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 (COUNTRY).

For the HIV test, we need a few (more) 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 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. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of (nearby) facilities offering counseling 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 take the HIV test?

229. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
PARENT/OTHER ADULT RESPONSIBLE REFUSED 2 (GO TO 239)

(SIGN) _____________


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Cote d'Ivoire 2011
Survey form view entire document:  text 
Declaration of consent for HIV test

READ THE CONSENT TO EACH RESPONDENT. CIRCLE CODE 1 IN 709 IF THE RESPONDENT ACCEPTS THE HIV TEST AND CODE 3 IF SHE REFUSES.

FOR WOMEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HER PARENT/OTHER ADULT IDENTIFIED IN 707 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE 2 IN 709 IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT 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 the Ivory Coast. HIV treatment is free. This survey will assist the government to develop programs to prevent and treat AIDS.

For the HIV test, we 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 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 (RESULTS OF THE ADOLESCENT) either.

If you want to know if you have HIV or not, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

GRANTED 1-(SIGN) _____________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2-(SIGN)_________________
RESPONDENT REFUSED 3-(SIGN)______________

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Eswatini (Swaziland) 2006
Survey form view entire document:  text 
CONSENT STATEMENT FOR HIV TEST FROM WOMEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 534 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES. FOR GIRLS AGE 12-14 AND NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 530) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 534 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we 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 Swaziland

For the HIV test, we need a few more drops of blood from a finger. Again the equipment used in taking the blood is clean and completely safe It has never been used before and will be thrown away after each test

No names will be attached to the blood sample which will keep the results completely anonymous. For this reason, we will not be able to know (your/NAME OF ADOLESCENT) test results, and so we will not be able to tell you the test results either.

If you want to know whether you (your child) have HIV, I can provide you with a list of nearby facilities offering counseling and testing for HIV I will also give you a voucher that you can use at any of these facilities.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide. Will you (allow NAME OF ADOLESCENT to) take the HIV test?


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Ethiopia 2011
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231. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER:

INTERVIEWER NUMBER _____
GRANTED 1 (SIGN) _____
RESPONDENT REFUSED 2 (SIGN) _____ (GO TO 239)

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Ethiopia 2016
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213. CIRCLE THE CODE AND SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

GRANTED 1 (SIGN) ___ (FIELDWORKER NUMBER) ___
RESPONDENT REFUSED 2 (SIGN) ___ (FIELDWORKER NUMBER) ___ (GO TO 229)
NOT PRESENT/OTHER 3 (GO TO 229)

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Ghana 2014
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229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1 (SIGN) ____________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) ____________ (GO TO 239)

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Guinea 2012
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328) Did any staff member at the health facility speak to you about family planning methods?

YES 1
NO 2

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Guinea 2018
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425e) CHECK 424:

NUMBER OF DOSES EQUALS 4 OR MORE
NUMBER OF DOSES EQUALS 3 (GO TO 426)

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India 2005
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80. READ CONSENT STATEMENT FOR HIV TESTING TO (WO)MAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
[ASK FOR WOMEN AND MEN ONLY]

GRANTED 1 (SIGN) ________
REFUSED 2 (SIGN) ________

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India 2015
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356) ASK CONSENT FOR DBS COLLECTION FROM PARENT/ OTHER ADULT IDENTIFIED IN 307 AS RESPONSIBLE FOR NEVER MARRIED 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 India. For the HIV test, we need a few (more) 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 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. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide 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 take the HIV test?

358) ASK FOR 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 India. For the HIV test, we need a few (more) 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 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. If you want to know whether you have HIV, I can provide you with a list of nearby facilities offering counselling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?


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Kenya 2008
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525 READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

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

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Lesotho 2009
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240A READ THE HIV TEST CONSENT STATEMENT.
FOR NEVERMARRIED MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 238 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR HIV TEST
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 Lesotho.
For the HIV test, we need a few more drops of blood from a finger. Again the equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
No 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/NAME OF ADOLESCENT's) test results either.
If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV.
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) take the HIV test?


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Lesotho 2014
Survey form view entire document:  text 
230) 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 Lesotho.

For the HIV test, we need a few more 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 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. If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV.

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 take the HIV test?


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Liberia 2007
Survey form view entire document:  text 
525 READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

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

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Liberia 2013
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417) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

GRANTED 1 SIGN______________
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT 5
OTHER 6

(IF REFUSED, NOT PRESENT OR OTHER, GO TO 428)

NAME FROM COLUMN 2

NAME______________

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Malawi 2010
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525F. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME, ENTER YOUR INTERVIEWER CODE.

GRANTED 1 (SIGN) ______________
RESPONDENT REFUSED 2 (SIGN) ______________ (GO TO 526)
INTERVIEWER CODE____

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Malawi 2016
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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. 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 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 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. If you want to know whether you have HIV, I can provide you with a list of (nearby facilities offering counseling and testing for HIV). I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?


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Mali 2006
Survey form view entire document:  text 
INFORMED CONSENT STATEMENT (HIV Test):

INFORMED CONSENT FOR ADULT 18 YEARS OR MORE
As part of this survey, we are doing a study of HIV/AIDS among women aged 15-49 years and men aged 15-59 years. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually mortal. We are currently giving HIV tests to see how serious a problem AIDS is in Mali.

For the HIV test, we ask all the eligible women and men to give a couple drops of blood from a finger. To take this blood we use sterile instruments, new material which is not reusable. It has never been used before and will be thrown away after the test.

The blood will then be sent to a lab to be analyzed. No name will be linked to the result. Thus, we will not be able to tell you your test results. No one else will know that result of the blood test either. However, I will give a reference paper to go to a Centre de D├ępistage Volontaire (voluntary testing center) to have a free test if you wish.

Do you have any questions? Now, do you agree to take this HIV test?

PROCEED TO COLUMN (67) AND CIRCLE THE APPROPRIATE CODE.


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Mali 2012
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239) ASK FOR CONSENT FOR THE HIV TEST FROM THE PARENT/OTHER ADULT.
REQUEST FOR CONSENT FOR HIV TEST. Will you allow (NAME OF ADOLESCENT) to participate in the HIV test?

239A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1_________(SIGNATURE)
REFUSED 2

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Namibia 2013
Survey form view entire document:  text 
228. (12) ASK FOR CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

As a 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 (COUNTRY).

For the HIV test, we need a few (more) 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 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. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of (nearby) facilities offering counseling 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 take the HIV test?

229. (12) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1
PARENT/OTHER ADULT RESPONSIBLE REFUSED 2 (GO TO 239)

(SIGN) _____________


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Niger 2012
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229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED 1- SIGN____________
REFUSED BY PARENT/OTHER ADULT RESPONSIBLE 2- SIGN__________
(IF REFUSED, GO TO 239)

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Rwanda 2010
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530) CHECK 525:
HAD FEVER OR COUGH?

YES (GO TO 531)
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

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Rwanda 2014
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309) CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.

GRANTED 1 (SIGN) _______________
RESPONDENT REFUSED 2 (SIGN) ____________ (GO TO 310)
INTERVIEWER NUMBER _____

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Senegal 2017
Survey form view entire document:  text 
212) 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. The HIV testing is being done to see how many people have HIV.

For the HIV test, we need a few (more) 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 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. If you want to know if you have HIV, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that 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 for the HIV testing?


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South Africa 2016
Survey form view entire document:  text 
ADULT RESPONDENT CONSENT FOR HIV TESTING

251) ASK CONSENT FOR HIV TESTING.

PROVIDE ADULT RESPONDENT WITH CONSENT FORM.

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Togo 2013
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255) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

GRANTED (SIGN) __________ 1
REFUSED BY PARENT/OTHER RESPONSIBLE ADULT (SIGN) __________ 2
PARENT/OTHER RESPONSIBLE ADULT NOT PRESENT (SIGN) __________ 3
(IF REFUSED OR NOT PRESENT, GO TO 266)

256) 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 Togo.

For the HIV test, we need a few (more) 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 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. If you want to know you HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?
You can say yes, or you can say no to the test. It is up to you to decide.

Will you take in the HIV test?


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Zambia 2007
Survey form view entire document:  text 
525 READ THE HIV TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

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

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Zambia 2013
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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.

GRANTED 1
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (IF REFUSED, GO TO 252)
SIGN______________________________

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Zambia 2018
Survey form view entire document:  text 
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.


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Zimbabwe 2005
Survey form view entire document:  text 
1315) READ THE HIV CONSENT STATEMENT TO THE RESPONDENT.

We are also asking people in this survey to help us find out how big the HIV problem is in Zimbabwe. We would like you to take part in the HIV test by allowing us to collect a few more drops of blood from your finger.

This blood will be tested later on in the laboratory. We will not keep any name with the blood. Because there will be no name with the blood when it is tested, we will not be able to give you the result of the test and no one will be able to trace the test back to you.

If you want to know your HIV status, I can tell you where to go to get tested for HIV.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of HIV and AIDS.

Do you agree to give blood for the HIV test?

CIRCLE CODE AND SIGN.

FURTHER DISCUSS ANAEMIA TESTING PROCESS TO PUT RESPONDENT AT EASE.

CONSENT (SIGN) __________ 1
REFUSED 2 (SKIP TO 1317)

FURTHER DISCUSS HIV TESTING PROCESS TO PUT RESPONDENT AT EASE.


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Zimbabwe 2015

No questionnaire text is available for this sample.