FORMATTING DATE: 15 June 2018
ENGLISH LANGUAGE: 15 June 2018
REPUBLIC OF CAMEROON
Peace - Work - Fatherland
NATIONAL INSTITUTE OF STATISTICS
2018 CAMEROON DEMOGRAPHIC AND HEALTH SURVEY (2018 CDHS)
BIOMARKER QUESTIONNAIRE
HOUSEHOLD NOT SELECTED FOR MAN'S SURVEY
REGION
DIVISION
SUB-DIVISION
LOCALITY
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
FIRST VISIT:
HEALTH TECHNICIAN NAME_______
NEXT VISIT:
TIME_______
FINAL VISIT:
MONTH_______
YEAR _2018_
TOTAL NUMBER OF VISITS______
NOTES:
TOTAL ELIGIBLE WOMEN________
TOTAL ELIGIBLE MEN_______
TOTAL ELIGIBLE CHILDREN_______
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)_________ 96
NATIVE LANGUAGE OF RESPONDENT
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)_________ 96
NO 2
TEAM LEADER
NUMBER_______
CONTROLLER
NUMBER_______
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT, AND MALARIA TEST FOR CHILDREN AGE 0-5
101) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102 IN THE SAME ORDER THEY APPEAR. IF MORE THAN SIX CHILDREN.
102) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.
NAME________
NAME_______
NAME_______
103) COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM HOUSEHOLD SCHEDULE. IF COMPLETE DATE OF BIRTH NOT PROVIDED ASK: What is (NAME)'s date of birth?
MONTH________
YEAR________
104) CHECK 103: CHILD BORN IN 2013-2018?
NO 2 (SKIP TO 133)
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 HEALTH TECHNICIAN 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) NAME OF PARENT / OTHER ADULT RESPONSIBLE FOR THE CHILD.
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 anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment use 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 AND SIGN YOUR NAME.
REFUSED 2 (SIGN)________
NOT PRESENT / OTHER 3
113) ASK CONSENT FOR MALARIA TEST FROM PARENT / OTHER ADULT.
As part of this survey, we are asking children all over the country to take a test to see if they have malaria. Malaria is a serious illness caused by a parasite transmitted by a mosquito bite. This survey will assist the government to develop programs to prevent malaria.
We ask that all children born in 2013 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. The same drops of blood taken for anemia testing will be used for malaria testing. One drop of blood will be tested for malaria immediately and the results will be given to you on the spot. A treatment will be proposed to children having a simple malaria if they are not yet on treatment. The children having serious malaria will be referred to a health structure.
All results 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.
114) CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR HEALTH TECHNICIAN NUMBER.
REFUSED 2 (SIGN AND ENTER YOUR HEALTH TECH. NUMBER)_______
NOT PRESENT / OTHER 3
115) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
116) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
117) CIRCLE THE CODE FOR THE MALARIA RDT.
NOT PRESENT 2 (SKIP TO 119)
REFUSED 3 (SKIP TO 119)
OTHER 6 (SKIP TO 119)
118) RECORD THE RESULT OF THE MALARIA RDT HERE AND IN THE ANEMIA AND MALARIA PAMPHLET.
POSITIVE PAN 2 (SKIP TO 121)
POSITIVE, Pf and PAN 3 (SKIP TO 121)
NEGATIVE 4
OTHER 6
119) CHECK 116: HEMOGLOBIN RESULT.
7.0 G/DL OR ABOVE 2 (SKIP TO 133)
NOT PRESENT 3 (SKIP TO 133)
REFUSED 4 (SKIP TO 133)
OTHER 6 (SKIP TO 133)
120) SEVERE ANEMIA REFERRAL.
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.
The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately. (SKIP TO 133).
121) Does (NAME) suffer from any of the following illnesses or symptoms:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
122) CHECK 121: ANY 'YES' CIRCLED?
YES (SKIP TO 125)
123) CHECK 116: HEMOGLOBIN RESULT.
7.0 G/DL OR ABOVE 2
NOT PRESENT 3
REFUSED 4
OTHER 6
124) In the past two weeks has (NAME) taken or is taking ACT given by a health professional or community health worker to treat the malaria? VERIFY BY ASKING TO SEE TREATMENT.
NO 2 (SKIP TO 127)
125) SEVERE MALARIA REFERRAL.
RECORD THE RESULT OF THE MALARIA RDT ON THE REFERRAL FORM.
The malaria test shows that (NAME OF CHILD) has malaria. Your child also has symptoms of severe malaria. The malaria treatment I have will not help your child, and I cannot give you the medication. Your child is very ill and must be taken to a health facility right away. (SKIP TO 131).
126) ALREADY TAKING ACT REFERRAL STATEMENT.
You have told me that (NAME OF CHILD) had already received ACT for malaria. Therefore, I cannot give you additional ACT. However, the test shows that he / she has malaria. If your child has a fever for two days after the last dose of ACT, you should take the child to the nearest health facility for further examination. (SKIP TO 131).
127) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT / OTHER ADULT.
The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called ACT. ACT is very effective and in a few days it should get rid of the fever and other symptoms. You do not have to give the child the medicine. This is up to you. Please tell me whether you accept the medicine or not.
128) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN)_______
OTHER 6
129) CHECK 128: MEDICATION ACCEPTED.
REFUSED 2 (SKIP TO 131)
OTHER 6 (SKIP TO 131)
130) TREATMENT FOR CHILDREN WHOSE MALARIA TEST IS POSITIVE.
TREATMENT WITH ARTESUNATE-AMODIAQUINE (AA).
ALSO TELL THE PARENT / OTHER ADULT:
-- A high temperature or fever
-- Fast or difficulty breathing
-- Not able to drink or breastfeed
-- Gets sicker or does not get better in two days
(SKIP TO 133).
##NOTE: NOT SURE HOW TO TRANSCRIBE TABLE
131) CHECK 116: HEMOGLOBIN RESULT.
7.0 G/DL OR ABOVE 2 (SKIP TO 133)
NOT PRESENT 3 (SKIP TO 133)
REFUSED 4 (SKIP TO 133)
OTHER 6 (SKIP TO 133)
132) SEVERE ANEMIA REFERRAL.
RECORD THE RESULT OF THE ANEMIA TEST ON THE REFERRAL FORM.
The anemia test shows that (NAME OF CHILD) has severe anemia. Your child is very ill and must be taken to a health facility immediately.
133) 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 102-133 ARE REPEATED FOR CHILDREN 4-6
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15-49
201) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9. NAME FROM COLUMN 2.
NAME_______
NAME_______
NAME_______
203) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-49 YEARS 2
204) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207) MEASURER: ENTER YOUR HEALTH TECHNICIAN NUMBER.
18-49 YEARS 2 (SKIP TO 210)
209) CHECK 204: MARITAL STATUS.
OTHER 2
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT FOR WOMEN AGE 15-49
NAME FROM COLUMN 2.
NAME_______
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
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.
RESPONDENT REFUSED (SIGN)________
(IF REFUSED, SKIP TO 233)
NOT PRESENT / OTHER 3 (SKIP TO 233)
211A) CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2 (SKIP TO 229)
DON'T KNOW 8 (SKIP TO 229)
216) RECORD NAME OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
PARENTAL / RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
217) 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 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. 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.
Will you allow (NAME OF MINOR) to take the anemia test?
218) CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)_______
(IF REFUSED, SKIP TO 233)
NOT PRESENT / OTHER 3 (SKIP TO 233)
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
219) 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 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 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.
Will you take the anemia test?
220) CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)________
(IF REFUSED, SKIP TO 233)
NOT PRESENT / OTHER 3 (SKIP TO 233)
220A) CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
229) PREPARE EQUIPMENT AND SUPPLIES FOR ANEMIA TEST.
231) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
233) GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END INTERVIEW.
FORMATTING DATE: 15 June 2018
ENGLISH LANGUAGE: 15 June 2018
REPUBLIC OF CAMEROON
Peace - Work - Fatherland
NATIONAL INSTITUTE OF STATISTICS
2018 CAMEROON DEMOGRAPHIC AND HEALTH SURVEY (2018 CDHS)
BIOMARKER QUESTIONNAIRE
HOUSEHOLD SELECTED FOR MAN'S SURVEY
REGION
DIVISION
SUB-DIVISION
LOCALITY
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
FIRST VISIT:
HEALTH TECHNICIAN NAME______
NEXT VISIT:
TIME______
FINAL VISIT:
MONTH______
YEAR _2018_
TOTAL NUMBER OF VISITS______
NOTES:
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)_________ 96
NATIVE LANGUAGE OF RESPONDENT
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)_________ 96
NO 2
TEAM LEADER
NUMBER_____
CONTROLLER
NUMBER_____
HIV TESTING FOR WOMEN AGE 15-64
201) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 203, AND 204. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202) CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9. NAME FROM COLUMN 2.
NAME_____
NAME_____
NAME_____
203) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-64 YEARS 2 (SKIP TO 212)
204) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
ADULT RESPONDENT CONSENT FOR HIV TESTING
212) DBS COLLECTION: ASK CONSENT FOR DBS COLLECTION FROM ADULT RESPONDENT.
As part of the survey we 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 big the AIDS problem is in Cameroon.
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 filter paper 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?
213) DBS COLLECTION: CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR HEALTH TECHNICIAN NUMBER.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR HEALTH TECH. NUMBER)_____
NOT PRESENT / OTHER 3
HIV TESTING FOR WOMEN AGE 15-64
NAME FROM COLUMN 2.
NAME_______
213A) HOME-BASED HIV TESTING: ASK CONSENT FOR HOME-BASED HIV TESTING FROM ADULT 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 Cameroon. 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. We will use two tests to determine the HIV result and the result of the tests 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.
213B) HOME-BASED HIV TESITNG: CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN)_______
NOT PRESENT / OTHER 3
213C) CHECK 213: ADULT CONSENT FOR DBS COLLECTION.
CODE '1' CIRCLED (SKIP TO 214)
213D) CHECK 213B: ADULT CONSENT GRANTED HOME-BASED TESTING.
CODES '2' OR '3' CIRCLED 2 (SKIP TO 238)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
214) ADDITIONAL TESTING: ASK CONSENT FOR ADDITIONAL TESTING FROM ADULT RESPONDENT.
We ask you to allow NATIONAL INSTITUTE OF STATISTICS to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
215) ADDITIONAL TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND SKIP TO 229)_______
216) RECORD NAME OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
PARENTAL / RESPONSIBLE ADULT CONSENT FOR HIV TESTING
221) DBS COLLECTION: ASK CONSENT FOR DBS COLLECTION FROM PARENT / RESPONSIBLE ADULT.
As part of the survey we 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 big the AIDS problem is in Cameroon.
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 filter paper so we will not be able to tell you the test results. 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 the HIV testing in a laboratory?
222) DBS COLLECTION: CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR HEALTH TECHNICIAN NUMBER.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN AND ENTER YOUR HEALTH TECH. NUMBER)_______
NOT PRESENT / OTHER 3
222A) HOME-BASED HIV TESTING: ASK CONSENT FOR HOME-BASED HIV TESTING FROM PARENT / RESPONSIBLE ADULT.
If (NAME OF MINOR) wants to know her HIV status right now, we can do a rapid test and tell her 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 Cameroon. 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. We will use two tests to determine the HIV result and the result of the tests 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 or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the rapid HIV testing?
222B) HOME-BASED HIV TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)_____
NOT PRESENT / OTHER 3
222C) CHECK 222 AND 222B: DBS COLLECTION OR HOME-BASED HIV TESTING GRANTED.
NOT A SINGLE '1' CIRCLED (SKIP TO 238)
222D) CHECK 222: DBS COLLECTION GRANTED.
CODE '1' NOT CIRCLED (SKIP TO 224B)
MINOR RESPONDENT CONSENT FOR HIV TEST
223) DBS COLLECTION: ASK CONSENT FOR HIV TEST FROM MINOR RESPONDENT.
As part of the survey we 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 big the AIDS problem is in Cameroon.
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 filter paper 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?
224) DBS COLLECTION: CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)_______
NOT PRESENT / OTHER 3
224A) CHECK 222B: HOME-BASED HIV TESTING GRANTED.
CODE '1' NOT CIRCLED (SKIP TO 224D)
224B) HOME-BASED HIV TESTING: ASK CONSENT FOR HOME-BASED HIV TESTING 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 Cameroon. 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. We will use two tests to determine the HIV result and the result of the tests 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?
224C) HOME-BASED HIV TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)_______
NOT PRESENT / OTHER 3
224D) CHECK 222 AND 224: DBS COLLECTION GRANTED BY PARENT AND MINOR.
AT LEAST ONE CODE '1' NOT CIRCLED (SKIP TO 229)
PARENTAL / RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
225) ADDITIONAL TESTING: ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT / ADULT.
We ask you to allow NATIONAL INSTITUTE OF STATISTICS to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF 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?
226) ADDITIONAL TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)_______ (SKIP TO 229)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
227) ADDITIONAL TESTING: ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
We ask you to allow the NATIONAL INSTITUTE OF STATISTICS to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
228) ADDITIONAL TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)______
229) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
230) ADDITIONAL TESTS.
IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 226 AND 228.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
232) 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.
233) RECORD THE RESULT OF THE "DETERMINE HIV 1/2" RDT HERE.
DETERMINE NON-REACTIVE 2 (SKIP TO 236)
NOT PRESENT 3 (SKIP TO 238)
REFUSED 4 (SKIP TO 238)
OTHER 5 (SKIP TO 238)
234) RECORD THE RESULT OF THE "UNIGOLD HIV" RDT HERE.
UNIGOLD NON-REACTIVE 2 (SKIP TO 237)
NOT PRESENT 3 (SKIP TO 238)
REFUSED 4 (SKIP TO 238)
OTHER 5 (SKIP TO 238)
235) CHECK 233 AND 234: REACTIVE RESULTS FOR BOTH DETERMINE HIV 1/2 AND UNIGOLD.
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.
236) CHECK 233: NON-REACTIVE RESULT ON DETERMINE HIV 1/2.
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING. SKIP TO 238.
237) CHECK 233 AND 234: REACTIVE RESULT ON DETERMINE HIV 1/2 AND NON-REACTIVE RESULT ON UNIGOLD.
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.
238) 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) FROM THE LIST OF PERSONS ELIGIBLE FOR BIOMARKERS, RECORD THE LINE NUBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303, AND 304. 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_______
303) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-64 YEARS 2 (SKIP TO 312)
304) CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
ADULT RESPONDENT CONSENT FOR HIV TESTING
312) DBS COLLECTION: ASK CONSENT FOR DBS COLLECTION FROM ADULT RESPONDENT.
As part of the survey we 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 big the AIDS problem is in Cameroon.
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 filter paper 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?
313) DBS COLLECTION: CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR HEALTH TECHNICIAN NUMBER.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR HEALTH TECH. NUMBER)______
NOT PRESENT / OTHER 3
NAME FROM COLUMN 2.
313A) HOME-BASED HIV TESTING: ASK CONSENT FOR HOME-BASED HIV TESTING FROM ADULT 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 Cameroon. 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. We will use two tests to determine the HIV result and the result of the tests 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?
313B) HOME-BASED HIV TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN)________
NOT PRESENT / OTHER 3
313C) CHECK 313: ADULT CONSENT FOR DBS COLLECTION.
CODE '1' CIRCLED (SKIP TO 314)
313D) CHECK 313B: ADULT CONSENT GRANTED HOME-BASED TESTING.
CODES '2' OR '3' CIRCLED 2 (SKIP TO 338)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
314) ADDITIONAL TESTING: ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the NATIONAL INSTITUTE OF STATISTICS to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
315) ADDITIONAL TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND SKIP TO 329)______
316) RECORD NAME OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
PARENTAL / RESPONSIBLE ADULT CONSENT FOR HIV TESTING
321) DBS COLLECTION: ASK CONSENT FOR DBS COLLECTION FROM PARENT / RESPONSIBLE ADULT.
As part of the survey we 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 big the AIDS problem is in Cameroon.
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 filter paper so we will not be able to tell you the test results. 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 the HIV testing in a laboratory?
322) DBS COLLECTION: CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR HEALTH TECHNICIAN NUMBER.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN AND ENTER YOUR HEALTH TECH. NUMBER)______
NOT PRESENT / OTHER 3
322A) HOME-BASED HIV TESTING: ASK CONSENT FOR HOME-BASED HIV TESTING FROM PARENT / RESPONSIBLE ADULT.
If (NAME OF MINOR) wants to know his HIV status right now, we can do a rapid test and tell him 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 Cameroon. 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. We will use two tests to determine the HIV result and the result of the tests 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 or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the rapid HIV testing?
322B) HOME-BASED HIV TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)______
NOT PRESENT / OTHER 3
322C) CHECK 322 AND 322B: DBS COLLECTION OR HOME-BASED HIV TESTING GRANTED.
NOT A SINGLE '1' CIRCLED (SKIP TO 338)
322D) CHECK 322: DBS COLLECTION GRANTED.
CODE '1' NOT CIRCLED (SKIP TO 324B)
MINOR RESPONDENT CONSENT FOR HIV TESTING
323) DBS COLLECTION: ASK CONSENT FOR HIV TEST FROM MINOR RESPONDENT.
As part of the survey we 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 big the AIDS problem is in Cameroon.
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 filter paper 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?
324) DBS COLLECTION: CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)______
NOT PRESENT / OTHER 3
324A) CHECK 322B: HOME-BASED HIV TESTING GRANTED.
CODE '1' NOT CIRCLED (SKIP TO 324D)
324B) HOME-BASED HIV TESTING: ASK CONSENT FOR HOME-BASED HIV TESTING 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 Cameroon. 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. We will use two tests to determine the HIV result and the result of the tests 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?
324C) HOME-BASED HIV TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)______
NOT PRESENT / OTHER 3
324D) CHECK 322 AND 324: DBS COLLECTION GRANTED BY BOTH PARENT AND MINOR.
AT LEAST ONE CODE '1' NOT CIRCLED (SKIP TO 329)
PARENTAL / RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
325) ADDITIONAL TESTING: ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT / ADULT.
We ask you to allow the NATIONAL INSTITUTE OF STATISTICS to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF 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?
326) ADDITIONAL TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT / OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN)_____ (SKIP TO 329)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
327) ADDITIONAL TESTING: ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
We ask you to allow the NATIONAL INSTITUTE OF STATISTICS to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
328) ADDITIONAL TESTING: CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)______
329) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
330) ADDITIONAL TESTS.
IF ADULT RESPONDENT, CHECK 315; IF MINOR RESPONDENT, CHECK 326 AND 328.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
332) 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.
333) RECORD THE RESULT OF THE "DETERMINE HIV 1/2" RDT HERE.
DETERMINE NON-REACTIVE 2 (SKIP TO 336)
NOT PRESENT 3 (SKIP TO 338)
REFUSED 4 (SKIP TO 338)
OTHER 5 (SKIP TO 338)
334) RECORD THE RESULT OF THE "UNIGOLD HIV" RDT HERE.
UNIGOLD NON-REACTIVE 2 (SKIP TO 337)
NOT PRESENT 3 (SKIP TO 338)
REFUSED 4 (SKIP TO 338)
OTHER 5 (SKIP TO 338)
335) CHECK 333 AND 334: REACTIVE RESULTS FOR BOTH DETERMINE HIV 1/2 AND UNIGOLD.
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.
336) CHECK 333: NON-REACTIVE RESULT ON DETERMINE HIV 1/2.
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING. SKIP TO 338.
337) CHECK 333 AND 334: REACTIVE RESULT ON DETERMINE HIV 1/2 AND NON-REACTIVE RESULT ON UNIGOLD.
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.
338) 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.
HEALTH TECHNICIAN'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
TEAM LEADER'S OBSERVATIONS
CONTROLLER'S OBSERVATIONS