IDENTIFICATION:

LOCAL GOVERNMENT AREA: ____

DISTRICT NAME: ____

DCODE ____

SETTLEMENT NAME: ____

SCODE ____

NAME OF HOUSEHOLD HEAD: ____

TEL: ____

EA NUMBER: ____

CLUSTER NUMBER ____

HOUSEHOLD NUMBER ____

AREA OF RESIDENCE: ____

INTERVIEWER VISITS:

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*

NEXT VISIT:
DATE____
TIME____

THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*

FINAL VISIT
DAY____
MONTH____
YEAR 2013
INT. NUMBER____
RESULT

TOTAL NUMBER OF VISITS____

*RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD ____

TOTAL ELIGIBLE WOMEN ____

TOTAL ELIGIBLE MEN ____

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

SUPERVISOR
NAME ____

FIELD EDITOR
NAME ____

OFFICE EDITOR ____

KEYED BY ____

INTRODUCTION AND CONSENT

Hello. My name is ____. We are from the Gambia Bureau of Statistics and the Ministry of Health and Social Welfare. We are doing a survey concerned with family health and education. I would like to ask questions on education, marriage, household characteristics, water and sanitation, bed nets, salt iodization etc. The interview will take about one hour. All the information we obtain will remain strictly confidential and your answers will never be identified. During this time I would like to speak with all males aged 15 - 59 and females aged 15 - 49 in the household.
As part of the survey we also are asking some household members all over the country to take HIV, malaria, and anemia tests. HIV is the virus that causes AIDS. The HIV test is being done to see how big the AIDS problem is in the Gambia. All children under 5 and females aged 15 - 49 will be tested for malaria and anemia.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: ____ DATE: ____

HOUSEHOLD SCHEDULE

01) LINE NUMBER:

02) 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 AS APPROPRIATE QUESTIONS IN COLUMNS 5 - 28 FOR EACH PERSON.

03) 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

04) SEX:
Is (NAME) male or female?

RESIDENCE:

05) Does (NAME) usually live here?

06) Did (NAME) stay here last night?

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

IF AGE 15 OR OLDER:

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

ELIGIBILITY:

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

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

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

IF AGE 0-17 YEARS:

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

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

13) Does (NAME)'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'.

14) Is (NAME)'s natural father alive?

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'.

IF AGE 3 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

16) Has (NAME) ever attended school?

17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

SEE CODES BELOW.
IF LESS THAN 1 YEAR RECORD "00".

IF AGE 3-24 YEARS:

CURRENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school at any time during the (2012/2013) school year?

19) During this school year, what level and grade is (NAME) attending?
SEE CODES BELOW.

SCHOOL ATTENDANCE DURING LAST YEAR:

20) Did (NAME) attend school at any time during the previous (2011/2012) school year?

21) During the previous school year, what level and grade was (NAME) attending?
SEE CODES BELOW.
IF LESS THAN 1 YEAR RECORD "00"

22) IF AGE 0-7:
BIRTH REGISTRATION:
Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

PHYSICAL DISABILITIES (IF AGE 7-69):

EYE SIGHT:

23) Does (NAME) wear glasses?

24) Does (NAME) have difficulty seeing during the day (even if she / he is wearing glasses)?

HEARING:

25) Does (NAME) use a hearing aid?

26) Does (NAME) have difficulty hearing (even if she / he is using a hearing aid)?

LEGS:

27) Does (NAME) have any difficulty using his / her legs even for simple activities such as walking or climbing up the stairs?

28) Does (NAME) use a cane or crutches or wheelchair?

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?

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?

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

HOUSEHOLD CHARACTERISTICS

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

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

103) Where is that water source located?

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

105) Do you do anything to the water to make it safer to drink?

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

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

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

109) How many households use this toilet facility?

110) Does your household have:

Electricity?
A sofa?
A wardrobe?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
An air conditioner?
A generator or solar panel?
A computer?
A microwave oven?
A DVD/VCD player?
Satellite cable?
Satellite dish?
Internet connection?

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

112) Is the cooking usually done in the house, in a separate building, or outdoors?

113) Do you have a separate room which is used as a kitchen?

114) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

115) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

116) MAIN MATERIAL OF EXTERIOR WALLS. RECORD OBSERVATION.

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

118) Does any member of this household own:

A watch?
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?

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

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

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

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?
Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens, ducks or guinea fowl?
Pigs?

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

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

125) Who sprayed the dwelling?

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

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

128) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS GO TO THE NEXT PAGE.

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

129A) RECORD OR ASK THE SHAPE OF THE NET

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.

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

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

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

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

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

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.

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

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

140) WE WOULD LIKE TO CHECK WHETHER THE SALT USED IN YOUR HOUSEHOLD IS IODIZED. MAY I HAVE A SAMPLE OF THE SALT USED TO COOK MEALS IN YOUR HOUSEHOLD?
ONCE YOU HAVE TESTED THE SALT, CIRCLE NUMBER THAT CORRESPONDS TO TEST OUTCOME.

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

21) 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 TWO:

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?

204) CHECK 203:
CHILD BORN IN JANUARY 2008 OR LATER?

205) WEIGHT IN KILOGRAMS:

206) HEIGHT IN CENTIMETERS:

207) MEASURED LYING DOWN OR STANDING UP?

209) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD '00' IF NOT LISTED.

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

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 2008 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOU NAME.

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

As part of this survey, we are asking people all over the country to take a test to see if they have malaria. Malaria is a serious illness that is 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 2008 or later take part in malaria testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. (We will use blood from the same finger prick made for the anemia test). A few blood drops will be collected on a slide(s) and taken to a laboratory for testing. You will not be told the results of laboratory testing. 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 to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the malaria testing?

213) CIRCLE THE APPROPRIATE CODE AND SIGN YOU NAME.

214) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

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

216) RECORD RESULT CODE OF THE MALARIA RDT.

217) RESULT OF THE MALARIA RDT TEST.

218) READ INFORMATION FOR MALARIA TREATMENT AND CONSENT STATEMENT TO PARENT OR OTHER ADULT RESPONSIBLE FOR THE CHILD.

The malaria test shows that your child has malaria. We can give you free medicine. The medicine is called Coartem and 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.

219) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

220) TREATMENT FOR CHILDREN WITH POSITIVE MALARIA TESTS

ALSO TELL THE PARENT/ADULT RESPONSIBLE FOR THE CHILD: If (NAME) has a high fever, fast or difficult breathing, is not able to drink or breastfeed, gets sicker or does not get better in two days, you should take him/her to a health professional for treatment right away.

221) RECORD THE RESULT CODE OF MALARIA TREATMENT OR REFERRAL.

222) STICK 1ST BAR CODE LABEL FOR THE CHILD'S MALARIA TEST

(BAR CODE LABEL)

STICK THE 2ND BAR CODE LABEL ON THE CHILD'S SLIDE AND THE 3RD ON THE MALARIA TRANSMITTAL FORM

223) 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 224.

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

224) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 225. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

225) LINE NUMBER FROM COLUMN 9:
NAME FROM COLUMN 2:

226) WEIGHT IN KILOGRAMS

227) HEIGHT IN CENTIMETERS

228) AGE: CHECK COLUMN 7.

229) MARITAL STATUS: CHECK COLUMN 8.

230) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED,

231) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 230 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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 ADOLESCENT) 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 to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to participate in the anemia test?

232) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

233) ASK FOR 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 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 to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?

234) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

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

236) AGE: CHECK COLUMN 7.

237) MARITAL STATUS: CHECK COLUMN 8.

238) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 230 AS 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 The Gambia. 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 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?

239) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

240) 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 The Gambia. 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 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 to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

241) CIRCLE THE APPROPRIATE COD, SIGN YOU NAME, AND ENTER YOUR INTERVIEWER NUMBER.

242) AGE: CHECK COLUMN 7.

243) MARITAL STATUS: CHECK COLUMN 8.

243A) RECORD LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

244) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT OR OTHER ADULT IDENTIFIED IN 243A AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

We ask you to allow The National Public Health Laboratory of the Ministry of Health and Social Welfare 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 ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

245) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

246) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow The National Public Health Laboratory of the Ministry of Health and Social Welfare 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?

247) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

248) ADDITIONAL TESTS:

CHECK 245 AND 247:

249) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

250) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

251) STICK 1ST BAR CODE LABEL FOR THE WOMEN'S HIV TEST

(STICK THE 1ST BAR CODE LABEL HERE.)

STICK THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

252) GO BACK TO 226 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE WOMEN, GO TO 253.

TESTING FOR MEN AGE 15-59

254) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

255) AGE: CHECK COLUMN 7.

256) MARITAL STATUS: CHECK COLUMN 8.

256A) RECORD LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

257) ASK CONSENT FOR DBS COLLECTION FROM PARENT / OTHER ADULT IDENTIFIED IN 256A AS RESPONSIBLE FOR NEVER IN UNION MEN 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 the Gambia. 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 results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know his HIV status, I can provide him with a list of [nearby] facilities offering counseling and testing for HIV. I will also give him 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 for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the HIV test?

257A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

258) 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 the Gambia. 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 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 to the test, or you can say no. It is up to you to decide.
Will you take the HIV test?

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

260) AGE: CHECK COLUMN 7.

254) LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

261) MARITAL STATUS: CHECK COLUMN 8.

262) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 257A AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17.

We ask you to allow The National Public Health Laboratory of the Ministry of Health and Social Welfare 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 ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

263) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

264) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow The National Public Health Laboratory of the Ministry of Health and Social Welfare 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?

265) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

266) ADDITIONAL TESTS:

CHECK 263 AND 265:

IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER AND GO BACK TO 255

267) PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

269) BAR CODE LABEL MEN'S HIV TEST

(STICK THE 1ST BAR CODE LABEL HERE.)

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

270) GO BACK TO 255 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF NEXT PAGE; IF NO MORE MEN, END INTERVIEW.

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS
(TO BE ADDED TO THE HOUSEHOLD QUESTIONNAIRE)

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD NUMBER IS '16' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 05, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.