IDENTIFICATION
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PLOT NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
ADMINISTRATIVE REGION
NATURAL REGION
SANITATION DISTRICT NUMBER
LOCATION OF HOUSEHOLD

Household selected for men's survey/tests/health spending?

INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR 2018
INT. NUMBER
RESULT

TOTAL NO. OF VISITS

TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONNAIRE: FRENCH 01
LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

SUPERVISOR
NAME
DATE

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the National Institute of Statistics. We are conducting a survey about health all over Guinea. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

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

SIGNATURE OF INTERVIEWER
DATE

100) RECORD THE TIME

HOUSEHOLD SCHEDULE

1) LINE NO.

2) USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

After listing the names and recording the relationship and sex for each person, ask questions 2a-2c to be sure that the listing is complete.

Then ask appropriate questions in columns 5-20 for each person.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

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

RESIDENCE

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

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

IF AGE 15 OR OLDER

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

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

10) IF HOUSEHOLD SELECTED FOR MAN'S SURVEY, CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

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

Just to make sure that I have a complete listing:
2A) Are there any other persons such as small children or infants that we have not listed?

2B) In addition, are there any other people who many 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?

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 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 5 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?

IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during the (2015-2016) school year?

19) During this/that school year, what level and grade (is/was) (NAME) attending?

IF AGE 0-4 YEARS
BIRTH REGISTRATION
20) Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

IF HOUSEHOLD SELECTED FOR HEALTH CARE SPENDING MODULE:

HOSPITALIZATION
20b) In the last six months, has (NAME) spend the night in a health care establishment for medical treatment?

20c) CIRCLE THE LINE NUMBER OF THE HOUSEHOLD MEMBER ELIGIBLE FOR THE HOSPITALIZATION MODULE.
CHECK COLUMN 20B FOR CODE 1 "YES".

NO HOSPITALIZATION
20d) In the past 4 weeks, has (NAME) received care from a health care provider or pharmacist without staying the night?

20e) CIRCLE THE LINE NUMBER OF THE HOUSEHOLD MEMBER ELIGIBLE FOR THE NO HOSPITALIZATION MODULE
CHECK COLUMN 20D FOR CODE 1 "YES"

HOUSEHOLD CHARACTERISTICS

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

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

103) Where is the water source located?

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

105) CHECK 101 AND 102: CODE 14 OR 21 CIRCLED

106) In the past two weeks, was the water from this source not available for at least one full day?

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

108) What do you usually do to make the water safer to drink? Anything else?

RECORD ALL MENTIONED

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

IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

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

111) Including your own household, how many households use this toilet facility?

112) Where is this toilet facility located?

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

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

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

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

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

118) How many of the following animals does this household own?

IF NONE, ENTER 00
IF 95 OR MORE, ENTER 95
IF UNKNOWN, ENTER 98

Milk cows or bulls?

Other cattle?

Horses, donkeys, or mules?

Goats?

Sheep?

Pigs?

Ducks?

Chickens?

Guinea fowl/other poultry?

Other?

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 your household have:

a) EDG (Guinean) Electricity?

b) Electricity from another source?

c) A radio?

d) A television?

e) A fan?

f) A refrigerator/freezer?

g) A gas camping stove?

h) A table?

i) Chairs?

j) A cabinet?

k) A couch?

l) A bookcase?

m) A desk computer?

n) A laptop?

122) Does any member of your household own:

a) A watch?

b) A clock?

c) A landline telephone?

d) A simple mobile phone?

e) An Android mobile phone?

f) A bicycle? Yes 1 No 2

g) A motorcycle or motor scooter?

h) A cart pulled by an animal?

i) A car or truck?

j) A motor boat?

k) A canoe?

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

124) Does anyone in your household smoke? Would you say daily, weekly, monthly, less than monthly, or never?

127) Does your household have any mosquito nets?

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

129) Ask the respondent to show you the nets in the household.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

130) How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00.
RECORD THE NUMBER OF MONTHS

131) 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.

134) Did you get the net through the mass distribution campaigns of 2009 (meaning 8 or 9 years ago), the campaign of 2013 (meaning 4 or 5 years ago), the campaign of 2016 (meaning 1 or 2 years ago), during an antenatal care visit, or during an immunization visit?

135) Where did you get the net?

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

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

138) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139.

ADDITIONAL HOUSEHOLD CHARACTERISTICS

139) We would like to learn about the places that households use to watch their hands. Can you please show me where members of your household most often wash their hands?

140) Observe presence of water at the place for handwashing.
RECORD OBSERVATION

141) Observe presence of soap, detergent, or other cleansing agent at the place for handwashing.
RECORD OBSERVATION.

142) Observe main materials of the floor in the dwelling.
RECORD OBSERVATION.

143) Observe main material of the roof of the dwelling.
RECORD OBSERVATION.

144) Observe main materials of the exterior walls of the dwelling.
RECORD OBSERVATION.

145) I 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?

TEST SALT FOR IODINE

HOSPITALIZATION EXPENSES

500) CHECK THE COVER PAGE: Household selected for survey on healthcare expenses?

501) CHECK COLUMN 20C OF THE HOUSEHOLD TABLE.

502) Check column 20c in the household table: Record the number and name of each household member who has been hospitalized. Then ask: Now I'd like to ask you some questions about the members of your household who have been hospitalized in a healthcare facility for at least one night in the last 6 months.

503) LINE NUMBER OF MEMBER FROM COLUMN 20C FROM THE HOUSEHOLD TABLE

504) NAME FROM COLUMN 2 OF THE HOUSEHOLD TABLE

505) Where did (NAME) most recently spend the night for care?

506) The last time (name) went for treatment, what was the reason?

507) How much was spent on the services and treatment (name) received during the last hospitalization?
We want to know the total cost tied to the hospitalization, including all charges connected to exams, drugs, and other things.
RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000

508) In the last six months, has (NAME) spend the night in a health care facility a different time for a different reason?

509) Where did (NAME) most recently spend the night for care?

510) The last time (NAME) went for treatment, what was the reason?

511) How much was spent on the services and treatment (NAME) received during the last hospitalization?
We want to know the total cost tied to the hospitalization, including all charges connected to exams, drugs, and other things.
RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000

512) Other than the two hospitalizations you just told me about, has (NAME) spend another night a health care facility for care in the last 6 months?

513) Where did (NAME) most recently spend the night for care?

514) The last time (NAME) went for treatment, what was the reason?

515) How much was spent on the services and treatment (NAME) received during the last hospitalization?
We want to know the total cost tied to the hospitalization, including all charges connected to exams, drugs, and other things.
RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000

516) Other than the three hospitalizations you just told me about, has (NAME) spend another night a health care facility for care in the last 6 months?

517) In total, how many times has (NAME) spent the night in a health care facility for fare in the last 6 months?

518) Is (NAME) covered by any kind of health insurance of exemption?

519) What kind of health insurance did (NAME) have during his/her last hospitalization in a health care facility?

520) GO BACK TO 505 IN THE NEXT COLUMN OR, IF NO MORE HOSPITALIZED PATIENTS, GO TO 601.

SELECTION FOR HEALTHCARE EXPENSES WITHOUT HOSPITALIZATION (PAPER OPTION)

601) CHECK COLUMN 20E

SELECTION TABLE FOR SICK, NON-HOSPITALIZED PERSON WHO RECEIVED PAID CARE LAST TIME IN THE LAST FOUR WEEKS

Look at the last digit of the household number on the cover page, this is the line number you should go to. Check the total number of sick, non-hospitalized eligible people (column 20e) in the household table. This is the number of the column you will go to. Follow the intersection of the selected line and the column and circle the number in the corresponding cell. This is the number of the person selected for the sick, non-hospitalized questions in the list of sick, non-hospitalized individuals in column 20e of the household questionnaire. Record the name and line number of the sick, non-hospitalized individual selected in q602.

Example: The number of the household questionnaire is "716" and the column 203 in the household table shows that there are three sick, non-hospitalized individuals eligible in the household (Line number 02, 04, and 05). Since the last digit of the number of the household questionnaire is "six" go to line "6" and since there are three eligible sick, non-hospitalized individual in the household, go to column "3". Follow the line and column and find the number in the cell where they meet ("2") and circle this number. Now go to the household table and find the second eligible sick, non-hospitalized individual for the question for sick, non-hospitalized individuals (line number 04 in this example). Write the name and line number of the sick, non-hospitalized individual selected in q 602.

602) Name of sick, non-hospitalized individuals selected

602a) Line number and name of sick, non-hospitalized person (from 602)

603) Now I would like to ask you some questions about the medical care without hospitalization that (NAME) received over the last four weeks. Where did (NAME) get care without hospitalization the last time?

604) The last time (NAME) sought care, what was the main reason?

605a) How much was spent for these services and treatment that (name) received at (name of service provider from q603)?
Please include the expenses associated with the consultation and all other expenses like drugs, exams, transportation, and other.
RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000

605b) How much were the expenses for:

a) Consultation

b) Drugs

c) Laboratory exams

d) X-ray (MRI, Scans, EK, Mammograms, etc.)

e) Transportation

f) Other

RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000
IF FREE, RECORD 00000000
IF COST NOT SPECIFIED, RECORD 99999994
IF IN KIND, RECORD 99999995
IF DON'T KNOW 99999998

606a) Has (NAME) received care from a service provider or pharmacists at another time over the course of the last four week, without hospitalization?

606a) Where did (NAME) get care without hospitalization the last time?

606b) The second to last time (NAME) sought care, what was the main reason?

606c) How much was spent for these services and treatment that (name) received at (name of service provider from q606a)?
Please include the expenses associated with the consultation and all other expenses like drugs, exams, transportation, and other.
RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000

606d) How much were the expenses for:
a) Consultation

b) Drugs

c) Laboratory exams

d) X-ray (MRI, Scans, EK, Mammograms, etc.)

e) Transportation

f) Other

RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000
IF FREE, RECORD 00000000
IF COST NOT SPECIFIED, RECORD 99999994
IF IN KIND, RECORD 99999995
IF DON'T KNOW 99999998

606e) Has (NAME) received care from a service provider or pharmacists at another time over the course of the last four week, without hospitalization?

606f) Where did (NAME) get care without hospitalization the last time?

606g) The third to last time (NAME) sought care, what was the main reason?

606h) How much was spent for these services and treatment that (NAME) received at (NAME OF SERVICE PROVIDER FROM Q606F)?
Please include the expenses associated with the consultation and all other expenses like drugs, exams, transportation, and other.

RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000

606i) How much were the expenses for:
a) Consultation

b) Drugs

c) Laboratory exams

d) X-ray (MRI, Scans, EK, Mammograms, etc.)

e) Transportation

f) Other

RECORD THE AMOUNT.
IF MORE THAN 94 000 000 FRANCS, RECORD 94 000 000
IF FREE, RECORD 00000000
IF COST NOT SPECIFIED, RECORD 99999994
IF IN KIND, RECORD 99999995
IF DON'T KNOW 99999998

606j) Has (NAME) received care from a service provider or pharmacists at another time over the course of the last four week, without hospitalization?

607) How many other times has (NAME) received care over the last four weeks?

608) How many times was money spent?

609) Is (NAME) covered by any kind of health insurance of exemption?

610) What kind of health insurance was used when (NAME) received care the last time?

611) Sometimes people by vitamins, drugs, and other plant-based remedies without consulting a health care provider, a pharmacist, or a traditional healer. They can also buy products like bandages, thermometers, or other medical devices without a consultation.
Over the last four weeks, how much have you spent on these types of products for members of your household?

RECORD THE AMOUNT.
IF MORE THAN 94,000,000 FRANCS, RECORD 94,000,000

ANEMIA TEST FOR CHILDREN AGE 0-5

201) Check column 11 of the household schedule. Record the line number and the name for all eligible children 0-5 years in q. 102 in order according to the line number; if more than six children, use additional questionnaire(s).

202) Check line number from column 11 in household questionnaire

203) If mother interviewed, copy child's date of birth (day, month, and year) from birth history. IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s date of birth?

204) CHECK 203: Child born in January 2013 or later?

205a) Is anthropometry data (weight and height) available?
FILTER FOR [CAPI] ONLY AND IF AN ANTHROPOMETRY AGENT IS USING A SEPARATE PAPER QUESTIONNAIRE TO RECORD WEIGHT AND HEIGHT

205) Weight in kilograms

206) Height in centimeters

207) Measured lying down or standing up?

207a) Presence of bilateral edema on feet

208) Measurer: Enter your interviewer number

209) CHECK 203: If child age 0-5 months, i.e. was child born in month of interview or five previous months?

210) Line number from parent/other adult responsible for the child (from column 1 of household table). RECORD 00 IF NONE LISTED.

111) Ask consent for anemia test from parent/other adult identified in 210 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 and set up 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 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 member 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?

212) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

215) PREPARE THE EQUIPMENT AND SUPPLIES FOR THE ANEMIA TEST.

216) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA AND MALARIA PAMPHLET.

217) CHECK 217: Hemoglobin level

221) Reference declaration for serious malaria
The diagnostic test for malaria shows that (name of child) has serious malaria. Your child is seriously ill and must be taken to a health care establishment immediately.

234) Go back to Q 202 in next column of this questionnaire or the first column of the extra questionnaire. If no more children, go to 300 to check if women are eligible for anemia and HIV tests.

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

301) Check column 9 of the household questionnaire. Record the line number, name, and marital status for all women eligible for Q 302, 303, and 304. If more than 3 women, use additional questionnaire(s).

302) Check household questionnaire:

303) Check household questionnaire:

304) CHECK HOUSEHOLD SCHEDULE:

WEIGHT AND HEIGHT FOR WOMEN AGE 15-49

305a) Is anthropometry data (weight and height) available?
Filter for [capi] only and if an anthropometry agent is using a separate paper questionnaire to record weight and height

305) Weight in kilograms

306) Height in centimeters

307) Measurer: Enter your interview number

308) CHECK 303: AGE

309) CHECK 304: MARITAL STATUS

ANEMIA AND HIV TEST FOR WOMEN AGE 18-49

ADULT RESPONDENT CONSENT FOR ANEMIA TEST
ADULT RESPONDENT CONSENT

310) Ask for 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 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?

311) Circle the code and sign your name.

311a) Check 226 in woman's questionnaire or ask: Are you pregnant?

ADULT RESPONDENT CONSENT FOR DBS COLLECTION
ADULT RESPONDENT CONSENT

312) 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 the result of your test, I can give you a card with a code tied to your test and a phone number, which you can call in a month or two to get the results of your test. If you want to go in person to get the result of your test, you can call the same number to get the information on how to get there.

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?

313) Circle the code, sign your name, and enter your interviewer number.

316) Line number from parent/other adult responsible for the child

(RECORD 00 IF NONE LISTED)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
PARENT/RESPONSIBLE ADULT CONSENT

317) Ask for 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.

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 to the test, or you can say no. It is up to you to decide.

Will you allow (NAME OF MINOR) to take the anemia test?

318) Circle the appropriate code and sign.

MINOR RESPONDENT CONSENT FOR ANEMIA TEST
MINOR RESPONDENT CONSENT

319) 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 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 to the test, or you can say no. It is up to you to decide.

Will you take the anemia test?

320) Circle the code and sign your name.

320a) CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: are you pregnant?

PARENT/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
PARENT/RESPONSIBLE ADULT CONSENT

321) Ask for consent for DBS collection from parent/adult

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 the results of (name of minor)'s test either. If (name of minor) wants to know her HIV status, I can give her a card with a code tied to her test and a phone number, which (name of minor) can call in a month or two to get the results of her test. If (name of minor) want to go in person to get the result of her test, (name of minor) can call the same number to get the information on how to get there.

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 minor) to give blood for the HIV test?

322) Circle the appropriate code, sign and record your interviewer number

MINOR RESPONDENT CONSENT FOR DBS COLLECTION
MINOR RESPONSIBLE CONSENT

323) Ask consent for DBS collection from minor 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. 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 the results of your test either. If you want to know the result of your test, I can give you a card with a code tied to your test and a phone number, which you can call in a month or two to get the results of your test. If you want to go in person to get the result of your test, you can call the same number to get the information on how to get there.

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?

324) Circle the appropriate code and sign your name.

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

331) Record hemoglobin level here and in anemia pamphlet

332) Place bar code stickers here
Put the 1st bar code here

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

333) GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, GO TO 401.

HIV TEST FOR MEN AGE 15-59

401) Check column 10 of the household questionnaire. Record the line number, name, and marital status for all men eligible for Q 402, 403, and 404. If more than 3 men, use additional questionnaire(s).

402) Check household questionnaire:

403) Check household questionnaire:

COLUMN 7 (AGE):

404) Check household schedule:

COLUMN 8 (MARITAL STATUS):

408) Check 403: Age

409) Check 404: Marital status

HIV TEST FOR MEN AGE 18-59

ADULT RESPONDENT CONSENT FOR DBS COLLECTION
ADULT RESPONSIBLE CONSENT

412) 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 the result of your test, I can give you a card with a code tied to your test and a phone number, which you can call in a month or two to get the results of your test. If you want to go in person to get the result of your test, you can call the same number to get the information on how to get there.

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?

413) Circle the code, sign your name, and enter your interviewer number.

HIV TEST FOR MINOR MEN AGE 15-17

NAME FROM COLUMN 2

416) Record the line number of the parent/other adult responsible for the adolescent.

LINE NUMBER OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT.
(RECORD 00 IF NOT LISTED)

PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
PARENT/RESPONSIBLE ADULT CONSENT

421) Ask for consent for DBS collection from parent/adult

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 test is being done in this survey to understand how many people have contracted the virus.

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 the results of (name of minor)'s test either. If (name of minor) wants to know her HIV status, I can give her a card with a code tied to her test and a phone number, which (name of minor) can call in a month or two to get the results of her test. If (name of minor) want to go in person to get the result of her test, (name of minor) can call the same number to get the information on how to get there.

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 minor) to give blood for the HIV test?

422) Circle the appropriate code, sign and record your interviewer number

MINOR RESPONDENT CONSENT FOR DBS COLLECTION
MINOR RESPONDENT CONSENT

423) Ask consent for DBS collection from minor 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. 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 the results of your test either. If you want to know the result of your test, I can give you a card with a code tied to your test and a phone number, which you can call in a month or two to get the results of your test. If you want to go in person to get the result of your test, you can call the same number to get the information on how to get there.

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?

424) Circle the appropriate code and sign your name.

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

432) Place bar code stickers here
Put the 1st bar code here

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

433) GO BACK TO 402 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE MEN, GO TO 434.

434) END OF HOUSEHOLD QUESTIONNAIRE.
RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT THE INTERVIEW:

COMMENTS ON SPECIFIC QUESTIONS:

NOTES ON BIOMARKER TESTS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS

EDITOR'S OBSERVATIONS

REPUBLIC OF GUINEA

201) Check with the respondent who filled out the household questionnaire. Record the line number and name of all the children age 0-5 in Q 202 in order according to the line number, next follow the questions to take the height and weight of each child born in January 2013 or later. Later during the day, have the respondent record the data for this extra questionnaire on her tablet. If there are more than 4 children in the household, use supplementary questionnaire(s).

202) LINE NUMBER

203) If mother interviewed, copy the month and year of the child's birth according to the birth history.
IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s date of birth?

204) CHECK 203: Child born 2013 or later?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) Measured lying down or standing up?

207a) Edema: Presence of bilateral edema in feet?

208) Measurer: Field agent number

234) Go back to Q 202 in next column of this questionnaire or to the 1st column of the extra questionnaires; if there are no more children, go to 300 to check if the women are eligible for the anemia and HIV tests.

Field agent observations
Comments about the children's weight and height measurements

SUPPLEMENTARY QUESTIONNAIRE FOR WEIGHT AND HEIGHT OF WOMEN AGE 15-49

300) CLUSTER NUMBER
HOUSEHOLD NUMBER

301) Check with the respondent who filled out the household questionnaire. Record the line number and name of all women age 15-49 in the household in q 302 according to the line number. Then take the weight and height of all women. For each woman in the household, record in the table her weight and height if she is weighed and measured, or her result code. Later in the day, have the respondent record the data for the extra questionnaire in her tablet. If there are more than 3 women in the household, use an additional questionnaire(s).

302) CHECK HOUSEHOLD QUESTIONNAIRE:

Measurement of weight and height of woman age 15-49

305) WEIGHT IN KILOGRAMS

306) HEIGHT IN CENTIMETERS

307) MEASURER: ENTER YOUR INTERVIEWER NUMBER

INTERVIEWER NUMBER

333) GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE. IF NO MORE WOMEN, HOUSEHOLD QUESTIONNAIRE ENDS HERE FOR ANTHROPOMETRY.

OBSERVATIONS FROM THE FIELDWORKER
COMMENTS ABOUT THE WOMEN'S WEIGHT AND HEIGHT