IDENTIFICATION

STATE __
DISTRICT __
TEHSIL/TALUK __
CITY/TOWN/VILLAGE __
TYPE OF PSU (URBAN =1, RURAL =2) __
PSU NUMBER __
STRUCTURE NUMBER __
HOUSEHOLD NUMBER __
NAME OF HOUSEHOLD HEAD __
ADDRESS OF HOUSEHOLD __
IS HOUSEHOLD SELECTED FOR THE STATE MODULE? (YES = 1, NO = 2) __
IS HOUSEHOLD SELECTED FOR DRIED BLOOD SPOT (DBS) COLLECTION? (YES = 1, NO =2) __

HEALTH INVESTIGATOR VISITS

FIRST VISIT
DATE __

NEXT VISIT:
DATE __
TIME __

SECOND VISIT
DATE __

NEXT VISIT:
DATE __
TIME __

THIRD VISIT
DATE __

FINAL VISIT
DAY __
MONTH __
YEAR __

TOTAL NUMBER OF VISITS __

*LANGUAGE OF QUESTIONNAIRE ENGLISH

TOTAL NUMBER OF ELIGBILE WOMEN AGE 15+ __
TOTAL NUMBER OF ELIGIBLE CHILDREN __
TOTAL NUMBER OF ELIGIBLE MEN AGE 15+ __

SUPERVISOR
NAME __
DATE __

HEALTH INVESTIGATOR
NAME __
DATE __

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

201. FROM THE LIST OF ELIGIBLE CHILDREN, RECORD THE NAME AND LINE NUMBER IN THE SAME ORDER THEY APPEAR IN THE HOUSEHOLD SCHEDULE.

IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202. NAME AND LINE NUMBER

203. IF MOTHER IS INTERVIEWED, COPY CHILD'S DATE OF BIRTH FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED, ASK DATE OF BIRTH.

What is (NAME)'s birth date?

204. CHECK 203: CHILD BORN IN JANUARY 2014 OR LATER?

205. WEIGHT IN KILOGRAMS

206. HEIGHT IN CENTIMETERS

207. MEASURED LYING DOWN OR STANDING UP?

208. CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

209. NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD.

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 test will assist the government to develop programs to prevent and treat anemia. We ask that children born in 2014 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.

211. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPLHET.

213. GO BACK TO 203 IN THE NEXT COLUMN ON THIS PAGE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 301.

WEIGHT, HEIGHT, WAISTE, AND HIP CIRCUMFRENCE, BLOOD PRESSURE, BLOOD GLUCOSE, HEMOGLOBIN MEASUREMENT AND COLLECTION OF DRIED BLOOD SPOTS FOR WOMEN

301. FROM THE LIST OF ELIBILE WOMEN AGE 15+ IN THE HOUSEHOLD QUESTIONNAIRE, RECORD THE NAME, LINE NUMBER, AGE, AND MARITAL STATUS IN THE SAME ORDER THEY APPEAR IN THE HOUSEHOLD SCHEDULE.
WRITE THE NAME OF EACH WOMEN AT THE TOP OF THE FOLLOWING PAGES.
IF THERE ARE MORE THAN THREE WOMAN, USE ADDITIONAL QUESTIONNAIRE(S).

302. NAME, LINE NUMBER, AGE, MARITAL STATUS

303. WEIGHT IN KILOGRAMS

304. HEIGHT IN CENTIMETERS

305. WAIST CIRCUMFERENCE IN CENTIMETERS

306. HIP CIRCUMFERENCE IN CENTIMETERS

307. AGE: CHECK 302

308. MARITAL STATUS: CHECK 302

309. RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT

310. ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 309 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.

I would like to measure (NAME OF ADOLESCENT)'s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of the blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)'s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey You can also decide at any time not to participate in the blood pressure measurement. 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 me to measure (NAME OF ADOLESCENT)'s blood pressure?

311. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

312. ASK CONSENT FOR BLOOD PRESSURE FROM RESPONDENT.

I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of the blood pressure measurement will be explained to you. If you blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 me to measure your blood pressure?

313. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

314. Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements. Have you done any of the following within the past 30 minutes:

a. Eaten anything?
b. Had coffee, tea, cola or other drink that has caffeine?
c. Smoked any tobacco product>
d. Used any other type of tobacco such as gutka, paan masala with tobacco, other chewing tobacco, or snuff?

315. May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I used the right equipment.

316. USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE.

317. RECORD TIME OF FIRST BP READING

318. TAKE THE FIRST BLOOD PRESSURE READING.
RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE

319. Before this survey, has your blood pressure ever been checked?

320. Were you told on two or more different occasions by a doctor, nurse or ANM that you had hypertension or high blood pressure?

321. To lower your blood pressure, are you now taking a prescribed medication?

322. CHECK THAT IS HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

323. May I take your blood pressure at this time?

324. RECORD TIME OF SECOND BP READING

325. TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

326. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT

327. May I take your blood pressure at this time?

328. RECORD TIME OF THIRD BP READING

329. TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

330. RECORD THE SUM OF THE SYSTOLIC MEASURES

331. CALCULATE THE AVERAGE SYSTOLIC PRESSURED BY DIVIDING THE SUM IN 330 BY 2.

332. RECORD THE SUM OF THE DIASTOLIC MEASURES.

333. CALCULATE THE AVERAGE DIASTOLIC PRESSURE BY DIVIDING THE SUM IN 332 BY 2.

333A. IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE.

334. RECORD THE SYSTOLIC MEASURE FROM 318.

335. RECORD THE DIASTOLIC MEASURE FROM 318.

335A. IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECOND SYSTOLIC AND DIASTOLIC NUMBERS HERE.

336. RECORD THE SYSTOLIC MEASURE FROM 325.

337. RECORD THE DIASTOLIC MEASURE FROM 325.

338. CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.

339. RECORD THE NUMBER YOU CIRCLED IN 338 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS.

339A. IF 338 = 6 (GO TO 378A)

340. AGE: CHECK 302

341. MARITAL STATUS: CHECK 302

342. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 309 AS RESPONSIBLE FOR NEVER MARRIED 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 test 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 take the anemia test?

343. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

344. 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. The test 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?

345. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

346. Are you pregnant now?

347. AGE: CHECK 302

348. MARITAL STATUS: CHECK 302

349. ASK CONSENT FOR BLOOD GLUCOSE FROM PARENT/OTHER ADULT IDENTIFIED IN 309 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.

As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you and (NAME OF ADOLESCENT) with an explanation of the meaning of the blood sugar numbers. If (NAME OF ADOLESCENT)'s blood sugar is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any counseling, further testing or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having (NAME OF ADOLESCENT)'s blood sugar measured now.
Will you allow me to proceed to take (NAME OF ADOLESCENT)'s measurement?

350. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

351. ASK CONSENT FOR BLOOD GLUCOSE FROM RESPONDENT.

As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you with an explanation of the meaning of your blood sugar numbers. If your blood sugar is high, we will suggest that you consult a health facility or doctor since we cannot provide any counseling, further testing, or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me,
You can say yes or no to having your blood sugar measured now.
Will you allow me to proceed to take your measurement?

352. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

353. When was the last time you had something to eat?

354. When was the last time you had something to drink, other than plain water?

355. Before this survey, has your blood glucose ever been checked?

356. Were you told on two or more different occasions by a doctor, nurse, or ANM that your blood glucose level was high?

357. To lower your blood glucose level, are you now taking a prescribed medicine?

358. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR DBS

359. AGE: CHECK 302

360. MARITAL STATUS: CHECK 302

361. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 309 AS RESPONSIBLE FOR NEVER MARRIED WOMEN AGE 15-17.

As part of this survey, we also are asking people all over the country to take a test for malaria, HbA1c, and vitamin D. Malaria is a common cause of fever and can be treated with medicines. Malaria can be present in patients with or sometimes without fever. It is important to find out the type of malaria and whether the currently available drugs will be effective for treating persons with malaria. The second test, HbA1c, a form hemoglobin, is done to estimate the three-month average blood sugar levels to find out if the blood sugar levels are controlled in diabetic patients taking medicines. Vitamin D levels in the blood are measured to detect vitamin D deficiency, which is very common in India. Vitamin D deficiency causes brittleness of bones and can lead to fractures.

The tests will be done at national level laboratories to obtain advanced information on these conditions and will be used by the government to improve health programmes. For the 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 and we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. Information regarding care to be taken in case of fever and diabetes will be given along with a referral letter to the nearest health care facility for diagnosis and treatment. Information on ways to prevent vitamin D deficiency will also be provided.

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 tests?

362. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

363. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

As part of the survey we also are asking people all over the country to take a test for malaria, HbA1c and vitamin D. Malaria is a common cause of fever and can be treated with medicines. Malaria can be present in patients with or sometimes without fever. It is important to find out the type of malaria and whether the currently available drugs will be effective for treating persons with malaria. The second test, HbA1c, a form hemoglobin, is done to estimate the three-month average blood sugar levels to find out if the blood sugar levels are controlled in diabetic patients taking medicines. Vitamin D levels in the blood are measured to detect vitamin D deficiency, which is very common in India. Vitamin D deficiency causes brittleness of bones and can lead to fractures.

The tests will be done at national level laboratories to obtain advanced information on these conditions and will be used by the government to improve health programmes. For the 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 and we will not be able to tell you the test results. No one else will be able to know the test results. Information regarding care to be taken in case of fever and diabetes will be given along with a referral letter to the nearest health care facility for diagnosis and treatment. Information on ways to prevent vitamin D deficiency will also be provided.

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 to take the tests?

364. CIRCLE THE APPROPRIATE CODE, SIGN YOUR NAME.

365. AGE: CHECK 302

367. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 309 AS RESPONSIBLE FOR NEVER MARRIED WOMEN.

We ask you to allow (NAME OF AGENCY) to store part of (NAME OF ADOLESCENT)'s 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 tests in this survey.

Will you allow us to keep the blood sample stored for additional testing?

368. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

369. ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT.

We ask you to allow (NAME OF AGENCY) to store part of your 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 still 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 tests in this survey.

Will you allow us to keep your blood sample stored for additional testing?

370. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

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

373. RECORD THE TIME OF THE BLOOD GLUCOSE.

374. RECORD BLOOD GLUCOSE IN MG/DL

374A. AGE: CHECK 302

375. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

375A. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR DBS

376. BAR CODE LABEL

377. MARK FILTER PAPER CARD FOR DIABETES TESTING

378. MARK FILTER PAPER CARD FOR ADDITIONAL TEST.

378A. CHECK 302

379. Have you ever undergone a screening test for cervical cancer?

380. Have you ever undergone a breast examination for breast cancer?

381. Have you ever undergone an oral cavity examination for oral cancer?

382. 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.

WEIGHT, HEIGHT, WAIST, AND HIP CIRCUMFERENCE, BLOOD PRESSURE, BLOOD GLUCOSE, HEMOGLOBIN MEASUREMENT, AND COLLECTION OF DRIED BLOOD SPOTS FOR MEN

401. NAME, LINE NUMBER, AGE, MARITAL STATUS

402. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR OTHER MODULES

403. WEIGHT IN KILOGRAMS

404. HEIGHT IN CENTIMETERS

405. WAIST CIRCUMFERENCE IN CENTIMETERS

406. HIP CIRCUMFERENCE IN CENTIMETERS

407. AGE: CHECK 401

408. MARITAL STATUS: CHECK 401

409. RECORD NAME OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

410. ASK CONSENT FOR BLOOD PRESSURE FROM PARENT/OTHER ADULT IDENTIFIED IN 409 AS RESPONSIBLE FOR NEVER MARRIED MEN AGE 15-17.

I would like to measure (NAME OF ADOLESCENT)'s blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is used to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you and (NAME OF ADOLESCENT) after the measurement process is completed. The results of the blood pressure measurement will be explained to you. If (NAME OF ADOLESCENT)s blood pressure is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 me to measure (NAME OF ADOLESCENT)'s blood pressure?

411. CIRCLE THE APPROPRIATE CODE AND SIGN YOU NAME.

411A. CHECK THE COVER PAGE:THE HOUSEHOLD SELECTED FOR OTHER MODULES?

412. ASK CONSENT FOR BLOOD PRESURE FROM RESPONDENT.

I would like to measure your blood pressure. This will be done three times, with an interval of about five minutes between measurements. This is a harmless procedure. Blood pressure measurement is sued to find out if a person has high blood pressure. If not treated, high blood pressure may eventually cause serious damage to the heart. The results of this blood pressure measurement will be given to you after the measurement process is completed. The results of blood pressure measurement will be explained to you. If your blood pressure is high, we will suggest that you consult a health facility or doctor since we cannot provide any further testing or treatment during the survey. You can also decide at any time not to participate in the blood pressure measurement. 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 me to measure your blood pressure?

413. CIRCE THE APPROPRIATE CODE AND SIGN YOUR NAME.

413A. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR OTHER MODULES.

414. Before taking your blood pressure, I would like to ask a few questions about things that may affect these measurements. Have you done any of the following within the past 30 minutes:

a. Eaten anything?
b. Had coffee, tea, cola or other drink that has caffeine?
c. Smoked any tobacco products?
d. Used any other type of tobacco such as gutkha, paan, masala, with tobacco, other chewing tobacco, or snuff?

415. May I begin the process of measuring your blood pressure? I will begin by measuring the circumference of your arm to make sure that I use the right equipment.

416. USE THE ARM CIRCUMFERENCE MEASUREMENT TO SELECT THE APPROPRIATE BLOOD PRESSURE MONITOR CUFF

417. RECORD TIME OF FIRST BP READING

418. TAKE THE FIRST BLOOD PRESSURE READING.
RECORD THE SYSTOLIC AND DIASTOLIC PRESSURES.

419. Before this survey, has your blood pressure ever been checked?

420. Were you told on two or more different occasions by a doctor, nurse, or ANM that you had hypertension or high blood pressure?

421. To lower your blood pressure, are you now taking a prescribed medicine?

422. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE SECOND BLOOD PRESSURE MEASUREMENT.

423. May I take your blood pressure at this time?

424. RECORD TIME OF SECOND BP READING

425. TAKE THE SECOND BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

426. CHECK THAT IT HAS BEEN AT LEAST 5 MINUTES BEFORE TAKING THE THIRD BLOOD PRESSURE MEASUREMENT

427. May I take your blood pressure at this time?

428. RECORD TIME OF THIRD BP READING

429. TAKE THE THIRD BLOOD PRESSURE READING. RECORD THE SYSTOLIC AND DIASTOLIC PRESSURE.

430. RECORD THE SUM OF THE SYSTOLIC MEASURES

431. CALCULATE THE AVERAGE SYSTOLIDC PRESSURES BY DIVIDING THE SUM IN 430 BY TWO.

432. RECORD THE SUM OF THE DIASTOLIC MEASURES

433. CALCULATE THE AVERAGE DIASTOLIC PRESSURES BY DIVIDING THE SUM IN 432 BY 2.

433A. IF ONLY ONE MEASUREMENT WAS TAKEN, RECORD THE FIRST SYSTOLIC AND DIASTOLIC NUMBERS HERE.

434. RECORD THE SYSTOLIC MEASURE FROM 418.

435. RECORD THE DIASTOLIC MEASURE FROM 418.

435A. IF ONLY TWO MEASUREMENTS WERE TAKEN, RECORD THE SECOND SYSTOLIC AND DIASTOLIC NUMBERS HERE.

436. RECORD THE SYSTOLIC MEASURE FROM 425.

437. RECORD THE DIASTOLIC MEASURE FROM 425.

438. CIRCLE THE SINGLE NUMBER WHERE THE AVERAGE DIASTOLIC AND SYSTOLIC MEASURES MEET.

439. RECORD THE NUMBER YOU CIRCLED IN 438 IN THE CHART BELOW. THEN USE THE INSTRUCTIONS TO THE RIGHT OF THAT NUMBER TO COMPLETE A BLOOD PRESSURE REPORT AND REFERRAL FORM FOR THE RESPONDENT. GIVE THE FORM TO THE RESPONDENT AND ANSWER ANY QUESTIONS.

439A. IF 438 = 6 (GO TO 477A)

439B. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR OTHER MODULES?

440. AGE: CHECK 401

441. MARITAL STATUS: CHECK 401

442. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 409 AS RESPONSIBLE FOR NEVER MARRIED MEN 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 test will assist the government to develop programmes 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 take the anemia test?

443. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

444. 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. The test will assist the government to develop programmes 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?

445. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

446. AGE: CHECK 401

447. MARITAL STATUS: CHECK 401

448. ASK CONSENT FOR BLOOD GLUCOSE FROM PARENT/OTHER ADULT IDENTIFIED IN 409 AS RESPONSIBLE FOR NEVER MARRIED MEN AGE 15-17.

As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you and (NAME OF ADOLESCENT) with an explanation of the meaning of the blood sugar numbers. If (NAME OF ADOLESCENT)'s blood sugar is high, we will suggest that (NAME OF ADOLESCENT) consult a health facility or doctor since we cannot provide any counseling, further testing, or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having (NAME OF ADOLESCENT)'s blood sugar measured now.
Will you allow me to proceed to take (NAME OF ADOLESCENT)'s measurement?

449. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME,

450. ASK CONSENT FOR BLOOD GLUCOSE FROM RESPONDENT.

As part of this survey, we are also measuring the level of sugar in the blood. If it is not treated, a high level of blood sugar may increase the risk for heart disease and stroke. For the blood sugar 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 sugar 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. The results of this blood sugar test will be given to you with an explanation of the meaning of the blood sugar numbers. If your blood sugar is high, we will suggest that you consult a health facility or doctor since we cannot provide any counseling, further testing, or treatment during the survey.

Do you have any questions about the blood sugar measurement so far? If you have any questions about the procedure at any time, please ask me.
You can say yes or no to having your blood sugar measured now.
Will you allow me to proceed to take your measurement?

451. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

452. When was the last time you had something to eat?

453. When was the last time you had something to drink other than plain water?

454. Before this survey, has your blood glucose ever been checked?

455. Were you told on two or more different occasions by a doctor, nurse, or ANM that your blood glucose level was high?

456. To lower your blood glucose level, are you now taking a prescribed medicine?

457. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR DBS

458. AGE: CHECK 401

459. MARITAL STATUS: CHECK 401

40. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 409 AS RESPONSIBLE FOR NEVER MARRIED MEN AGE 15-17.

As part of this survey we are also asking people all over the country to take a test for malaria, HbA1c, and vitamin D. Malaria is a common cause of fever and can be treated with medicines. Malaria can be present in patients with or sometimes without fever. It is important to find out the type of malaria and whether the currently available drugs will be effective for treating persons with malaria. The second test, HbA1c, a form of hemoglobin, is done to estimate the three-month average blood sugar levels to find out if the blood sugar levels are controlled in diabetic patients taking medicines. Vitamin D levels in the blood are measured to detect Vitamin D deficiency, which is very common in India. Vitamin D deficiency causes brittleness of bones and can lead to factures.

The tests will be done at national level laboratories to obtain advanced information on these conditions and will be used by the Government to health programmes. For the tests, 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 and we will not be able to tell you the test results. No one else will be able to know (NAME OF ADOLESCENT)'s test results either. Information regarding care t be taken in case of fever and diabetes will be given along with a referral letter to the nearest health care facility for diagnosis and treatment. Information on ways to prevent vitamin D deficiency will also be provided.

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 tests?

461. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

462. ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.

As part of this survey we are also asking people all over the country to take a test for malaria, HbA1c, and vitamin D. Malaria is a common cause of fever and can be treated with medicines. Malaria can be present in patients with or sometimes without fever. It is important to find out the type of malaria and whether the currently available drugs will be effective for treating persons with malaria. The second test, HbA1c, a form of hemoglobin, is done to estimate the three-month average blood sugar levels to find out if the blood sugar levels are controlled in diabetic patients taking medicines. Vitamin D levels in the blood are measured to detect Vitamin D deficiency, which is very common in India. Vitamin D deficiency causes brittleness of bones and can lead to factures.

The tests will be done at national level laboratories to obtain advanced information on these conditions and will be used by the Government to health programmes. For the tests, 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 and we will not be able to tell you the test results. No one else will be able to know your test results. Information regarding care to be taken in case of fever and diabetes will be given along with a referral letter to the nearest health care facility for diagnosis and treatment. Information on ways to prevent vitamin D deficiency will also be provided.

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 the tests to be taken?

463. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

464. AGE: CHECK 401

465. MARITAL STATUS: CHECK 401

466. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 409 AS RESPONISBLE.

We ask you to allow (NAME OF AGENCY) to store part of (NAME OF ADOLESCENT)'s 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 tests in this survey.

Will you allow us to keep the blood sample stored for additional testing?

467. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

468. ASK CONSENT FOR ADDITIONAL TESTING, FROM RESPONDENT.

We ask you to allow (NAME OF AGENCY) to store part of your 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 tests in this survey.

Will you allow us to keep the blood sample stored for additional testing?

469. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

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

472. RECORD THE TIME OF THE BLOOD GLUCOSE TEST

473. RECORD BLOOD GLUCOSE IN MG/DL

473A. CHECK THE COVER PAGE: IS THE HOUSEHOLD SELECTED FOR OTHER MODULES?

474. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

475. BAR CODE LABEL

476. MARK FILTER PAPER CARD FOR DIABETES TESTING.

477. MARK FLTER PAPER CARD

477A. AGE: CHECK 401

478. Have you ever undergone an oral cavity examination?

479. GO BACK TO 402 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

HEALTH INVESTIGATOR'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING BIOMARKERS

COMMENTS ABOUT RESPONDENT: __
COMMENTS ON SPECIFIC TESTS/QUESTIONS: __
ANY OTHER COMMENTS: __

SUPERVISOR'S OBSERVATIONS: __

NAME OF SUPERVISOR: __
DATE: __