2019-20 LIBERIA DEMOGRAPHIC AND HEALTH SURVEY BIOMARKER QUESTIONNAIRE
GOVERNMENT OF LIBERIA
LIBERIA INSTITUTE OF STATISTICS AND GEO-INFORMATION SERVICES
IDENTIFICATION
PLACE NAME _____________________
NAME OF HOUSEHOLD HEAD ______________________
CLUSTER NUMBER ________________
HOUSEHOLD NUMBER _____________________
HOUSEHOLD SELECTED FOR MAN'S SURVEY AND BIOMARKERS?
NO 2
VISITS 1, 2, 3
DATE ___________
BIOMAKER'S NAME ________________
NEXT VISIT:
DATE _______________
TIME _______________
FINAL VISIT
DAY ______________
MONTH ______________
YEAR 20__
TOTAL NUMBER OF VISITS __________________
NOTES:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
TOTAL ELIGIBLE WOMEN _______________
TOTAL ELIGIBLE MEN ______________
TOTAL ELIGIBLE CHILDREN _____________
SUPERVISOR
NAME ____________________
NUMBER ____________________
WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5
101. INTERVIEWER TO COMPLETE Q.102 USING TABLET REPORT AND Q. 103 USING BIRTH HISTORY
USE THE INTERVIEWER'S MENU AND SELECT THE APPROPRIATE OPTION TO LIST ALL CHILDREN AGE 0-5 ELIGIBLE FOR BIOMARKER TESTING. RECORD THE COMPLETE NAME, AGE, AND THE LINE NUMBER AS THEY APPEAR IN THE REPORT ON YOUR TABLET. LIST EACH CHILD IN THE SAME ORDER SHOWN IN THE REPORT. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). WRITE THE NAME OF EACH ELIGIBLE CHILD ON EACH SUBSEQUENT PAGES.
102. FROM TABLET'S REPORT: WRITE CHILD'S COMPLETE FIRST/LAST NAME, AGE, AND LINE NUMBER FROM HOUSEHOLD QUESTIONNAIRE.
AGE ___________
LINE NUMBER _________
103. INTERVIEWER OR SUPERVISOR TO COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY.
MONTH ______________
YEAR ____________
103A. MEASURER AND ASSISTANT START FROM HERE
104. CHECK 103: CHILD BORN IN 2014-2020?
NO 2 (SKIP TO 114)
105. ASSISTANT TO RECORD WEIGHT IN KILOGRAMS.
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
106. CHECK 103 TO DETERMINE HOW CHILD NEEDS TO BE MEASURED.
ASSISTANT TO RECORD HEIGHT/LENGTH IN CENTIMETERS
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
107. CHILD MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.
109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
OLDER 2
110. WRITE THE NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD
111. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. We ask that all children born in 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.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
112. CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2 _______________(SIGN)
NOT PRESENT/OTHER 3 (SKIP TO 114)
113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
REFUSED 995
OTHER 996
114. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49
201. INTERVIEWER TO COMPLETE Q.202-204A USING TABLET REPORT
USE THE APPROPRIATE OPTION FROM THE INTERVIEWER'S MENU TO LIST ALL WOMEN AGE 15-49 ELIGIBLE FOR BIOMARKER TESTING. IN EACH COLUMN, WRITE THE COMPLETE NAME, AGE AND LINE NUMBER AS THEY APPEAR IN THE REPORT ON YOUR TABLET. ALSO CIRCLE THE APPROPRIATE CODE FOR QUESTION 203. IF THE WOMAN'S AGE IS 15-17, COMPLETE QUESTION 204. USING THE MARITAL STATUS INFORMATION PRINTED IN THE TABLET'S REPORT. IF THERE ARE MORE THAN THREE WOMEN, USE ASSITIONAL QUESTIONNAIRE(S).
202. FROM TABLET'S REPORT:
WRITE WOMAN'S AGE
WRITE WOMAN'S LINE NUMBER
AGE ____________
LINE NUMBER ___________
203. FROM TABLET'S REPORT:
CIRCLE CODE FOR AGE GROUP.
18-49 YEARS 2 (SKIP TO 204A)
204. FROM TABLET'S REPORT:
CIRCLE CODE FOR MARITAL STATUS
OTHER 2
204B. BIOMARKER START FROM HERE:
BEFORE PROCEEDING WITH THE CONSENT STATEMENTS, ASK THE RESPONDENT HER AGE AND MARITAL STATUS TO CONFIRM THE INFORMATION IN Q203/Q204. IF THERE ARE ANY DISCREPANCIES THAT AFFECT THE INFORMED CONSENT PATTERN (MINOR VS. ADULT); GO BACK TO Q203/Q204 AND MAKE CORRECTIONS. PLEASE INFORM THE INTERVIEWER OF NEEDED ADJUSTMENTS IN THE HOUSEHOLD SCHEDULE (QH07/GH08), IF NECESSARY.
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207. MEASURER: ENTER YOUR FIELDWORKER NUMBER
18-49 YEARS 2 (SKIP TO 210)
209. CHECK 204: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
210. ASK CONSENT FOR ANEMIA TEST
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
211. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 212)
NO 2
DON'T KNOW 8
ADULT RESPONDENT CONSENT FOR DBS COLLECTION
212. ASK CONSENT FOR DBS COLLECT.
As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV. For the HIV testing, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?
213. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 216)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
214. ASK CONSENT FOR ADDIOTNAL TESTING:
We ask you to allow the National Reference Laboratory to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done. The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
215. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2
ADULT RESPONDENT CONSENT FOR RDT TESTING
216. ASK CONSENT FOR HIV RDT TEST.
If you want to know your HIV status right now, we can do a rapid diagnostic test and tell you the result. The testing is free and we will offer counseling before and after the test. For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in hospitals in Liberia. 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 result of the test will be available in about 15 minutes. If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for rapid HIV testing?
217. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 235)
218. WRITE THE NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
219. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ADULT
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF MINOR) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to take the anemia test?
220. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 223)
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
221. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT/RESPONSIBLE ADULT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you take the anemia test?
222. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 223)
NO 2
DON'T KNOW 8
PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
223. ASK CONSENT FOR DBBS 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 can lead to AIDS. The HIV test 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 (NAME OF MINOR)'s test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the HIV testing?
224. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 231)
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
225. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT
As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV. For the HIV testing, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?
226. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 231)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
227. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT
We ask you to allow the National Reference Laboratory to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done. The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
228. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 231)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
229. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT
We ask you to allow the National Reference Laboratory 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?
230. CIRCLE THE CODE AND SIGN YOUR NAME
MINOR RESPONDENT REFUSED 2
PARENTAL/RESPONSIBLE ADULT CONSENT FOR RDT TESTING
231. ASK CONSENT FOR RDT TEST FROM PARENT/ADULT
If you want (NAME OF MINOR) to know her HIV status right now, we can do a rapid diagnostic test and tell her the result. The testing is free and we will offer counseling before and after the test. For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in hospitals in Liberia. 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 result of the test will be available in about 15 minutes. If the test is positive, I will give (NAME OF MINOR) a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for rapid HIV testing?
232. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 235)
MINOR RESPONDENT CONSENT FOR RDT TEST
233. ASK CONSENT FOR RDT TEST FROM MINOR RESPONDENT
If you want to know your HIV status right now, we can do a rapid diagnostic test and tell you the result. The testing is free and we will offer counseling before and after the test. For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in hospitals in Liberia. 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 result of the test will be available in about 15 minutes. If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for rapid HIV testing?
234. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3
235. PREPARE EQUIPTMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S)
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 228 AND 230.
IF CONSENT HAS NOT BEEN GRANTED, WRITE 'NAT' ON THE FILTER PAPER.
237. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
239. RECORD THE RESULT OF THE 'DETERMINE HIV RDT' HERE
NEGATIVE 2 (SKIP TO 243)
NOT PRESENT 3 (SKIP TO 245)
REFUSED 4 (SKIP TO 245)
OTHER 5 (SKIP TO 245)
240. RECORD THE RESULT OF THE 'SD BIOLINE HIV RDT' HERE
NEGATIVE 2
NOT PRESENT 3 (SKIP TO 245)
REFUSED 4 (SKIP TO 245)
OTHER 5 (SKIP TO 245)
241. RECORD THE RESULT OF THE 'UNIGOLD HIV RDT'
NEGATIVE 2 (SKIP TO 243)
NOT PRESENT 3 (SKIP TO 245)
REFUSED 4 (SKIP TO 245)
OTHER 5 (SKIP TO 245)
242. IF 239 AND 240 ARE POSITIVE OR 239 AND 241 ARE POSITIVE, RESPONDENT IS HIV POSITIVE:
INFORM SURVEY PARTICIPANT ABOUT POSITIVE HIV STATUS AND PROVIDE POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV CARE AND TREATMENT SERVICES ARE AVAILABLE.
243. IF 239 IS NEGATIVE OR 240 AND 241 ARE NEGATIVE, RESPONDENT IS HIV NEGATIVE:
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING
245. WHILE TESTING THIS PERSON, WAS ANY RDT INVALID/DID ANY RDT FAIL TO RUN, THAT IS, THE CONTROL BAND DID NOT APPEAR?
RDT CONDUCTED, NONE INVALID 2 (SKIP TO 249)
NO RDT CONDUCTED 3 (SKIP TO 249)
246. RECORD NUMBER OF INVALID RESULTS USING 'DETERMINE HIV RDT'
247. RECORD NUMBER OF INVALID RESULTS USING 'SD BIOLINE HIV RDT'
248. RECORD NUMBBER OF INVALID RESULTS USING 'UNICOLD HIV RDT' HERE
249. GO TO 401 IN THE NEXT SECTION OF THIS QUESTIONNAIRE AND CONTINUE WITH THE SAME WOMAN
301. INTERVIEWER TO COMPLETE Q. 302-304A USING TABLET REPORT
USE THE APPROPRIATE OPTION FROM THE INTERVIEWER'S MENU TO LIST ALL MEN AGE 15-59 ELIGIBLE FOR BIOMARKER TESTING. IN EACH COLUMN, WRITE THE COMPLETE NAME, AGE AND LINE NUMBER AS THEY APPEAR IN THE REPORT ON YOUR TABLET. ALSO CIRCLE THE APPROPRIATE CODE FOR QUESTION 303. IF THE MAN'S AGE IS 15-17, COMPLETE QUESTION 304
USING THE MARITAL STATUS INFORMATION PRINTED IN THE TABLET'S REPORT.
IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
WRITE MAN'S LINE NUMBER
NAME ________________
AGE __________
LINE NUMBER _________________
303. FROM TABLET'S REPORT:
CIRCLE CODE FOR AGE GROUP
18-59 YEARS 2 (SKIP TO 304A)
304. FROM TABLET'S REPORT:
CIRCLE CODE FOR MARITAL STATUS
OTHER 2
304B. BIOMARKER START FROM HERE:
BEFORE PROCEEDING WITH THE CONSENT STATEMENTS, ASK THE RESPONDENT HIS AGE AND MARITAL STATUS TO CONFIRM THE INFORMATION IN Q303/Q304. IF THERE ARE ANY DISCREPANCIES THAT AFFECT THE INFORMED CONSENT PATTERN (MINOR VS. ADULT); GO BACK TO Q303/Q304 AND MAKE CORRECTIONS. PLEASE INFORM THE INTERVIEWER OF NEEDED ADJUSTMENTS IN THE HOUSEHOLD SCHEDULE (QH07/QH08), IF NECESSARY.
18-59 YEARS 2 (SKIP TO 310)
309. CHECK 304. MARITAL STATUS
OTHER 2
310. ASK CONSENT FOR DBS COLLECTION
As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV. For the HIV testing, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?
311. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 314)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
312. ASK CONSENT FOR ADDITIONAL TESTING
We ask you to allow the National Reference Laboratory 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?
313. CIRCLE THE CODE AND SIGN YOUR NAME
RESPONDENT REFUSED 2
ADULT RESPONDENT CONSENT FOR RDT TESTING
314. ASK CONSENT FOR HIV RDT TEST
If you want to know your HIV status right now, we can do a rapid diagnostic test and tell you the result. The testing is free and we will offer counseling before and after the test. For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in hospitals in Liberia. 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 result of the test will be available in about 15 minutes. If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for rapid HIV testing?
315. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 329)
316. WRITE THE NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT
PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
317. ASK 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 can lead to AIDS. The HIV test 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 (NAME OF MINOR)'s test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for the HIV testing?
318. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 325)
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
319. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT
As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV. For the HIV testing, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the HIV testing?
320. CIRCLE THE CODE AND SIGN YOUR NAME
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 325)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
321. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT
We ask you to allow the National Reference Laboratory to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done. The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?
322. CIRCLE THE CODE AND SIGN YOUR NAME
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 325)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
323. ASK CONSENT FOR ADDITIONAL TESTINF FROM MINOR RESPONDENT
We ask you to allow the National Reference Laboratory 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?
324. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2
PARENTAL/RESPONSIBLE ADULT CONSENT FOR RDT TESTING
325. ASK CONSENT FOR RDT TEST FROM PARENT/ADULT
If you want (NAME OF MINOR) to know her HIV status right now, we can do a rapid diagnostic test and tell him the result. The testing is free and we will offer counseling before and after the test. For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in hospitals in Liberia. 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 result of the test will be available in about 15 minutes. If the test is positive, I will give (NAME OF MINOR) a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood for rapid HIV testing?
326. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 329)
MINOR RESPONDENT CONSENT FOR RDT TEST
327. ASK CONSENT FOR RDT TEST FROM MINOR RESPONDENT
If you want to know your HIV status right now, we can do a rapid diagnostic test and tell you the result. The testing is free and we will offer counseling before and after the test. For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in hospitals in Liberia. 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 result of the test will be available in about 15 minutes. If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for rapid HIV testing?
328. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3
329. PREPARE EQUIPTMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
PUT THE 1ST BAR CODE LABEL HERE
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
IF ADULT RESPONDENT, CHECK 313: IF MINOR RESPONDENT, CHECK 322 AND 324.
IF CONSENT HAS NOT BEEN GRANTED, WRITE 'NAT' ON THE FILTER PAPER
332. RECORD THE RESULT OF THE 'DETERMINE HIV RDT' HERE
NEGATIVE 2 (SKIP TO 336)
NOT PRESENT 3 (SKIP TO 337)
REFUSED 4 (SKIP TO 337)
OTHER 5 (SKIP TO 337)
333. RECORD THE RESULT OF THE 'SD BIOLINE HIV RDT' HERE.
NEGATIVE 2
NOT PRESENT 3 (SKIP TO 337)
REFUSED 4 (SKIP TO 337)
OTHER 5 (SKIP TO 337)
334. RECORD THE RESULT OF THE 'UNIGOLD HIV RDT'
NEGATIVE 2 (SKIP TO 336)
NOT PRESENT (SKIP TO 337)
REFUSED 4 (SKIP TP 337)
OTHER 5 (SKIP TO 337)
335. IF 332 AND 333 ARE POSITIVE OR 332 AND 334 ARE POSITIVE.
RESPONDENT IS HIV POSITIVE:
INFORM SURVEY PARTICIPANT ABOUT POSITIVE HIV STATUS AND PROVIDE POST-TEST COUNCELING, AS PART OF POST-TEST COUNSELING, PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV CARE AND TREATMENT SERVICES ARE AVAILABLE
336. IF 332 IS NEGATIVE OR 333 AND 334 ARE NEGATIVE, RESPONDENT IS HIV NEGATIVE:
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING.
337. WHILE TESTING THIS PERSON, WAS ANY RDT INVALID/DID ANY RDT FAIL TO RUN, THAT IS, THE CONTROL BAND DID NOT APPEAR?
RDT CONDUCTED, NONE INVALID 2 (SKIP TO 341)
NO RDT CONDUCTED 3 (SKIP TO 341)
338. RECORD NUMBER OF INVALID RESULTS USING 'DETERMINE HIV RDT'
RECORD NUMBER OF INVALID RESULTS, IF NONE INVALID, ENTER 00
339. RECORD NUMBER OF INVALID RESULTS USING 'SD BIOLINE HIV RDT'
RECORD NUMBER OF INVALID RESULTS, IF NONE INVALID, ENTER 00
340. RECORD NUMBER OF INVALID RESULTS USING 'UNIGOLD HIV RDT' HERE.
RECORD NUMBER OF INVALID RESULTS, IF NONE INVALID, ENTER 00
341. GO TO 501 IN THE NEXT SECTION OF THIS QUESTIONNAIRE AND CONTINUE WITH THE SAME MAN.
FIELDWORKER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SUPERVISOR'S OBSERVATIONS
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
EDITOR'S OBSERVATIONS
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2019-20 LIBERIA DEMOGRAPHIC AND HEALTH SURVEY CONSENT TO FOLLOW-UP STUDY
GOVERNMENT OF LIBERIA
LIBBERIA INSTITUTE OF STATISTICS AND GEO-INFORMATION SERVICES
IDENTIFICATION
PLACE NAME __________________
NAME OF HOUSEHOLD HEAD ___________________
CLUSTER NUMBER ________________
HOUSEHOLD NUMBER _________________
ADDRESS IN DETAIL _______________________
CONSENT TO FOLLOW-UP STUDY FOR WOMEN AGE 15-49
401. COPY INFORMATION FROM Q.202:
AGE ____________
LINE NUMBER ________________
402. COPY INFORMATION FROM Q.203:
18-49 YEARS 2 (SKIP TO 404)
403. COPY INFORMATION FROM Q.204:
OTHER 2
ADULT RESPONDENT CONSENT FOR FOLLOW UP STUDY
404. In the next few days, another team from the Ministry of Health would like to visit you to conduct additional blood testing for different health conditions. Knowing how many Liberians have health conditions helps the Ministry of Health plan programs to help keep our people healthy. If you agree, they will collect a small amount of blood from your arm. The information from the blood tests will help the Ministry of Health plan vaccination and treatment programs. You do not have to permit the visit but we hope you will agree since your participation will help the Ministry know which communities need help to prevent certain kinds of illnesses and what kind of help they need.
Do you have any questions? Do you agree to another visit by a Ministry of Health team?
(IF GRANTED, SKIP TO 411)
(IF REFUSED, SKIP TO 412)
RESPONDENT REFUSED 2
(IF GRANTED, SKIP TO 411)
(IF REFUSED, SKIP TO 412)
NOT PRESENT/OTHER 3 (SKIP TO 412)
406. NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT
PARENTAL/RESPONSIBLE ADULT CONSENT FOR FOLLOW UP STUDY
407. In the next few days, another team from the Ministry of Health would like to visit (NAME OF MINOR) to conduct additional blood testing for different health conditions. Knowing how many Liberians have health conditions helps the Ministry of Health plan programs to help keep our people healthy. If you agree, they will collect a small amount of blood from (NAME OF MINOR)'s arm. The information from the blood tests will help the Ministry of Health plan vaccination and treatment programs. You do not have to permit the visit but we hope you will agree since the participation of (NAME OF MINOR) will help the Ministry know which communities need help to prevent certain kinds of illnesses and what kind of help they need.
Do you have any questions? Do you agree for (NAME OF MINOR) to get another visit by a Ministry of Health team?
PARENT/OTHER RESPONSIBBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 412)
MINOR RESPONDENT CONSENT FOR FOLLOW UP STUDY
409. In the next few days, another team from the Ministry of Health would like to visit you to conduct additional blood testing for different health conditions. Knowing how many Liberians have health conditions helps the Ministry of Health plan programs to help keep our people healthy. If you agree, they will collect a small amount of blood from your arm. The information from the blood tests will help the Ministry of Health plan vaccination and treatment programs. You do not have to permit the visit but we hope you will agree since your participation will help the Ministry know which communities need help to prevent certain kinds of illnesses and what kind of help they need.
Do you have any questions? Do you agree to another visit by a Ministry of Health team?
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 412)
411. PLACE THE WHOLE BARCODE LABEL HERE
REFUSED 99995
OTHER 99996
412. GO BACK TO 204A IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.
CONSENT TO FOLLOW-UP STUDY FOR MEN AGE 15-59
501. COPY INFORMATION FROM 302:
AGE ____________________
LINE NUMBER ____________________
502. COPY INFORMATION FROM 303:
18-59 YEARS 2 (SKIP TO 504)
503. COPY INFORMATION FROM 304:
OTHER 2
ADULT RESPONDENT CONSENT FOR FOLLOW UP STUDY
504. In the next few days, another team from the Ministry of Health would like to visit you to conduct additional blood testing for different health conditions. Knowing how many Liberians have health conditions helps the Ministry of Health plan programs to help keep our people healthy. If you agree, they will collect a small amount of blood from your arm. The information from the blood tests will help the Ministry of Health plan vaccination and treatment programs. You do not have to permit the visit but we hope you will agree since your participation will help the Ministry know which communities need help to prevent certain kinds of illnesses and what kind of help they need.
Do you have any questions? Do you agree to another visit by a Ministry of Health team?
(IF GRANTED, SKIP TO 511)
(IF REFUSED, SKIP TO 512)
RESPONDENT REFUSED 2
(IF GRANTED, SKIP TO 511)
(IF REFUSED, SKIP TO 512)
NOT PRESENT/OTHER 3 (SKIP TO 512)
506. NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT
PARENTAL/RESPONSIBLE ADULT CONSENT FOR FOLLOW UP STUDY
507. In the next few days, another team from the Ministry of Health would like to visit (NAME OF MINOR) to conduct additional blood testing for different health conditions. Knowing how many Liberians have health conditions helps the Ministry of Health plan programs to help keep our people healthy. If you agree, they will collect a small amount of blood from (NAME OF MINOR)'s arm. The information from the blood tests will help the Ministry of Health plan vaccination and treatment programs. You do not have to permit the visit but we hope you will agree since the participation of (NAME OF MINOR) will help the Ministry know which communities need help to prevent certain kinds of illnesses and what kind of help they need.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 512)
MINOR RESPONDENT CONSENT FOR FOLLOW UP STUDY
509. In the next few days, another team from the Ministry of Health would like to visit you to conduct additional blood testing for different health conditions. Knowing how many Liberians have health conditions helps the Ministry of Health plan programs to help keep our people healthy. If you agree, they will collect a small amount of blood from your arm. The information from the blood tests will help the Ministry of Health plan vaccination and treatment programs. You do not have to permit the visit but we hope you will agree since your participation will help the Ministry know which communities need help to prevent certain kinds of illnesses and what kind of help they need.
Do you have any questions? Do you agree to another visit by a Ministry of Health team?
MINOR RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3 (SKIP TO 512)
511. PLACE THE WHOLE BARCODE LABEL HERE.
REFUSED 99995
OTHER 99996
512. GO BACK TO 301 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END QUESTIONNAIRE.
SUPERVISOR NUMBER _____________________
EBOLA ANTIBODY AND HEPATITIS B AND C TESTING FOR WOMEN AGE 15-49
601. CHECK 401:
WRITE WOMAN'S AGE
WRITE WOMAN'S LINE NUMBER
AGE ___________________
LINE NUMBER __________________
18-49 YEARS 2 (SKIP TO 603A)
603. CHECK 403: MARITAL STATUS
OTHER 2
603A. CHECK CONSENT FOR FOLLOW UP: IS BARCODE PRESENT?
YES (CONTINUE)
604. READ INTRODUCTION AND PURPOSE TO RESPONDENT
The National Public Health Institute of Liberia (NPHIL), the Ministry of Health, the World Health Organization, the United States Centers for Disease Control and other Liberia Demographic Health Survey partners are conducting a national survey about health issues. This includes testing for diseases like hepatitis and whether people's bodies carry the memory of illnesses they had in the past. The memory of some illnesses in your blood can protect you from getting that illness again. I would like to discuss this part of the survey with you. If I use some words that you do not understand, please ask me to explain.
The hepatitis B and C diseases are a result of an infection with the hepatitis B and C virus. These diseases may cause liver damage and other serious health problems. We are inviting you to allow us to examine your blood in order to know how many people have the hepatitis B and C virus. This information is very important to help the Ministry of Health to plan for programs to prevent and treat this disease. The results of the tests for hepatitis will be shared with you by phone in about three months. If the test shows that you have the hepatitis B or C virus, we will give you a referral to County Health Team or other health facility for counseling and advice about treatment.
The Ministry of Health is also interested in testing people for the memory of the Ebola virus disease. No one in Liberia has Ebola right now. We are inviting you to allow us to examine your blood for signs of remembering the Ebola virus because there is still a lot about Ebola virus disease that we do not know. What we do know is that people who were sick with Ebola carry a memory of Ebola in their blood. This memory protects them from getting Ebola again. We are looking to learn more about the differences in people whose bodies do and do not remember Ebola virus. We do not know if people can become infected with Ebola virus but not feel sick or how many Liberians are protected from Ebola today. We are inviting you to allow us to examine your blood for the memory of the Ebola virus. This information will help our Ministry of Health know where to offer vaccination programs and where to work closely with communities if Ebola ever returns.
605. READ PROCEDURE TO RESPONDENT
If you agree to participate in this part of the survey, we would like to collect 1 teaspoon (4
ml) of blood in total from a vein in your arm. We will test this blood later in the laboratory in
order to know if your body remembers the Ebola virus and if you have hepatitis B or C.
Blood collection will take about 15 minutes. The equipment we will use to take the blood
from your arm is clean and completely safe. We have not used it on anyone else and we will
safely dispose of it when we have finished.
606. READ RISKS TO RESPONDENT
The risk to you from this testing is small. The testing part of the survey is not harmful although you may experience a very small pain for a short time during blood sample collection. There are very minimal risks associated with having your blood drawn. You may get some bruising where the blood is taken from your arm. If you have any bleeding, swelling or other problem later, you should tell our study staff or your health worker.
607. READ BENEFITS TO RESPONDENT
The information we collect during our survey may not help you directly but it could benefit many other people in the future because it will help the Ministry of Health plan for programs to treat hepatitis and provide better services for Ebola survivors.
608. READ CONFIDENTIALITY TO RESPONDENT
What we talk about will be kept private. The results of these test will be kept confidential. To keep your privacy, we will keep the records under a number and will not record your name. We will keep the records in locked files. Only staff from this survey will be allowed to look at them. Your name or other facts that might point to you will not appear when we report the findings of this survey.
609. READ FUTURE TESTING STATEMENT TO RESPONDENT
We would like to ask your permission to store your leftover blood for future tests. These tests may be for other health issues, which are important to the health of Liberians. This sample will be stored for an indefinite amount of time but your name will not be on the sample. Your leftover blood will not be sold or used for commercial reasons. If you do not agree to future tests to your blood samples, we will destroy your blood samples after surveyrelated testing has been completed.
610. READ COST/PAYMENT STATEMENT TO RESPONDENT
Being part of this survey is up to you. If you decide not to participate in our survey, it will not affect any of your participation in other parts of the survey. It will not cost you or your family anything. You will not receive any money for your participation.
611. READ RIGHT TO REFUSE OR WITHDRAW TO RESPONDENT
You are free to participate in this survey or not. You can quit at any time if you wish. If you decide you do not want to take part, it will not affect any care or treatment you or your family members receive. If at any time you decide that you do not want to stay in the survey, you can leave and it will not affect any health care you or your family members receive.
612. READ PERSONS TO CONTACT TO RESPONDENT
This project has been approved by the UL PIRE Ethical Review Board. You will be offered a copy of this form to keep. If at any time you have questions about this survey you may contact the National Public Health Institute of Liberia or the UL PIRE IRB. You may also contact the National Public Health Institute of Liberia or the UL-PIRE IRB if you feel you have been harmed, or if you have questions about your rights as a survey participant. The contact person at the National Public Health Institute of Liberia is Mr. Bode Shobayo (Cell #: 0776787871).
ADULT RESPONDENT
613. READ TESTING FOR MEMORY OF EBOLA CONSENT TO RESPONDENT.
Would you allow me to take a sample of your blood from your arm for testing for the memory of Ebola?
You can say yes or no. It is up to you to decide.
614. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3
615. READ HEPATITIS B AND C TESTING CONSENT TO RESPONDENT
Would you allow me to take a sample of your blood from your arm for testing for Hepatitis B and C?
You can say yes or no. It is up to you to decide.
616. CIRCLE THE MODE AND ASK THE RESPONDENT TO SIGN BELOW.
RESPONDENT REFUSED 2
NOT PRESENT/OTHER 3
NEITHER GRANTED 2 (SKIP TO 640)
618. READ FUTURE TESTING CONSENT TO RESPONDENT
Do you agree for us to store your leftover blood for future testing?
You can say yes or no. It is up to you to decide.
619. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
RESPONDENT REFUSED 2
(SKIP TO 636A)
NOT PRESENT/OTHER 3 (SKIP TO 640)
620. WRITE THE NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT
PARENTAL/RESPONSIBLE ADULT CONSENT
621. READ THE FULL TEST TO THE PARENT/RESPONSIBLE ADULT
READ Q604-Q612
622. READ TESTING FOR MEMORY OF EBOLA CONSENT TO RESPONDENT
Would you allow me to take a sample of blood from (NAME OF MINOR)'s arm for testing for
the memory of Ebola?
You can say yes or no. It is up to you to decide.
623. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
IF REFUSED SKIP TO 627
RESPONDENT REFUSED 2
IF REFUSED SKIP TO 627
NOT PRESENT/OTHER 3 (SKIP TO 627)
MINOR RESPONDENT CONSENT
624. READ THE FULL TEXT TO THE MINOR
READ Q604-Q612.
625. READ TESTING FOR MEMORY OF EBOLA CONSENT TO RESPONDENT.
Would you allow me to take a sample of your blood from your arm for testing for the memory of Ebola?
You can say yes or no. It is up to you to decide.
626. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3
EBOLA ANTIBODY AND HEPATITIS B AND C TESTING FOR WOMEN AGE 15-49
601. CHECK 401:
WRITE WOMAN'S LINE NUMBER
NAME _________________
AGE ___________________
LINE NUMBER _________
PARENTAL/RESPONSIBLE ADULT CONSENT
HEPATITIS CONSENT
627. READ HEPATITIS B AND C TESTING CONSENT TO RESPONDENT
Would you allow me to take a sample of blood from (NAME OF MINOR)'s arm for testing for Hepatitis B and C?
You can say yes or no. It is up to you to decide.
628. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
IF REFUSED SKIP TO 631
NOT PRESENT/OTHER 3 (SKIP TO 631)
HEPATITIS CONSENT
628A. CHECK Q.626:
NEITHER 1 OR 2 CIRCLED 2
628B. READ THE FULL TEXT TO THE MINOR
READ Q.604-Q.612.
629. READ HEPATITIS B AND C TESTING CONSENT TO RESPONDENT
Would you allow me to take a sample of your blood from your arm for testing for Hepatitis B and C?
You can say yes or no. It is up to you to decide.
630. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3 (SKIP TO 640)
NEITHER GRANTED 2 (SKIP TP 640)
PARENTAL/RESPONSIBLE ADULT CONSENT
ADDITIONAL TESTING CONSENT
632. READ FUTURE TESTING CONSENT TO RESPONDENT
Do you agree for us to store (NAME OF MINOR)'s leftover blood for future testing?
You can say yes or no. It is up to you to decide.
633. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
IF REFUSED SKIP TO 636A
NOT PRESENT/OTHER 3 (SKIP TO 636A)
634. READ FUTURE TESTING CONSENT TO RESPONDENT
Do you agree for us to store your leftover blood for future testing?
You can say yes or no. It is up to you to decide.
635. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3
636A. DID RESPONDENT CONSENT TO BLOOD COLLECTION?
NO (SKIP TO 640)
636B. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
ENSURE CORRECT STICKERS ARE AFFIXED TO EACH VIAL
FOR ADULT REPONDENTS:
- IF "GRANTED" SELECTED IN EITHER 614 OR 616, AFFIX BARCODE
- IF "GRANTED" SELECTED IN 614, AFFIX RED STICKER (E)
- IF "GRANTED" SELECTED IN 616, AFFIX BLUE STICKER (H)
- IF "GRANTED" SELECTED IN 619, AFFIX YELLOW STICKER
FOR MINOR REPONDENTS:
- IF "GRANTED" SELECTED IN EITHER 626 OR 630, AFFIX BARCODE
- IF "GRANTED" SELECTED IN 626, AFFIX RED STICKER (E)
- IF "GRANTED" SELECTED IN 630, AFFIX BLUE STICKER (H)
- IF "GRANTED" SELECTED IN 635, AFFIX YELLOW STICKER
AFFIX THIRD BARCODE ON HEPATITIS B and C INFORMATION SHEET
637. WAS BLOOD SAMPLE TAKEN FROM RESPONDENT?
NO 2
640. GO BACK TO 601 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 701.
EBOLA ANTIBODY AND HEPATITIS B AND C TESTING FOR MEN AGE 15-59
701. CHECK 501:
WRITE MAN'S LINE NUMBER
NAME _______________
AGE _________________
LINE NUMBER _______________
18-59 YEARS 2 (SKIP TO 703A)
703. CHECK 503: MARITAL STATUS
OTHER 2
703A. CHECK CONSENT FOR FOLLOW UP. IS BARCODE PRESENT?
NO (SKIP TO 740)
704. READ INTRODUCTION AND PURPOSE TO RESPONDENT
The National Public Health Institute of Liberia (NPHIL), the Ministry of Health, the World Health Organization, the United States Centers for Disease Control and other Liberia Demographic Health Survey partners are conducting a national survey about health issues. This includes testing for diseases like hepatitis and whether people's bodies carry the memory of illnesses they had in the past. The memory of some illnesses in your blood can protect you from getting that illness again. I would like to discuss this part of the survey with you. If I use some words that you do not understand, please ask me to explain.
The hepatitis B and C diseases are a result of an infection with the hepatitis B and C virus. These diseases may cause liver damage and other serious health problems. We are inviting you to allow us to examine your blood in order to know how many people have the hepatitis B and C virus. This information is very important to help the Ministry of Health to plan for programs to prevent and treat this disease. The results of the tests for hepatitis will be shared with you by phone in about three months. If the test shows that you have the hepatitis B or C virus, we will give you a referral to County Health Team or other health facility for counseling and advice about treatment.
The Ministry of Health is also interested in testing people for the memory of the Ebola virus disease. No one in Liberia has Ebola right now. We are inviting you to allow us to examine your blood for signs of remembering the Ebola virus because there is still a lot about Ebola virus disease that we do not know. What we do know is that people who were sick with Ebola carry a memory of Ebola in their blood. This memory protects them from getting Ebola again. We are looking to learn more about the differences in people whose bodies do and do not remember Ebola virus. We do not know if people can become infected with Ebola virus but not feel sick or how many Liberians are protected from Ebola today. We are inviting you to allow us to examine your blood for the memory of the Ebola virus. This information will help our Ministry of Health know where to offer vaccination programs and where to work closely with communities if Ebola ever returns.
705. READ PROCEDURE TO RESPONDENT
If you agree to participate in this part of the survey, we would like to collect 1 teaspoon (4 ml) of blood in total from a vein in your arm. We will test this blood later in the laboratory in order to know if your body remembers the Ebola virus and if you have hepatitis B or C. Blood collection will take about 15 minutes. The equipment we will use to take the blood from your arm is clean and completely safe. We have not used it on anyone else and we will safely dispose of it when we have finished.
706. READ RISKS TO RESPONDENT
The risk to you from this testing is small. The testing part of the survey is not harmful although you may experience a very small pain for a short time during blood sample collection. There are very minimal risks associated with having your blood drawn. You may get some bruising where the blood is taken from your arm. If you have any bleeding, swelling or other problem later, you should tell our study staff or your health worker.
707. READ BENEFITS TO RESPONDENT
The information we collect during our survey may not help you directly but it could benefit many other people in the future because it will help the Ministry of Health plan for programs to treat hepatitis and provide better services for Ebola survivors.
708. READ CONFIDENTIALITY TO RESPONDENT
What we talk about will be kept private. The results of these test will be kept confidential. To keep your privacy, we will keep the records under a number and will not record your name. We will keep the records in locked files. Only staff from this survey will be allowed to look at them. Your name or other facts that might point to you will not appear when we report the findings of this survey.
709. READ FUTURE TESTING STATEMENT TO RESPONDENT
We would like to ask your permission to store your leftover blood for future tests. These tests may be for other health issues, which are important to the health of Liberians. This sample will be stored for an indefinite amount of time but your name will not be on the sample. Your leftover blood will not be sold or used for commercial reasons. If you do not agree to future tests to your blood samples, we will destroy your blood samples after survey related testing has been completed.
710. READ COST/PAYMENT STATEMENT TO RESPONDENT
Being part of this survey is up to you. If you decide not to participate in our survey, it will not affect any of your participation in other parts of the survey. It will not cost you or your family anything. You will not receive any money for your participation.
711. READ RIGHT TO REFUSE OR WITHDRAW TO RESPONDENT
You are free to participate in this survey or not. You can quit at any time if you wish. If you decide you do not want to take part, it will not affect any care or treatment you or your family members receive. If at any time you decide that you do not want to stay in the survey, you can leave and it will not affect any health care you or your family members receive.
712. READ PERSONS TO CONTACT TO RESPONDENT
This project has been approved by the UL PIRE Ethical Review Board. You will be offered a copy of this form to keep. If at any time you have questions about this survey you may contact the National Public Health Institute of Liberia or the UL PIRE IRB. You may also contact the National Public Health Institute of Liberia or the UL-PIRE IRB if you feel you have been harmed, or if you have questions about your rights as a survey participant. The contact person at the National Public Health Institute of Liberia is Mr. Bode Shobayo (Cell #: 0776787871).
EVD CONSENT
713. READ TESTING FOR MEMORY OF EBOLA CONSENT TO RESPONDENT
Would you allow me to take a sample of your blood from your arm for testing for the memory of Ebola?
You can say yes or no. It is up to you to decide.
714. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3
715. READ HEPATITIS B AND C TESTING CONSENT TO RESPONDENT
Would you allow me to take a sample of your blood from your arm for testing for Hepatitis B and C?
You can say yes or no. It is up to you to decide.
716. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3
717. CHECK Q. 714 AND Q. 716
NEITHER GRANTED 2 (SKIP TO 740)
718. READ FUTURE TESTING CONSENT TO RESPONDENT
Do you agree for us to store your leftover blood for future testing?
You can say yes or no. It is up to you to decide.
719. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
(SKIP TO 736A)
NOT PRESENT/OTHER 3 (SKIP TO 740)
720. WRITE THE NAME OF THE PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT
PARENTAL/RESPONSIBLE ADULT CONSENT
EVD CONSENT
721. READ THE FULL TEXT TO THE PARENT/RESPONSIBLE ADULT
READ Q704 - Q712.
722. READ TESTING FOR MEMORY OF EBOLA CONSENT TO RESPONDENT
Would you allow me to take a sample of blood from (NAME OF MINOR)'s arm for testing for the memory of Ebola?
You can say yes or no. It is up to you to decide.
723. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
IF REFUSED SKIP TO 727
NOT PRESENT/OTHER 3 (SKIP TO 727)
EVD CONSENT
724. READ THE FULL TEXT TO THE MINOR
READ Q704-Q712
725. READ TESTING FOR MEMORY OF EBOLA CONSENT TO RESPONDENT.
Would you allow me to take a sample of your blood from your arm for testing for the memory of Ebola?
You can say yes or no. It is up to you to decide.
726. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
IF REFUSED SKIP TO 727
NOT PRESENT/OTHER 3
PARENTAL/RESPONSIBLE ADULT CONSENT
HEPATITIS CONSENT
727. READ HEPATITIS B AND C TESTING CONSENT TO RESPONDENT
Would you allow me to take a sample of blood from (NAME OF MINOR)'s arm for testing for Hepatitis B and C?
You can say yes or no. It is up to you to decide.
728. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
IF REFUSED SKIP TO 731
NOT PRESENT/OTHER 3 (SKIP TO 731)
728A. CHECK Q. 626
NEITHER 1 OR 2 CIRCLED 2
728B. READ THE FULL TEXT TO THE MINOR
READ Q704 - Q712.
729. READ HEPATITIS B AND C TESTING CONSENT TO RESPONDENT
Would you allow me to take a sample of your blood from your arm for testing for Hepatitis B and C?
You can say yes or no. It is up to you to decide.
730. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3 (SKIP TO 740)
NEITHER GRANTED 2 (SKIP TO 740)
PARENTAL/RESPONSIBLE ADULT CONSENT
ADDITIONAL TESTING CONSENT
732. READ FUTURE TESTING CONSENT TO RESPONDENT
Do you agree for us to store (NAME OF MINOR)'s leftover blood for future testing?
You can say yes or no. It is up to you to decide.
733. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW.
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
IF REFUSED, SKIP TO 736A
NOT PRESENT/OTHER 3 (SKIP TO 736A)
734. READ FUTURE TESTING CONSENT TO RESPONDENT
Do you agree for us to store your leftover blood for future testing?
You can say yes or no. It is up to you to decide.
735. CIRCLE THE CODE AND ASK THE RESPONDENT TO SIGN BELOW
_______________________________(INTERVIEWER SIGNATURE)
RESPONDENT REFUSED 2
_______________________________(INTERVIEWER SIGNATURE)
NOT PRESENT/OTHER 3
736A. DID RESPONDENT CONSENT TO BLOOD COLLECTION
NO (SKIP TO 740)
736B. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
ENSURE CORRECT STICKERS ARE AFFIXED TO EACH VIAL
FOR ADULT REPONDENTS:
- IF "GRANTED" SELECTED IN EITHER 714 OR 716, AFFIX BARCODE
- IF "GRANTED" SELECTED IN 714, AFFIX RED STICKER (E)
- IF "GRANTED" SELECTED IN 716, AFFIX BLUE STICKER (H)
- IF "GRANTED" SELECTED IN 719, AFFIX YELLOW STICKER
FOR MINOR REPONDENTS:
- IF "GRANTED" SELECTED IN EITHER 726 OR 730, AFFIX BARCODE
- IF "GRANTED" SELECTED IN 726, AFFIX RED STICKER (E)
- IF "GRANTED" SELECTED IN 730, AFFIX BLUE STICKER (H)
- IF "GRANTED" SELECTED IN 735, AFFIX YELLOW STICKER
AFFIX THIRD BARCODE ON HEPATITIS B AND C INFORMATION SHEET
737. WAS BLOOD SAMPLE TAKEN FROM RESPONDENT?
NO 2
740. GO BACK TO 701 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END QUESTIONNAIRE
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
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SUPERVISOR'S OBSERVATIONS
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EDITOR'S OBSERVATIONS
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2019-20 LIBERIA DEMOGRAPHIC AND HEALTH SURVEY
BIOMARKER QUESTIONNAIRE
REVISIT
GOVERNMENT OF LIBERIA
LIBERIA INSTITUTE OF STATISTICS AND GEO-INFORMATION SERVICES
PLACE NAME __________________
NAME OF HOUSEHOLD HEAD __________________
CLUSTER NUMBER __________________
HOUSEHOLD NUMBER ___________________
BIOMARKER VISITS
DATE
BIOMARKER'S NAME
NEXT VISIT:
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR 20__
NOTES:
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TOTAL ELIGIBLE CHILDREN __________________
NUMBER ____________
WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5
101. SUPERVISOR TO COMPLETE Q. 102-105 USING TABLET REPORT
USE THE SUPERVISORS MENU AND SELECT THE APPROPRIATE OPTION TO LIST ALL CHILDREN AGE 0-5 ELIGIBLE FOR REVISIT. RECORD THE COMPLETE NAME, AGE AND THE LINE NUMBER AS THEY APPEAR IN THE REPORT ON YOUR TABLET. LIST EACH CHILD IN THE SAME ORDER SHOWN IN THE REPORT. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). WRITE THE NAME OF EACH ELIGIBLE CHILD ON EACH SUBSEQUENT PAGES.
102. FROM TABLET'S REPORT:
WRITE CHILD'S COMPLETE FIRST/LAST NAME, AGE, AND LINE NUMBER.
AGE ____________
LINE NUMBER _______________
103. FROM TABLET REPORT COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR)
MONTH _____________
YEAR ____________
104. CHECK 103: CHILD BORN IN 2014-2020?
NO 2
105. FROM TABLET REPORT INDICATE HOW CHILD WAS MEASURED FIRST TIME: LYING DOWN OR STANDING UP?
STANDING UP 2
MEASURER AND ASSISTANT START FROM HERE
106. ASSISTANT TO RECORD WEIGHT IN KILOGRAMS.
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
107. CHECK 103 TO DETERMINE HOW CHILD NEEDS TO BE MEASURED.
ASSISTANT TO RECORD HEIGHT/LENGTH IN CENTIMETERS
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
108. CHILD MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
109. MEASURER: ENTER YOUR FIELDWORKER NUMBER
FIELDWORKER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
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