STATISTICS SIERRA LEONE

IDENTIFICATION

LOCALITY NAME_______
NAME OF HOUSEHOLD HEAD__________
CLUSTER NUMBER_______
HOUSEHOLD NUMBER_______
LOCAL COUNCIL______
DISTRICT_________
PROVINCE _________
CHIEFOOM_____
SECTION______
ENUMERATION AREA______

URBAN/RURAL

FREETOWN, OTHER CITY, TOWN, RURAL

IS THIS HOUSEHOLD SELECTED FOR THE MALE SURVEY?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE____
INTERVIEWER'S NAME____
RESULT____

RESULT

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME_____

FINAL VISIT
DAY_____
MONTH____
YEAR 2008
INT. NUMBER________
RESULT_____

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD____

TOTAL ELIGIBLE WOMEN_____

TOTAL ELIGIBLE MEN____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

INTERVIEW LANGUAGE

NATIVE LANGUAGE OF RESPONDENT

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE______

OFFICE EDITOR _____
KEYED BY______

Introduction and Consent

Hello. My name is _______________________________________ and I am working with Statistics Sierra Leone. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete.

As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer:_______
Date:______

HOUSEHOLD SCHEDULE

1) LINE NO.

2) USUAL RESIDENTS AND VISITORS : Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2 (HH7) TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON.

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

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

5) RESIDENCE: Does (NAME) usually live here?

6) RESIDENCE: Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

8) MARITAL STATUS IF AGE 10 OR OLDER: What is (NAME'S) current marital status?

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

10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

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

TICK HERE IF CONTINUATION SHEET USED____

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

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

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

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS

13) Is (NAME)'s natural mother still alive?

14) Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD '00'.

16) Is (NAME)'s natural father still alive?

17) Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
IF NO, RECORD '00'

EVER ATTENDED SCHOOL IF AGE 3 YEARS OR OLDER

23) Has (NAME) ever attended school?

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

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 3-24 YEARS

25) Did (NAME) attend school at anytime during the (2007-2008) school year?

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

27) Did (NAME) attend school at anytime during the previous school year, that is, (2006-2007)?

28) During that school year, what level and grade did (NAME) attend?

32) BIRTH REGISTRATION IF AGE 0-4 YEARS: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

HOUSEHOLD CHARACTERISTICS

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

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

103) Where is that water source located?

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

105) Who usually goes to this source to fetch the water for your household?

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

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

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

109) Do you share this toilet with other households?

110) How many households use this toilet facility?

111) Does your household have:

Electricity?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?

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

113) In this household, is food cooked on an open fire, an open stove or a closed stove?

114) Does this (fire/stove) have a chimney, a hood, or neither of these?

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

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

117) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

118) MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

119) MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

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

121) Does any member of this household own:

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

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

123) How many acres of agricultural land do members of this household own?

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

125) How many of the following animals does this household own?
IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'.
IF UNKNOWN, ENTER '98'.

Cows,calfs or bulls?
Horses, donkeys, or mules?
Pigs?
Goats?
Sheep?
Rabbits?
Rodents to breed?
Fowl: chickens, geese, ducks, turkeys?
Birds for sale?

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

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

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

129) ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

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

131) OBSERVE OR ASK THE BRAND/ TYPE OF MOSQUITO NET.

132) When you got the net, was it treated with an insecticide to kill or repel mosquitos?

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

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

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

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

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

138) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION)

CHILD LABOR

FOR CHILDREN AGED 5 THROUGH 14

Now I would like to ask about any work that children in this household may do.

201) LINE NUMBER

WRITE CHILD'S LINE NUMBER FROM COLUMN 1 IN THE HOUSEHOLD SCHEDULE. ONLY INCLUDE CHILDREN AGED 5-14 FROM COLUMN 7

202) NAME OF CHILD FROM COL. 2

WRITE CHILD'S NAME FROM COLUMN 2 IN THE HOUSEHOLD SCHEDULE.

203) WORK LAST WEEK: During the past week, did (NAME) do any kind of work for someone who is not a member of this household? IF YES: Was that for pay or unpaid?

204) Since last (DAY OF THE WEEK), about how many hours did (NAME) do this work for someone who is no ta member of this household?
INCLUDE ALL HOURS AT ALL JOBS.

205) WORK LAST YEAR: At any time during the past year, did (NAME) do any kind of work for someone who is not a member of this household? IF YES: Was that for pay or unpaid?

206) HOUSEHOLD CHORES: During the past week, did (NAME) help with household chores such as shopping collecting firewood, cleaning, fetching water, or caring for children?

207) Since last (DAY OF THE WEEK), about how many hours did (NAME) spend doing these chores?

208) WORK IN FAMILY BUSINESS OR FARM: During the past week, did (NAME) do any other family work, on the farm or in a business or selling goods in the street?

209) Since last (DAY OF THE WEEK), about how many hours did (NAME) do this work?

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

501) CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 508 AND FOR THE ANEMIA PROCEDURE IN 513

502) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

503) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

504) CHECK 503:
CHILD BORN IN JANUARY 2003 OR LATER?

505) WEIGHT IN KILOGRAMS

506 HEIGHT IN CENTIMETERS

507) MEASURED LYING DOWN OR STANDING UP?

508) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

509) CHECK 503:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OFINTERVIEW OR FIVE PREVIOUS
MONTHS?

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

511) READ CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.

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

513) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

514) GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 515.

CONSENT STATEMENT FOR ANEMIA FOR CHILDREN

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 request that all children born in 2003 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking 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 told to you right away. The result will be kept confidential.

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(S) OF CHILD(REN) to participate in the anemia test?

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

515) CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 516. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDER FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 519, FOR THE ANEMIA TEST PROCEDURE IN 528, AND FOR THE HIV TEST PROCEDURE IN 530.

516) LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

517) WEIGHT IN KILOGRAMS

518) HEIGHT IN CENTIMETERS

519) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

520) AGE:
CHECK COLUMN 7

521) MARITAL STATUS:
CHECK COLUMN 8.

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

523) READ ANEMIA TEST CONSENT STATEMENT. FORNEVER-IN-UNION WOMENAGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 523 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 523 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 in taking 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 told to you right away. The result will be kept confidential.

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 anemia test?

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

525) READ THE HIV TEST CONSENT STATEMENT. FORNEVER-IN-UNION WOMEN AGE 15-17,
ASK CONSENT FROM PARENT/ OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING
RESPONDENT'S CONSENT.

526) CHECK 523 AND 525 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME FOR THE THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 528 AND FOR THE HIV TEST PROCEDURE IN 530 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

527) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

528) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

529 BAR CODE LABEL
PUT THE 1ST BAR CODE LABEL HERE.
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

530) OUTCOME OF HIV TEST PROCEDURE

CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 525 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 525 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Sierra Leone.

For the HIV test, we need a few more drops of blood from a finger. Again the equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know (your/NAME OF ADOLESCENT's) test results either.

If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you (allow NAME OF ADOLESCENT to) take the HIV test?

530A) CHECK 530:
OUTCOME OF HIV TEST

530B) READ THE CONSENT STATEMENT FORADDITIONAL TESTS. FOR NEVER-INUNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/ OTHER ADULT IDENTIFIED IN 522
BEFORE ASKING RESPONDENT'S CONSENT.

530C) ADDITIONAL TESTS
CHECK 530B: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER. CHECK 530B: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

530D) GO BACK TO 517 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE WOMEN, GO TO 531.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 530B IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF SHE REFUSES.

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT
(SEE 522) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 530B IF THE PARENT (OTHER ADULT) REFUSES. CIRCLE CODE 1' IN 530B IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow Statistics Sierra Leone to store part of the blood sample at the laboratory
to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other data attached that could identify (you/NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for later use, (you/NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for later testing or research?

HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-59

531) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 532. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDER FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 535, FOR THE ANEMIA TEST PROCEDURE IN 543, AND FOR THE HIV TEST PROCEDURE IN 545.

532) LINE NUMBER (COLUMN 10)
NAME (COLUMN 2)

536) AGE:
CHECK COLUMN 7.

537) MARITAL STATUS:
CHECK COLUMN 8.

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

539) READ ANEMIA TEST CONSENT STATEMENT. FORNEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 539 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 539 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

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 in taking 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 told to you right away. The result will be kept confidential.

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 anemia test?

540) READ THE HIV TEST CONSENT STATEMENT. FORNEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/ OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

541) CHECK 539 AND 540 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).

A FINAL OUTCOME OF THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 543 AND FOR THE HIV TEST PROCEDURE IN 545 FOR EACH ELIGIBLE MAN EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

542) RECORD HEMOGLOBIN LEVEL
HERE AND IN ANEMIA PAMPHLET

543) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.

544) BAR CODE LABEL
PUT THE 1ST BAR CODE LABEL HERE. PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.

545) OUTCOME OF HIV TEST PROCEDURE

CONSENT STATEMENT FOR HIV TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 540 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT
(SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 540 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Sierra Leone.

For the HIV test, we need a few more drops of blood from a finger. Again the equipment used in taking the blood is clean and completely safe. It has never been used before and will be thrown away after each test.

No names will be attached so we will not be able to tell you the test results. No one else will be able to know (your/NAME OF ADOLESCENT's) test results either.

If you want to know whether you have HIV, I can provide you with a list of [nearby] facilities offering counseling and testing for HIV. I will also give you a voucher for free services for you (and for your partner if you want) that you can use at any of these facilities.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you (allow NAME OF ADOLESCENT to) take the HIV test?

545A) CHECK 530:
OUTCOME OF HIV TEST

545B) READ THE CONSENT STATEMENT FORADDITIONAL TESTS WITH LEFT OVERBLOOD. FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/ OTHER ADULT IDENTIFIED IN 522 BEFORE ASKING RESPONDENT'S CONSENT.

545C) ADDITIONAL TESTS

CHECK 545B::

IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL WRITE "NO ADDITIONAL WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.

545D) GO BACK TO 533 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE MEN, END INTERVIEW.

CONSENT STATEMENT FOR ADDITIONAL TESTS

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 545B IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF HE REFUSES.

FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE 538) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 540 IF THE PARENT (OTHER ADULT) REFUSES. CIRCLE CODE '1' IN 540 ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow Statistics Sierra Leone to store part of the blood sample at the laboratory to be used for testing or research in the future. We are not certain about what tests might be done.

The blood sample will not have any name or other data attached that could identify (you/NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for later use, (you/NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for later testing or research?