IDENTIFICATION

LOCALITY NAME __________

LOCAL COUNCIL __________

DISTRICT CODE _____

PROVINCE NAME AND CODE____

CHIEFDOM CODE _____

SECTION CODE _____

DHS CLUSTER NUMBER _____

ENUMBERATION AREA CODE _____

RURAL/URBAN

HOUSEHOLD NUMBER _____

NAME OF HOUSEHOLD HEAD __________

HOUSEHOLD SELECTED FOR MALE INTERVIEW AND FOR COLLECTION OF BLOOD SAMPLES?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER NAME __________
RESULT_____

RESULT

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT NUMBER _____
RESULT _____

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD _____

TOTAL ELIGIBLE WOMEN _____

TOTAL ELIGIBLE MEN _____

LINE NO OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

SUPERVISOR:
NAME____

FIELD EDITOR:
NAME____

OFFICE EDITOR: _____
KEYED BY: _____

TABLE FOR SELECTED MEN AND WOMEN FOR DOMESTIC VIOLENCE INTERVIEW

CHECK THE NUMBER OF THE QUESTIONNAIRE. THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER INDICATES THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBE OF ELIGIBLE MEN OR WOMEN ON THE COVERSHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS NUMBER IS USED TO IDENTIFY WHETHER THE FIRST ('1'), SECOND ('2'), THIRD ('3'), ETC. ELIGIBLE MAN OR WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE INTERVIEWED FOR THE DOMESTIC VIOLENCE MODULE.
FOR EXAMPLE, IF THE HOUSEHOLD NUMBER IS '16', GO TO ROW '6'. IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FIND THE BOX WHERE ROW '6' AND COLUMN '3' MEET. THE NUMBER IN THAT BOX ('2') INDICATES THAT THE SECOND ELIGIBLE WOMAN IN THE HOUSEHOLD LISTING SHOULD BE INTERVIEWED USING THE DOMESTIC VIOLENCE QUESTIONS.
SUPPOSE THE LINE NUMBERS OF THE THREE ELIGIBLE WOMEN ARE '02', '04', AND '07'. THE WOMAN TO BE INTERVIEWED IS THE SECOND ONE, I.E., THE ONE ON LINE '04'.

LAST DIGIT OF THE HOUSEHOLD NUMBER (ROW)

NUMBER OF ELIGIBLE MEN OR WOMEN IN THE HOUSEHOLD

ENTER THE LINE NUMBER OF SELECTED MAN OR WOMAN

INTRODUCTION AND CONSENT

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

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I being 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-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTOINS IN COLUMNS 5-20 FOR EACH PERSON.

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 quests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

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

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

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

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

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

8) MARITAL STATUS IF AGE 15 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

12) ELIGIBILITY: CIRCLE LINE NUMBER OF MAN OR WOMAN SLECTED FOR INTERVIEW

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

13) Is (NAME)'s natural mother 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'

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

16) 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 5 YEARS OR OLDER:

17) Has (NAME) ever attended school?

18) What is the highest level of school (NAME) has attended?

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

19) Did (NAME) attend school at any time during the 2012-2013 school year?

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

21) 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?

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

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

103) Where is that water source located?

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

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

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

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

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

109) How many households use this toilet facility?

110) Does your household have:

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

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

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

113A) Is the cooking usually done on an open fire, an open stove, or a closed stove?

113B) Does this (fire/stove) have a chimney, a hood, or neither of these?

114) MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

115) MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATIONS.

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

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

118) Does any member of this household own:

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

120) How many acres of agricultural land do members of this household own?
IF 995 OR MORE ACRES, CIRCLE '950'.

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

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

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

123A) During the last 3 months did you or any member of your household receive assistance from organizations or government agencies? We only want to know about assistance received from people that are not members of your family, friends, or neighbors. Did you receive any of the following:

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

125) Who sprayed the dwelling?

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

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

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

128A) RECORD IF THE NET IS HANGING OR NOT HANGING.

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

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

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

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

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

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

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

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137) Please show me where members of your household most often wash their hands.

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

139) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING.

139A) Do you have any kind of soap, detergent, or ash that you use for handwashing in your household?
IF YES: May I see it?

140) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.

FOR CHILDREN AGE 5 THROUGH 14: CHILD LABOR

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

142) NAME OF CHILD FROM COLUMN 2: WRITE CHILD'S NAME FROM COLUMN 2 IN THE HOUSEHOLD SCHEDULE.

WORK LAST WEEK:

143) 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 pay or unpaid?

144) Since last (DAY OF THE WEEK), how many hours did (NAME) do this work for someone who is not a member of this household. INCLUDE ALL HOURS AT ALL JOBS.

145) WORK IN 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?

HOUSEHOLD CHORES:

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

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

WORK IN FAMILY BUSINESS OR FARM:

148) During the past week, did (NAME) do any other family work, on the farm or in a business or selling goods in the street?

149) 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

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11, NAME FROM COLUMN 2

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

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

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

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

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

210) ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD:
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually resulted from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team. Do you have any questions? You can say yes to the test, or you can say no. It is up to you to decide. Will you allow (NAME OF CHILD) to participate in the anemia test?

211) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

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

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

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

214) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR AL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) LINE NUMBER FROM COLUMN 9, NAME FROM COLUMN 2

216) WEIGHT IN KILOGRAMS

217) HEIGHT IN CENTIMETERS

218) AGE:
CHECK COLUMN 7

219) MARITAL STATUS:
CHECK COLUMN 8

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

221) ASK CONSENT FOR ANEMIA TEST FROM PARENT/ OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17:
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to developed 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. If 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?

222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223) ASK CONSENT FOR ANEMIA TEST FROM RESPONSDENT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide. Will you take the anemia test?

224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

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

226) AGE:
CHECK COLUMN 7

227) MARITAL STATUS:
CHECK COLUMN 8

228) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17:
As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Sierra Leone. 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 ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know her HIV status, I can provide a list of [nearby] facilities offering counseling and testing for HIV. I will also give her a voucher for free services that can be used at any of these facilities.
Do you have any questions? You can say yes to the test, or you can say no. It is up to you to decide. Will you allow (NAME OF ADOLESCENT) to take the HIV test?

229) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

230) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT.
As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Sierra Leone. For the HIV test, we need a few (more) drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know 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 your partner if you want) that you can use at any of these facilities.
Do you have any questions? You can say yes to the test, or you can say no. It is up to you to decide. Will you take the HIV test?

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

232) AGE:
CHECK COLUMN 7

233) MARITAL STATUS:
CHECK COLUMN 8

234) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17:
We ask you to allow (SURVEY IMPLEMENTING ORGANZIATION/ MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

235) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

236) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) 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?

237) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

ADDITIONAL TESTS
238) CHECK 235 AND 237:
IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

240) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

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

242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 243.

WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-59

243) CHECK COLUMN 10 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN IN 244. IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE (S).

244) LINE NUMBER FROM COLUMN 10. NAME FROM COLUMN 2.

245) WEIGHT IN KILOGRAMS

246) HEIGHT IN CENTIMETERS

247) AGE:
CHECK COLUMN 7

248) MARITAL STATUS:
CHECK COLUMN 8

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

250) ASK CONSENT FOR ANEMIA TEST FROM PARENT/ OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION 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 survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions? You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME OF ADOLESCENT) to take the anemia test?

251) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

254) AGE:
CHECK COLUMN 7

255) MARITAL STATUS:
CHECK COLUMN 8

256) ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:
As part of the survey we also are asking people all over the country to take an HIV test. HIV is the virus that causes AIDS. AIDS is a very serious illness. The HIV test is being done to see how big the AIDS problem is in Sierra Leone.
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 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 ADOLESCENT)'s test results either. If (NAME OF ADOLESCENT) wants to know his HIV status, I can provide him with a list of (nearby) facilities offering counseling and testing for HIV. I will also give him a free voucher for free services that can be used at any of these facilities.
Do you have any questions? You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME OF ADOLESCENT) to take the HIV test?

257) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

258) ASK CONSENT FOR DBS COLLECTION FROM RESPONDENT:
As part of the survey we are also 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 in Sierra Leone.
For the HIV test, we need a few more 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. No names will be attached so we will not be able to tell you the test results. No one else will be able to know your test results either. If you want to know 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) what you can use at any of these facilities.
Do you have any questions? You can say yes to the test, or you can say no. It is up to you to decide. Will you take the HIV test?

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

260) AGE:
CHECK COLUMN 7

261) MARITAL STATUS:
CHECK COLUMN 8

262) ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/OTHER ADULT IDENTIFIED IN 249 AS RESPONSIBLE FOR NEVER IN UNION MEN AGE 15-17:
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/ MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify (NAME OF ADOLESCENT). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF ADOLESCENT) can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

263) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

264) ASK CONSENT FOR ADDITIONAL TESTING FROM RESPONDENT:
We ask you to allow (SURVEY IMPLEMENTING ORGANIZATION/MINISTRY OF HEALTH) to store part of the blood sample at the laboratory for additional tests or research. We are not certain about what additional tests might be done.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey. Will you allow us to keep the blood sample stored for additional testing?

265) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME

ADDITIONAL TESTS:
266) CHECK 263 AND 265: IF CONSENT HAS NOT BEEN GRANTED WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER

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

268) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

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

270) GO BACK TO 245 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.