[ANNEX E PAGE 305]

NATIONAL INSTITUTE OF STATISTICS- São Tomé e Príncipe
MS-DCS MINISTRY OF HEALTH -São Tomé e Príncipe

THE INFORMATION PROVIDED FOR THIS QUESTIONNAIRE IS STRICTLY CONFIDENTIAL ACCORDING TO THE 5/98 LAW

IDENTIFICATION AND LOCATION

AF.01- NAME OF HOUSEHOLD HEAD_________

AF.02- PLACE NAME_________

AF.03- CLUSTER NUMBER ___________

AF.04- REGION _______

REGION CODE_______

AF.05- STUDY DOMAIN: DISTRICT _______

DISTRICT CODE _______

AF.06- ENUMERATION AREA (EA) _______

EA CODE_______

AF.07-HOUSEHOLD NUMBER

NUMBER_______

AF.08- NAME AND LINE NUMBER OF MAN AND HIV TEST (YES = 1 / NO = 2)

AF.09- NAME OF MAN FOR SECTION 12 'QM' (YES = 1 / NO = 2)

INTERVIEWER VISITS

FIRST VISIT
DAY____
MONTH___
YEAR 2008
INTERVIEWER'S NAME_________
AF.10- RESULT*_________

NEXT VISIT
DAY___
MONTH___
YEAR___
TIME___

SECOND VISIT
DAY____
MONTH ___
YEAR 2008
INTERVIEWER'S NAME___
AF.09- RESULT*______

NEXT VISIT
DAY___
MONTH___
YEAR___
TIME___

THIRD VISIT
DAY____
MONTH___
YEAR2008
INTERVIEWER'S NAME___
AF.09- RESULT*______

FINAL VISIT
DAY_________
MONTH_________
YEAR 2008
INTERVIEWER'S CODE ______
INTERVIEWER'S NAME_________
RESULT CODE*______

TOTAL NUMBER OF VISITS_________

*RESULT CODES:

AF.11-TOTAL IN HOUSEHOLD_________

AF.12-TOTAL NUMBER OF ELIGIBLE WOMEN _________

AF.13-TOTAL NUMBER OF ELIGIBLE MEN _________

AF.14-LINE NUMBER OF RESPONDENT_________

SUPERVISOR
NAME_________
DAY___
MONTH___
YEAR___
CODE_________

FIELD EDITOR
NAME_________
DAY___
MONTH___
YEAR____
CODE_________

OFFICE EDITOR_________
CODE______

KEYED BY_________
CODE_____

[ANNEX E PAGE 306]

INFORMED CONSENT
Hello. My name is _________and I am working with the NATIONAL INSTITUTE OF STATISTICS and the MINISTRY OF HEALTH. We are conducting a national survey that asks men, women and children about various health issues. We would very much appreciate your participation in this survey. We will ask you questions about your health and your children's health. This information will help the government to plan health services. The survey usually takes about 15 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, however extremely important. You will be contributing to solve some of the problems we face. We hope that you will participate in this 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:________________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

[ANNEX E PAGE 307-308]

SECTION A. HOUSEHOLD SCHEDULE

(1) LINE NUMBER

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

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 4A-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

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

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

(4A) (DISTRICT IN WHICH THE PERSON WAS BORN) Where was (NAME) born (District)

If in a FOREIGN country record the name of the FOREIGN COUNTRY (see codes below)

CODES FOR Q.4A: REGION/DISTRICT/ FOREIGN COUNTRY

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

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

(7) (AGE) How old is (NAME)?

(8) (IF AGE 15 OR OLDER) (MARITAL STATUS) What is (NAME's) current marital status?

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

(10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

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

TICK HERE IF CONTINUATION SHEET USED____

2A) Just to make sure that I have 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?

[ANNEX E PAGE 309-310]

(13) IF AGE 0-17 (SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS) Is (NAME)'s natural mother alive?

(14) IF AGE 0-17 (SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS) 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) IF AGE 0-17 (SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS) Is (NAME)'s natural father alive?

(17) IF AGE 0-17 (SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS) 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'

(23) IF AGE 5 YEARS OR OLDER (EVER ATTENDED SCHOOL) Has (NAME) ever attended school?

(24)* IF AGE 5 YEARS OR OLDER (EVER ATTENDED SCHOOL) What is the highest level of school (NAME) has attended?
SEE CODES BELOW.
What is the highest grade (NAME) completed at that level?
SEE CODES BELOW.

(25) IF AGE 5-24 (CURRENT/RECENT SCHOOL ATTENDANCE) Did (NAME) attend school at any time during the (2007-2008) school year?

(26) IF AGE 5-24 (CURRENT/RECENT SCHOOL ATTENDANCE) During this/that school year, what level and grade [is/was] (NAME) attending?

(27) IF AGE 5-24 (CURRENT/RECENT SCHOOL ATTENDANCE) Did (NAME) attend school at any time during the previous school year, that is (2006-2007)?

(28) IF AGE 5-24 (CURRENT/RECENT SCHOOL ATTENDANCE) During that school year, what level and grade did (NAME) attend?

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

[ANNEX E PAGE 311-314]

SECTION B. HOUSEHOLD CHARACTERISTICS

101. What is the principal source of drinking water for members of your household?

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

103. Where is that water source?

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?

105A. What kind of recipient do you use to transport the water?

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 use?

109. Do you share this toilet facility with other households?

110. How many households use this toilet facility?

110A. Who is the owner of the house where you live?

111. Does your household have:

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?

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

117. What is the main material of the household floor?
(RECORD OBSERVATION)

118. What is the main material of the roof of the house?
(RECORD OBSERVATION)

119. What is the main material of the exterior walls of the house?
(RECORD OBSERVATION)

119A. How many divisions/rooms does the household have (not including kitchen and bathroom)?

120. How many rooms in your household are used for sleeping?

121. Does any member of your household own:

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

123. How many hectares of agricultural land do members of this household own?

127A. In your opinion, is a mosquito net affordable?

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'

128A. Why don't you have any mosquito nets in your household?

128B. How did you acquired or got most of the mosquito nets for your household?

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. 301

138. ASK THE RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.

TEST SALT FOR IODINE (7)
RECORD PPM (PARTS PER MILLION)

[ANNEX E PAGE 315]

SECTION C: SUPPORT FOR PERSONS WHO HAVE DIED

301. Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has any usual member of your household died in the last 12 months?

302. How many household members died in the last 12 months?

304. What was the name of the person who died (most recently/before him/her)?

305. Was (NAME) male or female?

306. How old was (NAME) when (he/she) died?

[ANNEX E PAGE 316-317]

SECTION D.1: WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

501. CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN AGE 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(SECTION A)
NAME FROM COLUMN 2

503. What is (NAME)'s birth date?
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 OF INTERVIEW 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 ANEMIA

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 QUESTION 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 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 you right away. The result will be kept strictly confidential and will not be shared with anyone other than the members of our survey team.

Do you have any questions?
You can say YES to the test, or you can say NO. It up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the anemia test?

[ANNEX E PAGE 318-319]

SECTION D.2: 93, HEIGHT, AND HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49

515. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN AGE 15-49 IN 516. IF MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDED 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 FROM COLUMN 9
NAME FROM 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 FOR NEVER-IN-UNION WOMEN AGE 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 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 you right away. The result will be kept strictly confidential and will not be shared with anyone other than the members of our survey team.

Do you have any questions?
You can say YES to the test, or you can say NO. It up to you to decide.
Will you (allow NAME OF ADOLESCENT to) participate in the anemia test?

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

524. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

525. READ THE HIV TEST CONSENT STATEMENT FOR NEVER-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 HAS BEEN CONSENT OBTAINED AND PROCEED WITH THE TESTS(S).

A FINAL OUTCOME FOR 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 OTHER REASON.

527. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

528. RECORD RESULT CODE OF ANEMIA TEST

529. BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE

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

530. OUTCOME OF HIV TEST PROCEDURE

WOMAN 1

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 São Tomé and Príncipe. 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 result 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 service 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 (allow NAME OF ADOLESCENT to) take the HIV test?

LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

530A. CHECK 530: OUTCOME OF HIV TEST

530B. READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FORM 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.

530D. GO BACK TO 517 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMNS OF ADDITIONAL QUESTIONNAIRES(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 the Ministry of Health 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 used, (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?

[ANNEX E PAGE 320-321]

SECTION D.3: WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-49

531. CHECK COLUMN 10 RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE MEN AGE 15-49 IN 532. IF MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 532C, FOR THE ANEMIA TEST PROCEDURE IN 543, AND FOR THE HIV TEST PROCEDURE IN 545.

532. LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

532A. WEIGHT IN KILOGRAMS

532B. HEIGHT IN CENTIMETERS

532C. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

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 FOR NEVER-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 QUESTION 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 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 you right away. The result will be kept strictly confidential and will not be shared with anyone other than the members of our survey team.

Do you have any questions?
You can say YES to the test, or you can say NO. It up to you to decide.
Will you (allow NAME OF ADOLESCENT to) participate in the anemia test?

LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

540. READ THE HIV TEST CONSENT STATEMENT FOR NEVER-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 HAS BEEN CONSENT OBTAINED AND PROCEED WITH THE TESTS(S).

A FINAL OUTCOME FOR 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 OTHER REASON.

542. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

543. RECORD RESULT CODE OF ANEMIA TEST

544. BAR CODE LABEL

PUT THE 1ST BAR CODE LABEL HERE

PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND 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 São Tomé and Príncipe. 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 result 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 service 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 (allow NAME OF ADOLESCENT to) take the HIV test?

LINE NUMBER FROM COLUMN 10
NAME FROM COLUMN 2

545A. CHECK 545: OUTCOME OF HIV TEST

545B. READ THE CONSENT STATEMENT FOR ADDITIONAL TESTS FOR NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FORM PARENT/OTHER ADULT IDENTIFIED IN 538 BEFORE ASKING RESPONDENT'S CONSENT.

545C. ADDITIONAL TESTS

CHECK 545B: IF CONSENT HAS NOT BEEN GRANTED 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 QUESTIONNAIRES(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 545B IF THE PARENT (OTHER ADULT) REFUSES. CIRCLE CODE '1' IN 545B IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

We ask you to allow the Ministry of Health 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 used, (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?

[ANNEX E PAGE 322]

TO USE IN CASE THAT HOUSEHOLD IS SELECTED FOR "DOMESTIC VIOLENCE", SECTION 12. DOMESTIC VIOLENCE MODULE FOR WOMEN'S QUESTIONNAIRE

(VERIFY COVER PAGE)

1. IF ONLY ONE ELIGIBLE WOMAN IN HOUSEHOLD

In the first line of the chart below, write eligible woman's name and the line number (see column 9, section A in Household Characteristics part of the questionnaire): this women will answer Section 12 Domestic Violence Module.

2. IF MORE THAN ONE ELIGIBLE WOMEN IN HOUSEHOLD

a) In the chart below, record all eligible women's name and line number (see column 9, section A in Household Characteristics part of the questionnaire), start from oldest to youngest women.

b) Check cover page of Household questionnaire and consider the last digit of household number. Then circle the correct digit in the first line in the chart below (the one that goes from 1 to 0). Then, go down the line until you get to the number of the last eligible women. Circle the digit corresponding the crossing between the column and the line.

c) The last circled digit, indicate the NUMBER of women to record when answering Section 12 of Women's questionnaire. Circle in the chart below the LINE NUMBER of selected woman.

Number

1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th

Woman's Name

Woman's Age

Line number

1
2
3
4
5
6
7
8
9
0

[obs. the chart has in the first line all number 1, in the second line 2 and 1, then 1,2 and 3, then 1,2,3 and 4 ending in the line below (5th),then starting 1,2,3,4 and 5, ending in the line below, then starting 1,2,3,4,5 and 6 ending in the line below, then 1,2,3,4,5,6 and 7 ending in the line below, then 1,2,3,4,5,6,7 and 8 ending in the line below, then 1,2,3,4,5,6,7,8,9, ending in the 9th line and having 1 and 2. Line 10th has 1,2,3,4,5,6,7,8,9 and 10]