HOUSEHOLD QUESTIONNAIRE
IDENTIFICATION
PLACE NAME________
NAME OF HOUSEHOLD HEAD______
DHS CLUSTER NUMBER_________
PSU CODE_______
HOUSEHOLD NUMBER__________
REGION
MANZINI 2
SHISELWENI 3
LUBOMBO 4
URBAN/RURAL
RURAL 2
SELECTED FOR YOUTH SURVEY AND TESTING
NO 2
LARGE CITY/SMALL CITY/TOWN/RURAL
SMALL CITY 2
TOWN 3
RURAL 4
INTERVIEWER VISIT 1 (REPEAT FOR VISITS 2 AND 3)
DATE_______
INTERVIEWER'S NAME______
RESULT_____
NEXT VISIT:
DATE_______
TIME________
FINAL VISIT
DAY______
MONTH______
YEAR 2006
INT. NUMBER______
RESULT_______
NEXT VISIT:
DATE_____
TIME_______
TOTAL NUMBER OF VISITS_______
RESULT CODES:
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)________9
TOTAL PERSONS IN HOUSEHOLD______
TOTAL WOMEN 15-49______
TOTAL MEN 15-49_______
TOTAL AGE 12-14_____
TOTAL CHILDREN 0-5______
TOTAL AGE 50+______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____
SUPERVISOR
NAME_______
DATE______
FIELD EDITOR
NAME_______
DATE_______
OFFICE EDITOR_______
KEYED BY_________
(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 NAMES, RELATIONSHIPS, AND SEX, ASK Qs. 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-35 FOR EACH MEMBER OF THE HOUSEHOLD.
(3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
WIFE OR HUSBAND/PARTNER 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
NIECE/NEPHEW BY BLOOD 09
NIECE/NEPHEW BY MARRIAGE 10
OTHER RELATIVE 11
ADOPTED/FOSTER/STEPCHILD 12
NOT RELATED 13
DON'T KNOW 96
(4) SEX
Is (NAME) male or female?
FEMALE 2
(5) RESIDENCE
Does (NAME) usually live here?
NO 2
(6) RESIDENCE
Did (NAME) stay here last night?
NO 2
(8) IF AGE 15 OR OLDER: MARITAL STATUS
What is (NAME'S) current marital status?
MARRIED/LIVING TOGETHER 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED/NEVER LIVED WITH A PARTNER 4
(9) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
(10) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL MEN AGE 15-49
(11) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL PERSONS AGE 12-14
(12) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
(13) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL MEN AND WOMEN AGE 50+
(14) IF AGE 18-59: SICK PERSON
Has (NAME) been very sick for at least three months during the past 12 months? By very sick I mean that (NAME) was too sick to work or do normal activities around the house for at least three of the past 12 months.
NO 2
DK 8
IF AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
(15) Is (NAME)'s natural mother alive?
N 2 (GO TO 18)
DK 8 (GO TO 18)
(16) Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NO. SEE BELOW.
(17) IF MOTHER DOES NOT LIVE IN HOUSEHOLD
Has (NAME)'s mother been very sick for at least 3 months during the past 12 months? By very sick I mean too sick to work or do normal activities around the house for at least three of the past 12 months?
NO 2
DK 8
(18) Is (NAME)'s natural father alive?
N 2 (GO TO 21)
DK 8 (GO TO 21)
(19) Does (NAME)'s natural father live in this house- hold?
IF YES: What is his name?
RECORD FATHER'S LINE NO. SEE BELOW.
(20) IF FATHER DOES NOT LIVE IN HOUSEHOLD
Has (NAME)'s father been very sick for at least 3 months during the past 12 months? By very sick I mean too sick to work or do normal activities around the house for at least three of the past 12 months?
NO 2
DK 8
(21) CHECK QS. 15 TO 20
CIRCLE LINE NUMBER FOR THE CHILD WHOSE MOTHER AND/OR FATHER HAS DIED (Q. 15 AND18) OR IS SICK (Q. 17 AND 20).
(22) CHECK Q.15 AND Q. 18
IF YES TO Q.15 AND Q.18 (BOTH PARENTS ALIVE), CIRCLE '1', OTHERWISE CIRCLE '2'
2
(23) BROTHERS
Does (NAME) have any natural brothers under the age of 18? By natural brothers,
I mean born to the same mother and same father.
N 2 (GO TO 25)
DK 8 (GO TO 25)
(24) BROTHERS
Do all of (NAME)'s natural brothers under the age of 18 live in this household?
NO 2
(25) SISTERS
Does (NAME) have any natural sisters under the age of 18? By natural sisters,
I mean born to the same mother and same father.
N 2 (GO TO 27)
SK 8 (GO TO 27)
(26) SISTERS
Do all of (NAME)'s natural sisters under the age of 18 live in this household?
NO 2
Qs. 16 AND 19: RECORD '00' IF PARENT IS NOT LISTED IN THE HOUSEHOLD SCHEDULE
(27) IF AGE 5 YEARS OR OLDER: HIGHEST EDUCATION LEVEL
Has (NAME) ever attended school?
NO 2 (GO TO 33)
(28) IF AGE 5 YEARS OR OLDER: HIGHEST EDUCATION LEVEL
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.
GRADE______
(29) IF AGE 5-24 YEARS: RECENT SCHOOL ATTENDENCE
Did (NAME) attend school at any time during the (2005-2006) school year?
NO 2 (GO TO 31)
(30) IF AGE 5-24 YEARS: RECENT SCHOOL ATTENDENCE
During this/that school year, what level and grade [is/was] (NAME) attending?
SEE CODES BELOW.
GRADE______
(31) IF AGE 5-24 YEARS: RECENT SCHOOL ATTENDENCE
Did (NAME) attend school at any time during the previous school year, that is, (2004-2005)?
NO 2 (GO TO 33)
(32) IF AGE 5-24 YEARS: RECENT SCHOOL ATTENDENCE
During that school year, what level and grade did (NAME) attend?
SEE CODES BELOW.
GRADE______
(33) 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?
SEE CODES BELOW.
(34) IF AGE 5-17 YEARS: BASIC MATERIAL NEEDS
Does (NAME) have at least one meal per day?
NO 2
DK 8
(35) IF AGE 5-17 YEARS: BASIC MATERIAL NEEDS
Does (NAME) have a pair of shoes?
NO 2
DK 8
(36) IF AGE 5-17 YEARS: BASIC MATERIAL NEEDS
Does (NAME) have at least two sets of clothing?
NO 2
DK 8
CODES FOR Qs. 28, 30, AND 32
EDUCATION LEVEL:
HIGHER PRIMARY 2
SECONDARY 3
HIGH SCHOOL 4
TERTIARY 5
FON'T KNOW 8
EDUCATION GRADE
DON'T KNOW 98
CODES FOR Q. 33
REGISTRATION 2
NEITHER 3
DON'T KNOW 8
101) What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (SKIP TO 106)
PUBLIC TAP/STANDPIPE 13 (SKIP TO 103)
UNPROTECTED WELL 32(SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91 (SKIP TO 102)
OTHER (SPECIFY)_____96 (SKIP TO 103)
102) What is the main source of water used by your household for other purposes such as cooking and hand washing?
PIPED INTO YARD/PLOT 12 (SKIP TO 106)
PUBLIC TAP/STANDPIPE 13
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY)_____96
103) Where is that water source located?
ELSEWHERE 2
104) How long does it take to go there, get water, and come back?
ON PREMISES 996 (SKIP TO 106)
DON'T KNOW 998
105) Who usually goes to this source to fetch the water for your household?
ADULT MAN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY)______6
106) Do you treat your water in any way to make it safer to drink?
NO 2 (SKIP TO 108)
DON'T KNOW 8 (SKIP TO 108)
107) What do you usually do to the water to make it safer to drink? Anything else? RECORD ALL MENTIONED.
ADD BLEACH/CHLORINE/JIG B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY)______X
DON'T KNOW Z
108) What kind of toilet facility do members of your household usually use?
VENTILATED IMPROVED PRIVY 22
NO FACILITY/BUSH/FIELD 31 (SKIP TO 111)
OTHER (SPECIFY)_____96
109) Do you share this toilet facility with other households?
NO 2 (SKIP TO 111)
110) How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
111) Does your household have:
Electricity?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
A stove?
A watch or clock?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
112) What type of fuel does your household mainly use for cooking?
CHARCOAL 02
WOOD 03
GAS 04
PARAFFIN 05
COAL 06
NO FOOD COOKED IN THE HOUSEHOLD 07
OTHER (SPECIFY)______96
113) In this household, is food usually cooked on a stove or an open fire?
PROBE FOR TYPE.
OPEN FIRE OR STOVE WITH CHIMNEY/HOOD 2
CLOSED STOVE WITH CHIMNEY 3
OTHER (SPECIFY)_____6
114 Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2
OUTDOORS 3
OTHER (SPECIFY)______6
(2-6 SKIP TO 116)
115) Do you have a separate room which is used as a kitchen?
NO 2
116) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
117) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.
PALM/BAMBOO 22
WOOD PLANKS 23
ASBESTOS 32
TILES 33
SLATE 34
CONCRETE 25
118) MAIN MATERIAL OF THE WALLS. RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
MUD 13
STONE WITH MUD 22
PLYWOOD 24
CARTON 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
MUD BLOCKS 35
WOOD PLANKS/SHINGLES 36
119) TYPE OF WINDOWS.
RECORD OBSERVATION.
NO 2 (SKIP TO 120)
NO 2
NO 2
NO 2
NO 2
NO 2
120) How many rooms in this household are usually used for sleeping?
121) Does any member of this household own:
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A tractor?
NO 2
NO 2
NO 2
NO 2
NO 2
122) Does any member of this household own any land that can be used for agriculture?
NO 2 (SKIP TO 124)
123) How many square meters of agricultural land do members of this household own?
IF MORE THAN 9500, ENTER '9500'. IF UNKNOWN, ENTER '9998'.
MORE THAN 9500 9500
DON'T KNOW 9998
124) Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (SKIP TO 126)
125) How many of the following animals does this household own? Cattle?
Milk cows? Horses, donkeys, or mules? Goats? Sheep? Chickens?
IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.
COWS_____
HORSES/DONKEYS/MULES____
GOATS_____
SHEEP______
CHICKENS______
126) Does any member of this household have a bank account?
NO 2
127) Does your household have any mosquito or bed nets that can be used while sleeping?
NO 2 (SKIP TO 138)
128) How many bed nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
129) ASK THE RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
NOT OBSERVED 2
NOT OBSERVED 2
130) OBSERVE OR ASK THE BRAND OF MOSQUITO NET
BLUE 12
GREEN 18
GREEN 22 (SKIP TO 135)
NOT SURE 98
131) Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 133)
NOT SURE 8 (SKIP TO 133)
132) Who slept under this mosquito net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO._______
133) How many months ago did your household obtain the mosquito net? IF LESS THAN ONE MONTH, RECORD '00'. IF 37 MONTHS OR MORE, CIRCLE CODE '96'. IF DON'T KNOW, RECORD '98'.
MORE THAN 3 YEARS AGO 96
DK 98
134) When you got the net, was it treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
135) Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitos?
NO 2 (SKIP TO 137)
NOT SURE 8 (SKIP TO 137)
136) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'. IF 25 MONTHS OR MORE, CIRCLE CODE '96'. IF DON'T KNOW/UNSURE, CIRCLE '98'.
MORE THAN 2 YEARS AGO 96
DK 98
137) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138.
138) During the last 12 months, has anyone sprayed the interior walls of your dwelling against mosquitoes?
IF NOT SPRAYED, RECORD '95'
IF 'YES', How many months ago was the house sprayed? RECORD '00' IF LESS THAN ONE MONTH.
NOT SPRAYED 95 ( SKIP TO 140)
PRIVATE COMPANY 2
HOUSEHOLD MEMBER 3
OTHER (SPECIFY)_____6
DON'T KNOW 8
140) Would you like to have a (another) mosquito net?
NO 2 ( SKIP TO 142)
141) What colour of mosquito or bed net would you prefer?
GREEN 2
WHITE 3
OTHER (SPECIFY)_____6
DK/NO PREFERENCE 8
142) ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)
LESS THAN 15 PPM 2
15 PPM OR HIGHER 3
NO SALT IN HH 4
SALT NOT TESTED (SPECIFY)_______5
SUPPORT FOR SICK PEOPLE
201) CHECK COLUMNS 7 AND 14 IN THE HOUSEHOLD SCHEDULE:
AT LEAST ONE___
NONE____(SKIP TO 301)
202) ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-59, BEGINNING WITH THE FIRST SICK PERSON LISTED IN THE HOUSEHOLD SCHEDULE. ASK THE QUESTIONS ABOUT ALL OF THESE PEOPLE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).
203) NAME AND LINE NUMBER FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE
LINE NUBER______
LINE NUBER______
LINE NUBER______
204) You told me that in your household, (NAME OF EACH SICK PERSON IN 203) has(ve) been very sick for at least three of the past 12 months. I would like to ask you about any formal, organized help or support that your household may have received for [that/each of those] person(s) for which you did not have to pay.
By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.
205) Now I would like to ask you about the support you received for (NAME).
In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?
NO 2 (SKIP TO 207)
DK 8 (SKIP TO 207)
206) Did your household receive any medical support at least once a month while (NAME) was sick?
NO 2
DK 8
207) In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did not have to pay?
NO 2 (SKIP TO 209)
DK 8 (SKIP TO 209)
208) Did your household receive any emotional or psychological support in the past 30 days?
NO 2
DK 8
209) In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?
NO 2 (SKIP TO 211)
DK 8 (SKIP TO 211)
210) Did your household receive any material support in the past 30 days?
NO 2
DK 8
211) In the last 12 months, has your household received any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?
NO 2 (SKIP TO 213)
DK 8 (SKIP TO 213)
212) Did your household receive any social support in the past 30 days?
NO 2
DK 8
213) In the last 30 days, has (NAME) had severe pain, mild pain, or no pain at all?
MILD 2
NOT AT ALL 3 (SKIP TO 215)
214) When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?
SOME TIME 2
NOT AT ALL 3
215) In the last 30 days, did (NAME) suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Did (NAME) suffer severely or mildly?
MILD 2
NOT AT ALL 3 (SKIP TO 217)
216) Was (NAME) able to reduce or stop the (nausea/coughing/diarrhea/constipation) most of the time, some of the time or not at all?
SOME TIME 2
NOT AT ALL 3
217) GO BACK TO 205 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE SICK PEOPLE, GO TO 301.
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?
NO 2 (SKIP TO 401)
DON'T KNOW 8 (SKIP TO 401)
302) How many household members died in the last 12 months?
303) ASK 304-322 FOR ONE PERSON AT A TIME. IF MORE THAN 3 PEOPLE HAVE DIED, USE ADDITIONAL QUESTIONNAIRE(S).
304) What was the name of the person who died (most recently/before him/her)?
NAME 2ND DEATH______
NAME 3RD DEATH______
305) Was (NAME) male or female?
FEMALE 2
306) How old was (NAME) when (he/she) died?
307) Was (NAME) very sick for at least three of the 12 months before (he/she) died? By very sick, I mean that (NAME) was too sick to work or do normal activities around the house for at least three months.
NO 2 (SKIP TO 322)
DK 8 (SKIP TO 322)
308) CHECK 306: AGE OF PERSON AT DEATH
18-59____
309) I would like to ask you about any formal, organized help or support that your household may have received fo [NAME] before (he/she) died, for which you did not have to pay. By formal, organized support I mean help provided b someone working for a program. This program could be government, private, religious, charity, or community based.
310) In the last 12 months, did your household receive any medical supplies for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?
NO 2 (SKIP TO 312)
DK 8 (SKIP TO 312)
311) Did your household receive any medical support at least once a month while (NAME) was sick?
NO 2
DK 8
312) In the last 12 months, did your household receive any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did not have to pay?
NO 2 (SKIP TO 314)
DK 8 (SKIP TO 314)
313) Did your household receive any emotional or psychological support in the last 30 days before (NAME's) death?
NO 2
DK 8
314) In the last 12 months, did your household receive any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?
NO 2 (SKIP TO 316)
DK 8 (SKIP TO 316)
315) Did your household receive any material support in the last 30 days before (NAME)'s death?
NO 2
DK 8
NAME OF 1ST DEATH_____
NAME OF 2ND DEATH______
NAME OF 3RD DEATH_____
316) In the last 12 months, did your household receive any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?
NO 2 (SKIP TO 318)
DK 8 ( SKIP TO 318)
317) Did your household receive any social support in the last 30 days before (NAME)'s death?
NO 2
DK 8
318) In the 30 days before (NAME) died, did he/she have severe pain, mild pain, or no pain at all?
MILD 2
NOT AT ALL 3 (SKIP TO 320)
319) When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?
SOME TIME 2
NOT AT ALL 3
320) In the 30 days before (NAME) died, did he/she suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Did (NAME) suffer severely or mildly?
MILD 2
NOT AT ALL 3 (SKIP TO 322)
321) Was (NAME) able to reduce or stop the (nausea/coughing/diarrhea/constipation) most of the time, some of the time or not at all?
SOME TIME 2
NOT AT ALL 3
322) GO BACK TO 304 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE PEOPLE HAVE DIED, GO TO 401.
SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN
401) CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE: ANY CHILD AGE 0-17?
NO CHILD AGE 0-17____ (END INTERVIEW)
402) CHECK COLUMN 14 IN THE HOUSEHOLD SCHEDULE: ANY ADULT AGE 18-59 WHO IS SICK?
AT LEAST ONE SICK ADULT AGE 18-59___ (GO TO 405 AND LIST ALL CHILDREN AGE 0-17 IN THE HOUSEHOLD)
403) CHECK 306 IN THE PREVIOUS SECTION: ANY ADULT AGE 18-59 WHO DIED IN PAST 12 MONTHS?
AT LEAST ONE ADULT AGE 18-59 IN 306___ (GO TO 405 AND LIST ALL CHILDREN AGE 0-17 IN THE HOUSEHOLD)
404) CHECK COLUMN 21 IN THE HOUSEHOLD SCHEDULE: ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LIVING IN THE HOUSEHOLD AND/OR IS SICK?
NO CHILD WHOSE MOTHER AND OR FATHER HAS DIED AND/OR IS SICK AND NOT IN HOUSEHOLD___ (END INTERVIEW)
405) RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AGE 0-17 AS APPROPRIATE, BEGINNING WITH THE FIRST CHILD AND CONTINUING IN THE ORDER IN WHICH THEY ARE LISTED IN THE HOUSEHOLD SCHEDULE OR IN 21, AS APPROPRIATE. IF THERE ARE MORE THAN 8 CHILDREN TO BE LISTED, USE ADDITIONAL QUESTIONNAIRE(S).
NAME____
LINE NUMBER____
AGE____
(REPEAT FOR 2ND, 3RD AND 4TH CHILD)
407) I would like to ask you about any formal, organized help or support that your household may have received for (NAME OF EACH CHILD IN 406) and for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based
408) Now I would like to ask you about the support your household received for (NAME). In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?
NO 2
DK 8
409) In the last 12 months, has your household received any emotions or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home and for which you did not have to pay?
NO 2 (SKIP TO 411)
DK 8 (SKIP TO 411)
410) Did your household receive any emotional or psychological support in the past three months?
NO 2
DK 8
411) In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?
NO 2 (SKIP TO 413)
DK 8 (SKIP TO 413)
412) Did your household receive any material support in the past three months?
NO 2
DK 8
413) In the last 12 months, has your household received any social support for (NAME) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?
NO 2 (SKIP TO 415)
DK 8 (SKIP TO 415)
414) Did your household receive any social support in the past three months?
NO 2
DK 8
AGE 5-17___
416) In the last 12 months, has your household received any support for (NAME'S) schooling, such as allowance, free admission, books or supplies, for which you did
not have to pay?
NO 2
DK 8
417) GO BACK TO 406 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); OR, IF NO MORE CHILDREN, END INTERVIEW.
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR CHILDREN AGE 0-11
501) CHECK COVER:
HOUSEHLD NOT SELECTED FOR YOUTH___
RECORD LINE NUMBER, AGE, AND NAME OF ALL CHILDREN AGE 0-5 (SEE COLUMNS 2, 7 AND 12)
HOUSEHOLD SELECTED FOR YOUTH____
RECORD LINE NUMBER, AGE, AND NAME OF ALL CHILDREN AGE 0-11 (SEE COLUMNS 1, 2, 7, 12)
IF THERE ARE MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME OF THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 513 AND FOR THE HIV TEST PROCEDURE IN 518 FOR EACH ELIGIBLE CHILD, EVEN IF THE CHILD WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
CHILD 1
CHILD 2
CHILD 3
502) LINE NUMBER (COLUMNS 1 AND 12)
NAME (COLUMN 2)
AGE (COLUMN 7)
NAME______
AGE IN YEARS______
503) What is (NAME'S) birth date? IF MOTHER INTER- VIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK DAY, MONTH AND YEAR.
MONTH_______
YEAR_______
504) CHECK 502 AND 503: CHILD AGE 0-5 OR BORN IN JANUARY 2001 OR LATER?
NO 2 (SKIP TO 509)
507) MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
508) RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
509) AGE: CHECK 503 IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?
OLDER 2
HOUSEHOLD NOT SELECTED FOR YOUTH 2
0-5 YEARS 2
6-11 YEARS 3 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 523)
510) LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD. RECORD '00' IF NOT LISTED.
511) READ ANAEMIA TEST CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.
(SIGN)__________
REFUSED 2
(IF REFUSED, CIRCLE '3' IN 513)
CONSENT STATEMENT FOR ANAEMIA 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 age 6 months to 17 years 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?
512) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
513) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.
NOT PRESENT 2
REFUSED 3
OTHER 6
514) CHECK COVER AND AGE OR MONTH AND YEAR OF BIRTH:
2-11 YEARS OR BORN BEFORE JULY 2004 2
516) READ HIV TEST CONSENT STATEMENT TO PARENT/OTHER ADULT RESPONSIBLE FOR CHILD. CIRCLE CODE AND SIGN.
(SIGN)_________
REFUSED 2
(IF REFUSED, CIRCLE '3' IN 518)
CONSENT STATEMENT FOR HIV TEST
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 Swaziland
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 the test results either
If you want to know whether your child 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 your child (REN) 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 CHILD(REN)) to take the HIV test?
517) BAR CODE LABEL
PUT THE FIRST BAR CODE LABEL HERE:
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
518) OUTCOME OF HIV TEST PROCEDURE
NOT PRESENT 2
REFUSED 3
OTHER 6
519) A FINAL OUTCOME OF THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 513 AND FOR THE HIV TEST PROCEDURE IN 518 FOR EACH ELIGIBLE CHILD EVEN IF THE CHILD WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
520) READ CONSENT STATEMENT FOR ADDITIONAL TEST ASK CONSENT FROM PARENT/OTHER ADULT RESPONSIBLE CHILD. CIRCLE CODE AND SIGN.
(SIGN)________
REFUSED 2
CHECK 520:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
522) O 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 523.
CONSENT STATEMENT FOR STORAGE OF SAMPLE
We ask you to allow the Central Statistical Office 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 (NAME OF CHILD(REN)). You do not have to agree. Will you allow us to keep the blood sample stored for later testing or research?
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 12 AND OLDER
523) CHECK COVER:
HOUSEHLD NOT SELECTED FOR YOUTH___
RECORD LINE NUMBER, AGE, AND NAME OF ALL WOMEN AGE 15-49 (SEE COLUMNS 9, 7 AND 2)
HOUSEHOLD SELECTED FOR YOUTH____
RECORD LINE NUMBER, AGE, AND NAME OF ALL WOMEN AGE 12 AND OLDER (SEE COLUMNS 9, 11, 13, 7, AND 2)
IF THERE ARE MORE THAN SIX WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME FOR THE HEIGHT AND WEIGHT MUST BE RECORDED IN 527, THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 536, AND THE HIV TEST PROCEDURE IN 538 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
524) LINE NUMBER (COLUMNS 9 AND 11)
NAME (COLUMN 2)
AGE (COLUMN 7)
NAME_____
AGE IN YEARS_____
527) RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
15-17 YEARS 2
18 AND OLDER 3 (SKIP TO 531)
529) CHECK COLUMN 8: MARITAL STATUS
OTHER 2 (SKIP TO 531)
530) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
531) READ ANAEMIA TEST CONSENT STATEMENT. FOR GIRLS AGE 12-14 AND NEVER-IN- UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 530 BEFORE ASKING RESPONDENT'S CONSENT.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN)_________
(IF CODE '2' OR '3' CIRCLED, CIRCLE '3' IN 536)
CONSENT STATEMENT FOR ANEMIA TEST FROM WOMEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 531 IF RESPONDENT CONSENTS TO THE ANAEMIA TEST AND CODE '3' IF SHE REFUSES. FOR GIRLS AGE 12-14 AND NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 530) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 531 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 anaemia 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 you participate in the anaemia 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 OF ADOLESCENT to) take the anemia test?
CONSENT STATEMENT FOR ANEMIA TEST FROM GIRLS AGE 12-14
We are asking children like you to take a blood test. The test is for a problem in the blood that can happen when a person does not eat well or has been sick. This will help the government to plan programs to prevent and treat this problem in children.
We would like you to take the test. You will have to give a few drops of blood from a finger. The needle we use is clean and safe. It has not been used before and we will throw it away after we use it with you.
We will do the blood test right away and tell you the results. No one will be told the results.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide. Do you want to be tested for this blood problem?
15+ YEARS 2
533) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK:
Are you pregnant?
NO 2
DK 8
534) READ THE HIV TEST CONSENT STATEMENT. FOR GIRLS AGE 12-14 AND NEVER-IN UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 530 BEFORE ASKING RESPON- DENT'S CONSENT.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN)_________
(IF CODE '2' OR '3' CIRCLED, CIRCLE '3' IN 538)
535) RECORD HEMOGLOBIN LEVEL HERE AND IN ANAEMIA PAMPHLET.
536) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.
NOT PRESENT 2
REFUSED 3
OTHER 6
CONSENT STATEMENT FOR HIV TEST FROM WOMEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 534 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF SHE REFUSES. FOR GIRLS AGE 12-14 AND NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 530) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 534 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 Swaziland
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 to the blood sample which will keep the results completely anonymous. For this reason, we will not be able to know (your/NAME OF ADOLESCENT) test results, and so we will not be able to tell you the test results either.
If you want to know whether you (your child) 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 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?
CONSENT STATEMENT FOR HIV TEST FROM GIRLS AGE 12-14
We 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. We are doing the HIV test to see how big the AIDS problem is in Swaziland
We would like you to take the test. You will have to give a few drops of blood from a finger. The needle we use is clean and completely safe It has not been used before and we will throw it away after we use it with you
We will not write your name on the blood sample. No one will know that it is your blood. We will not be able to give you the test results
If you want to know if you have HIV, I can provide you the names of places that can help you.
I will also give you a note for free testing that you can use at any of these places.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide. Do you want to be tested for HIV?
PUT THE FIRST BAR CODE LABEL HERE.
PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.
538) OUTCOME OF HIV TEST PROCEDURE
NOT PRESENT 2
REFUSED 3
OTHER 6
539) A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 536 AND FOR THE HIV TEST PROCEDURE IN 538 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
540) A FINAL OUTCOME FOR THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 536 AND FOR THE HIV TEST PROCEDURE IN 538 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
BLOOD NOT TAKEN____ (GO TO NEXT WOMAN)
541) READ THE CONSENT STATE- MENT FOR ADDITIONAL TESTS. FOR GIRLS AGE 12-14 AND NEVER- IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/ OTHER ADULT IDENTIFIED IN 530 BEFORE ASKING RESPONDENT'S CONSENT.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN)_________
CHECK 541:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
CONSENT STATEMENT FOR STORAGE OF SAMPLE FROM WOMEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 541 IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND
CODE '3' IF SHE REFUSES.
FOR GIRLS AGE 12-14 AND NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 530) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 541 IF THE PARENT (OTHER ADULT) REFUSES. CIRCLE CODE '1' IN 539 IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
We ask you to allow the Central Statistical Office 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. Will you allow us to keep the blood sample stored for later testing or research?
CONSENT STATEMENT FOR STORAGE OF SAMPLE FROM GIRLS AGE 12-14
We ask you to allow the Central Statistical Office 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. You do not have to agree. Will you allow us to keep the blood sample stored for later testing or research?
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 12 AND OLDER
RECORD LINE NUMBER, AGE, AND NAME OF ALL MEN AGE 15-49 (SEE COLUMNS 2, 7 AND 10)
HOUSEHOLD SELECTED FOR YOUTH___
RECORD LINE NUMBER, AGE, AND NAME OF ALL MEN AGE 12 AND OLDER (SEE COLUMNS 2, 7, 10, 11, AND 13)
IF THERE ARE MORE THAN SIX MEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME FOR THE HEIGHT AND WEIGHT MUST BE RECORDED IN 547, FOR THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 554 AND FOR THE HIV TEST PROCEDURE IN 556 FOR EACH ELIGIBLE MAN EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
544) LINE NUMBER (COLUMNS 10 AND 11)
NAME (COLUMN 2)
AGE (COLUMN 7)
NAME___________
AGE IN YEARS__________
547) RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
15-17 YEARS 2
18+ YEARS 3 (SKIP TO 551)
549) CHECK COLUMN 8: MARITAL STATUS
OTHER 2 (GO TO 551)
550) RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
551) READ ANEMIA TEST CONSENT STATEMENT. FOR BOYS AGE 12-14 AND NEVER IN UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 550 BEFORE ASKING RESPINDENT'S CONSENT.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN)_______
(IF CODE '2' OR '3' CIRCLED, CIRCLE '3' IN 554)
CONSENT STATEMENT FOR ANEMIA TEST FROM MEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 551 IF RESPONDENT CONSENTS TO THE ANAEMIA TEST AND CODE '3' IF HE REFUSES.
FOR BOYS AGE 12-14 AND NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 550) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 551 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?
CONSENT STATEMENT FOR ANEMIA TEST FROM BOYS AGE 12-14
We are asking children like you to take a blood test. The test is for a problem in the blood that can happen when a person does not eat well or has been sick. This will help the government to plan programs to prevent and treat this problem in children.
We would like you to take the test. You will have to give a few drops of blood from a finger. The needle we use is clean and safe. It has not been used before and we will throw it away after we use it with you.
We will do the blood test right away and tell you the results. No one will be told the results.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide. Do you want to be tested for this blood problem?
552) READ THE HIV TEST CONSENT STATEMENT. FOR BOYS AGE 12-14 AND NEVER-IN UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 550 BEFORE ASKING RESPONDENT'S CONSENT
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN)___________
(IF CODE '2' OR '3' CIRCLED, CIRCLE '3' IN 556)
553) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
554) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.
NOT PRESENT 2
REFUSED 3
OTHER 6
555) BAR CODE LABEL
PUT THE FIRST BAR CODE LABEL HERE.
PUT THE SECOND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE THIRD ON THE TRANSMITTAL FORM.
556) OUTCOME OF HIV TEST PROCEDURE
NOT PRESENT 2
REFUSED 3
OTHER 6
CONSENT STATEMENT FOR HIV TEST FROM MEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 552 IF RESPONDENT CONSENTS TO THE HIV TEST AND CODE '3' IF HE REFUSES.
FOR BOYS AGE 12-14 AND NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 550) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 552 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 Swaziland.
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 to the blood sample which will keep the results completely anonymous. For this reason, we will not be able to know (your/NAME OF ADOLESCENT) test results, and so we will not be able to tell you the test results either.
If you want to know whether you (your child) 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 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?
CONSENT STATEMENT FOR HIV TEST FROM BOYS AGE 12-14
We 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 We are doing the HIV test to see how big the AIDS problem is in Swaziland
We would like you to take the test. You will have to give a few drops of blood from a finger. The needle we use is clean and completely safe It has not been used before and we will throw it away after we use it with you
We will not write your name on the blood sample. No one will know that it is your blood. We will not be able to give you the test results
If you want to know if you have HIV, I can provide you the names of places that can help you. I will also give you a note for free testing that you can use at any of these places.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide. Do you want to be tested for HIV?
557) CHECK 556: OUTCOME OF HIV TEST
BLOOD NOT TAKEN____ (GO TO NEXT MAN)
558) A FINAL OUTCOME FOR THE ANAEMIA TEST PROCEDURE MUST BE RECORDED IN 552 AND FOR THE HIV TEST PROCEDURE IN 554 FOR EACH ELIGIBLE MAN EVEN IF HE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
559) READ THE CONSENT STATE- MENT FOR ADDITIONAL TESTS WITH LEFT OVER BLOOD. FOR BOYS AGE 12-14 AND NEVER-IN UNION MEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 550 BEFORE ASKING RESPON- DENT'S CONSENT.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN)_______
560) ADDITIONAL TESTS
CHECK 559:
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TEST" ON THE FILTER PAPER.
CONSENT STATEMENT FOR STORAGE OF SAMPLE FROM MEN AGE 15 AND OLDER
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 559 IF RESPONDENT CONSENTS TO THE ADDITIONAL TESTS AND CODE '3' IF HE REFUSES.
FOR BOYS AGE 12-14 AND NEVER-IN-UNION MEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 550) BEFORE ASKING THE ADOLESCENT FOR HIS CONSENT. CIRCLE CODE '2' IN 558 IF THE PARENT (OTHER ADULT) REFUSES. CIRCLE CODE '1' IN 559 ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
We ask you to allow the Central Statistical Office 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. Will you allow us to keep the blood sample stored for later testing or research?
CONSENT STATEMENT FOR STORAGE OF SAMPLE FROM BOYS AGE 12-14
We ask you to allow the Central Statistical Office 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. You do not have to agree. Will you allow us to keep the blood sample stored for later testing or research?