FORMATTING DATE: 09 Jun 2015
ENGLISH LANGUAGE: 23 Oct 2014

IDENTIFICATION
PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER

FIELDWORKER VISITS
DATE
FIELDWORKER'S NAME

NEXT VISIT

FINAL VISIT

TOTAL NUMBER OF VISITS

NOTES:

TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN

LANGUAGE OF QUESTIONNAIRE** 01 ENGLISH
LANGUAGE OF INTERVIEW**
NATIVE LANGUAGE OF RESPONDENT**

TRANSLATOR

**LANGUAGE CODES:

SUPERVISOR

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

101. CHECK COLUMN 11 IN HOUSEHOLD QUESTIONNAIRE RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 102; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

102. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 11.

103. IF MOTHER INTERVIEWED: COPY CHILD'S DATE OF BIRTH (DAY, MONTH, AND YEAR) FROM BIRTH HISTORY. IF MOTHER NOT INTERVIEWED ASK:
What is (NAME)'s date of birth?

104. CHECK 103: CHILD BORN IN 2013-2018?

105. WEIGHT IN KILOGRAMS.

106. HEIGHT IN CENTIMETERS.

107. MEASURED LYING DOWN OR STANDING UP?

108. MEASURER: ENTER YOUR FIELDWORKER NUMBER.

109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?

110. LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR THE CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.

111. ASK CONSENT FOR ANEMIA TEST FROM PARENT / OTHER ADULT.
As part of this survey, we are asking people all over the country to take an anemia test.
Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. We ask that all children born in 2013 or later take part in the anemia testing and give a few drops of blood from a finger or heel. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes or no. It is up to you to decide.

112. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

113. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.

114. GO BACK TO 103 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 201.

##NOTE: QUESTIONS 102-114 REPEATED FOR CHILDREN 4-6

HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR WOMEN AGE 15-49

201. CHECK COLUMN 9 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE WOMEN IN 202, 208, AND 209. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

202. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9.

208. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):

209. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):

NAME FROM COLUMN 2.
NAME________

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

211. CIRCLE THE CODE AND SIGN YOUR NAME.

211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

212. ASK CONSENT FOR DBS COLLECTION.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few (more) drops of blood from a finger. The blood will be collected on a paper card. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.

213. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

214. ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other information attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?

215. CIRCLE THE CODE AND SIGN YOUR NAME.

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

214. ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other information attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?

215. CIRCLE THE CODE AND SIGN YOUR NAME.

ADULT RESPONDENT CONSENT FOR RDT TESTING

216. ASK CONSENT FOR HIV RDT TEST.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?

217. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

218. RECORD LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

PARENTAL / RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST

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

220. CIRCLE THE CODE AND SIGN YOUR NAME.

PARENTAL / RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

221. ASK CONSENT FOR DBS COLLECTION FROM PARENT / ADULT.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few (more) drops of blood from a finger. The blood will be collected on a paper card. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take the blood. No names will be written on the paper card so we will not be able to tell you the results of (NAME OF MINOR)'s test. No one else will be able to know (NAME OF MINOR)'s test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood on a paper card for HIV testing in a laboratory?

222. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

PARENTAL / RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

223. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT / ADULT.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?

224. CIRCLE THE CODE AND SIGN YOUR NAME.

PARENTAL / RESPONSIBLE ADULT CONSENT FOR RDT TESTING

225. ASK CONSENT FOR RDT TEST FROM PARENT / ADULT.
If you want (NAME OF MINOR) to know her HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give (NAME OF MINOR) a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.

226. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

MINOR RESPONDENT CONSENT FOR ANEMIA TEST

227. CHECK 220: WAS CONSENT GRANTED?

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

229. CIRCLE THE CODE AND SIGN YOUR NAME.

229A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

230. CHECK 222: WAS CONSENT GRANTED?

231. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
As part of the survey we also are asking people all over the country to give blood for HIV testing. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few (more) drops of blood from a finger. The blood will be collected on a paper card. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood on a paper card for HIV testing in a laboratory?

232. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

233. CHECK 224: WAS CONSENT GRANTED?

234. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
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?

235. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR RDT TEST

236. CHECK 226: WAS CONSENT GRANTED?

237. ASK CONSENT FOR RDT TEST FROM MINOR RESPONDENT.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.

238. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

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

240. ADDITIONAL TESTS.
IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 224 AND 235.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.

241. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

242. PLACE BAR CODE LABEL.

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

243. RECORD THE RESULT OF THE "DETERMINE HIV RDT" HERE.

244. RECORD THE RESULT OF THE "UNIGOLD HIV RDT" HERE.

245. IF 243 AND 244 ARE POSITIVE, RESPONDENT IS HIV POSITIVE:
INFORM SURVEY PARTICIPANT ABOUT POSITIVE HIV STATUS AND PROVIDE POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV CARE AND TREATMENT SERVICES ARE AVAILABLE.

246. IF 243 IS NEGATIVE, RESPONDENT IS HIV NEGATIVE:
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING.
SKIP TO 248

247. IF 243 IS POSITIVE AND 244 IS NEGATIVE, RESPONDENT'S HIV STATUS IS INDETERMINATE:
INFORM THE RESPONDENT OF INDETERMINATE TEST RESULT, AND CONDUCT POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, RECOMMEND THAT RESPONDENT IS RETESTED WITHIN 14 DAYS AND PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV TESTING CAN BE CONDUCTED.

248. WHILE TESTING THIS PERSON, WAS ANY RDT INVALID / DID ANY RDT FAIL TO RUN, THAT IS, THE CONTROL BAND DID NOT APPEAR?

249. RECORD NUMBER OF INVALID RESULTS USING "DETERMINE HIV RDT".

250. RECORD NUMBER OF INVALID RESULTS USING "UNIGOLD HIV RDT" HERE.

251. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, GO TO 301.

HIV TESTING FOR MEN AGE 15-59

301. CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 308, AND 309.
IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).

302. CHECK HOUSEHOLD QUESTIONNAIRE:
LINE NUMBER FROM COLUMN 10.
NAME FROM COLUMN 2.

308. CHECK HOUSEHOLD QUESTONNAIRE COLUMN 7 (AGE):

309. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):

HIV TESTING FOR MEN AGE 15-59

NAME FROM COLUMN 2.
NAME_________

ADULT RESPONDENT CONSENT FOR DBS COLLECTION

310. ASK CONSENT FOR DBS COLLECTION.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few drops of blood from a finger. The blood will be collected on a paper card. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood on a paper card for HIV testing in a laboratory?

311. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING

312. ASK CONSENT FOR ADDITIONAL TESTING.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research.
These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other data attached that could identify you. You do not have to agree. If you do not want the blood sample stored for additional testing, you can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?

313. CIRCLE THE CODE AND SIGN YOUR NAME.

ADULT RESPONDENT CONSENT FOR RDT TEST

314. ASK CONSENT FOR RDT TEST.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with medical personnel, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the rapid HIV testing?

315. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

316. RECORD LINE NUMBER OF PARENT / OTHER ADULT RESPONSIBLE FOR ADOLESCENT.

PARENT / RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION

317. ASK CONSENT FOR DBS COLLECTION FROM PARENT / ADULT.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few drops of blood from a finger. The blood will be collected on a paper card. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take the blood. No names will be written on the paper card so we will not be able to tell you the results of (NAME OF MINOR)'s test. No one else will be able to know (NAME OF MINOR)'s test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you allow (NAME OF MINOR) to give blood on a paper card for HIV testing in a laboratory?

318. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

PARENTAL / RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING

319. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT / ADULT.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
The blood sample will not have any name or other data attached that could identify (NAME OF MINOR). You do not have to agree. If you do not want the blood sample stored for additional testing, (NAME OF MINOR) can still participate in the HIV testing in this survey.
Will you allow us to keep the blood sample stored for additional testing?

320. CIRCLE THE CODE AND SIGN YOUR NAME.

PARENTAL / RESPONSIBLE ADULT CONSENT FOR RDT TEST

321. ASK CONSENT FOR RDT TEST FROM PARENT / ADULT.
If you want (NAME OF MINOR) to know his HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give (NAME OF MINOR) a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
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 MINOR) to give blood for the rapid HIV test?

322. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

MINOR RESPONDENT CONSENT FOR DBS COLLECTION

323. CHECK 318: WAS CONSENT GRANTED?

324. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
As part of the survey we also are asking people all over the country to give blood for HIV testing to be done in a laboratory. HIV is the virus that can lead to AIDS. The HIV testing is being done to see how many people have HIV.
For the HIV testing, we need a few drops of blood from a finger. The blood will be collected on a paper card. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after we take your blood. No names will be written on the paper card so we will not be able to tell you the test results. No one else will be able to know your test results either.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood on a paper card for HIV testing in a laboratory?

325. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING

326. CHECK 320: WAS CONSENT GRANTED?

327. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
We ask you to allow the Ministry of Health to store part of the blood sample at the laboratory for additional tests or research. These additional tests could include tests to see if individuals are protected against diseases such as measles and rubella, or other tests.
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 an 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?

328. CIRCLE THE CODE AND SIGN YOUR NAME.

MINOR RESPONDENT CONSENT FOR RDT TEST

329. CHECK 322: WAS CONSENT GRANTED?

330. ASK CONSENT FOR RDT TEST FROM MINOR RESPONDENT.
If you want to know your HIV status right now, we can do a rapid test and tell you the result. The testing is free and we will offer counseling before and after the test.
For the rapid HIV test, we need a few (more) drops of blood from a finger. We will use the same rapid tests used in the hospitals in Zambia. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The result of the test will be available in 20-30 minutes.
If the test is positive, I will give you a referral form to go to the nearest health facility for follow up with health technicians, as is recommended by the Ministry of Health.
Do you have any questions?
You can say yes or no. It is up to you to decide.
Will you give blood for the rapid HIV testing?

331. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR FIELDWORKER NUMBER.

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

333. ADDITIONAL TESTS.
IF ADULT RESPONDENT, CHECK 313; IF MINOR RESPONDENT, CHECK 320 AND 328.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.

334. PLACE BAR CODE LABEL.
PUT THE 1ST BAR CODE LABEL HERE.

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

335. RECORD THE RESULT OF THE "DETERMINE HIV RDT" HERE.

336. RECORD THE RESULT OF THE "UNIGOLD HIV RDT" HERE.

337. IF 335 AND 336 ARE POSITIVE, RESPONDENT IS HIV POSITIVE:
INFORM SURVEY PARTICIPANT ABOUT POSITIVE HIV STATUS AND PROVIDE POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV CARE AND TREATMENT SERVICES ARE AVAILABLE.

338. IF 335 IS NEGATIVE, RESPONDENT IS HIV NEGATIVE:
INFORM THE RESPONDENT OF NEGATIVE TEST RESULT, AND CONDUCT POST-TEST COUNSELING.
SKIP TO 340

339. IF 335 IS POSITIVE AND 336 IS NEGATIVE, RESPONDENT'S HIV STATUS IS INDETERMINE:
INFORM THE RESPONDENT OF INDETERMINATE TEST RESULT, AND CONDUCT POST-TEST COUNSELING. AS PART OF POST-TEST COUNSELING, RECOMMEND THAT RESPONDENT IS RETESTED WITHIN 14 DAYS AND PROVIDE A REFERRAL TO THE NEAREST HEALTH FACILITY WHERE HIV TESTING CAN BE CONDUCTED.

340. WHILE TESTING THIS PERSON, WAS ANY RDT INVALID / DID ANY RDT FAIL TO RUN, THAT IS, THE CONTROL BAND DID NOT APPEAR?

341. RECORD NUMBER OF INVALID RESULTS USING "DETERMINE HIV RDT"

342. RECORD NUMBER OF INVALID RESULTS USING "UNIGOLD HIV RDT" HERE.

343. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE MEN, END INTERVIEW.

FIELDWORKER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING BIOMARKERS

SUPERVISOR'S OBSERVATIONS
EDITOR'S OBSERVATIONS