ZIMBABWE
PLACE NAME:
NAME OF HOUSEHOLD HEAD:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
FIRST VISIT
DATE
INTERVIEWER'S NAME
SECOND VISIT
DATE
INTERVIEWER'S NAME
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
FINAL VISIT
DAY
MONTH
YEAR
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
TOTAL ELIGIBLE CHILDREN
NOTES
02 NDEBELE
03 SHONA
02 NDEBELE
03 SHONA
NO 2
FIELD EDITOR
NAME
NUMBER
OFFICE EDITOR
NUMBER
KEYED BY
NUMBER
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT, AND HIV TESTING 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.
NAME ___
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?
MONTH ___
YEAR ___
104. CHECK 103: CHILD BORN IN 2010-2015?
NO 2 (GO TO 121)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994 (GO TO 108)
REFUSED 9995 (GO TO 108)
OTHER 9996 (GO TO 108)
107. MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
108. MEASURER: ENTER YOUR INTERVIEWER NUMBER.
108A. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD FROM COLUMN 1 OF HOUSEHOLD SCHEDULE.
RECORD '00' IF NOT LISTED
109. CHECK 103: CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR 5 PREVIOUS MONTHS?
OLDER 2
PARENTAL/RESPONSIBLE ADULT CONSENT FOR CHILD ANEMIA TEST
111. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT FORM.
112. CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) ___
NOT PRESENT 3
PARENTAL/RESPONSIBLE ADULT CONSENT FOR CHILD DBS COLLECTION
113. ASK CONSENT FOR DBS COLLECTION FROM PARENT/OTHER ADULT
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT FORM.
114. CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) ___ (GO TO 117)
(SIGN AND ENTER YOUR INTERVIEWER NUMBER) ___
NOT PRESENT 3 (GO TO 117)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR CHILD ADDITIONAL TESTING
115. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENT CONSENT FROM.
116. CIRCLE THE CODE AND SIGN YOUR NAME.
REFUSED 2 (SIGN) ___
NOT PRESENT 3
117. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
CHECK 116.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
119. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
IF LESS THAN 2 YEARS, USE A BAR CODE ON BLUE PAPER.
IF 2 YEARS OR MORE, USE A BAR CODE ON WHITE PAPER.
PUT THE 1ST BAR CODE LABEL
REFUSED 99995
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3 RD ON THE TRANSMITTAL FORM.
121. 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 122.
HIV TESTING FOR CHILDREN AGE 6-14
122. CHECK COLUMN 11A IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 6-14 YEARS IN QUESTION 123; IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
123. CHECK HOUSEHOLD QUESTIONNAIRE:
LINE NUMBER FROM COLUMN 11A.
NAME FROM COLUMN 2.
NAME ___
124. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
12-14 YEARS 2
125. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
EMANCIPATED ADOLESCENT CONSENT FOR DBS COLLECTION
126. ASK CONSENT FOR DBS COLLECTION.
PROVIDE ADOLESCENT WITH EMANCIPATED ADOLESCENT CONSENT FORM.
127. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR INTERVIEWER NUMBER) (GO TO 142)
NOT PRESENT 3 (GO TO 142)
EMANCIPATED ADOLESCENT CONSENT FOR ADDITIONAL TESTING
128. ASK CONSENT FOR ADDITIONAL TESTING.
PROVIDE ADOLESCENT WITH EMANCIPATED ADOLESCENT CONSENT FORM.
129. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 140)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
130. ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT FORM.
131. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 142)
NOT PRESENT 3 (GO TO 142)
132. CHECK 124: CHILD AGE 6 YEARS?
7-14 YEARS 2
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
133. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
PROVIDE MINOR WITH ASSENT FORM.
134. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOU INTERVIEWER NUMBER.
MINOR RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR INTERVIEWER NUMBER) (GO TO 142)
NOT PRESENT 3 (GO TO 142)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
135. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT FORM.
136. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 140)
137. CHECK 124: CHILD AGE 6 YEARS?
7-14 YEARS 2
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
138 ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
PROVIDE MINOR WITH ASSENT FORM.
139. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)
IF EMANCIPATED ADOLESCENT RESPONDENT, CHECK 129; IF MINOR RESPONDENT, CHECK 136 AND 139
IF CONSENT HAS NOT BEEN GRANTED, WRITE 'NO ADDITIONAL TESTS' ON THE FILTER PAPER.
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
142. GO BACK TO 123 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE CHILDREN GO TO 201.
WEIGHT, HEIGHT, 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, 203, AND 204.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
202. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 9.
NAME ___
203. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-49 YEARS 2
204. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207. MEASURER: ENTER YOUR INTERVIEWER NUMBER.
18-49 YEARS 2 (GO TO 210)
209. CHECK 204: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
210. ASK CONSENT FOR ANEMIA TEST.
PROVIDE ADULT CONSENT FORM.
211. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT 2 (SIGN) (GO TO 212)
NOT PRESENT 3 (GO TO 212)
211A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
ADULT RESPONDENT CONSENT FOR DBS COLLECTION
212. ASK CONSENT FOR DBS COLLECTION.
PROVIDE CONSENT FORM.
213. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR INTERVIEWER NUMBER) (GO TO 229)
NOT PRESENT 3 (GO TO 229)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
214. ASK CONSENT FOR ADDITIONAL TESTING.
PROVIDE ADULT CONSENT FORM.
215. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 229)
216. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
217. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT.
218. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 221)
NOT PRESENT 3 (GO TO 221)
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
219. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
PROVIDE ADOLESCENT WITH ADOLESCENT ASSENT FORM.
220. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) (GO TO 221)
NOT PRESENT 3 (GO TO 221)
220A. CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?
NO 2
DON'T KNOW 8
PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
221. ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT.
222. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 229)
NOT PRESENT 3 (GO TO 229)
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
223. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
PROVIDE ADOLESCENT WITH ADOLESCENT ASSENT FORM.
224. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
MINOR RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR INTERVIEWER NUMBER) (GO TO 229)
NOT PRESENT 3 (GO TO 229)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
225. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT.
226. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 229)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
227. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
PROVIDE ADOLESCENT WITH ADOLESCENT ASSENT FORM.
228. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)
229. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
IF ADULT RESPONDENT, CHECK 215; IF MINOR RESPONDENT, CHECK 226 AND 228.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
231. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
233. GO BACK TO 202 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE.
WEIGHT, HEIGHT, HEMOGLOBIN MEASUREMENT AND HIV TESTING FOR MEN AGE 15-54
301. CHECK COLUMN 10 IN HOUSEHOLD QUESTIONNAIRE. RECORD THE LINE NUMBER, NAME, AGE, AND MARITAL STATUS FOR ALL ELIGIBLE MEN IN 302, 303, AND 304.
IF THERE ARE MORE THAN THREE MEN, USE ADDITIONAL QUESTIONNAIRE(S).
302. CHECK HOUSEHOLD QUESTIONNAIRE: LINE NUMBER FROM COLUMN 10.
NAME ___
303. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 7 (AGE):
18-49 YEARS 2
304. CHECK HOUSEHOLD QUESTIONNAIRE COLUMN 8 (MARITAL STATUS):
OTHER 2
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
307. MEASURER: ENTER YOUR INTERVIEWER NUMBER.
18-54 YEARS 2 (GO TO 310)
309. CHECK 304: MARITAL STATUS
OTHER 2
ADULT RESPONDENT CONSENT FOR ANEMIA TEST
310. ASK CONSENT FOR ANEMIA TEST.
PROVIDE ADULT CONSENT FORM.
311. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT 2 (SIGN)
NOT PRESENT 3
ADULT RESPONDENT CONSENT FOR DBS COLLECTION
312. ASK CONSENT FOR DBS COLLECTION.
PROVIDE CONSENT FORM.
313. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR INTERVIEWER NUMBER) (GO TO 329)
NOT PRESENT 3 (GO TO 329)
ADULT RESPONDENT CONSENT FOR ADDITIONAL TESTING
314. ASK CONSENT FOR ADDITIONAL TESTING.
PROVIDE ADULT CONSENT FORM.
315. CIRCLE THE CODE AND SIGN YOUR NAME.
RESPONDENT REFUSED 2 (SIGN AND GO TO 329)
316. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT.
RECORD '00' IF NOT LISTED
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ANEMIA TEST
317. ASK CONSENT FOR ANEMIA TEST FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT.
318. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 321)
NOT PRESENT 3 (GO TO 321)
MINOR RESPONDENT CONSENT FOR ANEMIA TEST
319. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.
PROVIDE ADOLESCENT WITH ADOLESCENT ASSENT FORM.
320. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN) (GO TO 321)
NOT PRESENT 3 (GO TO 321)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR DBS COLLECTION
321. ASK CONSENT FOR DBS COLLECTION FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT.
322. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 329)
NOT PRESENT 3 (GO TO 329)
MINOR RESPONDENT CONSENT FOR DBS COLLECTION
323. ASK CONSENT FOR DBS COLLECTION FROM MINOR RESPONDENT.
PROVIDE ADOLESCENT WITH ADOLESCENT ASSENT FORM.
324. CIRCLE THE CODE, SIGN YOUR NAME, AND ENTER YOUR INTERVIEWER NUMBER.
MINOR RESPONDENT REFUSED 2 (SIGN AND ENTER YOUR INTERVIEWER NUMBER) (GO TO 329)
NOT PRESENT 3 (GO TO 329)
PARENTAL/RESPONSIBLE ADULT CONSENT FOR ADDITIONAL TESTING
325. ASK CONSENT FOR ADDITIONAL TESTING FROM PARENT/ADULT.
PROVIDE PARENT/RESPONSIBLE ADULT WITH PARENTAL CONSENT.
326. CIRCLE THE CODE AND SIGN YOUR NAME.
PARENT/OTHER RESPONSIBLE ADULT REFUSED 2 (SIGN) (GO TO 329)
MINOR RESPONDENT CONSENT FOR ADDITIONAL TESTING
327. ASK CONSENT FOR ADDITIONAL TESTING FROM MINOR RESPONDENT.
PROVIDE ADOLESCENT WITH ADOLESCENT ASSENT FORM.
328. CIRCLE THE CODE AND SIGN YOUR NAME.
MINOR RESPONDENT REFUSED 2 (SIGN)
329. PREPARE EQUIPMENT AND SUPPLIES ONLY FOR THE TEST(S) FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST(S).
IF ADULT RESPONDENT, CHECK 315; IF MINOR RESPONDENT, CHECK 326 AND 328.
IF CONSENT HAS NOT BEEN GRANTED, WRITE "NO ADDITIONAL TESTS" ON THE FILTER PAPER.
331. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.
NOT PRESENT 994
REFUSED 995
OTHER 996
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995
OTHER 99996
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT'S FILTER PAPER AND THE 3RD ON THE TRANSMITTAL FORM.
333. GO BACK TO 302 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE.
TO BE FILLED IN AFTER COMPLETING BIOMARKERS
SUPERVISOR'S OBSERVATIONS
EDITOR'S OBSERVATIONS