As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?
DECLARATION OF CONSENT FOR ANEMIA AND HIV TEST FROM THE PARENT/OTHER ADULT RESPONSIBLE FOR THE ADOLESCENT
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.
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 the Benin.
This survey will assist the government to develop programs to prevent and treat anemia and AIDS.
For the anemia and HIV test, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.
For the HIV 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 results of (NAME OF THE ADOLESCENT) either.
If you want to know (NAME OF ADOLESCENT)'s HIV status, I can provide a list of [nearby] facilities to (NAME OF ADOLESCENT) that offer counseling and testing for HIV. I will also give you a voucher for free services for (NAME OF ADOLESCENT) to 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.
708A) ASK FOR CONSENT FOR THE ANEMIA TEST TO THE PARENT/OTHER RESPONSIBLE ADULT
REQUEST FOR CONSENT FROM PARENT/OTHER RESPONSIBLE ADULT FOR THE ANEMIA TEST
Will you allow (NAME OF ADOLESCENT) to take the anemia test?
708B) CIRCLE THE APPROPRIATE CODE FOR THE CONSENT FOR THE ANEMIA TEST AND SIGN YOUR NAME.
210) Ask for 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 each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?
211) Circle the code and sign your name.
As part of this survey, we would like to know anemia levels in women and children. Anemia is a serious health problem that is caused by poor nutrition. The results of this survey will help the government to put in place programs to treat and prevent anemia.
We would like you (and all of your children born in 1998 or later) to participate in the anemia test by giving a few drops of blood from your finger. For this test, we use sterilized, individual instruments that are clean and risk-free. The blood will be analyzed using new equipment and the results will be given to you immediately after the blood draw. Results are confidential.
Now, can you tell me if you agree to participate in the anemia test?
46. READ CONSENT STATEMENT TO THE PARENT/RESPONSIBLE ADULT:
CIRCLE CODE AND SIGN.
As part of this survey, we are asking children 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 2011 or later take part in anemia testing in this survey 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. If the test shows that your child has severe anemia, meaning a hemoglobin level below 8g.dl, we will refer him/her to the closest health center for follow up.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to take the anemia test?
CONSENT STATEMENT:
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1995* or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
*For fieldwork beginning in 2001, 2002, or 2003, the year should be 1996, 1997, or 1998 respectively.
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
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.
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
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 2006 or later take part in anemia testing in this survey 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 member of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to take the anemia test?
FOR WOMEN AGES 15-17 WHO HAVE NEVER BEEN IN A UNION, ASK FOR THE CONSENT OF HER PARENT/OTHER ADULT IDENTIFIED IN 707 BEFORE ASKING FOR THE CONSENT OF THE ADOLESCENT HERSELF. CIRCLE CODE 2 IN 708 IF THE PARENT/ADULT REFUSES. ONLY CONDUCT THE TEST IF YOU OBTAINED BOTH CONSENTS, THAT OF THE PARENT/ADULT AND OF THE ADOLESCENT 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. The results of this survey will assist the government to develop programs to prevent and treat anemia.
For the anemia test, we need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than member of our survey team.
Do you have any questions?
You can say yes, or you can say no to the test. It is up to you to decide.
Will you allow (NAME of adolescent) to take the 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.
We ask that all children born in 1994 or later take part in anemia testing in this survey 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 to the test, or you can say no. It is up to you to decide.
408. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
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?
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
We ask you to allow CSA and The Ethiopian Public Health Institute to store part of the blood sample at the laboratory for additional tests such as Hepatitis B or C, Measles, and/or Rubella.
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?
CONSENT STATEMENT:
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1995* or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
*For fieldwork beginning in 2001, 2002, or 2003, the year should be 1996, 1997, or 1998 respectively.
As a 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 anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to test, or you can say no. It is up to you to decide. Will you take the anemia test?
224. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ____________
CONSENT STATEMENT:
As part of this survey, we are studying anemia in women, men, and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 2000 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 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 results told to you right away. The results will be kept strictly confidential.
May I now ask that you (and NAME OF CHILD(REN)) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
310) Ask for 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 each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anemia test?
CODE 'A' NOT CIRCLED
Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?
The blood will be tested for anaemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anaemia test?
342) ASK CONSENT FOR ANAEMIA TEST FROM RESPONDENT.
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia. For the anaemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anaemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anaemia 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.
We request that all children born in 2002 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 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?
(IF REFUSED, GO TO 227).
CONSENT STATEMENT FOR ANEMIA TEST
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 223 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 RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 222) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 223 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH 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.
We request that all children born in 2004 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 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 strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you (allow NAME OF ADOLESCENT to) take the 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.
We ask that all children born in 2007 or later take part in anemia testing in this survey 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 to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD) to participate in the anemia test?
211. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
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. The survey will assist the government to develop programs to prevent and treat anemia.
For 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?
CONSENT STATEMENT:
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1995* or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
*For fieldwork beginning in 2001, 2002, or 2003, the year should be 1996, 1997, or 1998 respectively.
CONSENT STATEMENT FOR ANAEMIA TEST.
As part of this survey, we are asking people all over the country to take an anaemia test.
Anaemia 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 anaemia.
For the anaemia 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 anaemia immediately, and the result told to you right away.
The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you (allow NAME OF ADOLESCENT to) take the anemia test?
As part of this survey, we are asking people all over the country to take an anaemia test. Anaemia 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 anaemia.
For the anaemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anaemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you take the anaemia test?
224) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
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 in developing programs to prevent and treat anemia. For this test, we 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 is confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say 'Yes' to the test, or you can say 'No'. It is your decision.
Now, will you allow (name of adolescent age 15-17 years) to take the anemia test?
CIRCLE THE APPROPRIATE CODE IN QUESTION 212A AND SIGN.
212A. READ ANEMIA TEST CONSENT STATEMENT TO THE PARENT OR ADULT IDENTIFIED IN QUESTION 211. (FOR ADOLESCENTS AGE 15-17 AND NEVER IN UNION):
212B. ASK CONSENT FROM ADULTS/YOUTHS FOR THE 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 in developing programs to prevent and treat anemia.
For this test, we 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 is confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say 'Yes' to the test, or you can say 'No'. It is your decision.
Now, will you agree to take the anemia test?
CIRCLE THE APPROPRIATE CODE IN QUESTION 212C AND SIGN.
212C. READ ANEMIA TEST CONSENT STATEMENT TO ADULT WOMAN AGE 18-49, ADULT MAN AGE 18-59, OR YOUTH:
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 results told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?
219. 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 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 you blood. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF PARENT OR RESPONSIBLE ADULT) right away. The result will be kept strictly confidential and will not be share 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?
238A) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
217) Ask for 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.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you and (name of 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 to the test, or you can say no. It is up to you to decide.
Will you allow (name of minor) to take the anemia test?
218) Circle the appropriate code and sign.
As a 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 anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to test, or you can say no. It is up to you to decide. Will you take the anemia test?
224. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ____________
201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN AGE 0 TO 5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILREN, USE ADDITIONAL QUESTIONNAIRE(S).
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
As part of this survey, we are asking people from 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 2062 or later take part in anemia testing in this survey 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 to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF CHILD/NAMES OF CHILDREN) to participate in the anemia test?
211) CIRCLE THE APPROPRIATE CODE AND SIGN YOU NAME.
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 2068 or later take part in anemia testing in this survey 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. Will you allow (NAME OF CHILD) to participate in the anemia test?
210. ASK CONSENT FOR ANEMIA TEST.
As part of the survey, we are asking people all over the country to take an anemia test. Anemia is a serious health issue 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 test, we will need a few drops of blood from your 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 immediately be tested for anemia, and the results 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?
(54a) CONSENT FOR ANEMIA TESTING
SIGN ________
127) READ CONSENT STATEMENT TO THE WOMEN. CIRCLE CODE (AND SIGN).
SIGN _______
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia. For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test. The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?
CONSENT STATEMENT:
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1995* or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
*For fieldwork beginning in 2001, 2002, or 2003, the year should be 1996, 1997, or 1998 respectively.
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
CONSENT STATEMENT:
As part of this survey, we are studying anemia among women and children. Anemia is a serious health problem that results from poor nutrition. This survey will assist the government to develop programs to prevent and treat anemia.
We request that you (and all children born in 1995* or later) participate in the anemia testing part of this survey and give a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be analyzed with new equipment and the results of the test will be given to you right after the blood is taken. The results will be kept confidential.
May I now ask that you (and NAME OF CHILDREN) participate in the anemia test. However, if you decide not to have the test done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.
*For fieldwork beginning in 2001, 2002, or 2003, the year should be 1996, 1997, or 1998 respectively.
As part of this survey, we are asking people from 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 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.
Will you allow (NAME OF MINOR) to take the anemia test?
HEMOGLOBIN AND VITAMIN A MEASUREMENTS OF CHILDREN BORN IN 1995 OR LATER
READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT **
CIRCLE CODE (AND SIGN)
HEMOGLOBIN MEASUREMENT OF MEN 15-54
READ CONSENT STATEMENT TO WOMAN/PARENT/RESPONSIBLE ADULT **
CIRCLE CODE (AND SIGN)
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
112F) CIRCLE THE CODE AND SIGN YOUR NAME.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?
222) CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
As part of this survey, we are trying to find out more about anaemia, that is, low blood levels, in men, women, and children.
To know more about this problem in Zimbabwe, we are asking people in this survey all over the country to take a test. For the test, I will take a few drops of blood from your finger.
The test uses clean and completely safe equipment that is used only once and then thrown away. The blood will be tested with new equipment. The result will be given to you right after the test is done. We will not tell anyone else the results of the test.
Do you have any questions?
You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of anaemia.
Do you agree to give blood for the anaemia test?
CIRCLE CODE AND SIGN.
FURTHER DISCUSS ANAEMIA TESTING PROCESS TO PUT RESPONDENT AT EASE.
As a 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 government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used to take the blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide. Will you allow (NAME IF ADOLESCENT) to take the anemia test?
222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.
(SIGN) ___________
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.