 | Looking Deeper into the HIV Epidemic: A questionnaire for Tracing Sexual Networks (Joint United Nations Programme on HIV/AIDS, 1998, 24 p.) |
 |  | Appendix - Multi-site study : questionnaire I - Men and Women |
|
|
Part A: Household form
|
HOUSEHOLD IDENTIFICATION | ||||
|
001 |
City name |
________________________________ | ||
|
002 |
Cluster Number |
________________________________ | ||
|
003 |
Household/Dwelling number |
________________________________ | ||
|
004 |
INTERVIEW VISITS | | ||
| | |
Visit 1 |
Visit 2 |
Visit 3 |
| |
Date |
________ |
_________ |
________ |
| |
Interviewer |
________ |
_________ |
________ |
| |
Result* |
________ |
_________ |
________ |
| |
Result codes* | | | |
| |
Completed |
1 | | |
| |
No one at home |
2 | | |
| |
Refused |
3 | | |
| |
Household away for duration of survey |
4 | | |
| |
Dwelling vacant or address not a household |
5 | | |
| |
Dwelling not found |
6 | | |
| |
Postponed |
7 | | |
| |
Other (Specify) |
8 |
-------------------------------- | |
|
005 |
ID NO. |
________________________________ | ||
| |
Facilities Available in the Cluster | |
| |
| |
All -Weather Road |
|
Yes |
No |
| |
Health centre/hospital | |
Yes |
No |
| |
Trading centre (market) | |
Yes |
No |
| |
Electricity |
|
Yes |
No |
| |
Running Water |
|
Yes |
No |
| |
Hotel/Bar/Boarding house | |
Yes |
No |
HOUSEHOLD MEMBERS FORM
Enquire about anyone else aged 15 years or over (including non-family members) who slept in the household last day or night (e.g. servants, lodgers).
|
"Now I would like some information about the persons aged 15 years or over who usually live in this household. First what is the given name of the head of household?" [Record in line 01] |
|
Initials of first name |
Relationship |
From line __ & line __ |
Sex |
Age |
Slept here last day or night |
Eligibility Aged (15-49 who slept there) | ||
| | |
|
M |
F | |
Y |
N | |
|
Usual household members | ||||||||
|
01 Head |
___________ |
____&____ | | |
____ | | |
_________ |
|
02 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
03 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
04 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
05 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
06 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
07 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
08 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
09 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
10 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
11 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
12 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
| |
| | |
| | |
| |
| | |
| | |
| | |
|
|
| | |
| | |
| | |
| |
| | |
| | |
| |
| | |
| | |
| | |
|
|
| | |
| | |
| | |
| |
| | |
| | |
| |
| | |
| | |
| | |
|
|
| | |
| | |
| | |
| |
| | |
| | |
| |
|
All others | |
| | | | | | |
|
21 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
22 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
|
23 ______ |
___________ |
____&____ | | |
____ | | |
_________ |
| |
| | |
| | |
| |
| | |
| | |
| | |
|
|
|