Universal ID
Houshold #
Household member
DataFax Study Number
DataFax Plate Number
Visit Code
Enrollment Date(mm)
Enrollment Date(dd)
Enrollment Date(yy)
Enrollment Date
Staff ID
Team ID
1. Participant's sex
2. Age at last birthday
3.Highest level of school
3a.Highest grade complete
3a. DK/REF
4. Employment status
4. Other, specify text
5. Currently married
6.Husband/wife livng with
7. Currently pregnant
8. Age first sex.intercse
8. Never had sex/REF
9.How many people sex 6mo
9. REF
10. How often use condom
11. Partner 1 name REF
12. Prtr 1 Mo/Yr began
12.Prtr 1 Mo/Yr began REF
13. Prtr 1 Mo/Yr ended
13.Prtr 1 Mo/Yr ended REF
14. Partner 1 sex
No 2nd partner
11. Partner 2 name REF
12. Prtr 2 Mo/Yr began
12.Prtr 2 Mo/Yr began REF
13. Prtr 2 Mo/Yr ended
13.Prtr 2 Mo/Yr ended REF
14. Partner 2 sex
No 3rd partner
11. Partner 3 name REF
12. Prtr 3 Mo/Yr began
12.Prtr 3 Mo/Yr began REF
13. Prtr 3 Mo/Yr ended
13.Prtr 3 Mo/Yr ended REF
14. Partner 3 sex
14a.Prtr 1 circumcised?
15. Prtr 1 age first sex
15.Prtr 1 age 1st sex REF
14a.Prtr 2 circumcised?
15. Prtr 2 age first sex
15.Prtr 2 age 1st sex REF
14a.Prtr 3 circumcised?
15. Prtr 3 age first sex
15.Prtr 3 age 1st sex REF
16.Prtr 1:spse/reg/casual
17. Prtr 1: num days/sex
18. Condom use w/Prtr 1
16.Prtr 2:spse/reg/casual
17. Prtr 2: num days/sex
18. Condom use w/Prtr 2
16.Prtr 3:spse/reg/casual
17. Prtr 3: num days/sex
18. Condom use w/Prtr 3
19. Partner 1 money/gifts
20.Prtnr 1 vag sex 6 mo.
21.Prtnr 1 condom/vaginal
22.Prtnr 1 anal sex 6 mo.
23.Prtnr 1 condom/anal
19. Partner 2 money/gifts
20.Prtnr 2 vag sex 6 mo.
21.Prtnr 2 condom/vaginal
22.Prtnr 2 anal sex 6 mo.
23.Prtnr 2 condom/anal
19. Partner 3 money/gifts
20.Prtnr 3 vag sex 6 mo.
21.Prtnr 3 condom/vaginal
22.Prtnr 3 anal sex 6 mo.
23.Prtnr 3 condom/anal
24. Male prtnr 1 anal sex
25.Male Prtnr 1 w/condom
24. Male prtnr 2 anal sex
25.Male Prtnr 2 w/condom
24. Male prtnr 3 anal sex
25.Male Prtnr 3 w/condom
26.Male prtnr 1 HIV pos?
27.Male prtnr 1 takng ART
26.Male prtnr 2 HIV pos?
27.Male prtnr 2 takng ART
26.Male prtnr 3 HIV pos?
27.Male prtnr 3 takng ART
28.Ever been tested?
29.How many times tested?
29.Times tested-REF
30.Date last HIV test
30.Date last test-REF
31.Get result HIV test
32. Afraid to know result
32. Provider not give res
32. Need partner permissn
32. Test with partner
32. Not have time to wait
32. Other, specify
Other, specify text
33.Ask result of HIV test
34.Doctor told take ART
35.Currently taking ART
36a.test to know status
36a.Source-billboard
36a.Source-Radio
36a.Source-television
36a.Source-comm. group
36a.Source-healthcare prv
36a.Source-religious lead
36a.Source-friend
36a.Source-family member
36a.Source-other
36b.Reduce no. of prtnrs
36b.Source-billboard
36b.Source-Radio
36b.Source-television
36b.Source-comm. group
36b.Source-healthcare prv
36b.Source-religious lead
36b.Source-friend
36b.Source-family member
36b.Source-other
36c.Use condom every time
36c.Source-billboard
36c.Source-Radio
36c.Source-television
36c.Source-comm. group
36c.Source-healthcare prv
36c.Source-religious lead
36c.Source-friend
36c.Source-family member
36c.Source-other
36d.Male circumcision
36d.Source-billboard
36d.Source-Radio
36d.Source-television
36d.Source-comm. group
36d.Source-healthcare prv
36d.Source-religious lead
36d.Source-friend
36d.Source-family member
36d.Source-other
36e.ART is available
36e.Source-billboard
36e.Source-Radio
36e.Source-television
36e.Source-comm. group
36e.Source-healthcare prv
36e.Source-religious lead
36e.Source-friend
36e.Source-family member
36e.Source-other
36f. Pregnant women test
36f.Source-billboard
36f.Source-Radio
36f.Source-television
36f.Source-comm. group
36f.Source-healthcare prv
36f.Source-religious lead
36f.Source-friend
36f.Source-family member
36f.Source-other
36g. ART prev. transmissn
36g.Source-billboard
36g.Source-Radio
36g.Source-television
36g.Source-comm. group
36g.Source-healthcare prv
36g.Source-religious lead
36g.Source-friend
36g.Source-family member
36g.Source-other
36h. Other, specify
36h. Other, specify text
36h.Source-billboard
36h.Source-Radio
36h.Source-television
36h.Source-comm. group
36h.Source-healthcare prv
36h.Source-religious lead
36h.Source-friend
36h.Source-family member
36h.Source-other
37. Circumcision status
38.When circumcised
38. When circumcised-REF