Houshold #
Household member
DataFax Study Number
DataFax Plate Number
Visit Code
Visit Date(mm)
Visit Date(dd)
Visit Date(yy)
Visit Date
Staff ID
Team ID
1. Reason not participate
2. Don't have time
2. Know I'm HIV positive
2.Don't wish to be tested
2.No draw/take blood away
2. Find topic uncomfrtble
2. Partner not allow it
2. Parent not allow it
2. Test away from home
2. Test without partner
2. Breach of confident
2. Other, specify
2. Other, specify text