THE NATIONAL INSTITUTE OF HEALTH & FAMILY WELFARE, NEW DELHI

Mid-term evaluation of NACP Phase-V

Interview Schedule for Community member

CONSENT TO PARTICIPATE IN INTERVIEW

CONSENT TO PARTICIPATE IN INTERVIEW

INTERVIEWER- Read Out: Namaskar. My Name is (Please say your name here). On behalf of Govt of India I
am I am asked, to conduct mid-term evaluation of NACP Phase-V. We will be asking you questions
related to HIV/AIDS. The respondents should be in the age group of 15 years to 49 years. There is no
compulsion to reply. You may withdraw any moment from reply. We would appreciate your participation in this
survey. The information collected would be kept confidential. The survey would take a short time to complete.
Oral consent given (Circle one) YES – Continue No – Stop the survey

Schedule No.

Note for Coding: Answer and Coding for each question is must before handing over to NIHFW In charge.
After asking a particular question, if next questions are not relevant/applicable do not ask question and give code
88 in the question. If respondent is unable to reply give code 99. Your filled schedule will be re-examined by the
NIHFW team.

Sl.No. Questions Responses (please encircle) Skip

1.1 Name and Address of Respondent

1.2 Age (in years)

1.3 Sex Male………………………………….1
Female……………………………….2
1.4 Age at Marriage ( in years)
1.5 Place of Residence Rural………………………………….1
Urban………………………………...2
1.6 Education Illiterate………………………………0
Just Literate………………………....1
Primary………………………………………….2
Middle………………………………...3
High School………………………….4
Intermediate…………………………5
Graduate……………………………..6
Post Graduate……………………….7
Others (Specify)…………………….9
1.7 Occupation Unemployed…...……………………0
 Housewife……………………………1
Full time students…………………...2
Agricultural Labor…………………...3
Govt. / Pvt. job…………………...... 4
Industrial/Skilled worker…..………..5
Self employed………………………..6
Business……………………………..7
Petty Shop…….……………………..8
Others (Specify)………………….....9
1.8 Type of Family Nuclear Family……………………….1
Joint Family…………………………..2
1.9 Religion Hinduism………………………………1
Islam…………………………………..2
Christianity……………………………3
Buddhism……………………………..4
Jainism………………………………..5
Sikh……………………………………6
Other(specify)………………………...9

Community Member Profile

1. Name

2. Address

3. Sex Male -1, Female-2

4. Educational Status Illiterate-01. Literate-

02 Primary -03
Upper Primary-04
High School-05
Inter(10+2)-06
Graduate-07 Post
graduate-08 Above
Post Graduate-09,
No Response-10

Awareness & Prevention (Pl probe before writing Yes/No)

5. Have you heard about HIV Yes-01 No-02
6. Do you know how HIV/AIDS spreads? Yes-01 No-02
7. How it spreads? Probe Yea-1/No-2
8. Can HIV/AIDS be prevented by using protection (safe Yes-01 No-02
sex) ?
9. Do you know where to get an HIV test? ( Pl probe about Yes-01 No-02
ICTC etc)
10. Is HIV/AIDS transmitted through casual (explain) contact? Yes-01 No-02
 11. From where you got the information about HIV? Radio / TV / News
Paper / Health care
worker/ Relative /
teacher
12. Are you aware about HIV/AIDS Control programme> Yes-1/No-2
13. Are you aware about High Risk Group for HIV Infection Yes-1/No-2
14. If Yes Truck Drivers-1,
CSW-2, IVDU-3,
Migrant Workers-
4, Prisioners-5
Any Other-6
15. Can HIV spread from mother to child during Yes-1/N0-2/Do Not
pregnancy/birth Know-3
16. If Yes, What services are provide under the prograee Counselling1/
Screening-2/
Testing-3/
Treatmet-4
17. Are you aware about any person having HIV/AIDS Yes-1/No-2

18. If Yes, is he getting treatment from Government Hospital Yes-1/No-2

Testing & Treatment

19. Have you ever taken an HIV test? Yes-01 No-02
20. Do you know HIV testing is free at government centers? Yes-01 No-02
21. Is free HIV treatment (ART) available at government Yes-01 No-02
hospitals? Probe person knows
22. Can early HIV detection improve life expectancy? Yes-01 No-02
23. Are you aware about Co-infections/health issues due to Yes-1/No-2
HIV/AIDS? (Probe TB, Fungual Infection, Frequent
Diarrhoea, Weight loss etc)
24. Do you feel that government is doing enough to contain Yes-1/No-2/Do Not
HIV/AIDS inspection in society Know-3
25. If Not, what are your suggestions
26. What is your opinion about HIV/AIDS in society Increasing-1/
Decreasing-2/Do
 Not Know-3

Stigma & Discrimination

27. Would you like to work or study with an HIV-positive Yes-01 No-02
person?
28. Should HIV-positive individuals get equal job Yes-01 No-02
opportunities?
29. Are you aware of laws protecting HIV-positive people? Yes-01 No-02
(Probe)
30. Are you aware about any type of discrimination faced by Yes-1/No-2
HIV positive person in society?
31. If Yes, pl specify Termination of job-
1, Separation from
Friend-2, Family
Isolation-3,
Discrimination by
health staff-4,
Others(Specify)

Prevention in High-Risk Groups

32. Should HIV/AIDS education be mandatory in schools? Yes-01 No-02
33. Can HIV spread through unsterilized needles and unsafe Yes-01 No-02
blood transfusions?
34. Can an HIV-positive mother pass the virus to her baby? Yes-01 No-02
35. Do government centres provide free condoms and Yes-01 No-02
syringes for HIV prevention?
Government Initiatives & Awareness
36. Have you seen or heard an HIV/AIDS awareness campaign Yes-01 No-02
recently?
37. If Yes, Source of Information. Radio-1/TV-2/
News Paper-3/Bill
Board and Banner-
4/Health
Staff-5/NGO Staff-
6/Any Other
(Specify)-7
NA-8
38. Should the government increase HIV/AIDS awareness Yes-01 No-02
through TV, radio, and social media?
39. Which is the most effective medium for increasing Radio-1/TV-2/
awareness regarding HIV/AIDS (Pl probe) News Paper-3/Bill
Board and Banner-
 4/Health
Staff-5/NGO Staff-
6/Any Other
(Specify)-7
40. Do you support government programs for HIV/AIDS Yes-01 No-02
awareness?
41. Are you aware of India’s HIV/AIDS helpline? Yes-01 No-02

Date Name and Signature of interviewer