| QNo. | Questions and Instructions | Response | Code | ||
| 1 | Study ID Number |
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| 2 | What is the sex of the child Circle the correct answer | Male | 1 | ||
| Female | 2 | ||||
| 3 | What is the age of the patient? |
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| 4 | Child’s education | Nursery school | 1 | ||
| Primary school (what grade? | 2 | ||||
| Secondary School (what level form one-four) | 3 | ||||
| Position (performance in the class) |
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| Number of days missed school in this term |
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| 5 | What is the ethnic background of the mother? |
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| 6 | What is the ethnic background of the father? |
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| 7 | Residence a) Distance to BMC (average in KM) b) Money spent on transport to BMC-TSHS c) Average amount of money spent on clinic per day d) Money spent on last admission |
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| 8 | What is the relationship of the caretaker to the patient? | Parent Grandparents Other (specify) | 1 2 3 | ||
| 9 | What is the level of education of the caretaker? | Never went to school Complete primary school Incomplete primary school Secondary (form one-four) Secondary (form five-six) University/college | 1 2 3 4 5 6 | ||
| 10 | What is the employment status of the parents/caretaker? | Peasant Teacher Carpenter Nurse Doctor Self-employed Unemployed Others (specify) | 1 2 3 4 5 6 7 8 | ||
| 11 | What is the Marital status of the parent/caretaker? | Married Single Divorced Others (specify) | 1 2 3 4 | ||
| 12 | Is there a sibling or family member with SCD? | Yes Confirmed Not Confirmed No | 1
2 | ||
| 13 | Is there a family member who has done Sickling test? | Positive Negative | 1 2 | ||