BIGPIC Social Network Survey

Demographics

AMRS ID Number:

Family Name:

Given Name:

Middle Name:

Gender:

Date Of Birth:

Encounter Details

AMPATH Facility: *

Name of Interviewer: *

Interviewer ID:*

Interview Date:*

SECTION A - PARTICIPANT INFORMATION

Enter Participant ID:*

BIGPIC Group ID:*

SECTION B - IMPORTANT MATTERS

Please provide the following information of up to 5 people you talk to most frequently about important matters.

Person 1

Name of person: *

How do you know ? *

Specify Other: *

Is Male or Female? *

How long have you known him/her?

Years: *

Months: *

How often do you speak with him/her? *

Please indicate which groups or organization you participate in together (select all that apply). *

Church

Work

Club

GMV

Microfinance

Other

Specify other group: *

None

SECTION C - HEALTH MATTERS

Please provide the following information of up to 5 people you talk to most frequently about health matters.

Person 1

Name of person: *

How do you know ? *

Specify Other: *

Is Male or Female? *

How long have you known him/her?

Years: *

Months: *

How often do you speak with him/her? *

Please indicate which groups or organization you participate in together (select all that apply). *

Church

Work

Club

GMV

Microfinance

Other

Specify other group: *

None

SECTION D - MICROFINANCE GROUP

Do you belong a microfinance group? *

For microfinance group you spend the most time with, please list the names of up to 7 people in this group you talk to most often.

Person 1

First and Last Name: *

Do you talk to this person outside of group meetings? *

On a scale from 1 to 4, how close do you feel to this person? *

On average, how often do you talk to this person about health-matters? *

In my microfinance group, I...

I feel a sense of belonging to my group: *

I feel that I am a member of my group: *

I see myself as part of my group: *

I am enthusiastic about my group: *

I am happy to be in my group: *

My group is one of the best microfinance programs anywhere: *

SECTION E - GROUP MEDICAL VISIT GROUP

Do you belong a group medical visit group? *

For group medical visit group you spend the most time with, please list the names of up to 7 people in this group you talk to most often.

Person 1

First and Last Name: *

Do you talk to this person outside of group meetings? *

On a scale from 1 to 4, how close do you feel to this person? *

On average, how often do you talk to this person about health-matters? *

In my group medical visit group, I...

I feel a sense of belonging to my group: *

I feel that I am a member of my group: *

I see myself as part of my group: *

I am enthusiastic about my group: *

I am happy to be in my group: *

My group is one of the best microfinance programs anywhere: *

SECTION F - CLUBS, GROUPS, CHURCHES

Do you belong any clubs, groups, or churches? *

Please specify which club/group/church: *

For club/group/church you spend the most time with, please list the names of up to 7 people in this group you talk to most often.

Person 1

First and Last Name: *

Do you talk to this person outside of group meetings? *

On a scale from 1 to 4, how close do you feel to this person? *

On average, how often do you talk to this person about health-matters? *

In this club/group/church, I...

I feel a sense of belonging to my group: *

I feel that I am a member of my group: *

I see myself as part of my group: *

I am enthusiastic about my group: *

I am happy to be in my group: *

My group is one of the best programs anywhere: *