[NAME OF COUNTRY]
[NAME OF ORGANIZATION]

IDENTIFICATION (1)

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________

(1) This section should be adapted for country-specific survey design.

INTERVIEWER VISITS

FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________

NEXT VISIT:
DATE ______
TIME ______

FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __

TOTAL NUMBER OF VISITS: __

*RESULT CODES:

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH

**LANGUAGE CODES

SUPERVISOR
NAME ______
NUMBER __ __ __ __

FIELD EDITOR
NAME ______
NUMBER __ __ __ __

OFFICE EDITOR
NUMBER __ __

KEYED BY
NUMBER __ __

SECTION MC. MALE CHILD CIRCUMCISION

MC01. CHECK 213 AND 215:

MC02. CHECK 213 AND 215: FOR EACH MALE BORN IN 2010-2015, RECORD THE BIRTH HISTORY NUMBER IN MC03 AND THE NAME AND SURVIVAL STATUS IN MC04. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST MALE BIRTH. IF THERE ARE MORE THAN 2 MALE BIRTHS, USE ADDITIONAL QUESTIONNAIRE(S). Now I would like to ask some questions about your male children born since January 2010. (We will talk about each separately.)

MC03. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY.

MC04. FROM 212 AND 2016:

MC05. CHECK MC04: (1)

LIVING:
a) Some males are circumcised, that is, the foreskin is completely removed from the penis. Is (NAME) circumcised?

DEAD:
b) Some males are circumcised, that is, the foreskin is completely removed from the penis. Was (NAME) circumcised?

(1) Translation of circumcision should indicate removal of the foreskin and not merely coming of age ceremonies.

MC06. How old was (NAME) when he got circumcised? IF RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE. RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO

MC07. Who did the circumcision?

MC08. Where was it done?

MC09. Were there any complications?

MC10. What was the complication? Any other complications?

MC11. How much money was spent for the circumcision?

MC12. GO BACK TO MC05 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO NEXT SECTION.

Note: Recommended placement of Male Child Circumcision module: between Section 6 (Child Health and Nutrition) and Section 7 (Fertility Preferences). Insert and renumber questionnaire sections accordingly.