[NAME OF COUNTRY]
[NAME OF ORGANIZATION]

IDENTIFICATION

PLACE NAME______

CLUSTER NUMBER____

HOUSEHOLD NUMBER___

REGION______

URBAN/RURAL

LINE NUMBER OF WOMAN___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE_____
INTERVIEWER'S NAME_______
RESULT______

RESULT ____

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______
INTERVIEWER'S NAME____
RESULT____

TOTAL NUMBER OF VISITS___

FIELD EDITED BY
NAME_____
DATE______

OFFICE EDITED BY
NAME______
DATE______

KEYED BY
NAME______
DATE______

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE NUMBER OF PEOPLE LISTED IN THE HOUSEHOLD SCHEDULE.

102. RECORD THE NUMBER OF CHILDREN AGED 5 AND UNDER LISTED IN THE HOUSEHOLD SCHEDULE WHO NORMALLY LIVE IN THE HOUSEHOLD.

103. RECORD THE TIME.

104. First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in the countryside, in a town, or in a city?

105. How long have you been living continuously in (NAME OF VILLAGE, TOWN, CITY)?

106. Just before you moved here, did you live in the countryside, in a town, or in a city?

107. In what month and year were you born?

108. How old were you at your last birthday?
COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT.

109. Have you ever attended school?

110. What was the highest level of school you attended: primary, secondary, or higher?

111. What was the highest (GRADE, FORM, YEAR) you completed at that level?

112. CHECK 110:

113. Can you read a letter or newspaper easily, with difficulty, or not at all?

114. Do you usually read a newspaper or magazine at least once a week?

115. Do you usually watch television every week?

116. Do you usually listen to a radio every day?

117. What is the major source of drinking water for members of your household?

118. What is the major source of water for household use other than drinking (e.g., handwashing, cooking) for members of your household?

119. How long does it take to go there, get water, and come back?

120. What kind of toilet facility does your household have?

121. Do you have, right now, a cake of soap on the premises?

122. Does your house have:

123. Does any member of your household own:

124. MAIN MATERIAL OF THE FLOOR.
(RECORD OBSERVATION.)

130. COUNTRY-SPECIFIC QUESTION ON RELIGION.

140. COUNTRY-SPECIFIC QUESTION ON ETHNICITY.

SECTION 2. REPRODUCTION

201. Now I would like to ask about all the births you have had during your life. Have you ever given birth?

202. Do you have any sons or daughters you have given birth to who are now living with you?

203. How many sons live with you? And how many daughters live with you?
IF NONE ENTER '00'.

204. Do you have any sons or daughters you have given birth to who are alive but do not live with you?

205. How many sons are alive but do not live with you? And how many daughters are alive but do not live with you?
IF NONE ENTER '00'.

206. Have you ever given birth to a boy or a girl who was born alive but later died?
IF NO, PROBE: Any (other) boy or girl who cried or showed any sign of life but only survived a few hours or days?

207. How many boys have died? And how many girls have died?
IF NONE ENTER '00'.

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE ENTER '00'.

209. CHECK 208:
Just to make sure that I have this right: you have had in TOTAL ______ live births during your life. Is that correct?

210. CHECK 208:

211. Now I would like to talk to you about all of your births, whether still alive or not, starting with the first one you had. (RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS ON SEPARATE LINES AND MARK WITH A BRACKET.)

212. What name was given to your (first, next) baby?

213. Is (NAME) a boy or a girl?

214. In what month and year was (NAME) born?
PROBE: What is his/her birthday? OR: In what season?

215. Is (NAME) still alive?

216. IF DEAD: How old was (NAME) when he/she died?
RECORD DAYS IF LESS THAN ONE MONTH, MONTHS IF LESS THAN TWO YEARS, OR YEARS.

217. IF ALIVE: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

218. IF ALIVE: Is he/she living with you?

219. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

220. Was your last child born by caesarean section?

221. Are you pregnant now?

222. For how many months have you been pregnant?

223. Since you have been pregnant, have you been given any injection to prevent the baby from getting tetanus, that is, convulsions after birth?

223A. How many injections did you receive?

223B. Where did you go to get the (last) injection?

224. Did you see anyone for a check on this pregnancy?

225. Whom did you see?
PROBE FOR TYPE OF PERSON AND RECORD MOST QUALIFIED.

226. How long ago did your last menstrual period start?

227. When during her monthly cycle do you think a woman has the greatest chance of becoming pregnant?
PROBE: What are the days during the month when a woman has to be careful to avoid becoming pregnant?

228. PRESENCE OF OTHERS AT THIS POINT.

SECTION 3: CONTRACEPTION

301. Now I would like to talk about a different topic. There are various ways or methods that a couple can use to delay or avoid a pregnancy. Which of these ways or methods have you heard about?

CIRCLE CODE '1' IN 302 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN THE COLUMN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '2' IF METHOD IS RECOGNIZED AND CODE '3' IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE '1' OR '2' CIRCLED IN 302, ASK 303-305 BEFORE PROCEEDING TO THE NEXT METHOD.

302. Have you ever heard of (METHOD)?
READ DESCRIPTION.

303. Have you ever used (METHOD)?

304. Where would you go to obtain (METHOD) if you wanted to use it?

305. In your opinion, what is the main problem, if any, with using (METHOD)?

306. CHECK 303:

307. Have you ever used anything or tried in any way to delay or avoid getting pregnant?
MARK THE APPROPRIATE RESPONSE.

308. What have you used or done?
CORRECT 302-303 AND OBTAIN INFORMATION FOR 304 TO 306 AS NECESSARY.

309. CHECK 303:

310. The last time you used periodic abstinence, how did you determine on which days you had to abstain?

311. How many living children, if any, did you have when you first did something or used a method to avoid getting pregnant?
IF NONE ENTER '00'.

312. CHECK 221:

312A. CHECK 303:

313. Are you currently doing something or using any method to avoid getting pregnant?

314. Which method are you using?
314A. CIRCLE '06' FOR 'FEMALE STERILIZATION'.

315. Please show me the package of pills you are now using.
(RECORD NAME OF BRAND.)

316. How much does one packet (cycle) of pills cost you?

317. In what month and year did you (he) have the operation?

318. Have you visited a hospital, a health center, a clinic, a doctor, or a field worker to obtain a method to avoid pregnancy or instruction for using periodic abstinence in the last twelve months?

319. Where did you visit to obtain the method (or instructions)?
319A. Where did the sterilization take place?
319B. Where did you obtain the method (or instructions)?

320. Was there anything you particularly disliked about the services you received there?
IF YES: What?

321. CHECK 221:

322. CHECK 313, 314:

323. For how long have you been using (CURRENT METHOD) continuously?

324. Have you experienced any problems from using (CURRENT METHOD)?

325. What is the main problem you experienced?

325A. CHECK 314:

326. At any time during the same month, do you regularly use any method other than (CURRENT METHOD)?

327. Which method is that?

328. Have you ever used any other method or done anything else (since your last birth) before (CURRENT METHOD) to avoid getting pregnant?

329. Which method did you use before (CURRENT METHOD)?

330. In what month and year did you start using (METHOD BEFORE CURRENT) (the last time)?

331. For how long had you been using (METHOD BEFORE CURRENT) before you stopped using it (last time)?

332. What was the main reason you stopped using (METHOD BEFORE CURRENT) then?

333. CHECK 208:
ANY BIRTHS?

334. Since your last birth have you done anything or used any method to avoid getting pregnant?

335. Which was the last method you used?

336. In what month and year did you start using that method (last time)?

337. For how long had you been using (LAST METHOD) before you stopped using it (last time)?

338. What was the main reason you stopped using (LAST METHOD) then?

339. Do you intend to use a method to avoid pregnancy at any time in the future?

340. Which method would you prefer to use?

341. Do you intend to use (PREFERRED METHOD) in the next 12 months?

342. In the last month, have you heard a message about family planning on the radio?

343. Did you hear it once or more than once?

344. Is it acceptable or not acceptable to you for family planning information to be provided on radio or television?

345. COUNTRY-SPECIFIC QUESTIONS ON FAMILY PLANNING MESSAGES ON TELEVISION.

346. CHECK 221:

346A. CHECK 214:

347. Now I would like to get some more information about (your pregnancy and) the children you had in the last 5 years.
CHECK WHETHER PREGNANT AND RECORD NAMES OF BIRTHS SINCE JANUARY 1982. THEN ENTER EVER USE OF CONTRACEPTION. ASK QUESTIONS ABOUT ALL THESE BIRTHS.

CURRENTLY PREGNANT?

348. CHECK 306:

349. Before you became pregnant (with NAME) (but after PRECEDING BIRTH) (IF ANY), had you done anything or used any method, even for a short time, to avoid getting pregnant?

350. What was the last method you used then?

351. Did you use any method before that?
IF YES: What?
RECORD CODE. IF NONE, '00'.

352. For how long had you used (LAST METHOD) then?

353. Did you become pregnant while you were using (LAST METHOD)?

354. What was the main reason you stopped using (LAST METHOD)?

355. At the time you became pregnant (with NAME), did you want to have that child then, did you want to wait until later, or did you want no (more) children at all?

356. Did you want to have that child but at a later time, or not have another child at all?

SECTION 4. HEALTH AND BREASTFEEDING

401. CHECK 214:

402. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1982 IN THE TABLE. BEGIN WITH THE LAST BIRTH. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS.

403. When you were pregnant with (NAME) were you given any injection to prevent the baby from getting tetanus, that is, convulsions after birth?

404. When you were pregnant with (NAME), did you see anyone for a check on this pregnancy?
IF YES: Whom did you see?
PROBE FOR THE PERSON AND RECORD THE MOST QUALIFIED.

405. Who assisted with the delivery of (NAME)?

406. Did you ever feed (NAME) at the breast?

406A. Why did you never feed (NAME) at the breast?

407. Are you still breastfeeding (NAME)?
(IF DEAD, CIRCLE '2'.)
[FOR LAST BIRTH ONLY]

408. How many months did you breastfeed (NAME)?

408A. Why did you stop breastfeeding (NAME)?

409. How many months after the birth of (NAME) did your period return?

410. Have you resumed sexual relations since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

411. How many months after the birth of (NAME) did you resume sexual relations?

412. CHECK 407 FOR LAST BIRTH:

413. How many times did you breastfeed last night between sundown and sunrise?

414. How many times did you breastfeed yesterday during the daylight hours?

415. At any time yesterday or last night, was (NAME OF LAST CHILD) given any of the following?

416. CHECK 415:

417. Were any of these given in a bottle with a nipple?

418. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1982 BELOW. BEGIN WITH THE LAST BIRTH. THE HEADINGS IN THE TABLE SHOULD BE EXACTLY THE SAME AS THOSE AFTER Q. 402. ASK THE QUESTIONS ONLY FOR LIVING CHILDREN.

419. Do you have a health card for (NAME)?
IF YES: May I see it, please?

420. RECORD DATES OF IMMUNIZATIONS FROM HEALTH CARD.

421. Has (NAME) ever had a vaccination to prevent him/her from getting diseases?

422. Has (NAME) had diarrhea in the last 24 hours?

423. Has (NAME) had diarrhea in the last two weeks?

423A. Now I have some questions about (NAME's) last episode of diarrhea. How many days ago did the diarrhea start?

423B. CHECK 407:
LAST CHILD STILL BREASTFED?
[FOR LAST BIRTH ONLY]

423C. Did you breastfeed (NAME) when he/she had diarrhea then?

423D. When (NAME) had diarrhea then, was he/she given more, less, or the same amount to drink as before the diarrhea?

423E. Was (NAME) given either a home solution of sugar, salt, and water to drink, or a solution made from a special packet?
IF YES: Which?

423F. The last time (NAME) was given (home solution/special packet), did he/she get better, worse, or was there no change?

423G. How much of the (home solution/special packet) was (NAME) given every 24 hours?

423H. For how many days was (NAME) given (home solution/special packet)?

423I. Was (NAME) given more, less, or the same amount of solid food as was given before he/she had diarrhea?

RESPONSE SET FOR LAST BIRTH:

RESPONSE SET FOR ALL OTHER BIRTHS:

424. Was (NAME) taken to a private doctor, a hospital or clinic, a traditional doctor, or any other place during the last episode of diarrhea?
IF YES: Where was he/she taken (the last time)?

425. What treatments did (NAME) receive there (the last time)?
CIRCLE ALL TREATMENTS MENTIONED.

425A. Why was (NAME) not taken somewhere for treatment during the last episode of diarrhea?

426. CHECK 423E:

426A. Where did you learn how to prepare the sugar, salt and water solution given to (NAME)?

427. Have you ever heard of a special product called (LOCAL NAME) you can get for the treatment of diarrhea?

428. Have you ever seen a packet like this before?
(SHOW PACKET.)

429. Do you think this packet is used to cure the diarrhea, or that it is used to prevent the child from drying out?

430. Have you ever prepared one of these packets for yourself or for someone else?

431. How much water did you use to prepare the packet (the last time)?

432. Did you use boiled water, bottled water, or other water to prepare the packet (the last time)?

433. In what kind of container did you prepare the mixture of the packet and the water?

434. Did you prepare a new mixture every day or did you use the same mixture for more than one day?

435. Where can you get these packets?
PROBE: Anywhere else?
CIRCLE ALL PLACES MENTIONED.

436. How much do (you think) the packets cost?

437. Do you have one of these packets in your house now?

438. Can I see the packet?

439. Which places can you go if you want to get a vaccination for a child?
CIRCLE ALL PLACES MENTIONED.

SECTION 5. MARRIAGE

501. Have you ever been married or lived with a man?

502. Are you now married or living with a man, or are you widowed, divorced or not now living together?

503. Have you been married or lived with a man only once, or more than once?

504. In what month and year did you start living with your (first) husband or partner?

505. How old were you when you started living with him?

506. Are your mother and father still alive?

507. Are your (first) husband's/partner's mother and father still alive?

508. CHECK 506 AND 507:

509. Was (MENTION PARENTS NOT ALIVE NOW OR DON'T KNOW) alive at the time you began living together with your (first) husband or partner?

510. CHECK 509:

511. At the time you began living together, did you and your (first) husband/partner live with any of these parents for at least six months?

512. For about how many years did you live together with a parent at that time?

513. Are you now living either with your parents or your husband's parents?

514. In how many localities have you lived for six months or more since you were first married (started living together) including this place?

515. Have you ever had sexual intercourse?

516. Now we need some details about your sexual activity in order to get a better understanding of contraception and fertility. How old were you when you first had sexual intercourse?

517. Have you had sexual intercourse in the last four weeks?

518. How many times?

519. When was the last time you had sexual intercourse?

520. CHECK 221:

521. CHECK 313 AND 314:

522. If you became pregnant in the next few weeks, would you feel happy, unhappy, or would it not matter very much?

523. What is the main reason that you are not using a method to avoid pregnancy?

524. PRESENCE OF OTHERS AT THIS POINT.

SECTION 6. FERTILITY PREFERENCES

601. CHECK 314:

602. CHECK 502:

603. CHECK 221 AND MARK BOX:

NOT PREGNANT OR UNSURE: Now I have some questions about the future. Would you like to have a (another) child or would you prefer not to have (any) more children?

PREGNANT: Now I have some questions about the future. After the child you are expecting, would you like to have another child or would you prefer not to have any (more) children?

604. Would you say that you definitely do not want to have (more) children, or are you not sure?

605. Are you more inclined toward having a (another) child or toward not having a (another) child?

606. Would you say that you definitely want a (another) child, or are you not sure?

607. How long would you like to wait from now before the birth of a (another) child?

608. CHECK 215:
How old would your youngest child be?
IF NO LIVING CHILDREN, CIRCLE '96'.

609. Do you regret that you (your husband) had the operation not to have any children?

610. Would you like to have another child or would you prefer not to have any more children?

611. CHECK 202 AND 204:

NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?

HAS LIVING CHILDREN: If you could go back to the time that you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

RECORD SINGLE NUMBER OR OTHER ANSWER.

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 501:

702. Now I have some questions about your (most recent) husband/partner. Did your husband/partner ever attend school?

703. What was the highest level of school he attended: primary, secondary, or higher?

704. What was the highest (GRADE, FORM, YEAR) he completed at that level?

705. CHECK 703:

706. Can (could) he read a letter or newspaper easily, with difficulty, or not at all?

707. What kind of work does (did) your husband/partner mainly do?

708. CHECK 707:

709. Does (did) he earn a regular wage or salary?

710. Does (did) your husband/partner work mainly on his or family land, or on someone else's land?

711. Does (did) he work mainly for money or does (did) he work for a share of the crops?

712. Before you married your (first) husband, did you yourself ever work regularly to earn money, other than on a farm or in a business run by your family?

713. When you were earning money then, did you turn most of it over to your family or did you keep most of it yourself?

714. Since you were first married, have you ever worked regularly to earn money other than on a farm or in a business run by your family?

715. Have you ever worked regularly to earn money, other than on a farm or in a business run by your family?

716. During the time when you have earned money, have you turned most of it over to your family or have you kept most of it for yourself?

717. Are you now working to earn money other than on a farm or in a business run by your family?

718. RECORD THE TIME.

SECTION 8. WEIGHT AND LENGTH

INTERVIEWER: IN 801-803, RECORD THE LINE NUMBERS, NAMES, AND BIRTH DATES OF ALL LIVING CHILDREN BORN SINCE JANUARY 1, 1984, STARTING WITH THE YOUNGEST CHILD. CHECK AGE IN 804 TO IDENTIFY CHILDREN 3-36 MONTHS OF AGE. RECORD WEIGHT AND LENGTH IN 805 AND 806.

801. LINE NUMBER FROM QUESTION 212.

802. NAME FROM QUESTION 212.

803. DATE OF BIRTH FROM QUESTION 214.

804. CHECK AGE:
3-36 MONTHS?

805. WEIGHT (IN KILOGRAMS).

806. LENGTH (IN CENTIMETERS).

807. STATE REASON IF UNABLE TO RECORD.

808. NAME OF MEASURER AND ASSISTANT.

INTERVIEWER'S OBSERVATIONS

(TO BE FILLED IN AFTER COMPLETING INTERVIEW.)

PERSON INTERVIEWED:___________________

SPECIFIC QUESTIONS:___________________

OTHER ASPECTS:_________________

NAME OF INTERVIEWER:_________________
DATE:________________

SUPERVISOR'S OBSERVATIONS:___________
NAME OF SUPERVISOR:_____
DATE:______

EDITOR'S OBSERVATIONS:__________
NAME OF FIELD EDITOR:_________
DATE:__________

NAME OF KEYER: __________
DATE: ____________