[NAME OF COUNTRY]
[NAME OF ORGANIZATION]

IDENTIFICATION

PLACE NAME______
CLUSTER NUMBER____
HOUSEHOLD NUMBER___
REGION______

URBAN/RURAL

LINE NUMBER OF WOMAN___

INTERVIWERS VISITS
DATE_____
INTERVIEWER'S NAME_______
RESULT______

NEXT VISIT
DATE____
TIME_____

FINAL VISIT
MONTH______
YEAR______

TOTAL NUMBER OF VISITS___

TOTAL IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN____

RESULT CODES

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 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 CORERCT 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 listen to a radio at least once a week?

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

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

117. What kind of toilet does your household have?

118. At what age do children in this household use the same toilet facility as adults?

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

120. Does your house have:

Electricity?
A radio?
A television?
A refrigerator?

121. Does any member of your household own:

A bicycle?
A motorcycle?
A car?
A tractor?

122. MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION.

130. COUNTRY-SPECIFIC QUESTION ON RELIGION.

140. COUNTRY-SPECIFIC QUESTION ON ETHNICITY.

150. COUNTRY-SPECIFIC QUESTION ON ASSOCIATION MEMEBERSHIP.

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 AMSWERS 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 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.

(GO TO NEXT BIRTH)

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

218. Is he/she living with you?

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

220. Are you pregnant now?

221. For how many months have you been pregnant?

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

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

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

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

226. 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?

227. 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 PRECEED 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 CICRLED IN 302, ASK 303-305 BEFORE PORCEEDING 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?
(LIST OF CODES BELOW)

CODES FOR 304:

305 In your opinion, what is the main problem, if any, with using (METHOD)?
(LIST OF CODES BELOW)

CODES FOR 305:

306. CHECK 303:

307. Have you ever used anything or tried anything 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 220:

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

314. Which method are you using?

315. Where did you obtain (METHOD) the last time?

315A. Where did the sterilization take place?

315B. Where did you obtain instructions for this method?

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

317. Which method would you prefer to use?

318. Do you intend to use (PREFERRD METHOD) in the next 12 months?

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

SECTION 4. HEALTH AND BREASTFEEDING

401. CHECK 214:

402. ENTER THE NAME, LINE NUMBER, AND STATUS OF EACH BIRTH SINCE JAN. 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?

407. Are you still breastfeeding (NAME)?
IF DEAD, CIRCLE '2'.

408. How many months did you breastfeed (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)?

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?
[Question asked for most recent birth only.]

414. How many times did you breastfeed yesterday during the daylight hours?
[Question asked for most recent birth only.]

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

Plain water?
Juice?
Powdered milk?
Cow's or goat's milk?
Any other liquid?
Any solid or mushy food?

416. CHECK 415:

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

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

419. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE JAN. 1982 BELOW. BEGIN WITH THE LAST BIRTH. THE HEADINGS IN THE TABLE SHOULD BE EXACTLY THE SAME AS THOSE AFTER QUESTION 402.

ASK THE QUESTIONS ONLY FOR LIVING CHILDREN.

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

421. RECORD DATES OF IMMUNIZATIONS FROM HEALTH CARD.

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

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

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

425. 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?

426. The last time (NAME) had diarrhea, was he/she given a sugar-salt-water solution made from a special packet?

427. Was there anything (else) you or somebody did to treat the diarrhea?
IF YES: What was done?
CIRCLE CODE 1 FOR ALL MENTIONED.

(ALL GO TO NEXT COLUMN)

428. Have you ever heard of a special product called (LOCAL NAME) you can get for children with diarrhea?

429. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE JAN. 1982 BELOW. BEGIN WITH THE LAST BIRTH. THE HEADINGS IN THE TABLE SHOULD BE EXACTLY THE SAME AS THOSE AFTER QUESTION 419.

ASK THE QUESTIONS ONLY FOR LIVING CHILDREN. IF NO BIRTHS SINCE JAN. 1982, SKIP TO 501.

430. Has (NAME) had fever in the last four weeks?

431. Was (NAME) taken to a private doctor, a hospital or clinic, a traditional doctor, or any other place to treat the fever?
IF YES: Where was he/she taken?

432. Was there anything (else) you or somebody did to treat the fever?
IF YES: What was done?
CIRCLE CODE 1 FOR ALL MENTIONED.

433. Has (NAME) suffered from severe cough or difficult or rapid breathing in the last four weeks?

434. Was (NAME) taken to a private doctor, a hospital or clinic, a traditional doctor, or any other place to treat the problem?
IF YES: Where was he/she taken?

435. Was there anything (else) you or somebody did to treat the problem?
IF YES: What was done?
CIRCLE CODE 1 FOR ALL MENTIONED.

(ALL GO TO NEXT COLUMN)

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. Does your husband/partner live with you or is he now staying elsewhere?

504. Does your husband/partner have any other wives besides yourself?

505. How many other wives does he have?

506. Are you the first, second,...wife?

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

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

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

510. Are your mother and father still alive?

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

512. CHECK 510 AND 511:

513. Was (MENTION PARENTS NOT ALIVE NOW OR DK) alive at the time you began living with your (first) husband or partner?

514. CHECK 513:

515. 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?

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

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

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

519. Have you ever had sexual intercourse?

520. Now we need some information 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?

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

522. How many times?

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

524. CHECK 220:

525. CHECK 313 AND 314:

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

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

528. PRESENCE OF OTHERS AT THIS POINT.

SECTION 6. FERTILITY PREFERENCES

601. CHECK 502:

602. CHECK 220 AND MARK BOX:

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?
[Question is asked for 'NOT PREGNANT OR UNSURE' response]

After the child you are expecting, would you like to have another child or would you prefer not to have any (more) children?
[Question is asked for 'PREGNANT' response]

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

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

605. For how long should a couple wait before starting sexual intercourse after the birth of a baby?

606. Should a mother wait until she has completely stopped breastfeeding before starting to have sexual relations again, or doesn't it matter?

607. Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy?

608. How often have you talked to your husband/partner about this subject in the past year?

609. In general, do you approve or disapprove of couples using a method to avoid pregnancy?

610. CHECK 202 AND 204:

If you could choose exactly the number of children to have in your whole life, how many would that be?
RECORD SINGLE NUMBER OR OTHER ANSWER.
[Question is asked for 'NO LIVING CHILDREN' response]

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.
[Question is asked for 'HAS LIVING CHILDREN' response]

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.

YOUNGEST CHILD:

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 kgs).

806. LENGTH (in cms).

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 OBERVATIONS
Name of Supervisor:
Date:

EDITOR'S OBSERVATIONS
Name of Field Editor:
Date:
Name of Keyer:
Date: