[NAME OF COUNTRY]

[NAME OF ORGANIZATION]

IDENTIFICATION *

PLACE NAME _____

NAME OF HOUSEHOLD HEAD _____

CLUSTER NUMBER _____

HOUSEHOLD NUMBER _____

REGION _____

URBAN/RURAL

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE **

NAME AND LINE NUMBER OF WOMAN

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT***

NEXT VISIT
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT***

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT***

FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT

TOTAL NUMBER OF VISITS

***RESULT CODES:

COUNTRY SPECIFIC INFORMATION ON: LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVE LANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR USED

FIELD EDITED BY
NAME _____
DATE _____

OFFICE EDITED BY
NAME _____
DATE _____

KEYED BY
NAME _____
DATE _____

KEYED BY _____

* THIS SECTION SHOULD BE ADAPTED FOR COUNTRY-SPECIFIC SURVEY DESIGN.
** The following guidelines should be used to categorize urban sample points:
"Large cities" are national capitals and places with over 1 million population; "small cities" are places with between 50,000 and 1 million population; remaining urban sample points are "towns".

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD THE TIME.

102) 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 a city, in a town, or in the countryside?

103) In what month and year were you born?

104) How old were you at your last birthday?
COMPARE AND CORRECT 103 AND/OR 104 IF INCONSISTENT.

105) Have you ever attended school?

106) What is the highest level of school you attended: primary, secondary, or higher?

107) What is the highest (grade/form/year) you completed at that level? *

108) CHECK 106:

109) Can you read and understand a letter or newspaper easily, with difficulty, or not at all?

110) Do you usually read a newspaper or magazine at least once a week?

111) Do you usually listen to a radio at least once a week?

112) Do you usually watch television at least once a week?

113) COUNTRY-SPECIFIC QUESTION ON RELIGION.

114) COUNTRY-SPECIFIC QUESTION ON ETHNICITY.

*Revise according to the local education system.

115) CHECK QUESTION 4 IN THE HOUSEHOLD QUESTIONNAIRE

116) Now I would like to ask about the place in which you usually live.
Do you usually live in a city, in a town, or in the countryside?
IF CITY: In which city do you live? *

117) In which (STATE/PROVINCE) is that located? **

118) Now I would like to ask about the household in which you usually live.
What is the main source of water your household uses for handwashing and dishwashing? ***

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

120) Does your household get drinking water from this same source?

121) What is the source of drinking water for members of your household? ***

122) What kind of toilet facility does your household have?***

*Coding categories should be developed that are compatible with the 4 category system (large city, small city, town, countryside) used on the identification section of the cover sheet.

**Coding categories should be developed that are compatible with the regional categorization used on the identification section of the cover sheet.

***Coding categories to be developed locally and revised based on pretest, however the large categories must be maintained.

123) Does your household have:

124) How many rooms in your household are used for sleeping?

125) Could you describe the main material of the floor* of your home?

126) Does any member of your household own:

*Coding categories to be developed locally and revised based on pretest, however the large categories must be maintained. The material of walls or ceilings may be a better measure in some countries.

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 to whom you have given birth who are now living with you?

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

204) Do you have any sons or daughters to whom you have given birth 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, RECORD '00'.

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

207) In all, how many boys have died? And how many girls have died? IF NONE, RECORD '00'.

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

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

210) CHECK 208:

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

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

213) RECORD SINGLE OR MULTIPLE BIRTH STATUS.

214) Is (NAME) a boy or girl?

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

216) Is (NAME) still alive?

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

218) IF ALIVE: Is (NAME) living with you?

219) IF LESS THAN 15 YEARS OF AGE:
With whom does he/she live?
IF 15 OR OLDER, GO TO NEXT BIRTH.

220) IF DEAD:
How old was he/she when he/she died?
IF "1 YR.", PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

221) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

222) CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1985.* IF NONE, ENTER 0 AND GO TO 224.

223) FOR EACH BIRTH SINCE JANUARY 1985* ENTER "B" IN MONTH OF BIRTH IN COLUMN 1 OF CALENDAR AND "P" IN EACH OF THE 8 PRECEDING MONTHS. WRITE NAME TO THE LEFT OF THE "B" CODE.

224) AT THE BOTTOM OF THE CALENDAR, ENTER THE NAME AND BIRTH DATE OF THE LAST CHILD BORN PRIOR TO JANUARY 1985*, IF APPLICABLE.

*For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

225) Are you pregnant now?

226) How many months pregnant are you?

ENTER "P" IN COLUMN 1 OF CALENDAR IN MONTH OF INTERVIEW AND IN EACH PRECEDING MONTH PREGNANT.

227) At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to become pregnant at all?

228) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

229) When did the last such pregnancy end?

230) CHECK 229:

231) How many months pregnant were you when the pregnancy ended?

ENTER "T" IN COLUMN 1 OF CALENDAR IN MONTH PREGNANCY TERMINATED, AND "P" IN EACH PRECEDING MONTH PREGNANT.

232) Did you ever have any other such pregnancies?

233) ASK FOR DATES AND DURATIONS OF ANY OTHER PREGNANCIES BACK TO JANUARY 1985.* ENTER "T" IN COLUMN 1 OF CALENDAR IN MONTH PREGNANCY TERMINATED, AND "P" IN EACH PRECEDING MONTH PREGNANT.

234) When did your last menstrual period start?

235) Between the first day of a woman's period and the first day of her next period, are there certain times when she has a greater chance of becoming pregnant than other times?

236) During which times of the monthly cycle does a woman have the greatest chance of becoming pregnant?**

*For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.
**Coding categories to be developed locally and revised based on pretest.

SECTION 3. CONTRACEPTION

301) Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. Which 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 303-304 BEFORE PROCEEDING TO THE NEXT METHOD.

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

303) Have you ever used (METHOD)?

304) Do you know where a person could go to get (METHOD)?

305) CHECK 303:

306) Have you ever used anything or tried in any way to delay or avoid getting pregnant?

307) ENTER "0" IN COLUMN 1 OF CALENDAR IN EACH BLANK MONTH. (GO TO 339)

308) What have you used or done?
CORRECT 303-305 (AND 302 IF NECESSARY).

309) What is the first thing you ever did or method you ever used to delay or avoid getting pregnant?

310) Where did you go to get this method the first time?*

311) How many living children did you have at that time, if any? IF NONE, RECORD '00'.

312) CHECK 225:

313) CHECK 303:

314) Are you currently doing something or using any method to delay or avoid getting pregnant?

315) Which method are you using?*

315A) CIRCLE '06' FOR FEMALE STERILIZATION.

316) At the time you first started using the pill, did you consult a doctor or a nurse?*

317) At the time you last got pills. Did you consult a doctor or a nurse?*

318) May I see the package of pills you are using now?
RECORD NAME OF BRAND.

319) Do you know the brand name of the pills you are now using?
RECORD NAME OF BRAND.

320) How much does one (packet/cycle) of pills cost you?

321) In what month and year was the sterilization operation performed?

322) ENTER STERILIZATION METHOD CODE IN MONTH OF INTERVIEW IN COLUMN 1 OF CALENDAR AND IN EACH MONTH BACK TO DATE OF OPERATION OR TO JANUARY 1985** IF OPERATION OCCURRED BEFORE 1985**

323) CHECK 315:
SHE/HE STERILIZED: Where did the sterilization take place?***

USING ANOTHER METHOD: Where did you obtain (METHOD) the last time?***

324) How long does it take to travel from your home to this place?
IF LESS THAN 2 HOURS, RECORD MINUTES. OTHERWISE, RECORD HOURS.

325) Is it easy or difficult to get there?

326) What is the main reason you decided to use (CURRENT METHOD FROM 315) rather than some other method of family planning?

*Person consulted should be modified according to local practices.
**For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.
*** Coding categories to be developed locally and revised based on the pretest, however, large categories must be maintained.

327) Are you having any problems in using (CURRENT METHOD)?

328) What is the main problem?

329) CHECK 315 AND 321:

330) ENTER METHOD CODE FROM 315 IN CURRENT MONTH IN COLUMN 1 OF CALENDAR. THEN DETERMINE WHEN SHE STARTED USING THIS METHOD THIS TIME. ENTER METHOD CODE IN EACH MONTH OF USE.

ILLUSTRATIVE QUESTIONS:

331) I would like to ask some questions about all of the (other) periods in the last few years during which you or your partner used a method to avoid getting pregnant.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 1985*.

USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN EACH MONTH, ENTER CODE FOR METHOD OR "0" FOR NONUSE IN COLUMN 1. IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO LAST MONTH OF USE.

NUMBER OF CODES ENTERED IN COLUMN 2 MUST BE THE SAME AS THE NUMBER OF INTERRUPTIONS OF CONTRACEPTIVE USE IN COLUMN 1

ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.

ILLUSTRATIVE QUESTIONS:

COLUMN 1:

COLUMN 2:

IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: "How many months did it take you to get pregnant after you stopped using (METHOD)?" AND ENTER '0' IN EACH SUCH MONTH IN COLUMN 1.

*For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

332) CHECK CALENDAR:

333) I see that you were using (METHOD) in January 1985*. When did you start using (METHOD) that time?

THIS DATE SHOULD NOT PRECEDE THE DATE OF BIRTH OF ANY CHILD BORN BEFORE JANUARY 1985.*

334) I see that you were not using any method of contraception in January 1985*. Did you ever use a method before that?

335) CHECK 215:

336) Did you use a method between the birth of (NAME OF LAST CHILD BORN BEFORE JANUARY 1985*) and January 1985*?

337) When did you stop using a method the last time prior to January 1985*?

*For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

338) CHECK 315:

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

340) What is the main reason you do not intend to use a method?

341) Do you intend to use a method within the next 12 months?

342) When you use a method, which method would you prefer to use?

343) Where can you get (METHOD MENTIONED IN 342)?*

344) Do you know of a place where you can obtain a method of family planning?

*Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

345) Where is that?*

*Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

346) How long does it take to travel from your home to this place?
IF LESS THAN 2 HOURS, RECORD MINUTES. OTHERWISE, RECORD HOURS.

347) Is it easy or difficult to get there?

348) In the last month, have you heard a message about family planning on:

349) Is it acceptable or not acceptable to you for family planning information to be provided on the radio or television?

350) COUNTRY-SPECIFIC QUESTIONS ON FAMILY PLANNING MESSAGES ON RADIO AND TELEVISION.

*Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

SECTION 4A. PREGNANCY AND BREASTFEEDING

401) CHECK 222:

402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1985* IN THE TABLE.
ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).

Now I would like to ask you some more questions about the health of all your children in the past five years. (We will talk about one child at a time.)

LINE NUMBER FROM QUESTION 212

FROM QUESTION 212 AND QUESTION 216

403) At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you want no (more) children at all?

404) How much longer would you like to have waited?

405) When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy? **
IF YES: Whom did you see? Anyone else?
RECORD ALL PERSONS SEEN.

406) Were you given an antenatal card for this pregnancy?

407) How many months pregnant were you when you first saw someone for an antenatal check on this pregnancy?

408) How many antenatal visits did you have during this pregnancy?

409) When you were pregnant with (NAME), were you given an injection in the arm*** to prevent the baby from getting tetanus, that is, convulsions after birth?

410) During this pregnancy, how many times did you get this tetanus injection?

* For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.
** Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained. The category "trained traditional birth attendant" (or "trained community health worker') should be used where the respondents can identify this category. It is also important to choose the appropriate term for "antenatal" care.
*** Vaccination practices may vary from country to country and should specify where the injection is given, e.g., the arm.

411) Where did you give birth to (NAME)?*

412) Who assisted with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.*

* Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

413) Was (NAME) born on time or prematurely?

414) Was (NAME) delivered by caesarian section?

415) When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small?

416) Was (NAME) weighed at birth?

417) How much did (NAME) weigh?

418) Has your period returned since the birth of (NAME)?

419) ENTER "X" IN COLUMN 3 OF CALENDAR IN MONTH AFTER BIRTH AND IN EACH MONTH TO CURRENT MONTH (OR TO CURRENT PREGNANCY) (GO TO 421)

420) For how many months after the birth of (NAME) did you not have a period?

421) CHECK 225:
RESPONDENT PREGNANT?

422) Have you resumed sexual relations again since the birth of (NAME)?

423) ENTER "X" IN COLUMN 4 OF CALENDAR IN MONTH AFTER BIRTH AND IN EACH MONTH TO CURRENT MONTH. (GO TO 425)

424) For how many months after the birth of (NAME) did you not have sexual relations?

* Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

425) Did you ever breastfeed (NAME)?

426) ENTER "N" IN COLUMN 5 OF CALENDAR IN MONTH AFTER BIRTH

427) Why did you not breastfeed (NAME)?

428) How long after birth did you first put (NAME) to the breast?

IF LESS THAN 1 HOUR, RECORD '00' HOURS.
IF LESS THAN 24 HOURS, RECORD HOURS.
OTHERWISE, RECORD DAYS.

429) CHECK 216:
CHILD ALIVE?

430) Are you still breastfeeding (NAME)?

431) ENTER "X" IN COLUMN 5 OF CALENDAR IN MONTH AFTER BIRTH AND IN EACH MONTH TO CURRENT MONTH

432) How many times did you breastfeed last night between sunset and sunrise?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

433) How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

434) At any time yesterday or last night was (NAME) given any of the following?*:

435) CHECK 434: FOOD OR LIQUID GIVEN YESTERDAY?

* List of liquids and foods to be developed locally and revised based on the pretest.
This list should include common weaning foods.

436) For how many months did you breastfeed (NAME)?

437) Why did you stop breastfeeding (NAME)?

438) CHECK 216:
CHILD ALIVE?

439) Was (NAME) ever given water or anything else to drink or eat (other than breastmilk)?

440) How many months old was (NAME) when you started giving the following on a regular basis? :
IF LESS THAN 1 MONTH, RECORD '00'.

441) CHECK 216:
CHILD ALIVE?

442) Did (NAME) drink anything from a bottle with a nipple yesterday or last night?

443) GO BACK TO 403 FOR NEXT BIRTH; OR. IF NO MORE BIRTHS, GO TO 444.

* Terms to de developed locally and revised based on pretest (should include common weaning foods).

444) CHECK 215: ANY BIRTH IN 1982, 1983, OR 1984*?

445) Did you ever feed (NAME) at the breast?

446) How many months did you breastfeed (NAME)?

447) For how many months after the birth of (NAME) did you not have a period?

448) For how many months after the birth of (NAME) did you not have sexual relations?

449) CHECK 401:

*For fieldwork beginning in 1991, 1992, or 1993, the years should be adjusted.
**For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

SECTION 4B. IMMUNIZATION AND HEALTH

451) ENTER THE LINE NUMBER AND NAME OF EACH BIRTH SINCE JANUARY 1985* IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).

LINE NUMBER FROM QUESTION 212

452) Do you have a card where (NAME'S) vaccinations are written down? **
IF YES: May I see it, please?

453) Did you ever have a vaccination card for (NAME)?

454) (1) COPY VACCINATION DATES FOR EACH VACCINE FROM THE CARD. **
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.

455) Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, DPT 1-3, POLIO 1-3 AND/OR MEASLES VACCINE(S).

456) Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

457) Please tell me if (NAME) received any of the following vaccinations: **

458) CHECK 216:
CHILD ALIVE?

459) GO BACK TO 452 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 490.

* For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.
** To be developed locally since immunization practices may vary from country to country, as may the terms used for the written record and for vaccinations. For example, of polio vaccine is given at birth, revise categories in 454 accordingly.
*** Adapt question locally after determining the most common injection site (usually the left arm or shoulder). All children under 5 years will be checked for a BCG scar, normally during the height and weight measurement (see Section 8).

460) Has (NAME) been ill with a fever at any time in the last 2 weeks?

461) Has (NAME) been ill with a cough at any time in the last 2 weeks?

462) Has (NAME) been ill with a cough in the last 24 hours?

463) For how many days (has the cough lasted/did the cough last)?
IF LESS THAN 1 DAY, RECORD '00'.

464) When (NAME) had the illness with a cough, did he/she breathe faster than usual with short, rapid breaths?

465) CHECK 460 AND 461:
FEVER OR COUGH?

466) Was anything given to treat the fever/cough?

467) What was given to treat the fever/cough?* Anything else?
RECORD ALL MENTIONED.

468) Did you seek advice or treatment for the fever/cough?

469) Where did you seek advice or treatment? ** Anywhere else?
RECORD ALL MENTIONED.

* Appearance may aid in identifying syrup as antibiotic or an antimalarial (which a mother may describe as very bitter).
** Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

470) Has (NAME) had diarrhea in the last two weeks? *

471) GO BACK TO 452 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 490.

472) Has (NAME) had diarrhea in the last 24 hours? *

473) For how many days (has the diarrhea lasted/did the diarrhea last)?
IF LESS THAN 1 DAY, RECORD '00'.

474) Was there any blood in the stools?

475) CHECK 425/430:
LAST CHILD STILL BREASTFED?

476) During (NAME)'s diarrhea, did you change the frequency of breastfeeding?

477) Did you increase the number of breastfeeds or reduce them, or did you stop completely?

478) (Asides from breastmilk) Was he/she given the same amount to drink as before the diarrhea, or more, or less?

479) Was anything given to treat the diarrhea?

480) What was given to treat the diarrhea?** Anything else? RECORD ALL MENTIONED.

481) Did you seek advice or treatment for the diarrhea?

482) Where did you seek advice or treatment? *** Anywhere else?
RECORD ALL MENTIONED.

* The term (s) used for diarrhea in these questions should encompass the expressions used for all forms of diarrhea, including bloody stools which are consistent with dysentery, watery stools, etc.
** The response categories should be adopted to include terms used locally both for the ORS packet and for the recommended home fluid. The ingredients promoted by the National Control of Diarrheal Diseases Program or by the Ministry of Health for marketing the recommended home fluid should be reflected in the categories.
*** Coding categories to be developed locally and revised based on the pretest, however, the large categories must be maintained.

483) CHECK 480:
ORS FLUID FROM PACKET MENTIONED?

484) Was (NAME) given (FLUID FROM ORS PACKET -- LOCAL NAME) when he/she had the diarrhea?*

485) For how many days was (NAME) given (LOCAL NAME)?*

IF LESS THAN 1 DAY, RECORD '00'.

486) CHECK 480: RECOMMENDED HOME FLUID MENTIONED?

487) Was (NAME) given a recommended home fluid made from (RECOMMENDED INGREDIENTS) when he/she had the diarrhea?*

488) For how many days was (NAME) given the fluid made from (RECOMMENDED INGREDIENTS)?*

IF LESS THAN 1 DAY, RECORD '00'.

489) GO BACK TO 452 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 490.

* For terms for ORS packets and the recommended home fluid should correspond to the categories used in 480. The ingredients in the recommended home fluid should be reflected in the question as noted for question 480.

490) CHECK 480 AND 484 (ALL COLUMNS):

491) Have you ever heard of a special product called [LOCAL NAME] you can get for the treatment of diarrhea?

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

493) Have you ever prepared a solution with one of these packets to treat diarrhea in yourself or someone else? SHOW PACKET.

494) The last time you prepared the (LOCAL NAME), did you prepare the whole packet at once or only part of the packet?

495) How much water did you use to prepare (LOCAL NAME) the last time you made it?*

496) Where can you get the (LOCAL NAME) packet? PROBE: Anywhere else?
RECORD ALL PLACES MENTIONED. **

497) CHECK 480 AND 487 (ALL COLUMNS):

498) Where did you learn to prepare the recommended home fluid made from (RECOMMENDED INGREDIENTS) *** given to (NAME) when he/she had diarrhea?**

* Response codes to be developed according to local instructions for mixing ORS. If these include the use of a certain container, e.g. a soda bottle, this should be added as a response category.
** Coding categories for health facilities and providers to be developed locally and revised based on pretest, however, the large categories must be maintained.
*** Question to be developed locally according to the ingredients promoted for use in the recommended home fluid.

SECTION 5. MARRIAGE

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

502) ENTER "0" IN COLUMN 6 OF CALENDAR IN MONTH OF INTERVIEW, AND IN EACH MONTH BACK TO JANUARY 1985**.

503) IF NEVER IN UNION: Have you ever had sexual intercourse?

504) Are you now married or living with a man, or are you now widowed, divorced, or no longer living together?***

505) Is your husband/partner living with you now or is he staying elsewhere?

506) Have you been married or lived with a man only once, or more than once?

507) In what month and year did you start living with your (first) husband/partner?

508) How old were you when you started living with him?

509) CHECK 507 AND 508:
YEAR AND AGE GIVEN?

510) CHECK CONSISTENCY OF 507 AND 508:
YEAR OF BIRTH (103) PLUS AGE AT MARRIAGE (508) EQUALS CALCULATED YEAR OF MARRIAGE

IF NECESSARY, CALCULATE YEAR OF BIRTH
CURRENT YEAR MINUS CURRENT AGE (104) CALCULATED YEAR OF BIRTH

IS THE CALCULATED YEAR OF MARRIAGE WITHIN ONE YEAR OF THE REPORTED YEAR OF MARRIAGE (507)?

* Where visiting relationships are common, this category should be added to 501 and 504.
** For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.
*** Where polygynous unions are common, questions on this topic should be added (see DHS Model "B" Questionnaire, Questions 504 - 506).

511) DETERMINE MONTHS MARRIED OR IN UNION SINCE JANUARY 1985**. ENTER "X" IN COLUMN 6 OF CALENDAR FOR EACH MONTH MARRIED OR IN UNION, AND ENTER "0" FOR EACH MONTH NOT MARRIED/NOT IN UNION, SINCE JANUARY 1985**.

FOR WOMEN NOT CURRENTLY IN UNION OR WITH MORE THAN ONE UNION: PROBE FOR DATE COUPLE STOPPED LIVING TOGETHER OR DATE WIDOWED, AND FOR STARTING DATE OF ANY SUBSEQUENT UNION.

512) Now we need some details about your sexual activity in order to get a better understanding of family planning and fertility. How many times did you have sexual intercourse in the last four weeks?

513) How many times in a month do you usually have sexual intercourse?

514) When was the last time you had sexual intercourse?

515) How old were you when you first had sexual intercourse?

516) PRESENCE OF OTHERS AT THIS POINT.

** For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

SECTION 6. FERTILITY PREFERENCES

601) CHECK 315:

602) CHECK 504:

603) CHECK 225:

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) CHECK 225:

NOT PREGNANT OR UNSURE
How long would you like to wait from now before the birth of (a/another) child?

PREGNANT
How long would you like to wait after the birth of the child you are expecting before the birth of another child?

605) CHECK 216 AND 225:
HAS LIVING CHILD(REN) OR PREGNANT?

606) CHECK 225:

NOT PREGNANT OR UNSURE
How old would you like your youngest child to be when your next child is born?

PREGNANT
How old would you like the child you are expecting to be when your next child is born?

607) Given your present circumstances, if you had to do it over again, do you think (you/your husband) would make the same decision to have an operation not to have any more children?

608) Do you regret that (you/your husband) had the operation not to have any (more) children?

609) Why do you regret it?

610) Have you and your husband/partner ever discussed the number of children you would like to have?

611) Does your husband/partner want the same number of children that you want, or does he want more or fewer than you want?

612) CHECK 216:

HAS LIVING CHILD(REN)
If you could go back to the time 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?

NO LIVING CHILDREN
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.

613) What do you think is the best number of months or years between the birth of one child and the birth of the next child?

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

701) CHECK 501:

702) Did your (last) 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? *

* Revise according to the local education system.

705) What kind of work does (did) your (last) husband/partner mainly do?

706) CHECK 705:

707) (Does/did) your husband/partner work mainly on his own land or family land, or (does/did) he rent land, or (does/did) he work on someone else's land?

708) Have you lived in only one or in more than one community since January 1985?*

709) ENTER (IN COLUMN 7 OF CALENDAR) THE APPROPRIATE CODE FOR CURRENT COMMUNITY ("1" CITY, "2" TOWN, "3" COUNTRYSIDE). BEGIN IN THE MONTH OF INTERVIEW AND CONTINUE WITH ALL PRECEDING MONTHS BACK TO JANUARY 1985*. (GO TO 711)

710) In what month and year did you move to (NAME OF COMMUNITY OF INTERVIEW)?

ENTER (IN COLUMN 7 OF CALENDAR) "X" IN THE MONTH AND YEAR OF THE MOVE, AND IN THE SUBSEQUENT MONTHS ENTER THE APPROPRIATE CODE FOR THE TYPE OF COMMUNITY ("1" CITY, "2" TOWN, "3" COUNTRYSIDE). CONTINUE PROBING FOR PREVIOUS COMMUNITIES AND RECORD MOVES AND TYPES OF COMMUNITIES ACCORDINGLY.

ILLUSTRATIVE QUESTIONS

711) REFER TO PLACE OF RESIDENCE IN JANUARY 1985*:

When did you move to (PLACE OF RESIDENCE IN JANUARY 1985)?

712) Was the place you moved from a city, a town, or the countryside?

713) I would like to ask you some questions about working. Aside from your own housework, are you currently working?

714) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business.

Are you currently doing any of these things or any other work?

715) Have you ever worked since January 1985*?

716) ENTER "0" IN COLUMN 8 OF CALENDAR IN EACH MONTH FROM JANUARY 1985* TO CURRENT MONTH. (GO TO 721)

717) What is (was) your (most recent) occupation? That is, what kind of work do (did) you do?

718) USE CALENDAR TO PROBE FOR ALL PERIODS OF WORK, STARTING WITH CURRENT OR MOST RECENT WORK, BACK TO JANUARY 1985*. ENTER CODE FOR NO WORK OR FOR TYPE OF WORK IN COLUMN 8.

ILLUSTRATIVE QUESTIONS

* For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

719) CHECK COLUMN 8 OF CALENDAR:

720) I see that you were working in January 1985.* When did you start that job?

721) I see that you were not working in January 1985. Did you ever work prior to January 1985*?

722) When did your last job prior to January 1985* end?

723) CHECK 215/216/218:
HAS CHILD BORN SINCE JANUARY 1985* AND LIVING AT HOME?

724) CHECK 713 AND 714:
CURRENTLY WORKING?

725) While you are working, do you usually have (NAME OF YOUNGEST CHILD AT HOME) with you, sometimes have him/her with you, or never have him/her with you?

726) Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?

727) RECORD THE TIME

* For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

SECTION 8. HEIGHT AND WEIGHT

801) CHECK 222:

INTERVIEWER:
IN 802 (COLUMN 2-4) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE JANUARY 1985* AND STILL ALIVE.
IN 803 AND 804 RECORD THE NAME AND BIRTH DATE FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE JANUARY 1985*.
IN 806 AND 808 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN.
(NOTE: ALL RESPONDENTS WITH ONE OR MORE BIRTHS SINCE JANUARY 1985* SHOULD BE WEIGHED AND MEASURED EVEN IF ALL OF THE CHILDREN HAVE DIED. IF THERE ARE MORE THAN 3 LIVING CHILDREN BORN SINCE JANUARY 1985*, USE ADDITIONAL FORMS).

* For fieldwork beginning in 1991, 1992, or 1993, the year should be changed to 1986, 1987, or 1988, respectively.

802) LINE NUMBER FROM QUESTION 212

803) NAME FROM QUESTION 212 FOR CHILDREN

804) DATE OF BIRTH
FROM QUESTION 103 FOR RESPONDENT
FROM QUESTION 215 FOR CHILDREN, AND ASK FOR DAY OF BIRTH

805) BCG SCAR ON TOP OF LEFT SHOULDER**

[ask only for children]

** Adapt question locally after determining the most common injection site (usually the left arm or shoulder).

806) HEIGHT (In centimeters)

807) WAS HEIGHT/LENGTH OF CHILD MEASURED LYING DOWN OR STANDING UP?

808) WEIGHT (In kilograms)

809) DATE WEIGHED AND MEASURED

810) RESULT

811) NAME OF MEASURER: __________

NAME OF ASSISTANT: ___________

INTERVIEWER'S OBSERVATIONS

(TO BE FILLED IN AFTER COMPLETING INTERVIEW)

COMMENTS ABOUT RESPONDENT:
__________________________________

COMMENTS ON SPECIFIC QUESTIONS:
__________________________________

ANY OTHER COMMENTS:
__________________________________

SUPERVISOR'S OBSERVATIONS
__________________________________

NAME OF SUPERVISOR: ___________
DATE: __________

EDITOR'S OBSERVATIONS
__________________________________