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DEMOGRAPHIC AND HEALTH SURVEYS MODEL "A" QUESTIONNAIRE
FOR HIGH CONTRACEPTIVE PREVALENCE COUNTRIES

[NAME OF COUNTRY]
[NAME OF ORGANIZATION]

IDENTIFICATION

PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
REGION ___

URBAN OR RURAL?

Urban 1
Rural 2

LARGE CITY/SMALL CITY/TOWN/COUNTRYSIDE**

**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".

Large city 1
Small city 2
Town 3
Countryside 4

NAME AND LINE NUMBER OF WOMAN ___

INTERVIEWER VISITS*

*This section should be adapted for country-specific survey design.

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

***RESULT CODES

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7

TOTAL NUMBER OF VISITS

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

SUPERVISOR
NAME __________
DATE ______

FIELD EDITOR
NAME __________
DATE ______

OFFICE EDITOR __________
KEYED BY __________

SECTION 1. RESPONDENT'S BACKGROUND

101) Record the time.

HOUR ___
MINUTES ___

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?

CITY 1
TOWN 2
COUNTRYSIDE 3

103) How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

YEARS ___
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)

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

CITY 1
TOWN 2
COUNTRYSIDE 3

105) In what month and year were you born?

MONTH __________
DON'T KNOW MONTH 98
YEAR _____
DON'T KNOW YEAR 98

106) How old were you at your last birthday? COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

AGE IN COMPLETED YEARS ___

107) Have you ever attended school?

YES 1
NO 2 (GO TO 114)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

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

GRADE ___

110) CHECK 106:

AGE 24 OR BELOW ___
AGE 25 OR ABOVE ___ (GO TO 113)

111) Are you currently attending school?

YES 1 (GO TO 113)
NO 2

112) What was the main reason you stopped attending school?

GOT PREGNANT 01
GOT MARRIED 02
TO CARE FOR YOUNGER CHILDREN 03
FAMILY NEEDED HELP ON FARM OR IN BUSINESS 04
COULD NOT PAY SCHOOL FEES 05
NEEDED TO EARN MONEY 06
GRADUATED/HAD ENOUGH SCHOOLING 07
DID NOT PASS ENTRANCE EXAMS 08
DID NOT LIKE SCHOOL 09
SCHOOL NOT ACCESSIBLE/TOO FAR 10
OTHER (SPECIFY) __________ 96
DON'T KNOW 98

*Revise according to the local educational system

113) CHECK 108:

PRIMARY ___
SECONDARY OR HIGHER ___ (GO TO 115)

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

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 116)

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

YES 1
NO 2

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

YES 1
NO 2

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

YES 1
NO 2

118) COUNTRY-SPECIFIC QUESTION ON RELIGION.

119) COUNTRY-SPECIFIC QUESTION ON ETHNICITY.

120) CHECK QUESTION 4 IN THE HOUSEHOLD QUESTIONNAIRE.

THE WOMAN INTERVIEWED IS NOT A USUAL RESIDENT ___
THE WOMAN INTERVIEWED IS A USUAL RESIDENT ___ (GO TO 201)

121) Now I would like to ask you about the place in which you usually live.

What is the name of the place in which you usually live?

NAME OF PLACE __________

Is that a city, town, or in the countryside?*

CAPITAL CITY, LARGE CITY 1
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4

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

STATE/PROVINCE 01
STATE/PROVINCE 02
STATE/PROVINCE 03
STATE/PROVINCE 04
STATE/PROVINCE 05

123) Now I would like to ask about the household in which you usually live.
What is the main source of drinking water for members of your household?***

PIPED WATER
PIPED INTO RESIDENCE/YARD/PLOT 21 (GO TO 125)
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 125)
PUBLIC WELL 22
SURFACE WATER
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 125)
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 125)
OTHER (SPECIFY) _______ 96

*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 the pretest; however, the broad categories must be maintained.

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

MINUTES ___
ON PREMISES 996

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

FLUSH TOILET
OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT (VIP) LATRINE 22
NO FACILITY/BUSH/FIELD 31
OTHER (SPECIFY) __________ 96

126) Does your household have:**

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2

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

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) _______ 96

128) Does any member of your household own:**

A bicycle?
YES 1
NO 2
A motorcycle?
YES 1
NO 2
A car?
YES 1
NO 2

*Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
**Additional indicators of socioeconomic status may be added.
***In some countries, it may be desirable to ask an additional question on the material of walls or ceilings.

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?

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

203) How many sons live with you? And how many daughters live with you?

IF NONE, RECORD '00'.

SONS AT HOME ___
DAUGHTERS AT HOME ___

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

YES 1
NO 2 (GO TO 206)

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'.

SONS ELSEWHERE ___
DAUGHTERS ELSEWHERE ___

206) Have you ever given birth to a boy or a girl who was born alive but later died?

IF NO, PROBE: Any baby who cried or showed signs of life but survived only a few hours or days?

YES 1
NO 2 (GO TO 208)

207) How many boys have died? And how many girls have died?

IF NONE, RECORD '00'.

BOYS DEAD ___
GIRLS DEAD ___

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

TOTAL ___

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

YES 1
NO 2 (PROBE AND CORRECT 201-208, AS NECESSARY.)

210) CHECK 208:

ONE OR MORE BIRTHS
NO BIRTHS (GO TO 227)

211) Now I would like to record the names 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?

NAME __________

213) Were any of these births twins?

SINGLE 1
MULTIPLE 2

214) Is (NAME) a boy or a girl?

BOY 1
GIRL 2

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

MONTH ______
YEAR _____

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 219)

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

AGE IN YEARS ___

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

YES 1 (NEXT BIRTH)
NO 2 (NEXT BIRTH)

219) IF DEAD: How old was (NAME) when he/she died?

IF '1 YEAR', PROBE: How many months old was (NAME)?

RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

DAYS ___ 1
MONTHS ___ 2
YEARS ___ 3

220) FROM YEAR OF BIRTH OF (NAME) SUBTRACT YEAR OF PREVIOUS BIRTH.
IS THE DIFFERENCE 4 OR MORE?

YES 1 (NEXT BIRTH)
NO 2 (NEXT BIRTH)

221) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?

YES 1
NO 2

222) FROM YEAR OF INTERVIEW SUBTRACT YEAR OF LAST BIRTH.
IS THE DIFFERENCE 4 YEARS OR MORE?

YES 1 (GO TO 223)
NO 2 (GO TO 224)

223) Have you had any live births since the birth of (NAME OF LAST BIRTH)?

YES 1
NO 2

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

NUMBERS ARE THE SAME
CHECK:
FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED ___
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED ___
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED ___
FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS. ___
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

225) CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1991.*
IF NONE, RECORD '0'.

_____

226) FOR EACH BIRTH SINCE JANUARY 1989** ENTER 'B' IN THE MONTH OF BIRTH IN COLUMN 1 OF THE CALENDAR AND 'P' IN EACH OF THE 8 PRECEDING MONTHS. WRITE NAME TO THE LEFT OF THE 'B' CODE.

* For fieldwork beginning in 1995, 1996, or 1997, the year should be 1992, 1993, or 1994, respectively.
** For fieldwork beginning in 1995, 1996, or 1997, the year should be 1990, 1991, or 1992, respectively.

227) Are you pregnant now?

YES 1
NO 2 (GO TO 230)
UNSURE 8 (GO TO 230)

228) How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN COLUMN 1 OF CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR TOTAL NUMBER OF COMPLETED MONTHS.

MONTHS ___

229) 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 have any more children at all?

THEN 1
LATER 2
NOT WANT MORE CHILDREN 3

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

YES 1
NO 2 (GO TO 236)

231) When did the last such pregnancy end?

MONTH _____
YEAR _____

232) CHECK 231:

LAST PREGNANCY ENDED SINCE JANUARY 1989*
LAST PREGNANCY ENDED BEFORE JANUARY 1989* (GO TO 236)

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

RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN COLUMN 1 OF CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

MONTHS _____

234) Have you ever had any other pregnancies which did not result in a live birth?

YES 1
NO 2 (GO TO 236)

235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER PREGNANCY BACK TO JANUARY 1989*.

ENTER 'T' IN COLUMN 1 OF CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) When did your last menstrual period start?

(DATE, IF GIVEN) __________
DAYS AGO 1 ___
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___
IN MENOPAUSE 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

237) 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?

YES 1
NO 2 (GO TO 301)
DON'T KNOW 8 (GO TO 301)

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

DURING HER PERIOD 1
RIGHT AFTER HER PERIOD HAS ENDED 2
IN THE MIDDLE OF THE CYCLE 3
JUST BEFORE HER PERIOD BEGINS 4
OTHER __________ 96
DON'T KNOW 98

*For fieldwork beginning in 1995, 1996, or 1997, the year should be 1990, 1991, or 1992, respectively.

SECTION 3. CONTRACEPTION

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.

CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
THEN PROCEED DOWN COLUMN 302, 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 301 OR 302, ASK 303.

301) Which ways or methods have you heard about?

01) PILL: Women can take a pill every day.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
02) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
03) INJECTABLES: Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
04) IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
05) DIAPHRAGM, FOAM, JELLY: Women can place a sponge, suppository, diaphragm, jelly, or cream inside themselves before intercourse.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
06) CONDOM: Men can put a rubber sheath on their penis during sexual intercourse.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
07) FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
08) MALE STERILIZATION: Men can have an operation to avoid having any more children.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
09) RHYTHM, PERIODIC ABSTINENCE: Every moth that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
10) WITHDRAWAL: Men can be careful and pull out before climax.
SPONTANEOUS YES 1
PROBED YES 2
NO 3
11) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
SPONTANEOUS YES 1 (SPECIFY ________)
PROBED YES 2
NO 3

302) Have you ever heard of (METHOD)?

01) PILL: Women can take a pill every day.
PROBED YES 2
NO 3
02) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
PROBED YES 2
NO 3
03) INJECTABLES: Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
PROBED YES 2
NO 3
04) IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
PROBED YES 2
NO 3
05) DIAPHRAGM, FOAM, JELLY: Women can place a sponge, suppository, diaphragm, jelly, or cream inside themselves before intercourse.
PROBED YES 2
NO 3
06) CONDOM: Men can put a rubber sheath on their penis during sexual intercourse.
PROBED YES 2
NO 3
07) FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
PROBED YES 2
NO 3
08) MALE STERILIZATION: Men can have an operation to avoid having any more children.
PROBED YES 2
NO 3
09) RHYTHM, PERIODIC ABSTINENCE: Every moth that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
PROBED YES 2
NO 3
10) WITHDRAWAL: Men can be careful and pull out before climax.
PROBED YES 2
NO 3
11) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
NO 3

303) Have you ever used (METHOD)?

01) PILL: Women can take a pill every day.
YES 1
NO 2
02) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
03) INJECTABLES: Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
YES 1
NO 2
04) IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
YES 1
NO 2
05) DIAPHRAGM, FOAM, JELLY: Women can place a sponge, suppository, diaphragm, jelly, or cream inside themselves before intercourse.
YES 1
NO 2
06) CONDOM: Men can put a rubber sheath on their penis during sexual intercourse.
YES 1
NO 2
07) FEMALE STERILIZATION: Women can have an operation to avoid having any more children: Have you ever had an operation to avoid having any more children?
YES 1
NO 2
08) MALE STERILIZATION: Men can have an operation to avoid having any more children: Have you ever had a partner who had an operation to avoid having children?
YES 1
NO 2
09) RHYTHM, PERIODIC ABSTINENCE: Every moth that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
10) WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2
11) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1
NO 2

304) CHECK 303:

NOT A SINGLE "YES" (NEVER USED)
AT LEAST ONE "YES" (EVER USED) (GO TO 308)

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

YES 1 (GO TO 307)
NO 2

306) ENTER "0" IN COLUMN 1 OF CALENDAR IN EACH BLANK MONTH. (GO TO 331)

307) What have you used or done? CORRECT 303 AND 304 (AND 302 IF NECESSARY).

308) Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant. What was the first method you ever used?*

PILL 01
IUD 02
INJECTABLES 03
IMPLANTS 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
OTHER (SPECIFY) __________ 96

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

NUMBER OF CHILDREN ___

311) CHECK 303:

WOMAN NOT STERILIZED
WOMAN STERILIZED (GO TO 314A)

312) CHECK 227:

NOT PREGNANT, OR UNSURE
PREGNANT (GO TO 325)

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

YES 1
NO 2 (GO TO 325)

314) Which method are you using?*

314A) CIRCLE '07' FOR FEMALE STERILIZATION.

PILL 01
IUD 02 (GO TO 324)
INJECTABLES 03 (GO TO 324)
IMPLANTS 04 (GO TO 324)
DIAPHRAGM, FOAM OR JELLY 05 (GO TO 324)
CONDOM 06 (GO TO 324)
FEMALE STERILIZATION 07 (GO TO 318)
MALE STERILIZATION 08 (GO TO 318)
PERIODIC ABSTINENCE 09 (GO TO 323)
WITHDRAWAL 10 (GO TO 324)
OTHER (SPECIFY) __________ 96 (GO TO 324)

315) May I see the package of pills you are now using?

RECORD NAME OF BRAND IF PACKAGE IS SEEN.

PACKAGE SEEN 1 (GO TO 317)
BRAND NAME __________ (GO TO 317)
PACKAGE NOT SEEN 2

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

BRAND NAME __________
DON'T KNOW 98

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

COST _____ (GO TO 324)
FREE 996 (GO TO 324)
DON'T KNOW 998 (GO TO 324)

*Response categories may be added for other methods.
** Question should be maintained only in countries that have an active social marketing program.

318) Where did the sterilization take place?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE______
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
OTHER PUBLIC (SPECIFY) ______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR 23
MOBILE CLINIC 24
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26
OTHER (SPECIFY) ______ 96
DON'T KNOW 98

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

YES 1
NO 2 (GO TO 321)

320) Why do you regret the operation?

RESPONDENT WANTS ANOTHER CHILD 01
PARTNER WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
CHILD DIED 04
OTHER (SPECIFY) _____ 96

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

MONTH _____
YEAR _____

322) CHECK 321:

STERILIZED BEFORE JANUARY 1989**
ENTER CODE FOR STERILIZATION IN MONTH OF INTERVIEW IN COLUMN 1 OF THE CALENDAR AND EACH MONTH BACK TO JANUARY 1989.** (GO TO 329A)
STERILIZED AFTER JANUARY 1989**
ENTER CODE FOR STERILIZATION IN MONTH OF INTERVIEW IN COLUMN 1 OF THE CALENDAR AND IN EACH MONTH BACK TO THE DATE OF THE OPERATION. (GO TO 325)

323) How do you determine which days of your monthly cycle not to have sexual relations?

BASED ON CALENDAR 01
BASED ON BODY TEMPERATURE 02
BASED ON CERVICAL MUCUS (BILLIONS METHOD) 03
BASED ON BODY TEMPERATURE AND CERVICAL MUCUS 04
NO SPECIFIC SYSTEM 05
OTHER (SPECIFY) ______ 96

* Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
** For fieldwork beginning in 1995, 1996, or 1997, the year should be 1990, 1991, or 1992, respectively.

324) ENTER METHOD CODE FROM 314 IN CURRENT MONTH IN COLUMN 1 OF CALENDAR. THEN DETERMINE WHEN SHE STARTED USING METHOD THIS TIME. ENTER METHOD CODE IN EACH MONTH OF USE.

ILLUSTRATIVE QUESTIONS:

When did you start using continuously?
How long have you been using this method continuously?

325) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 1989.* USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1, ENTER CODE IN EACH MONTH OF METHOD USE OR '0' FOR NONUSE.
ILLUSTRATIVE QUESTIONS COLUMN 1:

- When was the last time you used a method? Which method was that?
- When did you start using that method? How long after the birth of (NAME)?
- How long did you use the method then?

IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD 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 2:

- Why did you stop using the (METHOD)?
- Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?

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.

327) CHECK 314:
CIRCLE METHOD CODE:

NOT ASKED 00 (GO TO 331)
PILL 01
IUD 02
INJECTABLES 03
IMPLANTS 04
DIAPHRAGM, FOAM OR JELLY 05
CONDOM 06
FEMALE STERILIZATION 07 (GO TO 329A)
MALE STERILIZATION 08 (GO TO 329A)
PERIODIC ABSTINENCE 09 (GO TO 332)
WITHDRAWAL 10 (GO TO 332)
OTHER (SPECIFY) __________ 96 (GO TO 332)

328) Where did you obtain (METHOD) the last time?**

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE ______
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
OTHER PUBLIC (SPECIFY) ______16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) _______ 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
OTHER (SPECIFY) _______ 36

* For fieldwork beginning in 1995, 1996, or 1997, the year should be 1990, 1991, or 1992, respectively.
** Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.

329) Do you know another place where you could have obtained (METHOD) the last time?*

329A) At the time of the sterilization operation, did you know another place where you could have received the operation?*

YES 1
NO 2 (GO TO 334)

330) People select the place where they get family planning services for various reasons.

What was the main reason you went to (NAME OF PLACE IN QUESTION 328 OR QUESTION 318) instead of some other place you know about?*

RECORD RESPONSE AND CIRCLE CODE.

__________
ACCESS-RELATED REASONS
CLOSER TO HOME 11 (GO TO 334)
CLOSER TO MARKET/WORK 12 (GO TO 334)
AVAILABILITY OF TRANSPORT 13 (GO TO 334)
SERVICE-RELATED REASONS
STAFF MORE COMPETENT/FRIENDLY 21 (GO TO 334)
CLEANER FACILITY 22 (GO TO 334)
OFFERS MORE PRIVACY 23 (GO TO 334)
SHORTER WAITING TIME 24 (GO TO 334)
LONGER HOURS OF OPERATION 25 (GO TO 334)
USE OTHER SERVICES AT THE FACILITY 26 (GO TO 334)
LOWER COST/CHEAPER 31 (GO TO 334)
WANTED ANONYMITY 41 (GO TO 334)
OTHER (SPECIFY) ______ 96 (GO TO 334)
DON'T KNOW 98 (GO TO 334)

331) What is the main reason you are not using a method of contraception to avoid pregnancy?

NOT MARRIED 11
FERTILITY-RELATED REASONS
NOT HAVING SEX 21
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
POSTPARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
PREGNANT 27
OPPOSITION TO USE
RESPONDENT OPPOSED 31
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
LACK OF KNOWLEDGE
KNOWS NO METHOD 41
KNOWS NO SOURCE 42
METHOD-RELATED REASONS
HEALTH CONCERNS 51
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COST TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
OTHER (SPECIFY) _____ 96
DON'T KNOW 98

*Include only in countries where at least 15 percent of women are using a modern method of contraception.

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

YES 1
NO 2 (GO TO 334)

333) Where is that?*

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
OTHER PUBLIC (SPECIFY) ______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
OTHER (SPECIFY) ______ 36

334) Were you visited by a family planning program worker in the last 12 months?

YES 1
NO 2

335) Have you visited a health facility for any reason in the last 12 months?

YES 1
NO 2 (GO TO 337)

336) Did any staff member at the health facility speak to you about family planning methods?

YES 1
NO 2

337) Do you think that breastfeeding can affect a woman's chance of becoming pregnant?

YES 1
NO 2 (GO TO 401)
DON'T KNOW 8

338) Do you think a woman's chance of becoming pregnant is increased or decreased by breastfeeding?

INCREASED 1 (GO TO 401)
DECREASED 2
DEPENDS 3
DON'T KNOW 8

339) CHECK 210:

ONE OR MORE BIRTHS
NO BIRTHS (GO TO 401)

340) Have you ever relied on breastfeeding as a method of avoiding pregnancy?

YES 1
NO 2 (GO TO 401)

341) CHECK 227 AND 311:

NOT PREGNANT OR UNSURE AND NOT STERILIZED
EITHER PREGNANT OR STERILIZED (GO TO 401)

342) Are you currently relying on breastfeeding to avoid getting pregnant?

YES 1
NO 2

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

SECTION 4A. PREGNANCY AND BREASTFEEDING

401) CHECK 225:

ONE OR MORE BIRTHS SINCE JANUARY 1991*
NO BIRTHS SINCE JANUARY 1991* (GO TO 465)

402) ENTER THE LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1991* IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRES).

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

403) LINE NUMBER FROM QUESTION 212

LINE NUMBER ___

404) FROM QUESTION 212 AND 216

NAME _______
ALIVE ___
DEAD ___

405) 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?

THEN 1 (GO TO 407)
LATER 2
NO MORE 3 (GO TO 407)

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

MONTHS 1 ___
YEARS 2 ___
DON'T KNOW 998

407) When you were pregnant with (name), did you see anyone for antenatal care for this pregnancy?**

IF YES: Whom did you see? Anyone else?

PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
OTHER (SPECIFY) __________ X
NO ONE Y (GO TO 410)

408) How many months pregnant were you when you first received antenatal care?

MONTHS _____
DON'T KNOW 98

409) How many times did you receive antenatal care during this pregnancy?

NUMBER OF TIMES _____
DON'T KNOW 98

410) 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?

YES 1
NO 2 (GO TO 412)
DON'T KNOW 8 (GO TO 412)

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

TIMES ___
DON'T KNOW 8

*For fieldwork beginning in 1995, 1996, or 1997, the year should be 1992, 1993, or 1994, respectively.
**Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained. It is also important to select the appropriate term for "antenatal care".
***Vaccination practices may vary; this question should specify where the injection is given, e.g., arm or shoulder.

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

HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC (SPECIFIC) ______ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY) ______ 36
OTHER (SPECIFY) ______ 96

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

HEALTH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
RELATIVE/FRIEND E
OTHER (SPECIFY) _____ X
NO ONE Y

414) Around the time of the birth of (NAME), did you have any of the following problems:

Long labor, that is, did your regular contractions last more than 12 hours?
YES 1
NO 2
Excessive bleeding that was so much that you feared it was life threatening?
YES 1
NO 2
A high fever with bad smelling vaginal discharge?
YES 1
NO 2
Convulsions not caused by fever?
YES 1
NO 2

415) Was (NAME) delivered by caesarean section?

YES 1
NO 2

416) When (NAME) was born, was he/she:

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8

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

417) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 419)

418) How much did (NAME) weigh?
RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

GRAMS FROM CARD 1 ___
GRAMS FROM RECALL 2 ___
DON'T KNOW 99998

419) Has your period returned since the birth of (NAME)?
[Most recent birth within the last 3 years]

YES 1 (GO TO 421)
NO 2 (GO TO 422)

420) Did your period return between the birth of (NAME) and your next pregnancy?
[Repeat questions for all children born in the last 3 years, excluding the most recent birth]

YES 1
NO 2 (GO TO 424)

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

MONTHS ___
DON'T KNOW 98

422) CHECK 227:
RESPONDENT PREGNANT?

NOT PREGNANT
PREGNANT OR UNSURE (GO TO 424)

423) Have you resumed sexual relations since the birth of (NAME)?
[Most recent birth within the last 3 years]

YES 1
NO 2 (GO TO 425)

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

MONTHS ___
DON'T KNOW 98

425) Did you ever breastfeed (NAME)?

YES 1
NO 2 (GO TO 431)

426) 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.

IMMEDIATELY 000
HOURS 1 ___
DAYS 2 ___

427) CHECK 404: CHILD ALIVE?

ALIVE
DEAD (GO TO 429)

428) Are you still breastfeeding (NAME)?

YES 1 (GO TO 432)
NO 2

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

MONTHS ___
DON'T KNOW 98

430) Why did you stop breastfeeding (NAME)?

MOTHER ILL/WEAK 01
CHILD ILL/WEAK 02
CHILD DIED 03
NIPPLE/BREAST PROBLEM 04
NOT ENOUGH MILK 05
MOTHER WORKING 06
CHILD REFUSED 07
WEANING AGE/AGE TO STOP 08
BECAME PREGNANT 09
STARTED USING CONTRACEPTION 10
OTHER (SPECIFY) ______ 96

431) CHECK 404: CHILD ALIVE?

ALIVE (GO TO 434)
DEAD (GO BACK TO 405 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 440)

432) How many times did you breastfeed last night between sunset and sunrise? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF NIGHTTIME FEEDINGS ___

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

NUMBER OF DAYLIGHT FEEDINGS ___

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

YES 1
NO 2
DON'T KNOW 8

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

Plain water?
YES 1
NO 2
DOESN'T KNOW 8
Sugar water?
YES 1
NO 2
DOESN'T KNOW 8
Juice?
YES 1
NO 2
DOESN'T KNOW 8
Herbal tea?
YES 1
NO 2
DOESN'T KNOW 8
Baby formula?
YES 1
NO 2
DOESN'T KNOW 8
Tinned, powdered milk?
YES 1
NO 2
DOESN'T KNOW 8
Fresh milk?
YES 1
NO 2
DOESN'T KNOW 8
Any other liquids?
YES 1
NO 2
DOESN'T KNOW 8
Any food made from [WHEAT, MAIZE, RICE, SORGHUM, or LOCAL GRAIN] such as [PORRIDGE, BREAD, or NOODLES]?
YES 1
NO 2
DOESN'T KNOW 8
Any food made from [CASSAVA, PLANTAIN, YAMS, or LOCAL TUBER]?
YES 1
NO 2
DOESN'T KNOW 8
Eggs, fish, or poultry?
YES 1
NO 2
DOESN'T KNOW 8
Meat?
YES 1
NO 2
DOESN'T KNOW 8
Any other solid or semi-solid foods?
YES 1
NO 2
DOESN'T KNOW 8

*List of liquids and foods to be adapted locally and revised based on the pretest. Additional liquids or foods should be added to include common weaning foods. All items shown here should be included.

436) CHECK 435: FOOD OR LIQUID GIVEN YESTERDAY?

"YES" TO ONE OR MORE
"NO/DON'T KNOW" TO ALL (GO TO 438)

437) (Aside from breastfeeding,) how many times did (NAME) eat yesterday, including both meals and snacks?

IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES _____
DON'T KNOW 8

438) On how many days during the last seven days was (NAME) given any of the following:*

RECORD THE NUMBER OF DAYS.

IF DON'T KNOW, RECORD '8'

Plain water?
PLAIN WATER _____
Any kind of milk (other than breast milk)?
MILK _____
Liquids other than plain water or milk?
OTHER LIQUIDS _____
Food made from [WHEAT, MAIZE, RICE, SORGHUM, or LOCAL GRAIN]?
FOOD MADE FROM [GRAIN] _____
Food made from [CASSAVA, PLANTAIN, YAMS, or LOCAL TUBER]?
FOOD MADE FROM [TUBER] _____
Eggs, fish, or poultry?
EGGS/FISH/POULTRY _____
Meat?
MEAT _____
Any other solid or semi-solid foods?
OTHER SOLID/SEMI-SOLID FOODS _____

439) GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 440.

*List of liquids and foods to be adapted locally and revised based on the pretest. Additional liquids or foods should be added to include common weaning foods. All items shown here should be included.

SECTION 4B. IMMUNIZATION AND HEALTH

440) ENTER LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1991* IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS USE ADDITIONAL QUESTIONNAIRES).

441) LINE NUMBER FROM QUESTION 212

LINE NUMBER ___

442) FROM QUESTION 212 AND 216.

NAME _______
ALIVE
DEAD (GO TO 442 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465).

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

YES, SEEN 1 (GO TO 445)
YES, NOT SEEN 2 (GO TO 447)
NO CARD 3

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

YES 1 (GO TO 447)
NO 2 (GO TO 447)

445)
(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.

BCG
DAY _____
MONTH _____
YEAR _____
POLIO (AT BIRTH)
DAY _____
MONTH _____
YEAR _____
POLIO 1
DAY _____
MONTH _____
YEAR _____
POLIO 2
DAY _____
MONTH _____
YEAR _____
POLIO 3
DAY _____
MONTH _____
YEAR _____
DPT 1
DAY _____
MONTH _____
YEAR _____
DPT 2
DAY _____
MONTH _____
YEAR _____
DPT 3
DAY _____
MONTH _____
YEAR _____
MEASLES
DAY _____
MONTH _____
YEAR _____

446) Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR MEASLES VACCINE(S).

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 445, AND GO TO 449)
NO 2 (GO TO 449)
DON'T KNOW 8 (GO TO 449)

*For fieldwork beginning in 1995, 1996, or 1997, the year should be 1992, 1993, or 1994, 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 the vaccinations.

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

YES 1
NO 2 (GO TO 449)
DON'T KNOW 8 (GO TO 449)

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

448A) A BCG vaccination against tuberculosis, that is, an injection in the left arm or shoulder that caused a scar?**

YES 1
NO 2
DON'T KNOW 8

448B) Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (GO TO 448E)
DON'T KNOW 8 (GO TO 448E)

448C) How many times?

NUMBER OF TIMES ___

448D) When was the first polio vaccine given, just after birth or later?

JUST AFTER BIRTH 1
LATER 2

448E) DPT vaccination, that is, an injection usually given at the same time as polio drops?

YES 1
NO 2 (GO TO 448G)
DOESN'T KNOW 8 (GO TO 448G)

448F) How many times?

NUMBER OF TIMES ___

448G) An injection to prevent measles?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 454)
DON'T KNOW 8 (GO TO 454)

451) When (NAME) was ill with a cough, did he/she breathe more rapidly than usual with short, rapid breaths?

YES 1
NO 2
DON'T KNOW 8

452) Did you seek advice or treatment for the cough?

YES 1
NO 2 (GO TO 454)

*To be developed locally since immunization practices may vary from country to country, as may the terms used for the vaccinations.
**Adapt question locally after determining the most common injection site (usually the left arm or shoulder). Children under 3 years will be checked for a BCG scar, normally during the height and weight measurement in Section 9.

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

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
COMMUNITY HEALTH WORKER E
OTHER PUBLIC (SPECIFY) _______ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
COMMUNITY HEALTH WORKER K
OTHER PRIVATE MEDICAL (SPECIFY) ______ L
OTHER SOURCE
SHOP M
TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) ______ X

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

YES 1
NO 2 (GO TO 464)
DON'T KNOW 8 (GO TO 464)

455) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

456) On the worst day of the diarrhea, how many bowel movements did (NAME) have?

NUMBER OF BOWEL MOVEMENTS ___
DON' T KNOW 98

457) Was he/she given the same amount to drink as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

458) Was he/she given the same amount of food to eat as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

*Coding categories to be developed locally and revised based on pretest; however, the large categories must be maintained.
**The term(s) used for diarrhea should encompass the expressions used for all forms of diarrhea including bloody stools (consistent with dysentery), watery stools, etc.

459) When (NAME) had diarrhea, was he/she given any of the following to drink:*

A fluid made from a special packet called (LOCAL NAME)?
YES 1
NO 2
DON'T KNOW 8
Thin watery gruel made from (RICE OR OTHER LOCAL GRAIN, TUBER, PLANTAIN)?
YES 1
NO 2
DON'T KNOW 8
Soup?
YES 1
NO 2
DON'T KNOW 8
Homemade sugar-salt-water solution (LOCAL UNACCEPTABLE FLUID)?
YES 1
NO 2
DON'T KNOW 8
Milk or infant formula?
YES 1
NO 2
DON'T KNOW 8
Yoghurt-based drink (OTHER LOCAL ACCEPTABLE FLUID)?
YES 1
NO 2
DON'T KNOW 8
Water?
YES 1
NO 2
DON'T KNOW 8
Any other liquids?
YES 1
NO 2
DON'T KNOW 8

460) Was anything (else) given to treat the diarrhea?

YES 1
NO 2 (GO TO 462)
DON'T KNOW 8 (GO TO 462)

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

PILL OR SYRUP A
INJECTION B
(I.V.) INTRAVENOUS C
HOME REMEDIES/HERBAL MEDICINES D
OTHER (SPECIFY) __________ X

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

YES 1
NO 2 (GO TO 464)

463) Where did you seek advice or treatment?* Anything else?
RECORD ALL MENTIONED.

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
COMMUNITY HEALTH WORKER E
OTHER PUBLIC (SPECIFY) ______ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
COMMUNITY HEALTH WORKER K
OTHER PRIVATE MEDICAL (SPECIFY) _____ L
OTHER SOURCE
SHOP M
TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____ X

464) GO BACK TO 442 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465.

*The response categories should be adapted to include terms used locally for the recommended home fluids (RHF). Ingredients promoted by the National Control of Diarrheal Diseases (CDD) Program or by the Ministry of Health (MOH) to make the RHF should be reflected in the categories. Unacceptable fluids identified by the CDD Program or the MOH should be included (e.g.: sweetened teas, soft drinks, fluids containing caffeine).
**Coding categories to be developed locally and revised based on pretest; however, the large categories must be maintained.

465) When a child has diarrhea, should he/she be given less to drink than usual, about the same amount, or more than usual?

LESS TO DRINK 1
ABOUT THE SAME AMOUNT TO DRINK 2
MORE TO DRINK 3
DON'T KNOW 8

466) When a child has diarrhea, should he/she be given less to eat than usual, about the same amount, or more than usual?

LESS TO EAT 1
ABOUT THE SAME AMOUNT TO EAT 2
MORE TO EAT 3
DON'T KNOW 8

467) When a child is sick with diarrhea, what signs of illness would tell you that he or she should be taken to a health facility or health worker? RECORD ALL MENTIONED.

REPEATED WATERY STOOLS A
ANY WATERY STOOLS B
REPEATED VOMITING C
ANY VOMITING D
BLOOD IN STOOLS D
FEVER F
MARKED THIRST G
NOT EATING/NOT DRINKING WELL H
GETTING SICKER/VERY SICK I
NOT GETTING BETTER J
OTHER (SPECIFY) ________ X
DON'T KNOW Z

468) When a child is sick with a cough, what signs of illness would tell you that he or she should be taken to a health facility or health worker? RECORD ALL MENTIONED.

RAPID BREATHING A
DIFFICULT BREATHING B
NOISY BREATHING C
FEVER D
UNABLE TO DRINK E
NOT EATING/NOT DRINKING WELL F
GETTING SICKER/VERY SICK G
NOT GETTING BETTER H
OTHER (SPECIFY) ________ X
DON'T KNOW Z

469) CHECK 459, ALL COLUMNS:

NO CHILD RECEIVED ORS
ANY CHILD RECEIVED ORS (GO TO 501)

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

YES 1
NO 2

SECTION 5. MARRIAGE*

501) PRESENCE OF OTHERS AT THIS POINT.

CHILDREN UNDER 10
YES 1
NO 2
HUSBAND/PARTNER
YES 1
NO 2
OTHER MALES
YES 1
NO 2
OTHER FEMALES
YES 1
NO 2

502) Are you currently married or living with a man?

YES, CURRENTLY MARRIED 1 (GO TO 507)
YES, LIVING WITH A MAN 2 (GO TO 507)
NO, NOT IN UNION 3

503) Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?

REGULAR SEXUAL PARTNER 1
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3

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

YES, FORMERLY MARRIED 1 (GO TO 506)
YES, LIVED WITH A MAN 2 (GO TO 511)
NO 3

505) ENTER '0' IN COLUMN 3 OF CALENDAR IN THE MONTH OF INTERVIEW, AND IN EACH MONTH BACK TO JANUARY 1989**. (GO TO 515)

506) What is your marital status now: are you widowed, divorced, or separated?

WIDOWED 1 (GO TO 511)
DIVORCED 2 (GO TO 511)
SEPARATED 3 (GO TO 511)

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

LIVES WITH HER 1
STAYING ELSEWHERE 2

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

ONCE 1
MORE THAN ONCE 2

512) CHECK 511:

MARRIED/LIVED WITH A MAN ONLY ONCE:
In what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH A MAN MORE THAN ONCE:
Now we will talk about your first husband/partner. In what month and year did you start living with him?

MONTH __________
DON'T KNOW MONTH 98
YEAR _____ (GO TO 514)
DON' T KNOW YEAR 98

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

AGE ___

514) DETERMINE MONTHS MARRIED OR IN UNION SINCE JANUARY 1989**. ENTER 'X' IN COLUMN 3 OF CALENDAR FOR EACH MONTH MARRIED OR IN UNION, AND ENTER '0' FOR EACH MONTH NOT MARRIED/NOT IN UNION, SINCE JANUARY 1989**.

FOR WOMEN WITH MORE THAN ONE UNION: PROBE FOR DATE WHEN CURRENT UNION STARTED AND, IF APPROPRIATE, FOR STARTING AND TERMINATION DATES OF ANY PREVIOUS UNIONS.

FOR WOMEN NOT CURRENTLY IN UNION: PROBE FOR DATE WHEN LAST UNION STARTED AND FOR TERMINATION DATE AND, IF APPROPRIATE, FOR THE STARTING AND TERMINATION DATES OF ANY PREVIOUS UNIONS.

*To add questions on polygamous unions, see 508-510 in DHS-III Basic Documentation Number 2 Model "B" Questionnaire.
**For field work beginning in 1995, 1996, or 1997, the year should be 1990, 1991, or 1992, respectively.

515) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.

When was the last time you had sexual intercourse (if ever)?

NEVER 000 (GO TO 608)
DAYS AGO 1 ___
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___
BEFORE LAST BIRTH 996

516) CHECK 301 AND 302:

KNOWS CONDOM:
The last time you had sex, was a condom used?

DOES NOT KNOW CONDOM:
Some men use a condom, which means that they put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?

YES 1
NO 2
DON'T KNOW 8

517) Do you know of a place where you can get condoms?

YES 1
NO 2 (GO TO 519)

518) Where is that?*

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE __________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
OTHER PUBLIC (SPECIFY) ______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) ______ 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
OTHER (SPECIFY) _______ 36

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

AGE ____
FIRST TIME WHEN MARRIED 96

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

SECTION 6. FERTILITY PREFERENCES

601) CHECK 314:

NEITHER STERILIZED (GO TO 602)
HE OR SHE STERILIZED (GO TO 612)

602) CHECK 227:

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 now, would you like to have another child or would you prefer not to have any more children?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 606)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 606)
UNDECIDED/DON'T KNOW 8 (604)

603) CHECK 227:

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

PREGNANT:
After the child you are expecting now, how long would you like to wait before the birth of another child?

MONTHS 1 ___
YEARS 2 ___

SOON/NOW 993 (GO TO 606)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 606)
AFTER MARRIAGE 995
OTHER (SPECIFY) _______ 996
DON' T KNOW 998

604) CHECK 227:

NOT PREGNANT OR UNSURE (GO TO 605)
PREGNANT (GO TO 607)

605) If you became pregnant in the next few weeks, would you be happy, unhappy, or would it not matter very much?

HAPPY 1
UNHAPPY 2
WOULD NOT MATTER 3

606) CHECK 313: USING A METHOD?

NOT ASKED
NOT CURRENTLY USING
CURRENTLY USING (GO TO 612)

607) Do you think you will use a method to delay or avoid pregnancy within the next 12 months?

YES (GO TO 609)
NO 2
DON'T KNOW 8

608) Do you think you will use a method to delay or avoid pregnancy at any time in the future?

YES 1
NO 2 (GO TO 610)
DON'T KNOW 8 (GO TO 610)

609) Which method would you prefer to use?

PILL 01 (GO TO 612)
IUD 02 (GO TO 612)
INJECTABLES 03 (GO TO 612)
IMPLANTS 04 (GO TO 612)
DIAPHRAGM/FOAM/JELLY 05 (GO TO 612)
CONDOM 06 (GO TO 612)
FEMALE STERILIZATION 07 (GO TO 612)
MALE STERILIZATION (GO TO 612)
PERIODIC ABSTINENCE 09 (GO TO 612)
WITHDRAWAL 10 (GO TO 612)
OTHER (SPECIFY) __________ 96 (GO TO 612)
UNSURE 98 (GO TO 612)

610) What is the main reason that you think you will never use a method?

NOT MARRIED 11
FERTILITY-RELATED REASONS
INFREQUENT SEX 22 (GO TO 612)
MENOPAUSAL/HYSTERECTOMY 23 (GO TO 612)
SUBFECUND/INFECUND 24 (GO TO 612)
WANTS MORE CHILDREN 26 (GO TO 612)
OPPOSITION TO USE
RESPONDENT OPPOSED 31 (GO TO 612)
HUSBAND OPPOSED 32 (GO TO 612)
OTHERS OPPOSED 33 (GO TO 612)
RELIGIOUS PROHIBITION 34 (GO TO 612)
LACK OF KNOWLEDGE
KNOWS NO METHOD 41 (GO TO 612)
KNOWS NO SOURCE 42 (GO TO 612)
METHOD-RELATED REASONS
HEALTH CONCERNS 51 (GO TO 612)
FEAR OF SIDE EFFECTS 52 (GO TO 612)
LACK OF ACCESS/TOO FAR 53 (GO TO 612)
COST TOO MUCH 54 (GO TO 612)
INCONVENIENT TO USE 55 (GO TO 612)
INTERFERES WITH BODY'S NORMAL PROCESSES 56 (GO TO 612)
OTHER (SPECIFY) __________ 96 (GO TO 612)
OTHER (SPECIFY) __________ 96 (GO TO 612)
DON'T KNOW 98 (GO TO 612)

611) Would you ever use a method if you were married?

YES 1
NO 2
DON'T KNOW 8

612) CHECK 216:

HAS LIVING CHILDREN:
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?

NUMBER ___
OTHER (SPECIFY) __________ 96 (GO TO 614)

PROBE FOR A NUMERIC RESPONSE.

613) How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter?

NUMBER BOYS ___
OTHER (SPECIFY) __________ 96
NUMBER GIRLS ___
OTHER (SPECIFY) __________ 96
NUMBER EITHER ___
OTHER (SPECIFY) __________ 96

614) Would you say that you approve or disapprove of couples using a method to avoid getting pregnant?

APPROVE 1
DISAPPROVE 2
NO OPINION 3

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

On the radio?
ACCEPTABLE 1
NOT ACCEPTABLE 2
DON'T KNOW 8
On the television?
ACCEPTABLE 1
NOT ACCEPTABLE 2
DON'T KNOW 8

616) In the last few months have you heard about family planning:

On the radio?
YES 1
NO 2
On the television?
YES 1
NO 2
In a newspaper or magazine?
YES 1
NO 2
From a poster?
YES 1
NO 2
From leaflets or brochures?
YES 1
NO 2

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

618) In the last few months have you discussed the practice of family planning with your friends, neighbors, or relatives?

YES 1
NO 2 (GO TO 620)

619) With whom? Anyone else? RECORD ALL MENTIONED.

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER (F)
MOTHER-IN-LAW G
FRIENDS/NEIGHBORS H
OTHER (SPECIFY) __________ X

620) CHECK 502:

YES, CURRENTLY MARRIED
YES, LIVING WITH A MAN
NO, NOT IN UNION (GO TO 701)

621) Spouses/partners do not always agree on everything. Now I want to ask you about your husband's/partner's views on family planning.

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

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

622) How often have you talked to your husband/partner about family planning in the past year?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

623) Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer than you want?

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8

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

701) CHECK 502 AND 504:

CURRENTLY MARRIED/LIVING WITH A MAN
FORMERLY MARRIED/LIVED WITH A MAN (GO TO 703)
NEVER MARRIED AND NEVER IN UNION (GO TO 709)

702) How old was your husband/partner on his last birthday?

AGE ___

703) Did your (last) husband/partner on ever attend school?

YES 1
NO 2 (GO TO 706)

704) What was the highest level of school he attended: primary, secondary, or higher?*

PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8 (GO TO 706)

705) What was the highest grade/form/year he completed at that level?*

GRADE ___
DON'T KNOW 98

706) What is/was your (last) husband/partner's occupation? That is, what kind of work does/did he mainly do?

__________

707) CHECK 706:

WORKS/WORKED IN AGRICULTURE
DOES/DID NOT WORK IN AGRICULTURE (GO TO 709)

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

HIS LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

709) Aside from your own housework, are you currently working?

YES 1 (GO TO 712)
NO 2

710) 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?

YES 1 (GO TO 712)
NO 2

711) Have you done any work in the last 12 months?

YES 1
NO 2 (GO TO 726)

712) What is your occupation, that is, what kind of work do you mainly do?

________

713) CHECK 712:

WORKS IN AGRICULTURE
DOES NOT WORK IN AGRICULTURE (GO TO 715)

714) Do you work mainly on your own land or on family land, or do you rent land, or work on someone else's land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

*Revise according to the local educational system.

715) Do you do this work for a member of your family, for someone else, or are you self-employed?

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

716) Do you usually work throughout the year, or do you work seasonally, or only once in a while?

THROUGHOUT THE YEAR 1 (GO TO 718)
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3 (GO TO 719)

717) During the last 12 months, how many months did you work?

NUMBER OF MONTHS _____

718) During the last 12 months, how many days a week did you usually work (in the months that you worked)?

NUMBER OF DAYS ____ (GO TO 720)

719) During the last 12 months, approximately how many days did you work?

NUMBER OF DAYS ____

720) Do you earn cash for your work?
PROBE: Do you make money for working?

YES 1
NO 2 (GO TO 723)

721) How much do you usually earn for this work?
PROBE: Is this by the day, by the week, or by the month?

PER HOUR 1 _____
PER DAY 2 _____
PER WEEK 3 _____
PER MOTH 4 _____
PER YEAR 5 _____
OTHER (SPECIFY) ______ 999996

722) CHECK 502:

YES, CURRENTLY MARRIED AND LIVING WITH A MAN:
Who mainly decides how the money you earn will be used: you, your husband/partner, you and your husband/partner jointly, or someone else?

NO, NOT IN UNION:
Who mainly decides how the money you earn will be used: you, someone else, or you and someone else jointly?

RESPONDENT DECIDES 1
HUSBAND/PARTNER DECIDES 2
JOINTLY WITH HUSBAND/PARTNER 3
SOMEONE ELSE DECIDES 4
JOINTLY WITH SOMEONE ELSE 5

723) Do you usually work at home or away from home?

HOME 1
AWAY 2

724) CHECK 217 AND 218:
IS A CHILD LIVING AT HOME WHO IS AGE 5 OR LESS?

YES
NO (GO TO 726)

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

RESPONDENT 01
HUSBAND/PARTNER 02
OLDER FEMALE CHILD 03
OLDER MALE CHILD 04
OTHER RELATIVES 05
NEIGHBORS 06
FRIENDS 07
SERVANTS/HIRED HELP 08
CHILD IS IN SCHOOL 09
INSTITUTIONAL CHILDCARE 10
HAS NOT WORKED SINCE LAST BIRTH 95
OTHER (SPECIFY) ______ 96

726) Have you lived in only one community or in more than one community since January 1989*?

ONE COMMUNITY 1
MORE THAN ONE COMMUNITY 2 (GO TO 728)

727) IN COLUMN 4 OF CALENDAR, ENTER 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 1989.* (GO TO 801)

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

IN COLUMN 4 OF CALENDAR, ENTER 'X' IN THE MONTH AND YEAR OF THE MOVE. IN SUBSEQUENT MONTHS ENTER THE APPROPRIATE CODE FOR TYPE OF COMMUNITY, ('1' CITY, '2' TOWN, '3' COUNTRYSIDE).

CONTINUE PROBING FOR PREVIOUS COMMUNITIES, AND RECORD MOVES AND TYPES OF COMMUNITIES ACCORDINGLY.

ILLUSTRATIVE QUESTIONS:

- Where did you live before.....?
- In what month and year did you arrive there?
- Is that place in a city, a town, or in the countryside?

*For fieldwork beginning in 1995, 1996, or 1997, the year should be 1990, 1991, or 1992, respectively.

SECTION 8. AIDS

801) Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 811)

802) From which sources of information have you learned most about AIDS? Any other sources? RECORD ALL MENTIONED.

RADIO A
TV B
NEWSPAPERS/MAGAZINES C
PAMPHLETS/POSTERS D
HEALTH WORKERS E
MOSQUES/CHURCHES F
SCHOOLS/TEACHERS G
COMMUNITY MEETINGS H
FRIENDS/RELATIVES I
WORK PLACE J
OTHER (SPECIFY) ______ X

803) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

YES 1
NO 2 (GO TO 807)
DON'T KNOW 8 (GO TO 807)

804) What can a person do? Any other ways?
RECORD ALL MENTIONED.

SAFE SEX* A
ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
SEEK PROTECTION FROM TRADITIONAL HEALER K
OTHER (SPECIFY) _______ W
OTHER (SPECIFY) _______ X
DON'T KNOW Z

805) CHECK 804:*

MENTIONED SAFE SEX
DID NOT MENTION SAFE SEX (GO TO 807)

806) What does "safe sex" mean to you?*

ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
OTHER (SPECIFY) _______ X
DON' T KNOW Z

807) Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

*To be used only in countries which use the term "safe sex" as part of an educational campaign.

808) Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?

ALMOST NEVER 1
SOMETIMES 2
ALMOST ALWAYS 3
DON'T KNOW 8

809) Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?

SMALL 1
MODERATE 2
GREAT 3
NO RISK AT ALL 4
HAS AIDS 5

810) Has your knowledge of AIDS influenced or changed your decisions about having sex or your sexual behavior? IF YES: PROBE: In what way? RECORD ALL MENTIONED.

DID NOT START SEX A
STOPPED ALL SEX B
STARTED USING CONDOMS C
RESTRICTED SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
OTHER (SPECIFY) _______ X
NO CHANGE IN SEXUAL BEHAVIOR Y
DON' T KNOW Z

811) RECORD THE TIME.

HOUR ___
MINUTES ___

SECTION 9. HEIGHT AND WEIGHT

901) CHECK 215:

ONE OR MORE BIRTHS SINCE JANUARY 1991*
NO BIRTHS SINCE JANUARY 1991* (END)

IN 902 (COLUMNS 2 AND 3) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE JANUARY 1991* AND STILL ALIVE. IN 903 AND 904 RECORD THE NAME AND BIRTH DATE FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE JANUARY 1991*. IN 906 AND 908 RECORD THE HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN. (NOTE: ALL RESPONDENTS WITH ONE OR MORE BIRTH SINCE 1991* SHOULD BE WEIGHED AND MEASURED EVEN IF ALL THE CHILDREN HAVE DIED. IF THERE ARE MORE THAN 2 LIVING CHILDREN BORN SINCE JANUARY 1991*, USE ADDITIONAL QUESTIONNAIRES.)

902) LINE NUMBER FROM QUESTION 212
[Only children born since January 1991]

LINE NO.____

903) NAME FROM QUESTION 212 FOR CHILDREN

NAME______

904) DATE OF BIRTH: FROM QUESTION 215, AND ASK FOR DAY OF BIRTH
[Only children born since 1991]

DAY _____
MONTH ______
YEAR _____

905) BCG SCAR ON TOP OF LEFT SHOULDER**
[Only children born since 1991]

SCAR SEEN 1
NO SCAR 2

906) HEIGHT (in centimeters)

___.___

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

LYING 1
STANDING 2

908) WEIGHT (in kilograms)

___.___

909) DATE, WEIGHED AND MEASURED

DAY _____
MONTH ______
YEAR _____

910) RESULT:

[ask once]
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) ______ 9
[ask for each child born since January 1991*]
CHILD MEASURED 1
CHILD SICK 2
CHILD NOT PRESENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY) ______ 6

911) NAME OF MEASURER ______
NAME OF ASSISTANT ______

*For fieldwork beginning in 1995, 1996, or 1997, the year should be 1992, 1993, or 1994, respectively.
**Adapt question locally after determining the most common injection site (usually the left arm or shoulder).

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

NAME OF EDITOR: __________
DATE: __________