WITH COMMENTARY
FOR LOW CONTRACEPTIVE PREVALENCE COUNTRIES
MACRO INTERNATIONAL INC.
DEMOGRAPHIC AND HEALTH SURVEYS, PHASE III
BASIC DOCUMENTATION, NUMBER 2
DECEMBER 1995
NAME OF COUNTRY __________
NAME OF ORGANIZATION __________
IDENTIFICATION
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
REGION ___
RURAL 2
CITY OR COUNTRY?
NOTE: LARGE CITIES ARE NATIONAL CAPITALS AND PLACES WITH A POPULATION OF OVER 1. MILLION; SMALL CITIES ARE PLACES WITH A POPULATION BETWEEN 50,000. AND 1. MILLION; REMAINING URBAN SAMPLE POINTS ARE CONSIDERED TOWNS.
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4
FIRST VISIT (REVIEW FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________
RESULT_____
NEXT VISIT
DATE _____
TIME ____
FINAL VISIT
DAY ____
MONTH ____
YEAR ____
NAME ____
RESULT ____
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________ 7
NO 2
SUPERVISOR
NAME __________
DATE ______
FIELD EDITOR
NAME __________
DATE ______
OFFICE EDITOR __________
KEYED BY __________
SECTION 1. RESPONDENT'S BACKGROUND
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?
TOWN 2
COUNTRYSIDE 3
103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
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?
TOWN 2
COUNTRYSIDE 3
105. In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
106. How old were you at your last birthday? COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.
107. Have you ever attended school?
NO 2 (GO TO 114)
108. What is the highest level of school you attended: primary, secondary, or higher?
*REVISE ACCORDING TO THE LOCAL EDUCATIONAL SYSTEM
SECONDARY 2
HIGHER 3
109. What is the highest (grade/form/year) you completed at that level?
*REVISE ACCORDING TO THE LOCAL EDUCATIONAL SYSTEM
AGE 25 OR ABOVE ___ (GO TO 113)
111. Are you currently attending school?
NO 2
112. What was the main reason you stopped attending school?
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
DON'T KNOW 98
SECONDARY OR HIGHER ___ (GO TO 115)
114. Can you read and understand a letter or newspaper easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 116)
115. Do you usually read a newspaper or magazine at least once a week?
NO 2
116. Do you usually listen to a radio every day?
NO 2
117. Do you usually watch television at least once a week?
NO 2
120. CHECK Q.4 IN THE HOUSEHOLD QUESTIONNAIRE.
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?
SMALL CITY 2
TOWN 3
COUNTRYSIDE 3
122. In which (state/province) is that located?
** CODING CATEGORIES SHOULD BE DEVELOPED THAT ARE COMPATIBLE WITH THE REGIONAL CATEGORIZATION USED ON THE IDENTIFICATION SECTION OF THE COVER SHEET.
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?
PUBLIC TAP 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61
124. How long does it take to go there, get water, and come back?
ON PREMISES 996
125. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
126. Does your household have:
** ADDITIONAL INDICATORS OF SOCIOECONOMIC STATUS MAY BE ADDED.
NO 2
NO 2
NO 2
NO 2
NO 2
127. Could you describe the main material of the floor of your home?
*** IN SOME COUNTRIES, IT MAY BE DESIRABLE TO ASK AN ADDITIONAL QUESTION ON THE MATERIAL OF WALLS OR CEILINGS.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
128. Does any member of your household own:
NO 2
NO 2
NO 2
201. Now I would like to ask about all the births you have had during your life.
Have you ever given birth?
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?
NO 2 (GO TO 204)
203. How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'.
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?
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'.
DAUGHTERS ELSEWHERE ___
206. Have you ever given birth to a boy or a girl who was born alive but later died?
If no, ask if any baby who cried or showed signs of life but survived only a few hours or days?
NO 2 (GO TO 208)
207. How many boys have died? And how many girls have died?
IF NONE, RECORD '00'.
GIRLS DEAD ___
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'.
Just to make sure that I have this right: you have had in total ___ births during your life. Is that correct?
NO 2 (PROBE AND CORRECT 201-208, AS NECESSARY)
NO BIRTHS 2 (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?
213. Were any of these births twins?
MULTIPLE 2
214. Is (NAME) a boy or a girl?
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?
NO 2 (GO TO 219)
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?
NO 2
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.
MONTHS ___ 2
YEARS ___ 3
220. FROM YEAR OF BIRTH OF (NAME) SUBTRACT YEAR OF PREVIOUS BIRTH.
IS THE DIFFERENCE 4 OR MORE?
NO 2 (GO TO NEXT BIRTH)
221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?
NO 2
222. FROM YEAR OF INTERVIEW SUBTRACT YEAR OF LAST BIRTH.
IS THE DIFFERENCE 4 YEARS OR MORE?
NO 2 (GO TO 224)
223. Have you had any live births since the birth of (NAME OF LAST BIRTH)?
NO 2
224. COMPARE 208. WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:
MARK BELOW WHETHER THE NUMBERS ARE CONSISTENT.
CHECK: FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED ___
CHECK: FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED ___
CHECK: FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS ___
225. CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1992.
IF NONE, RECORD '0'.
NO 2 (GO TO 236)
UNSURE 8 (GO TO 236)
228. How many months pregnant are you?
RECORD NUMBER OF COMPLETED 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?
LATER 2
NOT WANT MORE CHILDREN 3
236. When did your last menstrual period start?
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___
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?
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?
RIGHT AFTER HER PERIOD HAS ENDED 2
IN THE MIDDLE OF THE CYCLE 3
JUST BEFORE HER PERIOD BEGINS 4
DON'T KNOW 98
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?
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
302. Have you ever heard of (METHOD)?
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
303. Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE "YES" (EVER USED) (GO TO 309)
305. Have you ever used anything or tried in any way to delay or avoid getting pregnant?
NO 2 (GO TO 331)
307. What have you used or done?
CORRECT 302, 303, AND 304, IF NECESSARY.
309. Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.
How many living children did you have at that time, if any?
IF NONE, RECORD '00'.
310. When you first used family planning, did you want to have another child, but at a later time, or did you not want to have another child at all?
DID NOT WANT ANOTHER CHILD 2
OTHER (SPECIFY) __________ 6
WOMAN STERILIZED (GO TO 314A)
PREGNANT (GO TO 332)
313. Are you currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (GO TO 331)
314. Which method are you using?
314A. CIRCLE '07' FOR FEMALE STERILIZATION.
IUD 02 (GO TO 326)
INJECTABLES 03 (GO TO 326)
IMPLANTS 04 (GO TO 326)
DIAPHRAGM, FOAM OR JELLY 05 (GO TO 326)
CONDOM 06 (GO TO 326)
FEMALE STERILIZATION 07 (GO TO 318)
MALE STERILIZATION 08 (GO TO 318)
PERIODIC ABSTINENCE 09 (GO TO 323)
WITHDRAWAL 10 (GO TO 326)
OTHER (SPECIFY) __________ 96 (GO TO 326)
315. May I see the package of pills you are now using?
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.
DON'T KNOW 98
317. How much does one packet (cycle) of pills cost you?
FREE 996 (GO TO 326)
DON'T KNOW 998 (GO TO 326)
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.
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
OTHER PUBLIC (SPECIFY) ____ 16
PRIVATE DOCTOR 23
MOBILE CLINIC 24
OTHER PRIVATE MEDICAL (SPECIFY) ____ 26
DON'T KNOW 98
319. Do you regret that (you/your husband) had the operation not to have any (more) children?
NO 2 (GO TO 321)
320. Why do you regret the operation?
PARTNER WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
CHILD DIED 04
OTHER (SPECIFY) _______ 96
321. In what month and year was the sterilization performed?
YEAR _____ (GO TO 327)
323. How do you determine which days of your monthly cycle not to have sexual relations?
BASED ON BODY TEMPERATURE 02
BASED ON CERVICAL MUCUS (BILLINGS METHOD) 03
BASED ON BODY TEMPERATURE AND CERVICAL MUCUS 04
NO SPECIFIC SYSTEM 05
OTHER (SPECIFY) __________ 96
326. For how many months have you been using (method) continuously?
IF LESS THAN 1 MONTH, RECORD '00'.
8 YEARS OR LONGER 96
327. CHECK 314:
CIRCLE METHOD CODE:
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.
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
CHURCH 32
FRIEND/RELATIVE 33
329. Do you know another place where you could have obtained (method) the last time?
NO 2 (GO TO 334)
329a At the time of the sterilization operation, did you know another place where you could have received the operation?
NO 2
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.
CLOSER TO MARKET/WORK 12 (GO TO 334)
AVAILABILITY OF TRANSPORT 13 (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)
331. What is the main reason you are not using a method of contraception to avoid pregnancy?
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
POSTPARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
PREGNANT 27
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
KNOWS NO SOURCE 42
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
332. Do you know of a place where you can obtain a method of family planning?
NO 2 (GO TO 334)
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.
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
CHURCH 32
FRIEND/RELATIVE 33
334. Were you visited by a family planning program worker in the last 12 months?
NO 2
335. Have you visited a health facility for any reason in the last 12 months?
NO 2 (GO TO 337)
336. Did any staff member at the health facility speak to you about family planning methods?
NO 2
337. Do you think that breastfeeding can affect a woman's chance of becoming pregnant?
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?
DECREASED 2
DEPENDS 3
DON'T KNOW 8
NO BIRTHS (GO TO 401)
340. Have you ever relied on breastfeeding as a method of avoiding pregnancy?
NO 2 (GO TO 401)
EITHER PREGNANT OR STERILIZED (GO TO 401)
342. Are you currently relying on breastfeeding to avoid getting pregnant?
NO 2
SECTION 4A. PREGNANCY AND BREASTFEEDING
NO BIRTHS SINCE JANUARY 1992 (GO TO 501)
402. ENTER THE LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1992. 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 OF NEXT-TO-LAST BIRTH ___
404. FROM QUESTION 212 AND 216:
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?
LATER 2
NO MORE 3 (GO TO 407)
406. How much longer would you like to have waited?
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.
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
NO ONE Y (GO TO 410)
408. How many months pregnant were you when you first received antenatal care?
DON'T KNOW 98
409. How many times did you receive antenatal care during this pregnancy?
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?
NO 2 (GO TO 412)
DON'T KNOW 8 (GO TO 412)
411. During this pregnancy, how many times did you get this injection?
DON'T KNOW 8
412. Where did you give birth to (NAME)?
OTHER HOME 12
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC (SPECIFIC) __________ 26
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
OTHER (SPECIFY) __________ 96
413. Who assisted with the delivery of (NAME)?
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
RELATIVE/FRIEND E
OTHER (SPECIFY) __________ X
NO ONE Y
Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.
414. Around the time of the birth of (NAME), did you have any of the following problems:
NO 2
NO 2
NO 2
NO 2
415. Was (NAME) delivered by caesarean section?
NO 2
416. When (NAME) was born, was he/she:
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8
417. Was (NAME) weighed at birth?
NO 2 (GO TO 419)
418. How much did (NAME) weigh?
RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.
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]
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]
NO 2 (GO TO 424)
421. For how many months after the birth of (NAME) did you not have a period?
DON'T KNOW 98
422. CHECK 227:
RESPONDENT 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]
NO 2 (GO TO 425)
424. For how many months after the birth of (NAME) did you not have sexual relations?
DON'T KNOW 98
425. Did you ever breastfeed (NAME)?
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.
HOURS 1 ___
DAYS 2 ___
DEAD (GO TO 429)
428. Are you still breastfeeding (NAME)?
NO 2
429. For how many months did you breastfeed (NAME)?
DON'T KNOW 98
430. Why did you stop breastfeeding (NAME)?
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
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.
433. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC PROBE FOR APPROXIMATE NUMBER.
434. Did (NAME) drink anything from a bottle with a nipple yesterday or last night?
NO 2
DON'T KNOW 8
435. At any time yesterday or last night, was (NAME) given any of the following:
Plain water?
Sugar water?
Juice?
Herbal tea?
Baby formula?
Tinned, powdered milk?
Fresh milk?
Other liquids?
Food made from grain?
Food made from tuber?
Eggs/fish/poultry?
Meat?
Other solid/semi-solid foods?
Any other solid or semi-solid foods?
IF DON'T KNOW, RECORD '8'.
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
NO 2
DOESN'T KNOW 8
436. CHECK 435:
FOOD OR LIQUID GIVEN YESTERDAY?
"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'.
DON'T KNOW 8
438. On how many days during the last seven days was (NAME) given any of the following:
Plain water?
Any kind of milk (other than breast milk)?
Liquids other than plain water or milk?
Food made from (WHEAT, MAIZE, RICE, SORGHUM, OR LOCAL GRAIN)?
Food made from (CASSAVA, PLANTAIN, YAMS, OR LOCAL TUBER)?
Eggs, fish, or poultry?
Meat?
Any other solid or semi-solid foods?
IF DON'T KNOW, RECORD '8'.
SECTION 4B. IMMUNIZATION AND HEALTH
440. ENTER LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1992. 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
442. FROM QUESTION 212 AND 216.
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, NOT SEEN 2 (GO TO 447)
NO CARD 3
444. Did you ever have a vaccination card for (NAME)?
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.
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
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).
NO 2 (GO TO 449)
DON'T KNOW 8 (GO TO 449)
447. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?
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?
NO 2
DON'T KNOW 8
448B. Polio vaccine, that is, drops in the mouth?
NO 2 (GO TO 448E)
DON'T KNOW 8 (GO TO 448E)
448D. When was the first polio vaccine given, just after birth or later?
LATER 2
448E. DPT vaccination, that is, an injection usually given at the same time as polio drops?
NO 2 (GO TO 448G)
DOESN'T KNOW 8 (GO TO 448G)
448G. An injection to prevent measles?
NO 2
DON'T KNOW 8
449. Has (NAME) been ill with a fever at any time in the last 2 weeks?
NO 2
DON'T KNOW 8
450. Has (NAME) been ill with a cough at any time in the last 2 weeks?
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?
NO 2
DON'T KNOW 8
452. Did you seek advice or treatment for the cough?
NO 2 (GO TO 454)
453. Where did you seek advice or treatment?
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
COMMUNITY HEALTH WORKER E
OTHER PUBLIC (SPECIFY) __________ F
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
COMMUNITY HEALTH WORKER K
OTHER PRIVATE MEDICAL (SPECIFY) __________ L
TRADITIONAL PRACTITIONER N
454. Has (NAME) had diarrhea in the last two weeks?
NO 2 (GO TO 464)
DON'T KNOW 8 (GO TO 464)
455. Was there any blood in the stools?
NO 2 (GO TO 464)
DON'T KNOW 8 (GO TO 464)
456. On the worst day of the diarrhea, how many bowel movements did (NAME) have?
DON' T KNOW 98
457. Was he/she given the same amount to drink as before the diarrhea, or more, or less?
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?
MORE 2
LESS 3
DON'T KNOW 8
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)?
Thin watery gruel made from (rice or other local grain, tuber, plantain)?
Soup?
Homemade sugar-salt-water solution (local unacceptable fluid)?
Milk or infant formula?
Yoghurt-based drink (other local acceptable fluid)?
Water?
Any other liquids?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
460. Was anything (else) given to treat the diarrhea?
NO 2 (GO TO 462)
DON'T KNOW 8 (GO TO 462)
461. What was given to treat the diarrhea?
INJECTION B
(I.V.) INTRAVENOUS C
HOME REMEDIES/HERBAL MEDICINES D
OTHER (SPECIFY) __________ X
Anything else?
RECORD ALL MENTIONED.
462. Did you seek advice or treatment for the diarrhea?
NO 2 (GO TO 464)
463. Where did you seek advice or treatment?
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
COMMUNITY HEALTH WORKER E
OTHER PUBLIC (SPECIFY) __________ F
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
COMMUNITY HEALTH WORKER K
OTHER PRIVATE MEDICAL (SPECIFY) __________ L
TRADITIONAL PRACTITIONER N
Anything else?
RECORD ALL MENTIONED.
465. When a child has diarrhea, should he/she be given less to drink than usual, about the same amount, or more than usual?
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?
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?
ANY WATERY STOOLS B
REPEATED VOMITING C
ANY VOMITING D
BLOOD IN STOOLS E
FEVER F
MARKED THIRST G
NOT EATING/NOT DRINKING WELL H
GETTING SICKER/VERY SICK I
NOT GETTING BETTER J
DON'T KNOW Z
RECORD ALL MENTIONED.
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?
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
DON'T KNOW Z
RECORD ALL MENTIONED.
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?
NO 2
501. PRESENCE OF OTHERS AT THIS POINT.
NO 2
NO 2
NO 2
NO 2
502. Are you currently married or living with a man?
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?
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3
504. Have you ever been married or lived with a man?
YES, LIVED WITH A MAN 2 (GO TO 511)
NO 3 (GO TO 515)
506. What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (GO TO 511)
SEPARATED 3 (GO TO 511)
507. Is your husband/partner living with you now or is he staying elsewhere?
STAYING ELSEWHERE 2
508. Does your husband/partner have any other wives besides yourself?
NO 2 (GO TO 511)
509. How many other wives does he have?
DON'T KNOW 98 (GO TO 511)
510. Are you the first, second,... wife?
511. Have you been married or lived with a man only once, or more than once?
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?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
513. How old were you when you started living with him?
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)?
DAYS AGO 1. ___
WEEKS AGO 2. ___
MONTHS AGO 3. ___
YEARS AGO 4. ___
BEFORE LAST BIRTH 996
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?
NO 2
DON'T KNOW 8
517. Do you know of a place where you can get condoms?
NO 2 (GO TO 519)
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
FIELDWORKER 15
OTHER PUBLIC (SPECIFY) __________ 16
PHARMACY 22
PRIVATE DOCTOR 23
MOBILE CLINIC 24
FIELDWORKER 25
OTHER PRIVATE MEDICAL (SPECIFY) __________ 26
CHURCH 32
FRIEND/RELATIVE 33
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.
519. How old were you when you first had sexual intercourse?
FIRST TIME WHEN MARRIED 96
SECTION 6. FERTILITY PREFERENCES
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?
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?
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
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?
UNHAPPY 2
WOULD NOT MATTER 3
606. CHECK 313: USING A METHOD?
NOT CURRENTLY USING (GO TO 607)
CURRENTLY USING (GO TO 612)
607. Do you think you will use a method to delay or avoid pregnancy within the next 12 months?
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?
NO 2 (GO TO 610)
DON'T KNOW 8 (GO TO 610)
609. Which method would you prefer to use?
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 08 (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?
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
WANTS MORE CHILDREN 26
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
KNOWS NO SOURCE 42 (GO TO 612)
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
611. Would you ever use a method if you were married?
NO 2
DON'T KNOW 8
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?
OTHER (SPECIFY) ________ 96 (GO TO 614)
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?
OTHER (SPECIFY) __________ 96
NUMBER OF GIRLS ___
OTHER (SPECIFY) __________ 96
NUMBER OF EITHER ___
OTHER (SPECIFY) __________ 96
614. Would you say that you approve or disapprove of couples using a method to avoid getting pregnant?
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?
NOT ACCEPTABLE 2
DON'T KNOW 8
NOT ACCEPTABLE 2
DON'T KNOW 8
616. In the last few months have you heard about family planning:
On the radio?
On the television?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?
NO 2
NO 2
NO 2
NO 2
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?
NO 2 (GO TO 620)
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
MOTHER-IN-LAW G
FRIENDS/NEIGHBORS H
OTHER (SPECIFY) __________ X
YES, LIVING WITH A MAN (GO TO 621)
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?
DISAPPROVES 2
DON'T KNOW 8
622. How often have you talked to your husband/partner about family planning in the past year?
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?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK
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?
703. Did your (last) husband/partner ever attend school?
NO 2 (GO TO 706)
704. What was the highest level of school he attended:
SECONDARY HIGHER 3
DON'T KNOW 8 (GO TO 706)
705. What was the highest grade/form/year he completed at that level?
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?
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?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
709. Aside from your own housework, are you currently working?
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?
NO 2
711. Have you done any work in the last 12 months?
NO 2 (GO TO 801)
712. What is your occupation, that is, what kind of work do you mainly do?
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?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
715. Do you do this work for a member of your family, for someone else, or are you self-employed?
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?
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?
718. During the last 12 months, how many days a week did you usually work (in the months that you worked)?
719. During the last 12 months, approximately how many days did you work?
720. Do you earn cash for your work?
PROBE: Do you make money for working?
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 DAY 2 _____
PER WEEK 3 _____
PER MOTH 4 _____
PER YEAR 5 _____
OTHER (SPECIFY) __________ 999996
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?
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?
AWAY 2
724. CHECK 217 AND 218:
IS A CHILD LIVING AT HOME WHO IS AGE 5 OR LESS?
NO (GO TO 801)
725. Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?
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
801. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 811)
802. From which sources of information have you learned most about AIDS?
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?
NO 2 (GO TO 807)
DON'T KNOW 8 (GO TO 807)
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
DID NOT MENTION SAFE SEX (GO TO 807)
806. What does "safe sex" mean to you?
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?
NO 2
DON'T KNOW 8
808. Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?
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?
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.
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
MINUTES ___
NO BIRTHS SINCE JANUARY 1992 (END)
IN 902 (COLUMNS 2 AND 3) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE 1991* AND STILL ALIVE. IN 903 AND 904 RECORD THE NAME AND BIRTH DATE FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE 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 1991]
903. NAME FROM QUESTION 212 FOR CHILDREN
904. DATE OF BIRTH FROM QUESTION 215, AND ASK FOR DAY OF BIRTH
[ONLY CHILDREN BORN SINCE 1991]
MONTH __________
YEAR _____
905. BCG SCAR ON TOP OF LEFT SHOULDER
[ONLY CHILDREN BORN SINCE 1991]
NO SCAR 2
907. WAS LENGTH/HEIGHT OF CHILD MEASURED LYING DOWN OR STANDING UP?
STANDING 2
909. DATE, WEIGHED AND MEASURED
MONTH __________
YEAR _____
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) __________ 9
NAME OF ASSISTANT __________
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: __________