DEMOGRAPHIC AND HEALTH SURVEYS
MODEL WOMAN'S QUESTIONNAIRE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________
(1) This section should be adapted for country-specific survey design.
FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __
TOTAL NUMBER OF VISITS: __
*RESULT CODES:
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) __________
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NAME ______
NUMBER __ __ __ __
FIELD EDITOR
NAME ______
NUMBER __ __ __ __
OFFICE EDITOR
NUMBER __ __
KEYED BY
NUMBER __ __
DOMESTIC VIOLENCE MODULE
DV00) CHECK COVER PAGE: WOMAN SELECTED FOR DV MODULE?
WOMAN NOT SELECTED (GO TO NEXT SECTION)
DV01) CHECK FOR PRESENCE OF OTHERS: DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.
PRIVACY NOT POSSIBLE 2 (GO TO DV32)
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in [COUNTRY]. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions. If I ask you any question you don't want to answer, just let me know and I will go on to the next question.
FORMERLY MARRIED/LIVED WITH A MAN (READ IN PAST TENSE AND USE 'LAST' WITH (husband/partner)) (GO TO DV03)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO DV16)
DV03) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) (husband/partner)?
a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your female friends?
d) He (tries/tried) to limit your contact with your family?
e) He (insists/insisted) on knowing where you (are/were) at all times?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DK 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
DV04) Now I need to ask some more questions about your relationship with your (last) (husband/partner).
DV04A. Did your (last) (husband/partner) ever:
a) say or do something to humiliate you in front of others?
NO 2
b) threaten to hurt or harm you or someone close to you?
NO 2
c) insult you or make you feel bad about yourself?
NO 2
B. How often did this happen during the last 12 months: often, only sometimes or not at all?
a) say or do something to humiliate you in front of others?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) threaten to hurt or harm you or someone close to you?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) insult you or make you feel bad about yourself?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
DV05 A) Did your (last) (husband/partner) ever do any of the following things to you:
a) push you, shake you, or throw something at you?
NO 2
b) slap you?
NO 2
c) twist your arm or pull your hair?
NO 2
d) punch you with his fists or with something that could hurt you?
NO 2
e) kick you, drag you or beat you up?
NO 2
f) try to choke you or burn you on purpose?
NO 2
g) threaten to attack you with a knife, gun, or any other weapon?
NO 2
h) physically force you to have sexual intercourse with him when you did not want to?
NO 2
i) physically force you to perform any other sexual acts you did not want to?
NO 2
j) force you with threats or in any other way to perform sexual acts you did not want to?
NO 2
DV05 B) How often did this happen during the last 12 months: often, only sometimes, or not at all?
a) push you, shake you, or throw something at you?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) slap you?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) twist your arm or pull your hair?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
d) punch you with his fist or with something that could hurt you?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) kick you, drag you or beat you up?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) try to choke you or burn you on purpose?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) threaten to attack you with a knife, gun, or other weapon?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) physically force you to have sexual intercourse with him when you did not want to?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
i) physically force you to perform any other sexual acts that you did not want to?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
j) force you with threats or in any other way to perform sexual acts that you did not want to?
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
NOT A SINGLE 'YES' (GO TO DV09)
DV07) How long after you first (got married/started living together) with your (last) (husband/partner) did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD '00'.
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95
DV08) Did the following ever happen as a result of what your (last) (husband/partner) did to you:
NO 2
NO 2
NO 2
DV09) Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) (husband/partner) at times when he was not already beating or physically hurting you?
NO 2 (GO TO DV11)
DV10) In the last 12 months, how often have you done this to your (last) (husband/partner): often, only sometimes, or not at all?
SOMETIMES 2
NOT AT ALL 3
DV11) Does (did) your (last) (husband/partner) drink alcohol?
NO 2 (GO TO DV13)
DV12) How often does (did) he get drunk: often, only sometimes, or never?
SOMETIMES 2
NEVER 3
DV13) Are (Were) you afraid of your (last) (husband/partner): most of the time, sometimes, or never?
SOMETIMES AFRAID 2
NEVER AFRAID 3
MARRIED ONLY ONCE (GO TO DV16)
DV15) A. So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).
a) Did any previous (husband/partner) ever hit, slap, kick, or do anything else to hurt you physically?
NO 2
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
NO 2
c) Did any previous (husband/partner) humiliate you in front of others, threaten to hurt you or someone you care about, or insult you or make you feel bad about yourself?
NO 2
DV15B) How long ago did this happen?
a) How long ago did any previous (husband/partner) ever hit, slap, kick, or do anything else to hurt you physically?
12+ MONTHS AGO 2
DON'T REMEMBER 3
b) How long ago did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
12+ MONTHS AGO 2
DON'T REMEMBER 3
c) How long ago did any previous (husband/partner) humiliate you in front of others, threaten to hurt you or someone you care about, or insult you or make you feel bad about yourself?
12+ MONTHS AGO 2
DON'T REMEMBER 3
a) From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, or done anything else to hurt you physically?
NEVER MARRIED/NEVER LIVED WITH A MAN:
b) From the time you were 15 years old has anyone hit you, slapped you, kicked you, or done anything else to hurt you physically?
NO 2 (GO TO DV19)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO DV19)
DV17) Who has hurt you in this way?
Anyone else?
RECORD ALL MENTIONED.
FATHER/STEP-FATHER B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT BOYFRIEND F
FORMER BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAW J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
OTHER (SPECIFY) ________________ X
DV18) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?
SOMETIMES 2
NOT AT ALL 3
DV19) CHECK 201, 226, AND 230:
NEVER BEEN PREGNANT (GO TO DV22)
DV20) Has any one ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?
NO 2 (GO TO DV22)
DV21) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED.
MOTHER/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/PARTNER G
CURRENT BOYFRIEND H
FORMER BOYFRIEND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
OTHER IN-LAW L
TEACHER M
EMPLOYER/SOMEONE AT WORK N
POLICE/SOLDIER O
OTHER (SPECIFY) _______________ X
A. Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner). At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?
NO 2 (GO TO DV24A)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO DV24A)
NEVER MARRIED/NEVER LIVED WITH A MAN:
B. At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?
NO 2 (GO TO DV26)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO DV26)
DV23) Who was the person who was forcing you the very first time this happened?
FORMER HUSBAND/PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY) _______________ 96
a) In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?
NEVER MARRIED/NEVER LIVED WITH A MAN:
b) In the last 12 months has anyone physically forced you to have sexual intercourse when you did not want to?
NO 2 (GO TO DV25)
DV24A) CHECK DV05A (h-j) and DV15A(b)
NOT A SINGLE 'YES' (GO TO DV26)
EVER MARRIED/EVER LIVED WITH A MAN:
a) How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts by anyone, including (your/any) husband/partner?
NEVER MARRIED/NEVER LIVED WITH A MAN:
b) How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?
DON'T KNOW 98
DV26) CHECK DV05A (a-j), DV15A (a,b), DV16, DV20, DV22A, AND DV22B:
NOT A SINGLE 'YES' (GO TO DV30)
DV27) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?
NO 2 (GO TO DV29)
DV28) From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.
HUSBAND'S/PARTNER'S FAMILY B (GO TO DV30)
CURRENT/FORMER HUSBAND/PARTNER C (GO TO DV30)
CURRENT/FORMER BOYFRIEND C (GO TO DV30)
FRIEND E (GO TO DV30)
NEIGHBOR F (GO TO DV30)
RELIGIOUS LEADER G (GO TO DV30)
DOCTOR/MEDICAL PERSONNEL H (GO TO DV30)
POLICE I (GO TO DV30)
LAWYER J (GO TO DV30)
SOCIAL SERVICE ORGANIZATION K (GO TO DV30)
OTHER (SPECIFY) ______________ X (GO TO DV30)
DV29) Have you ever told anyone about this?
NO 2
DV30) As far as you know, did your father ever beat your mother?
NO 2
DON'T KNOW 8
THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.
DV31) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
DV32) INTERVIEWER'S COMMENTS / EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE _____