[NAME OF COUNTRY]
[NAME OF ORGANIZATION]

IDENTIFICATION (1)

PLACE NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
REGION

LARGE CITY/SMALL CITY/TOWN/RURAL (2)

NAME AND LINE NUMBER OF MAN

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

NEXT VISIT
DATE
TIME

TOTAL NUMBER OF VISITS

*RESULT CODES:

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

1 This section should be adapted for country-specific survey design.
2 The following guidelines should be used to categorize urban sample points: "Large cities" are national capitals and places with over 1 million population; "small cities" are places with between 50,000 and 1 million population; remaining urban sample points are "towns".

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT
INFORMED CONSENT

Hello. My name is _______________________________________ and I am working with (NAME OF ORGANIZATION). We are conducting a national survey that asks men and women about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes about 20 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
Signature of interviewer: _________
Date: _________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101 RECORD THE TIME.

102 How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

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

Questions 104-105 are part of the HIV/AIDS module and they should be deleted in surveys where the module is not adopted.

104 (1) In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?

105 (1) In the last 12 months, have you been away from your home community for more than one month at a time?

106 In what month and year were you born?

107 How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.

108 Have you ever attended school?

109 What is the highest level of school you attended: primary, secondary, or higher? (2)

110 What is the highest (grade/form/year) you completed at that level? (2)

111 CHECK 109:

112 Now I would like you to read this sentence to me. SHOW CARD TO RESPONDENT. (3)
IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE:
Can you read any part of the sentence to me?

113 Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)? (4)

114 CHECK 112:

115 Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?

116 Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

117 Do you watch television almost every day, at least once a week, less than once a week or not at all?

118 COUNTRY-SPECIFIC QUESTION ON RELIGION.

119 COUNTRY-SPECIFIC QUESTION ON ETHNICITY.

1 The question must be included in all surveys in which HIV testing is a component of the survey. It should be deleted in surveys where the HIV/AIDS module is not adopted.
2 Revise according to the local education system.
3 Each card should have four simple sentences appropriate to the country (e.g., "Parents love their children", "Farming is hard work", "The child is reading a book", "Children work hard at school"). Cards should be prepared for every language in which respondents are likely to be literate.
4 In countries with an interest in measuring participation across a number of literacy programs, an additional multiple-response question may be included for women who participated in a literacy program (for example, "What type of literacy programs have you participated in? PROBE: Any other programs?")

SECTION 2. REPRODUCTION

201 Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name.
Have you ever fathered any children with any woman?

202 Do you have any sons or daughters that you have fathered who are now living with you?

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

204 Do you have any sons or daughters that you have fathered who are alive but do not live with you?

205 How many sons are alive but do not live with you?
And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

206 Have you ever fathered a son or a daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

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

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

209 CHECK 208:

210 Did all of the children you have fathered have the same biological mother?

211 In all, how many women have you fathered children with?

212 How old were you when your (first) child was born?

213 CHECK 203 AND 205:

214 How many years old is your (youngest) child?

215 CHECK 214:

216 What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD

217 When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?

218 Were you ever present during any of those antenatal check-ups?

219 Was (NAME) born in a hospital or health facility?

220 What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?

221When a child has diarrhea, how much should he or she be given to drink: more than usual, the same amount as usual, less than usual, or should he or she not be given anything to drink at all?

SECTION 3. CONTRACEPTION

301 Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.
Which ways or methods have you heard about? (1)
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK:
Have you ever heard of (METHOD)?
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR METHODS 02, 07, 10, AND 11, ASK 302 IF 301 HAS CODE 1 CIRCLED.

The LAM method should be deleted in countries that do not have a LAM program.

302 Have you ever used (METHOD)?

303 In the last few months have you:

Heard about family planning on the radio?
Seen about family planning on the television?
Read about family planning in a newspaper or magazine?

304 In the last few months, have you discussed the practice of family planning with a health worker or health professional?

305 Now I would like to ask you about a woman's risk of pregnancy.
From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

306 Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods? (3)

307 Do you think that a woman who is breastfeeding her baby can become pregnant?

308 I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.
a) Contraception is women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.

309 CHECK 301 (07) KNOWS MALE CONDOM

310 Do you know of a place where a person can get condoms?

311 Where is that? (4)
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

312 If you wanted to, could you yourself get a condom?

Question 313-316 should be deleted in countries where female condoms are not actively promoted.

313 CHECK 301 (08) KNOWS FEMALE CONDOM (5)

314 (5) Do you know of a place where a person can get female condoms?

315 (5) Where is that? (4)
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

316 (5) If you wanted to, could you yourself get a female condom?

1 Other commonly used methods may be added to the list, such as diaphragm, foam, jelly, contraceptive patch, sponge, or specific fertility awareness methods such as the Standard Days Method.
2 The LAM method should be deleted in countries that do not have a LAM program. In these countries, LAM should also be deleted as a coding category in Q. 444.
3 In countries where the Standard Days Method is used, an appropriate response category for that method may be added.
4 Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
5 The question should be deleted in countries where female condoms are not actively promoted.

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401 Are you currently married or living together with a woman as if married?

402 Have you ever been married or lived together with a woman as if married?

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

404 Is your wife/partner living with you now or is she staying elsewhere?

Questions 405-407 and Question 409 should be deleted in countries where polygyny is not practiced and replaced with Question 605 from the Woman's Questionnaire with the word 'HUSBAND'S' replaced with 'WIFE'S' and 'HE' replaced with 'SHE'.

405 (1) Do you have more than one wife or woman you live with as if married?

406 (1) Altogether, how many wives do you have or other partners do you live with as if married?

407 CHECK 405:
ONE WIFE/ PARTNER
Please tell me the name of your wife (the woman you are living with as if married).

MORE THAN ONE WIFE/PARTNER
Please tell me the name of each of your current wives (and/or of each woman you are living with as if married).

RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.
IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.
ASK 408 FOR EACH PERSON.

In countries where polygyny is not practiced, Question 408 should be retained for only one wife/partner.

408 How old was (NAME) on her last birthday?

409 (1) CHECK 407:

410 Have you been married or lived with a woman only once or more than once?

411 In what month and year did you start living with your (wife/partner)?
411A Now I would like to ask a question about your first wife/partner.
In what month and year did you start living with your first wife/partner?

412 How old were you when you first started living with her?

413 CHECK FOR THE PRESENCE OF OTHERS.
BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

414 Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.
How old were you when you had sexual intercourse for the very first time?

415 CHECK 107:

416 Do you intend to wait until you get married to have sexual intercourse for the first time?

417 CHECK 107:

418 The first time you had sexual intercourse, was a condom used? (2)

419 When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

420 Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question. (GO TO 422)

421 When was the last time you had sexual intercourse with this person?

422 The last time you had sexual intercourse (with this second/third person), was a condom used? (2)

423 Was a condom used every time you had sexual intercourse with this person in the last12 months?

424 What was your relationship to this (second/third) person with whom you had sexual intercourse?
IF GIRLFRIEND:
Were you living together as if married?
IF YES, CIRCLE '2'.
IF NO, CIRCLE '3'.

425 For how long (have you had/did you have) a sexual relationship with this (second/third) person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

426 The last time you had sexual intercourse with this (second/third) person, did you or this person drink alcohol?

427 Were you or your partner drunk at that time?
IF YES: Who was drunk?

428 Apart from [this person/these two people], have you had sexual intercourse with any other person in the last 12 months?

429 In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'

430 CHECK 424 (ALL COLUMNS):

431 CHECK 424 AND 422 (ALL COLUMNS):

432 In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

433 The last time you paid someone in exchange for having sexual intercourse, was a condom used? (2)

434 Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?

435 In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'

436 (2) CHECK 422, MOST RECENT PARTNER (FIRST COLUMN):

437 (2) You told me that a condom was used the last time you had sex.
May I see the package of condoms you were using at that time?
RECORD NAME OF BRAND IF PACKAGE SEEN.

438(2) Do you know the brand name of the condom used at that time?
RECORD NAME OF BRAND.

439 (2) How many condoms did you get the last time?

440 The last time you obtained the condoms, how much did you pay in total, including the cost of the condom(s) and any consultation you may have had?

441(2) From where did you obtain the condom the last time? (3)
PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

442 CHECK 302 (02): RESPONDENT EVER STERILIZED

443 The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

444 What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED.

1 Delete Qs. 405-407 and 409 in countries where polygyny is not practiced and replace with Q. 605 from the Woman's Questionnaire with the word 'HUSBAND'S' replaced with 'WIFE'S' and 'HE' replaced with 'SHE'.
2 In countries with an active female condom program, the wording of the question should be modified to include reference to both the male and female condom.
3 Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.

SECTION 5. FERTILITY PREFERENCES

501 (1) CHECK 407:

502 CHECK 302:

503(1) (Is your wife (partner)/Are any of your wives (partners)) currently pregnant?

504 (1) CHECK 503:
NO WIFE/PARTNER PREGNANT OR DON'T KNOW
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?

WIFE(WIVES)/PARTNER(S) PREGNANT
Now I have some questions about the future. After the child (ren) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not to have any more children?

505 (2) CHECK 407:

506 CHECK 503:
WIFE/PARTNER NOT PREGNANT OR DON'T KNOW
How long would you like to wait from now before the birth of (a/another) child?

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

507 (2) How long would you like to wait from now before the birth of (a/another) child?

508 CHECK 203 AND 205:
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?

PROBE FOR A NUMERIC RESPONSE.

509 How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?

1 The wording of this question should be modified in countries where polygyny is not practiced. In Q. 501, change the filter question to 'CHECK 401, change the left-hand category to 'CURRENTLY MARRIED/LIVING WITH A MAN', and change the right-hand category to 'NOT IN UNION'.
2 This question should be deleted in countries where polygyny is not practiced.

SECTION 6. EMPLOYMENT AND GENDER ROLES

601 Have you done any work in the last seven days?

602 Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, or any other such reason?

603 Have you done any work in the last 12 months?

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

605 CHECK 604:

606 Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

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

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

609 Are you paid in cash or kind for this work or are you not paid at all?

610 (1) CHECK 407:

611 CHECK 609:

612 (1) Who usually decides how the money you earn will be used:
mainly you, mainly your (wife (wives)/partner(s)), or you and your (wife (wives)/partner(s)) jointly?

613 In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally:

614 I will now read you some statements about pregnancy.
Please tell me if you agree or disagree with them.
a) Childbearing is a woman's concern and there is no need for the father to get involved.
b) It is crucial for the mother's and child's health that a woman have assistance from a doctor or nurse at delivery.

615 Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:
If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

616 Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to?

1 The wording of this question should be modified in countries where polygyny is not practiced. In Q. 610, change the filter question to 'CHECK 401, change the left-hand category to 'CURRENTLY MARRIED', and change the right-hand category to 'NOT CURRENTLY MARRIED'.

SECTION 7. HIV/AIDS

701 Now I would like to talk about something else.
Have you ever heard of an illness called AIDS?

702 Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

703 (1) Can people get the AIDS virus from mosquito bites?

704 Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

705 (1) Can people get the AIDS virus by sharing food with a person who has AIDS?

706 Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

707 (1) Can people get the AIDS virus because of witchcraft or other supernatural means?

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

Questions 709-717 should be deleted in surveys where the HIV/AIDS module is not adopted.

709 (2) Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
During delivery?
By breastfeeding?

710 (2) CHECK 709:

711 (2) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?

712 (2) Have you heard about special antiretroviral drugs (USE LOCAL NAME) that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

712A CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

713 (2) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

714 (2) When was the last time you were tested?

715 (2) The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

716 (2) I don't want to know the results, but did you get the results of the test?

717 (2) Where was the test done? (3)
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

718 Do you know of a place where people can go to get tested for the AIDS virus?

719 Where is that? (3)
Any other place?
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

720 Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

721 If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?

722 If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

723 In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

Questions 724-730 are used to assess aspects of the President's Emergency Plan for AIDS Relief and must be included in the countries targeted for special initiatives under the Plan.

724 (4) Do you personally know someone who has been denied health services in the last 12 months because he or she has or is suspected to have the AIDS virus?

725 (4) Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she has or is suspected to have the AIDS virus?

726 (4) Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she has or is suspected to have the AIDS virus?

727 (4) CHECK 724, 725, AND 726:

728 (4) Do you personally know someone who has or is suspected to have the AIDS virus?

729 (4) Do you agree or disagree with the following statement:
People with the AIDS virus should be ashamed of themselves.

730 (4) Do you agree or disagree with the following statement:
People with the AIDS virus should be blamed for bringing the disease into the community.

Questions 731-732 should be deleted in surveys where the HIV/AIDS module is not adopted.

731 (2) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

732 Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS?

733 CHECK 701:
HEARD ABOUT AIDS
Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

NOT HEARD ABOUT AIDS
Have you heard about infections that can be transmitted through sexual contact?

734 CHECK 414:

735 CHECK 733: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

736 Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

737 Sometimes men experience an abnormal discharge from their penis.
During the last 12 months, have you had an abnormal discharge from your penis?

Questions 731-732 should be deleted in surveys where the HIV/AIDS module is not adopted.

738 Sometimes men have a sore or ulcer near their penis.
During the last 12 months, have you had a sore or ulcer near your penis?

739 CHECK 736, 737, AND 738:

740 The last time you had (PROBLEM FROM 736/737/738), did you seek any kind of advice or treatment?

741Where did you go? (3)
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

742 Husband and wives do not always agree in everything.
If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

Question 743 should be deleted in surveys where the HIV/AIDS module is not adopted.

743 (2) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

744 Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

745 Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women? (5)

746-757 are used to assess aspects of the President's Emergency Plan for AIDS Relief and must be included in the countries targeted for special initiatives under the Plan.

746 (4) Do you believe that young men should wait until they are married to have sexual intercourse?

747 (4) Do you think that most young men you know wait until they are married to have sexual intercourse?

748 (4) Do you believe that men who are not married and are having sex should only have sex with one partner?

749 (4) Do you think that most men you know who are not married and are having sex have sex with only one partner?

750 (4) Do you believe that married men should only have sex with their wives?

751 (4) Do you think that most married men you know have sex only with their wives?

752 (4) Do you believe that young women should wait until they are married to have sexual intercourse?

753 (4) Do you think that most young women you know wait until they are married to have sexual intercourse?

754 (4) Do you believe that women who are not married and are having sex should only have sex with one partner?

755 (4) Do you think that most women you know who are not married and are having sex have sex with only one partner?

756 (4) Do you believe that married women should only have sex with their husbands?

757 (4) Do you think that most married women you know have sex only with their husbands?

1 If 703, 705 and/or 707 do not apply to the local context, replace the question using a specific local misconception. At least two questions related to misconceptions are needed.
2 The question should be deleted in surveys where the HIV/AIDS module is not adopted.
3 Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
4 The question is used to assess aspects of the President's Emergency Plan for AIDS Relief and must be included in the countries targeted for special initiatives under the Plan.
5 In polygynous societies, the phrase 'other women' should be replaced by the phrase 'women other than his wives'.

SECTION 8. OTHER HEALTH ISSUES

801 Have you ever heard of an illness called tuberculosis or TB? (1)

802 How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

803 Can tuberculosis be cured?

804 If a member of your family got tuberculosis, would you want it to remain a secret or not?

805 (2) Some men are circumcised. Are you circumcised?

806 Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

807 Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

808 The last time you had an injection given to you by a health worker, where did you go to get the injection? (3)
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

809 Did the person who gave you that injection take the syringe and needle from a new, unopened package?

810 Do you currently smoke cigarettes?

811 In the last 24 hours, how many cigarettes did you smoke?

812 Do you currently smoke or use any other type of tobacco? (4)

813 What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

814 Are you covered by any health insurance? (5)

815 What type of health insurance?
RECORD ALL MENTIONED.

Questions 816-819 relate to the situation of orphans and vulnerable children and are part of the HIV/AIDS module. They should be included only in countries where HIV prevalence is higher than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents have died).

816 (6) CHECK 214:

817 (6) Now I would like to ask you about your own child(ren) who (is/are) under the age of 18.
Have you made arrangements for someone to care for (him/her/them) in the event that you fall sick or are unable to care for (him/her/them)?

818 (6) (Besides your own child/children), are you the primary caregiver for any children under the age of 18?

819 Have you made arrangements for someone to care for (this child/these children) in the event that you fall sick or are unable to care for (him/her/them)?

820 RECORD THE TIME.

1 Add local term for TB, if any.
2 Question may be omitted depending on the practice of male circumcision in specific countries.
Some countries may consider including the male circumcision module here.
3 Coding categories to be developed locally and revised based on the pretest; however, the broad categories must be maintained.
4 Use local terms.
5 If a health service prepayment plan or other types of plans are available in the country, add those types of plans in the question.
6 The question relates to the situation of orphans and vulnerable children is part of the HIV/AIDS module.
It should be included only in countries where HIV prevalence is greater than 5 percent or where more than 8 percent of children age 0-17 years are orphans (i.e., one or both biological parents have died).

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:
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COMMENTS ON SPECIFIC QUESTIONS:
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ANY OTHER COMMENTS:
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SUPERVISOR'S OBSERVATIONS
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NAME OF SUPERVISOR: ___________
DATE: ______________

EDITOR'S OBSERVATIONS
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NAME OF EDITOR: ______________
DATE: ______________