Data Cart

Your data extract

0 variables
0 samples
View Cart



BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2011
WOMAN'S QUESTIONNAIRE

NIPORT, MOHFW, and Mitra and Associates

IDENTIFICATION

CLUSTER NUMBER __________

HOUSEHOLD NUMBER __________

NAME OF THE HOUSEHOLD HEAD __________

NAME AND LINE NUMBER OF WOMAN __________

INTERVIEWER VISITS

FIRST VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

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

NEXT VISIT:
DATE____
TIME____

SECOND VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

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

NEXT VISIT:
DATE____
TIME____

THIRD VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

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

FINAL VISIT:
DAY____
MONTH____
YEAR____
INT. NUMBER____
RESULT:

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

TOTAL NUMBER OF VISITS____

NUMBER OF CHILD DEATHS 0-28 DAYS _______

NUMBER OF CHILD DEATHS 29 DAYS TO UNDER 5 YEARS _________

SUPERVISOR

NAME ___________
DATE ____________

FIELD EDITOR

NAME ___________
DATE ____________

OFFICE EDITOR ________

KEYED BY _________

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is__________________________. I am working with NIPORT, the Ministry of Health and Family Welfare, and Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all over Bangladesh. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If you I ask you 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.

Do you have any questions? May I begin the interview now?

SIGNATURE OF INTERVIEWER: ________________________

DATE: _______________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NO AGREE TO BE INTERVIEWED 2 (END)

101) RECORD THE TIME.

HOUR __________
MINUTES _________

102) In what month and year were you born?

MONTH ________
DON'T KNOW MONTH 98
YEAR ________
DON'T KNOW YEAR 9998

103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

AGE IN COMPLETED YEARS ________

103A) Are you now married, separated, deserted divorced, widowed, or have you never been married?

CURRENTLY MARRIED 1
SEPARATED 2
DESERTED 3
DIVORCED 4
WIDOWED 5
NEVER MARRIED 6 (END)

104) Have you ever attended school/madrasha?

YES 1
NO 2 (GO TO 108)

104A) What type of school have you last attended?

SCHOOL 1
MADRASHA 2

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

PRIMARY 1
SECONDARY 2
HIGHER 3

106) What is the highest class you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

CLASS ________

107) CHECK 105:

PRIMARY (GO TO 108)
SECONDARY OR HIGHER (GO TO 110)

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

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) ___________ 4
BLIND/VISUALLY IMPAIRED 5

109) CHECK 108:

CODE '2', '3', OR '4' CIRCLED (CONTINUE)
CODE '1' OR '5' CIRCLED (GO TO 111)

110) Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

111) Do you listen to the radio at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

112) Do you watch television at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

112A) Do you personally have a mobile phone?

YES 1 (GO TO 113)
NO 2

112B) Do you have access to a mobile phone?

YES 1
NO 2

113) What is your religion?

ISLAM 1
HINDUISM 2
BUDDHISM 3
CHRISTIANITY 4
OTHER (SPECIFY) 6

114) Do you belong to any of the following organizations:

Grameen Bank?
YES 1
NO 2
BRAC?
YES 1
NO 2
BRDB?
YES 1
NO 2
ASHA?
YES 1
NO 2
PROSHIKA?
YES 1
NO 2
Mother's Club?
YES 1
NO 2
Any other organization (such as micro credit)?
YES 1
NO 2
(SPECIFY) _______________

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 '0'.

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)
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 BIRTHS _________

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 (CONTINUE)
NO (PROBE AND CORRECT 201-208 AS NECESSARY.)

210) CHECK 208:

ONE OR MORE BIRTHS (CONTINUE)
NO BIRTHS (SKIP TO 226)

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 ROWS. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

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

NAME____
BIRTH HISTORY NUMBER____

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

BOY 1
GIRL 2

214) Were any of these births twins?

SING 1
MULT 2

215) In what month and year was (NAME) born?
PROBE: When is his/her birthday?

MONTH ________
YEAR _________

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

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
NO 2

219) IF ALIVE:
RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD).

HOUSEHOLD LINE NUMBER __________ (GO TO NEXT BIRTH IF MOST RECENT BIRTH; GO TO 221 FOR ALL OTHERS)

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

DAYS 1 ________
MONTHS 2_______
YEARS 3 ________

221) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

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

222) Have you had any live births since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

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

NUMBERS ARE THE SAME (CONTINUE)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

223A) CHECK 215, 216 AND 220 AND ENTER THE NUMBER OF DEATHS AT AGE DAYS, MONTHS, AND 2-4 YEARS SINCE JANUARY 2006. IF NONE, RECORD '0' AND SKIP TO 224.

NUMBER OF DEATHS____

223B) CHECK 223A. IF ONE OR MORE READ THE FOLLOWING STATEMENT:

We would like to get more information on the circumstances around the deaths of young children so that the government can provide services to help reduce these deaths. We would like to come back and talk with you about your child(ren's) death. Is this okay? _____________

224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER.

NUMBER OF BIRTHS __________
NONE 0 (GO TO 226)

225) C FOR EACH BIRTH SINCE JANUARY 2006, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LET OF THE'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

YES 1
NO 2
UNSURE 8 (GO TO 229A)

227) How many months pregnant are you?
C RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

MONTHS ________

228) When you got pregnant, did you want to get pregnant at that time?

YES 1 (GO TO 229A)
NO 2

229) Did you want to have a baby later on or did you not want any (more) children?

LATER 1
NO MORE 2

229A) Have you ever heard of menstrual regulation (MR)?

YES 1
NO 2 (GO TO 230)

229B) Have you ever used MR?

YES 1
NO 2 (GO TO 230)

229C) In the last three years did you use MR?

YES 1
NO 2 (GO TO 230)

229D) Where did you use it the last time?

PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL 11
SPECIALIZED GOVT. HOSPITAL (SPECIFY) _____________ 12
DISTRICT HOSPITAL 13
MCWC 14
UPAZILLA HEALTH COMPLEX 15
H and FWC 17
SAT. CLINIC/EPI OUTREACH 18
COMMUNITY CLINIC 19
GOVT. FIELD WORKER (FWA) 20
OTHER PUBLIC SECTOR (SPECIFY) ___________ 16
NGO SECTOR
NGO STATIC CLINIC 21
NGO SATELLITE CLINIC 22
NGO DEPO HOLDER 23
NGO FIELDWORKER 24
OTHER NGO SECTOR (SPECIFY) _______________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
QUALIFIED DOCTOR'S CHAMBER 32
NONQUALIFIED DOCTOR'S CHAMBER 33
PHARMACY/DRUG STORE 34
PRIVATE MEDICAL COLLEGE HOSPITAL (SPECIFY) __________ 35
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____________ 36
OTHER (SPECIFY) _____________ 96
DON'T KNOW 98

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

YES 1
NO 2 (GO TO 238)

231) When did the last such pregnancy end?

MONTH _________
YEAR __________

232) CHECK 231:

LAST PREGNANCY ENDED JAN. 2006 OR LATER (CONTINUE)
LAST PREGNANCY ENDED BEFORE JAN. 2006 (GO TO 238)

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

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

MONTHS __________

234) Since January 2006, have you had any other pregnancies that 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 NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2006
C ENTER 'T' IN THE CALENDAR INT HE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2006?

YES 1
NO 2 (GO TO 238)

237) When did the last such pregnancy that terminated before 2006 end?

MONTH ___________
YEAR ____________

238) When did your last menstrual period start?

(DATE, IF GIVEN) ___________
DAYS AGO 1 ________
WEEKS AGO 2 __________
MONTHS AGO 3 __________
YEARS AGO 4 ___________
IN MENOPAUSE/ HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

SECTION 3. CONTRACEPTION

302) CHECK 103A:

CURRENTLY MARRIED (CONTINUE)
SEPARATED/DESERTED/DIVORCED/WIDOWED (GO TO 311)

302A) CHECK 226:

NOT PREGNANT OR UNSURE (CONTINUE)
PREGNANT (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

304) Which method are you using?
CIRCLE ALL MENTIONED.
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION A (GO TO 307)
MALE STERILIZATION B (GO TO 307)
IUD C (GO TO 308A)
INJECTABLES D (GO TO 308A)
IMPLANTS E (GO TO 308A)
PILL F
CONDOM G (GO TO 306)
SAFE PERIOD/PERIODIC ABST. L (GO TO 308A)
WITHDRAWAL M (GO TO 308A)
OTHER (SPECIFY) ____________ X ( GO TO 308A)

305) May I see the brand name of the pills you are using?
RECORD NAME OF BRAND IF PACKAGE SEEN.
IF PACKAGE NOT SEEN SHOW THE BRAND CHART.
Please tell me among these which brand of pills are you using?
WRITE THE BRAND NAME.

PACKAGE/CHART SEEN 1 (GO TO 306A)
BRAND NAME (SPECIFY) _________ (GO TO 306A)
DON'T KNOW 8 (GO TO 306)

306) May I see the brand name of the condom you are using?
RECORD NAME OF BRAND IF PACKAGE SEEN.
IF PACKAGE NOT SEEN SHOW THE BRAND CHART.
Please tell me among these which brand of condom are you using?
WRITE THE BRAND NAME .

PACKAGE/CHART SEEN 1
BRAND NAME (SPECIFY) ___________
DON'T KNOW 8

306A) Who obtained the (pills/condoms) the last time you got them?

RESPONDENT 1 (GO TO 308A)
HUSBAND (GO TO 308A)
SON/DAUGHTER 3 (GO TO 308A)
OTHER RELATIVE 4 (GO TO 308A)
OTHER (SPECIFY) _________ (GO TO 308A)

307) In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE THE PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE ) ________________
PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL 11
SPECIALISED GOVT. HOSPITAL
HOSPITAL (SPECIFY) ____________ 12
DISTRICT HOSPITAL 13
MCWC 14
UPAZILLA HEALTH COMPLEX 15
H and FWC 17
OTHER PUBLIC SECTOR (SPECIFY) __________ 16
NGO SECTOR
NGO STATIC CLINIC 21
OTHER NGO SECTOR (SPECIFY) _________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
QUALIFIED DOCTOR'S CHAMBER 32
PRIVATE MEDICAL COLLEGE HOSPTIAL (SPECIFY) _________ 34
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ___________36
OTHER (SPECIFY) _____________ 96
DON'T KNOW 98

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

MONTH____
YEAR____

308A) Since what month and year have you been using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

MONTH __________
YEAR __________

309) CHECK 308/308A, 215 AND 231:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A

YES (GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).)
NO (GO TO 310)

310) CHECK 308/308A:

YEAR IS 2006 OR LATER (DO THE FOLLOWING): C ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING.
YEAR IS 2005 OR EARLIER (DO THE FOLLOWING): C ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2006. (THEN SKIP TO 314)

311) 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 2006.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

C IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:
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 THE LAST MONTH OF USE. NUMBER OF CODE SIN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTION 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:
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.

312) CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

NO METHOD USED (CONTINUE)
ANY METHOD USED (GO TO 314)

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

YES 1 (GO TO 324)
NO 2 (GO TO 324)

314) CHECK 304:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

NO CODE CIRCLED 00 (GO TO 324)
FEMALE STERILIZATION 01 (GO TO 325A)
MALE STERILIZATION 02 (325A)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
SAFE PERIOD 12 (GO TO 324)
WITHDRAWAL 13 (GO TO 324)
OTHER MODERN METHOD 96 (GO TO 324)

323) Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF THE PLACE) _____________________
PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL A
SPECIALISED GOVT. HOSPITAL
HOSPITAL (SPECIFY) ________________ B
DISTRICT HOSPITAL C
MCWC D
UPAZILLA HEALTH COMPLEX E
H and FWC F
SAT. CLINIC/EPI OUTREACH G
COMMUNITY CLINIC H
GOVT. FIELD WORKER (FWA) I
OTHER PUBLIC SECTOR (SPECIFY) ______________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SATELLITE CLINIC L
NGO DEPO HOLDER M
NGO FIELD WORKER N
OTHER NGO SECTOR (SPECIFY) _____________ O
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC P
QUALIFIED DOCTOR'S CHAMBER Q
NON-QUALIFIED DOCTOR'S CHAMBER R
PHARMACY S
PRIVATE MEDICAL COLLEGE HOSPITAL (SPECIFY) ______________ T
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) _____________ U
OTHER SOURCE
GROCERY V
FRIENDS/RELATIVES W
OTHER (SPECIFY) _____________ X

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

YES 1
NO 2 (GO TO 325A)


325) Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF THE PLACE(S)) _____________________
PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL A
SPECIALISED GOVT. HOSPITAL
HOSPITAL (SPECIFY) ________________ B
DISTRICT HOSPITAL C
MCWC D
UPAZILLA HEALTH COMPLEX E
H and FWC F
SAT. CLINIC/EPI OUTREACH G
COMMUNITY CLINIC H
GOVT. FIELD WORKER (FWA) I
OTHER PUBLIC SECTOR (SPECIFY) ______________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SATELLITE CLINIC L
NGO DEPO HOLDER M
NGO FIELD WORKER N
OTHER NGO SECTOR (SPECIFY) _____________ O
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC P
QUALIFIED DOCTOR'S CHAMBER Q
NON-QUALIFIED DOCTOR'S CHAMBER R
PHARMACY S
PRIVATE MEDICAL COLLEGE HOSPITAL (SPECIFY) ______________ T
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) _____________ U
OTHER SOURCE
GROCERY V
FRIENDS/RELATIVES W
OTHER (SPECIFY) _____________ X

325A) In some places, there is a clinic set up for a day or part of a day in someone's house or in a school. During the last three months, was there any such clinic in this village or mohalla?

YES 1
NO 2 (GO TO 325D)
DON'T KNOW 8 (GO TO 325D)

325B) Did you visit such temporary health clinic in the past three months?

YES 1
NO 2 (GO TO 235D)

325C) What services did you receive?

FAMILY PLANNING METHODS A
IMMUNIZATIONS B
CHILD GROWTH MONITORING C
TETANUS INJECTION D
ANTENATAL CARE E
VITAMIN A FOR CHILDREN F
OTHER (SPECIFY) __________ X
DON'T KNOW Z

325D) Are you aware of any community clinic in your area?

YES 1
NO 2 (GO TO 326)

325E) Did you visit the community clinic in the past three months?

YES 1
NO 2 (GO TO 326)

325F) What services did you receive?

FAMILY PLANNING METHODS A
IMMUNIZATIONS B
CHILD GROWTH MONITORING C
TETANUS INJECTION D
ANTENATAL CARE E
VITAMIN A FOR CHILDREN F
OTHER (SPECIFY) ____________ X
DON'T KNOW Z

326) In the last 6 months, were you visited by a fieldworker who talked to you bout family planning or gave you a family planning method?

TALKED 1
GAVE FAMILY PLANNING METHOD 2
TALKED AND GAVE METHOD 3
NO 4 (GO TO 401)

326A) Who visited you to talk about family planning or to give you family planning methods?
Anyone else?

Name __________________
GOVT. FP WORKER A
GOVT. HEALTH WORKER B
NGO WORKER C
OTHER (SPECIFY) _____________ X

326B) During the last six months, how many times did a health worker or workers visit you to talk about family planning or to give you family planning methods?

NUMBER OF TIMES __________
DON'T KNOW 98

326C) When was the last time you were visited by a fieldworker who talked to you about family planning?
IF MORE THAN ONE WORKER VISITED: When did the last worker visit you?
IF LESS THAN ONE MONTH AGO WRITE '0'

MONTHS AGO __________
DON'T KNOW 8

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2006 OR LATER (CONTINUE)
NO BIRTHS IN 2006 OR LATER (GO TO 601)

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).
Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.)

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER __________

404) FROM 212 AND 216

NAME ______________
LIVING (CONTINUE)
DEAD (CONTINUE)

405) When you got pregnant with (NAME), did you want to get pregnant at that time?

YES 1 (GO TO 408) (GO TO 430 FOR BIRTHS LATER THAN LAST BIRTH)
NO 2

406) Did you want to have a baby later on, or did you not want any (more) children?

LATER 1
NO MORE 2 (GO TO 408)

407) How much longer did you want to wait?
SECOND-FROM LAST BIRTH

MONTHS 1 ________
YEARS 2 _________
DON'T KNOW 998

408) Did you see anyone for antenatal care for this pregnancy? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2 (GO TO 415)

409) Whom did you see? (ONLY FOR MOST RECENT BIRTH)
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSONA ND RECORD ALL MENTIONED.
IF 'D' MENTIONED WRITE THE NAME OF THE CSBA.

NAME _______________
HEALTH PERSONNEL
QUALI. DOCTOR A
NURSE/MIDWIFE/PARAMEDIC B
FAMILY WELFARE VISITOR C
COMMUNITY SKILLED BIRTH ATTENDANT D
MA/SACMO E
HEALTH ASST. F
FAMILY WELFARE ASSISTANT G
OTHER PERSON
TRAINED TBA H
UNTRAINED TBA I
UNQUALIFIED DOCTOR J
NGO K
OTHER (SPECIFY) ____________ X

410) Where did you receive antenatal care for this pregnancy? (ONLY FOR MOST RECENT BIRTH)
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))____
HOME
HOME A
PUBLIC SECTOR
HOSP./MEDICAL COLLEGE B
SPE. MEDICAL COL. (SPECIFY) __________ C
DIST. HOSP. D
MCWC E
UPAZILLA HEALTH COMPLEX F
H and FAMILY WELFARE CENTRE G
SAT. CLINIC/EPI OUTREACH H
COMM. CLINIC I
OTHER (SPECIFY) __________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SAT CLINIC (SPECIFY) L
OTHER (SPECIFY) _____________ M
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC N
QUAL. DOCTOR P
PHARMACY Q
PVT. MED COLL.
HOSP. (SPECIFY) ____________ R
OTHER (SPECIFY)____________X

412) How many times did you receive antenatal care during this pregnancy? (ONLY FOR MOST RECENT BIRTH)

NUMBER OF TIMES ___________
DON'T KNOW 98

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2
DON'T KNOW 8

415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2 (GO TO 418)
DON'T KNOW 8 (GO TO 418)

416) During this pregnancy, how many times did you get a tetanus injection? (ONLY FOR MOST RECENT BIRTH)

TIMES _____
DON'T KNOW 8

417) CHECK 416: (ONLY FOR MOST RECENT BIRTH)

2 OR MORE TIMES (GO TO 430)
OTHER (CONTINUE)

418) At any time before this pregnancy, did you receive any tetanus injections? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2 (GO TO 430)
DON'T KNOW 8 (GO TO 430)

419) Before this pregnancy, how many times did you receive a tetanus injection? (ONLY FOR MOST RECENT BIRTH)
IF 7 OR MORE TIMES, RECORD '7'.

TIMES _________
DON'T KNOW 8

420) How many years ago did you receive the last tetanus injection before this pregnancy? (ONLY FOR MOST RECENT BIRTH)

YEARS AGO __________

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

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

433) Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.
IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.
IF 'D' MENTIONED WRITE THE NAME OF THE CSBA.

NAME ______________
NAME ______________
HEALTH PERSONNEL
QUAL. DOCTOR 1
NURSE/MIDWIFE/PARAMEDIC B
FAMILY WELFARE VISITOR C
COMMUNITY SKILLED BIRTH ATTENDANT D
MA/SACMO E
HEALTH ASST. F
FAMILY WELFARE ASSISTANT G
OTHER PERSON
TRAINED TBA H
UNTRAINED TBA I
UNQUALIFIED DOCTOR J
RELATIVES K
NEIGHBORS/FRIEND L
NGO WORKER M
OTHER (SPECIFY) ___________ X
NO ONE ASSISTED Y

434) Where did you give birth to (NAME)?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)____
HOME
HOME 11
PUBLIC SECTOR
HOSP./MEDICAL COLLEGE 21
SPE. MEDICAL COL. (SPECIFY) __________ 22
DIST. HOSP. 23
MCWC 24
UPAZILLA HEALTH COMPLEX 25
H and FAMILY WELFARE CENTRE 26
NGO SECTOR
NGO STATIC CLINIC 31
OTHER (SPECIFY) _____________ 36
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC 41
PVT. MED COLL. HOSP. (SPECIFY) ____________ 42
OTHER (SPECIFY)____________96 (GO TO 435A)

434A) How long after (NAME) was delivered did you stay there? (ONLY FOR MOST RECENT BIRTH)
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 ________
DAYS 2 ________
WEEKS 3 _________
DON'T KNOW 998

435) Was (NAME) delivered by cesarean, that is, did they cut your belly open to take the baby out?

YES 1 (GO TO 436)
NO 2

435A) CHECK 215:

LAST BIRTH IN JAN 2008 OR LATER (CONTINUE)
LAST BIRTH BEFORE 2008 JAN (GO TO 438)

435B) CHECK 434: (ONLY FOR MOST RECENT BIRTH)

DELIVERED AT HOME (CODE 11 CIRCLED) (CONTINUE)
DELIVERED AT HEALTH FACILITY (CIRCLED ANY CODE 21 TO 96) (GO TO 435F)

Now I would like to ask you some specific questions about what was done with (NAME) during and immediately following delivery.

435C) Was a Clean Delivery Kit used during the delivery of (NAME)? (ONLY FOR MOST RECENT BIRTH)
SHOW THE DELIVERY KIT

YES 1
NO 2
DON'T KNOW 8

435D) What was used to cut the cord? (ONLY FOR MOST RECENT BIRTH)

BLADE FROM DELIVERY KIT 1
BLADE FROM OTHER SOURCE 2
BAMBOO STRIPS 3
SCISSOR 4
OTHER (SPECIFY) _________ 6
CORD WAS NOT CUT 7 (GO TO 435F)
DON'T KNOW 8 (GO TO 435F)

435E) Was the __________ (INSTRUMENT IN 435D) boiled before the cord was cut? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2
DON'T KNOW 8

435E) Was anything applied to the cord immediately after cutting and tying it?

YES 1
NO 2
DON'T KNOW 8

435G) What was applied to the cord after it was cut and tied?
Anything else?
(ONLY FOR MOST RECENT BIRTH)

ANTIBIOTICS (POWDER/OINTM) A
ANTISEPTIC (DETOL/SAVLON HEXISOL) B
SPIRIT/ALCOHOL C
MUSTARD OIL WITH GARLIC D
CHEWED RICE E
TUMERIC JUICE/POWDER F
GINGER JUICE G
SHIDUR H
BORIC POWDER I
GENTIAN VIOLET (BLUE INK) J
TALCOM POWDER K
OTHER (SPECIFY) ___________ K
DON'T KNOW Z

435H) How long after delivery was (NAME) bathed for the first time? (ONLY FOR MOST RECENT BIRTH)
IF LESS THAN ONE DAY, RECORD IN HOURS IF LESS THAN ONE WEEK, RECORD IN DAYS

HOURS 1 __________
DAYS 2 __________
WEEKS 3 _________
NOT BATHED 995
DON'T KNOW 998

435I) How long after birth was (NAME) dried?

UNDER 5 MINUTES 1
5 TO 9 MINUTES 2
10 OR MORE MINUTES 3
NOT DRIED 4
DON'T KNOW 8

435J) How long after birth was (NAME) wrapped? (ONLY FOR MOST RECENT BIRTH)

UNDER 5 MINUTES 1
5 TO 9 MINUTES 2
10 OR MORE MINUTES 3
NO WRAPPED 4
DON'T KNOW 8

435K) CHECK 434: (ONLY FOR MOST RECENT BIRTH)

DELIVERED AT HOME (CODE 11 CIRCLED) (GO 438)
DELIVERED AT HEALTH FACILITY (CODE 21 TO 96) (CONTINUE)

436) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility? (ONLY FOR MOST RECENT BIRTH)

YES 1 (GO TO 439)
NO 2

437) Did anyone check on your health after you left the facility? (ONLY FOR MOST RECENT BIRTH)

YES 1 (GO TO 439)
NO 2 (GO TO 442)

438) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?

YES 1
NO 2 (GO TO 442)

439) Who checked on your health at that time? (ONLY FOR MOST RECENT BIRTH)
PROBE FOR MOST QUALIFIED PERSON.
IF '14' MENTIONED WRITE THE NAME OF CSBA.

NAME _________________
HEALTH PERSONNEL
QUAL. DOCTOR 11
NURSE/MIDWIRE/PARAMEDIC 12
FAMILY WELFARE VISITOR 13
COMMUNITY SKILLED BIRTH ATTENDANT 14
MA/SACMO 15
HEALTH ASST. 16
FAMILY WELFARE ASSISTANT 17
OTHER PERSON TRAINED
TBA 21
UNTRAINED TBA 22
UNQUALIFIED DOCTOR 23
NGO WORKER 31
OTHER (SPECIFY) ___________ 96

439A) Where did this first check take place? (ONLY FOR MOST RECENT BIRTH)

HOME
HOME 11 (GO TO 442)
PUBLIC SECTOR
HOSP./MEDICAL COLLEGE 21
SPE. MEDICAL COL. (SPECIFY) __________ 22
DIST. HOSP. 23
MCWC 24
UPAZILLA HEALTH COMPLEX 25
H and FAMILY WELFARE CENTRE 27
SAT. CLINIC/EPI OUTREACH 28
COMM. CLINIC 29
OTHER (SPECIFY) __________ 26
NGO SECTOR
NGO STATIC CLINIC 31
NGO SAT CLINIC (SPECIFY) 32
OTHER (SPECIFY) _____________ 36
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC 41
QUALIFIED. DOC. CHAMBER 42
UNQUALIFIED DOC. CHAMBER 43
PHARMACY 44
PVT. MED COLL. HOSP. (SPECIFY) ____________ 45
OTHER (SPECIFY)____________96 (SKIP TO 442)

440) How long after delivery did the first check take place? (ONLY FOR MOST RECENT BIRTH)
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 __________
DAYS 2 __________
WEEKS 3 __________
DON'T KNOW 998

442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2 (GO TO 446)
DON'T KNOW 8 (GO TO 446)

443) How many hours, days, or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS. AFTER BIRTH 1 ________
DAYS AFTER BIRTH 2 ________
WEEKS AFTER BIRTH 3 _________
DON'T KNOW 998

444) Who checked on (NAME)'s health at that time? (ONLY FOR MOST RECENT BIRTH)
PROBE FOR MOST QUALIFIED PERSON.
IF '14' MENTIONED WRITE THE NAME OF THE CSBA.

NAME _______________
HEALTH PERSONNEL
QUAL. DOCTOR 11
NURSE/MIDWIFE/PARAMEDIC 12
FAMILY WELFARE VISITOR 13
COMMUNITY SKILLED BIRTH ATTENDANT 14
MA/SACMO 15
HEALTH ASST. 16
FAMILY WELFARE ASSISTANT 17
OTHER PERSON
TRAINED TBA 21
UNTRAINED TBA 22
UNQUALIFIED DOCTOR 23
NGO WORKER 31
OTHER (SPECIFY) ___________ 96

445) Where did this first check of (NAME) take place? (ONLY FOR MOST RECENT BIRTH)
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) _____________________
HOME
HOME 11
PUBLIC SECTOR
HOSP./MEDICAL COLLEGE 21
SPE. MEDICAL COL. (SPECIFY) __________ 22
DIST. HOSP. 23
MCWC 24
UPAZILLA HEALTH COMPLEX 25
H and FAMILY WELFARE CENTRE 27
SAT. CLINIC/EPI OUTREACH 28
COMM. CLINIC 29
OTHER (SPECIFY) __________ 26
NGO SECTOR
NGO STATIC CLINIC 31
NGO SAT CLINIC (SPECIFY) 32
OTHER (SPECIFY) _____________ 36
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC 41
QUALIFIED. DOC. CHAMBER 42
UNQUALIFIED DOC. CHAMBER 43
PHARMACY 44
PVT. MED COLL. HOSP. (SPECIFY) ____________ 45
OTHER (SPECIFY)____________96

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 449)
NO 2 (GO TO 450)

448) Did your period return between the birth of (NAME) and your next pregnancy? (ONLY FOR BIRTHS OTHER THAN THE LAST BIRTH)

YES 1
NO 2 (GO TO 452)

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

MONTHS ________
DON'T KNOW 98

450) CHECK 226:
IS RESPONDENT PREGNANT?

NOT PREGNANT 1 (CONTINUE)
PREGNANT OR UNSURE 2 (GO TO 453)

451) Have you had sexual intercourse since the birth of (NAME)? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2 (GO TO 453)

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

MONTHS ________
DON'T KNOW 98

453) Did you ever breastfeed (NAME)?

YES 1
NO 2

454) CHECK 404: IS CHILD LIVING? (ONLY FOR MOST RECENT BIRTH)

LIVING (GO TO 460)
DEAD (GO BACK TO 405 IN NEXT COLUMN: OR IF NO MORE BIRTHS, GO TO 501)

455) How long after birth did you first put (NAME) to the breast? (ONLY FOR MOST RECENT BIRTH)
IF LESS THAN 1 HOUR, RECORD '00' HOURS. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.

IMMEDIATELY 000
HOURS 1 _______
DAYS 2 _______

456) In the first three days after delivery, was (NAME) given anything to drink other than breast milk? (ONLY FOR MOST RECENT BIRTH)

YES 1
NO 2 (GO TO 458)

457) What was (NAME) given to drink?
Anything else?
(ONLY FOR MOST RECENT BIRTH)
RECORD ALL LIQUIDS MENTIONED.

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
COFFEE I
HONEY J
OTHER (SPECIFY) ___________

458) CHECK 404: IS CHILD LIVING?

LIVING (CONTINUE)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

459) Are you still breastfeeding (NAME)?

YES 1 (GO TO 460)
NO 2

459A) For how many months did you breastfeed (NAME)?

MONTH ________
DON'T KNOW 98

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

YES 1
NO 2
DON'T KNOW 8

461) GO BACK TO 405 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 501.

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE NO MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

BIRTH HISTORY NUMBER ___________

503) FROM 212 AND 216

NAME _____________
LIVING (CONTINUE)
DEAD (GO TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE, OR IF NO MORE BIRTHS, GO TO 557)

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

YES, SEEN 1 (GO TO 506)
YES, NOT SEEN (GO TO 509)
NO CARD 3

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

YES 1 (GO TO 509)
NO 2 (GO TO 509)

506)
(1) COPY DATES FROM THE CARD.
(2) WRITE '44'IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.
(3) IF HEP-B IS GIVEN IN COMBINATION WITH DPT, RECORD SEPARATELY FOR BOTH DPT AND HEP-B.

506A)

DATE OF BIRTH
DAY _________
MONTH ________
YEAR ________
BBC
DAY _________
MONTH ________
YEAR ________
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY _________
MONTH ________
YEAR ________
POLIO 1
DAY _________
MONTH ________
YEAR ________
POLIO 2
DAY _________
MONTH ________
YEAR ________
DPT 1
DAY _________
MONTH ________
YEAR ________
DPT 2
DAY _________
MONTH ________
YEAR ________
DPT 3
DAY _________
MONTH ________
YEAR ________
HEP. B1
DAY _________
MONTH ________
YEAR ________
HEP. B2
DAY _________
MONTH ________
YEAR ________
HEP. B3
DAY _________
MONTH ________
YEAR ________
MEASLES
DAY _________
MONTH ________
YEAR ________
VITAMIN A
DAY _________
MONTH ________
YEAR ________

507) CHECK 506A:

BCG TO MEASLES ALL RECORDED (GO TO 510J)
OTHER (CONTINUE)

508) Has (NAME) had any vaccinations that are not recorded on this card, including vaccinations given in a national immunization day campaign?
RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 506A) (GO TO 510J)
NO 2 (GO TO 510J)
DON'T KNOW 8 (GO TO 510J)

509) Did (NAME) ever have any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign?

YES 1
NO 2 (GO TO 510 J)
DON'T KNOW 8

510) Please tell me if (NAME) had any of the following vaccinations:

510A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes as scar?

YES 1
NO 2
DON'T KNOW 8

510B) Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (GO TO 510E)
DON'T KNOW 8 (GO TO 510E)

510C) Was the first polio vaccine given in the first two weeks after birth or later?

FIRST 2 WEEKS 1
LATER 2

510D) How many times was the polio vaccine given?

NUMBER OF TIMES _________

510E) A DEPT./Pentavalent vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 510G)
DON'T KNOW 8 (GO TO 510G)

510F) How many time was the DPT/Pentavalent vaccination given?

NUMBER OF TIMES _________

510G) A measles injection or an MMR injection--that is, a shot in the arm at the age or 9 months or older--to prevent him/her from getting measles?

YES 1
NO 2
DON'T KNOW 8

510H) A HEP-B vaccination, that is, an injection given in the right thigh, sometimes given at the same time as DPT?

YES 1
NO 2 (GO TO 510J)
DON'T KNOW 8 (GO TO 510J)

510I) How many times was a HEP-B vaccination received?

NUMBER OF TIMES __________

510J) Did (NAME) receive any polio vaccine from the National Immunization Days (NID)?

YES 1
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

510K) At which national immunization day campaigns did (NAME) receive vaccinations?
RECORD ALL CAMPAIGNS MENTIONED.

CAMPAIGN 1 (POLIO/JAN 2010) A
CAMPAIGN 2 (POLIO/FEB 2010) B
CAMPAIGN 3 (POLIO/JAN 2011) C
CAMPAIGN 4 (POLIO/FEB 2011) D

511) Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

YES 1
NO 2
DON'T KNOW 8

512) In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)?
SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.

YES 1
NO 2
DON'T KNOW 8

513) Was (NAME) given any drug for intestinal worms in the last six months?

YES 1
NO 2
DON'T KNOW 8

514) Has (NAME) had diarrhea in the last 2 weeks?

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

515) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

516) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk).
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

517) When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

518) Did you seek advice or treatment for the diarrhea from any source?

YES 1
NO 2 (GO TO 522)

519) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))______________
PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL A
SPECIALIZED GOVT. HOSPITAL (SPECIFY) __________B
DISTRICT HOSP. C
MCWC D
UHC E
H and FWC F
SATELLITE CLINIC/EPI OUTREACH SITE G
COMMUNITY CLINIC H
FAMILY WELFARE ASSISTANT I
OTHER (SPECIFY) ____________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SATELLITE CLINIC L
NGO FIELD WORKER M
OTHER (SPECIFY) ___________ N
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC O
QUALIFIED ED DOCTOR P
UNQUALIFIED DOCTOR Q
PHARMACY R
PRIVATE MED. COLLEGE HOSPITAL (SPECIFY) _______________ S
OTHER PRIVATE SECTOR (SPECIFY) ____________T
OTHER (SPECIFY)_________ X

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea:
a) A fluid made from a special saline packet called ORSaline PACKET?
b) A homemade sugar-salt-water solution (laban gur)?
c) Zinc syrup?
d) Zinc tablets?

ORS PKT
YES 1
NO 2
DON'T KNOW 8
LABAN GUR
YES 1
NO 2
DON'T KNOW 9
ZINC SYRUP
YES 1
NO 2
DON'T KNOW 9
ZINC TABLET
YES 1
NO 2
DON'T KNOW 9

522A) CHECK 522:

ORS GIVEN (CONTINUE)
ORS NOT GIVEN (GO TO 525)

523) Where did you get the ORS packet?

PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL A
SPECIALIZED GOVT. HOSPITAL (SPECIFY) __________B
DISTRICT HOSP. C
MCWC D
UHC E
H and FWC F
SATELLITE CLINIC/EPI OUTREACH SITE G
COMMUNITY CLINIC H
FAMILY WELFARE ASSISTANT I
OTHER (SPECIFY) ____________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SATELLITE CLINIC L
NGO DEPO HOLDER M
NGO FIELD WORKER N
OTHER (SPECIFY) ___________ O
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC P
QUALIFIED ED DOCTOR Q
UNQUALIFIED DOCTOR R
PHARMACY S
PRIVATE MED. COLLEGE HOSPITAL (SPECIFY) _______________ T
OTHER PRIVATE SECTOR (SPECIFY) ____________U
OTHER SOURCE SHOP (SPECIFY)_________ V
FRIEND/RELATIVE W
OTHER (SPECIFY) ___________ X

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

YES 1
NO 2
DON'T KNOW 8

527) Has (NAME) had an illness with a cough at any time in the last 2 weeks?

YES 1
NO (GO TO 530)
DON'T KNOW 8 (GO TO 530)

528) When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

YES 1
NO 2 (GO TO 531)
DON'T KNOW (GO TO 531)

529) Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose?

CHEST ONLY 1 (GO TO 531)
NOSE ONLY 2 (GO TO 531)
BOTH 3 (GO TO 531)
OTHER (SPECIFY) ____________ (GO TO 531)
DON'T KNOW 8 (GO TO 531)

530) CHECK 525: HAD FEVER?

YES (CONTINUE)
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 557)

531) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough).
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

532) When (NAME) had a (fever/cough) was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

533) Did you seek advice or treatment for the illness from any source?

YES 1
NO 2 (GO TO 537)

536) Where did you first seek advice or treatment?
FILL UP THE BOXES ACCORDING TO THE SEQUENCE OF CARE RECEIVED.
SEQUENCE OF CARE

1__________
2__________
3__________
4__________
HOME A
PUBLIC SECTOR
MEDICAL COLLEGE B
SPECIALIZED GOVT. HOSPITAL (SPECIFY)____________ C
DISTRICT HOP. D
MCWC E
UHC F
H and FWC G
SATELLITE CLINIC/EPI OUTREACH SITE H
COMMUNITY CLINIC I
FAMILY WELFARE ASSIST. J
OTHER (SPECIFY) K
NGO SECTOR
NGO STATIC CLINIC L
NGO SATELLITE CLINIC M
NGO DEP HOLDER N
NGO FIELD WORKER O
OTHER (SPECIFY) __________ P
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC Q
QUALIFIED DOCTOR R
UNQUALIFIED DOCTOR S
PHARMACY/DRUG STORE T
PRIVATE MED. COLLEGE HOSPITAL (SPECIFY) _________ U
OTHER PVT (SPECIFY) _________ V
OTHER (SPECIFY) X

537) At any time during the illness, did (NAME) take any drugs for the illness?

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 557)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 557)

538) What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED.

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUINE B
QUININE D
COMBINATION WITH ARTEMISININ E
OTHER ANTI-MALARIAL (SPECIFY) __________ F
ANTIBIOTIC DRUGS
PILL/SYRUP G
INJECTION H
OTHER DRUGS
ASPIRIN I
ACETAMINOPHEN J
IBUPROFEN K
OTHER (SPECIFY) ______ X
DON'T KNOW Z

539) Did anybody prescribe the drug?

YES 1
NO 2 (GO TO 552)

540) Who prescribed the drug?

HEALTH PROFESSIONAL/WORKER
QUALIFIED DOCTOR A
NURSE/MIDWIFE/PARAMEDIC B
FAMILY WELFARE VISITOR C
CSBA D
MA/SACMO E
HEALTH ASSISTANT F
FAMILY WELFARE ASSISTANT G
OTHER PROVIDER
TRAINED TBA H
UNTRAINED TBA I
UNQUALIFIED DOCTOR J
DRUG SELLER K
NGO WORKER L
OTHER (SPECIFY) ___________ X
HEALTH PROFESSIONAL/WORKER
QUALIFIED DOCTOR A
NURSE/MIDWIFE/PARAMEDIC B
FAMILY WELFARE VISITOR C
CSBA D
MA/SACMO E
HEALTH ASSISTANT F
FAMILY WELFARE ASSISTANT G
OTHER PROVIDER
TRAINED TBA H
UNTRAINED TBA I
UNQUALIFIED DOCTOR J
DRUG SELLER K
NGO WORKER L
OTHER (SPECIFY) ___________ X

541) Where did you get the drug?

MEDICAL COLLEGE HOSPITAL A
SPECIALIZED GOVT. HOSPITAL (SPECIFY) __________B
DISTRICT HOSP. C
MCWC D
UHC E
H AND FWC F
SATELLITE CLINIC/EPI OUTREACH SITE G
COMMUNITY CLINIC H
FAMILY WELFARE ASSISTANT I
OTHER (SPECIFY) ____________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SATELLITE CLINIC L
NGO DEPO HOLDER M
NGO FIELD WORKER N
OTHER (SPECIFY) ___________ O
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC P
QUALIFIED ED DOCTOR Q
UNQUALIFIED DOCTOR R
PHARMACY S
PRIVATE MED. COLLEGE HOSPITAL (SPECIFY) _______________ T
OTHER PRIVATE SECTOR (SPECIFY) ____________U
OTHER SOURCE SHOP (SPECIFY)_________ V
FRIEND/RELATIVE W
OTHER (SPECIFY) ___________ X

552) GO TO 503 IN NEXT-TO-LAST COLUMN OF NEW QUESTIONNAIRE; OR, IF NO MORE BIRTHS, GO TO 557.

557) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2009 OR LATER LIVING WITH THE RESPONDENT. RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 558

ONE OR MORE (CONTINUE)
NONE (GO TO 601)
(NAME) ___________________

558) Now I would like to ask you about liquids or foods that (NAME FROM 557) had yester during the day or at night. I am interested in whether your child had the item I mentioned even if it was combined with other foods.

Did (NAME FROM 557) (drink/eat):

a) Plain water
YES 1
NO 2
DON'T KNOW 8
b) Juice or juice drinks?
YES 1
NO 2
DON'T KNOW 8
d) Milk such as tinned, powdered, or fresh animal milk?
IF YES: How many times did (NAME) drink milk?
IF 7 OR MORE TIMES, RECORD '7'.
YES, NUMBER OF TIMES DRANK MILK ______ 1
NO 2
DON'T KNOW 8
e) Infant formula like Lactogen?
IF YES: How many times did (NAME) drink infant formula?
IF 7 OR MORE TIMES, RECORD '7'.
YES, NUMBER OF TIMES DRANK FORMULA ________ 1
NO 2
DON'T KNOW 8
f) Any other liquids?
YES 1
NO 2
DON'T KNOW 8
g) Yogurt?
IF YES: How many times did (NAME) eat yogurt?
IF 7 OR MORE TIMES, RECORD '7'.
YES, NUMBER OF TIMES ATE YOGURT _______ 1
NO 2
DON'T KNOW 8
h) Any commercially fortified baby food like Cerelac?
YES 1
NO 2
DON'T KNOW 8
i) Bread, rice, noodles, porridge, or other foods made from grains?
YES 1
NO 2
DON'T KNOW 8
j) Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?
YES 1
NO 2
DON'T KNOW 8
k) White potatoes, white yams, manioc, cassava, or any other foods made from roots?
YES 1
NO 2
DON'T KNOW 8
l) Any dark green, leafy vegetables like spinach, poi sag, methi, kolmi, kochu, palak?
YES 1
NO 2
DON'T KNOW 8
m) Ripe mangoes, papayas, ripe kathal, bangi or other Vitamin A rich fruits?
YES 1
NO 2
DON'T KNOW 8
n) Any other fruits like banana, grapes, apple, guava or other vegetables like cabbae, patal, kopi?
YES 1
NO 2
DON'T KNOW 8
o) Liver, kidney, heart or other organ meats?
YES 1
NO 2
DON'T KNOW 8
p) Any meat, such as beef, pork, lamb, goat, chicken, or duck?
YES 1
NO 2
DON'T KNOW 8
q) Eggs?
YES 1
NO 2
DON'T KNOW 8
r) Fish, shrimps, or crab?
YES 1
NO 2
DON'T KNOW 8
s) Any foods made from beans, peas, lentils or nuts?
YES 1
NO 2
DON'T KNOW 8
t) Cheese or other food made from milk like paneer?
YES 1
NO 2
DON'T KNOW 8
u) Any other solid, semi-solid, or soft food (bengali sweets)?
YES 1
NO 2
DON'T KNOW 8

559) CHECK 558 (CATEGORIES "g" THROUGH "u"):

NOT A SINGLE "YES" (CONTINUE)
AT LEAST ONE "YES" (GO TO 561)

560) Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?
IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

YES 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY)
NO 2 (GO TO 601)

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES _______
DON'T KNOW 8

SECTION 6. MARRIAGE.

601) CHECK 103A:

CURRENTLY MARRIED (GO TO 694A)
SEPARATED/DESERTED/DIVORCED/WIDOWED (GO TO 609)

604) Is your husband living with you now or is he staying elsewhere?

LIVING WITH HER 1 (GO TO 605)
STAYING ELSEWHERE 2

604A) How often did he come home in the past 12 months?

NUMBER OF TIMES __________
DID NOT COME IN THE LAST 12 MONTHS 96

605) RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

NAME ______________
LINE NO. _________

609) Have you been married only once or more than once?

ONLY ONCE 1
MORE THAN ONCE 2

610) CHECK 609:

MARRIED ONLY ONCE: In what month and year did you start living with your (husband/partner)?
MONTH _______
DON'T KNOW MONTH 98
YEAR __________ (GO TO 612)
DON'T KNOW YEAR 9998
MARRIED MORE THAN ONCE: Now I would like to ask 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 612)
DON'T KNOW YEAR 9998

611) How old were you when you first started living with him?

AGE __________

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

613) Now I would like to ask 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?

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 701)
AGE IN YEARS ________
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

614) 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 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.

615) 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.

DAYS AGO 1 _______
WEEKS AGO 2 _______
MONTHS AGO 3_______
YEARS AGO 4________ (GO TO 701)

616) How many times during the last month did you have sexual intercourse?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

NUMBER OF TIMES __________

SECTION 7. FERTILITY PREFERENCES

701) CHECK 103A:

CURRENTLY MARRIED (CONTINUE)
SEPARATED/DESERTED/DIVORCED/WIDOWED (GO TO 712)

701A) CHECK 304A:

NEITHER STERILIZED (CONTINUE)
HE OR SHE STERILIZED (GO TO 710)

702) CHECK 226:

PREGNANT (CONTINUE)
NOT PREGNANT OR UNSURE (GO TO 704)

703) 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 ANOTHER CHILD 1 (GO TO 705)
NO MORE 2 (GO TO 711)
UNDECIDED/DON'T KNOW 8 (GO TO 711)

704) 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 707)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 712)
UNDECIDED/DON'T KNOW 8 (GO TO 710)

705) CHECK 226:

NOT PREGNANT OR UNSURE (ASK THE FOLLOWING): How long would you like to wait from now before the birth of (a/another) child?
MONTHS 1 __________
YEARS 2__________
SOON/NOW 993 (GO TO 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
OTHER (SPECIFY)__________ 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)
PREGNANT (ASK THE FOLLOWING): After the birth of 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 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
OTHER (SPECIFY)__________ 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)

706) CHECK 226:

NOT PREGNANT OR UNSURE (CONTINUE)
PREGNANT (GO TO 711)

707) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING (CONTINUE)
CURRENTLY USING (GO TO 712)

708) CHECK 705:

NOT ASKED (CONTINUE)
24 OR MORE MONTHS OR 02 OR MORE YEARS (CONTINUE)
00-23 MONTHS OR 00-01 YEAR (GO TO 711)

709) CHECK 703 AND 704:

WANTS TO HAVE A/ANOTHER CHILD (ASK THE FOLLOWING): You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy?
Any other reason?
RECORD ALL REASONS MENTIONED.
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN'T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHER OPPOSED K
RELIGION PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
OTHER (SPECIFY) ______________ X
DON'T KNOW Z
WANTS NO MORE/NONE (ASK THE FOLLOWING): You have said that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy?
Any other reason?
RECORD ALL REASONS MENTIONED.
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN'T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHER OPPOSED K
RELIGION PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
OTHER (SPECIFY) ______________ X
DON'T KNOW Z

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED (CONTINUE)
NOT CURRENTLY USING (CONTINUE)
CURRENTLY USING (GO TO 712)

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

YES 1
NO 2 (GO TO 711B)
DON'T KNOW 8 (GO TO 711B)

711A) Which contraceptive method would you prefer to use?

FEMALE STERILIZATION 01 (GO TO 712)
MALE STERILIZATION 02 (GO TO 712)
IUD 03 (GO TO 712)
INJECTABLES 04 (GO TO 712)
IMPLANTS 05 (GO TO 712)
PILL 06 (GO TO 712)
CONDOM 07 (GO TO 712)
SAFE PERIOD 12 (GO TO 712)
WITHDRAWAL 13 (GO TO 712)
OTHER (SPECIFY) _______________ 96 (GO TO 712)
UNSURE 98 (GO TO 712)

711B) What is the main reason that you think you will not use a contraceptive method at any time in the future?

FERTILITY-RELATED REASONS
INFREQUENT SEX/NO SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
WANTS AS MANY CHILDREN AS POSSIBLE 26
OPPOSITION TO USE
RESPONDENT OPPOSED 31
HUSBAND/PARTNER 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
COSTS TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NORMAL PROCESSES 56
OTHER (SPECIFY) ____________ 96
DON'T KNOW 98

712) CHECK 216:

HAS LIVING CHILDREN (ASK THE FOLLOWING): 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?
NONE 00 (GO TO 714)
NUMBER ___________
OTHER (SPECIFY) _______________ 96 (GO TO 714)
NO LIVING CHILDREN (ASK THE FOLLOWING): If you could choose exactly the number of children to have in your whole life, how many would that be?
NONE 00 (GO TO 714)
NUMBER ___________
OTHER (SPECIFY) _______________ 96 (GO TO 714)

713) 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 if it's a boy or a girl?

NUMBER OF BOYS ______
NUMBER OF GIRLS ______
NUMBER OF EITHER ______
OTHER (SPECIFY) ____________ 96

714) In the last month have you:

Heard about family planning on the radio?
YES 1
NO 2
Seen anything about family planning on the television?
YES 1
NO 2
Read about family planning in a newspaper or magazine?
YES 1
NO 2
Read about family planning in a poster, billboard or leaflet?
YES 1
NO 2
Heard about family planning from a community event
YES 1
NO 2

714A) In the last month have you heard about family planning from any community health worker?

YES 1
NO 2 (GO TO 716)

714B) Were these government or no-government workers?

GOVERNMENT A
NON-GOVERNMENT B
DON'T KNOW C

716) CHECK 103A:

YES, CURRENTLY MARRIED (CONTINUE)
SEPARATED/DESERTED/DIVORCED/WIDOWED (GO TO 801)

717) CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING (CONTINUE)
NOT CURRENTLY USING OR NOT ASKED (GO TO 720)

718) Would you say that using contraception is mainly your decision, mainly your (husband's/partner's) decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) ___________ 6

719) CHECK 304:

NEITHER STERILIZED (CONTINUE)
HE OR SHE STERILIZED (GO TO 801)

720) Does your (husband/partner) want 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 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 103A:

CURRENTLY MARRIED (CONTINUE)
SEPARATED/DESERTED/DIVORCED/WIDOWED (GO TO 803)

802) How old was your (husband) on his last birthday?

AGE IN COMPLETED YEARS __________

803) Did your (last)(husband) ever attend school or madrasha?

YES 1
NO 2 (GO TO 806)

803A) What type of schooling did your husband last attend?

SCHOOL 1
MADRASHA 2

804) What level of schooling did he last attend?

PRIMARY 1
SECONDARY 2
COLLEGE AND HIGHER 3

805) What is the highest class he completed at that level?

CLASS _________

806) CHECK 901:

CURRENTLY MARRIED/LIVING WITH A MAN (ASK THE FOLLOWING): What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?
OCCUPATION: ____________________
FORMERLY MARRIED/LIVED WITH A MAN (ASK THE FOLLOWING): What was your (last) (husband's/partner's) occupation? That is, what kind of work did he mainly do?
OCCUPATION: ________________

807) Aside from your own housework, have you done any work in the last seven days?

YES 1 (GO TO 811)
NO 2

808) 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.
In the last seven days, have you done any of these things or any other work?

YES 1 (GO TO 811)
NO 2

809) 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, maternity leave, or any other such reason?

YES 1 (GO TO 811)
NO 2

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

YES 1
NO 2 (GO TO 815)

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

OCCUPATION: ______________

812) 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

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

THROUGH THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

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

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4

815) CHECK 103A:

CURRENTLY MARRIED
SEPARATED/DESERTED/DIVORCED/WIDOWED (GO TO 823A)

816) CHECK 814:

CODE 1 OR 2 CIRCLED (CONTINUE)
OTHER (GO TO 820)

817) Who usually decides how the money you earn will be used: you, you, your husband, you and your husband jointly, or someone else?

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
OTHER (SPECIFY) ___________ 6

820) Who usually makes decisions about health care for yourself: you, you, your husband, your and your husband jointly, or someone else?

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER 6

821) Who usually makes decisions about making major household purchases?

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER 6

822) Who usually makes decisions about visits to your family or relatives?

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER 6

823) Who usually makes decisions about your child health care?

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER 6

823A) Do you go to a health centre or hospital alone or with your young children?

YES, ALONE 1 (GO TO 825)
YES, WITH CHILDREN 2 (GO TO 825)
NO 3
OTHER (SPECIFY) ___________ 6

823B) Can you go to a health centre or hospital alone or with your young children?

YES, ALONE 1
YES, WITH CHILDREN 2
NO 3
OTHER (SPECIFY) _____________ 6

825) PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)

CHILDREN under 10
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3

826) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
YES 1
NO 2
DON'T KNOW 8
If she neglects the children?
YES 1
NO 2
DON'T KNOW 8
If she argues with him?
YES 1
NO 2
DON'T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON'T KNOW 8
If she burns the food?
YES 1
NO 2
DON'T' KNOW 8

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

YES 1
NO (GO TO 937)

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

YES 1
NO 2
DON'T KNOW 8

903) Can people get the AIDS virus from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

906) Can people get the AIDS virus because of witchcraft or other supernatural means?

YES 1
NO 2
DON'T KNOW 8

906A) Can people get the AIDS virus by using unsterilized needle or syringe?

YES 1
NO 2
DON'T KNOW 8

906B) Can people get the AIDS virus through unsafe blood transfusion?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

908) Can the virus that causes AIDS be transmitted from a mother to her baby?

During pregnancy?
YES 1
NO 2
DON'T KNOW 8
During delivery?
YES 1
NO 2
DON'T KNOW 8
By breastfeeding?
YES 1
NO 2
DON'T KNOW 8

937) CHECK 901:

HEARD ABOUT AIDS (ASK THE FOLLOWING): Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
YES 1
NO 2
NOT HEARD ABOUT AIDS? (ASK THE FOLLOWING): Have you heard about infections that can be transmitted through sexual contact?
YES 1
NO 2

937A) Have you ever heard about

a) Syphilis?
YES 1
NO 2
b) Gonorrhea?
YES 1
NO 2

938) CHECK 613:

HAS HAD SEXUAL INTERCOURSE (CONTINUE)
NEVER HAD SEXUAL INTERCOURSE (GO TO 945A)

939) CHECK 937 and 937A: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES (CONTINUE)
NO (GO TO 941)

940) 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?

YES 1
NO 2
DON'T KNOW 8

941) Sometimes women experience a bad-smelling abnormal genital discharge.

During the last 12 months, have you had a bad-smelling abnormal genital discharge?
YES 1
NO 2
DON'T KNOW 8

942) Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

YES 1
NO 2
DON'T KNOW 8

943) CHECK 940, 941, AND 942:

HAS HAD AN INFECTION (ANY 'YES')
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 945A)

944) The last time you had (PROBLEM FROM 940/941/942), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 945A)

945) Where did you go?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ____________________
PUBLIC SECTOR
MEDICAL COLLEGE HOSPITAL A
SPECIALISED GOVT. HOSPITAL
HOSPITAL (SPECIFY) ________________ B
DISTRICT HOSPITAL C
MCWC D
UHC E
H and FWC F
SATELLITE CLINIC/EPI OUTREACH SITE G
COMMUNITY CLINIC H
FAMILY WELFARE ASST. I
OTHER (SPECIFY) ______________ J
NGO SECTOR
NGO STATIC CLINIC K
NGO SATELLITE CLINIC L
NGO DEPO HOLDER M
NGO FIELD WORKER N
OTHER (SPECIFY) _____________ O
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC P
QUALIFIED DOCTOR Q
UNQUALIFIED DOCTOR R
PHARMACY/DRUG STORE S
PRIVATE MEDICAL COLLEGE HOSPITAL (SPECIFY) ______________ T
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) _____________ U
OTHER SOURCE (SPECIFY) _______________ X

945A) Husbands and wives do not always agree on 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?

YES 1
NO 2
DON'T KNOW 8

1001) How often do you eat three 'square meals' (full stomach meals) a day in the past 12 months (not a festival day)?

MOSTLY (3 MEALS EACH DAY) 1
SOMETIMES (3 MEALS PER DAY) 2
RARELY (3 MEALS PER DAY 1-6 TIMES THIS YEAR) 3
NEVER 4

1002) In the last 12 months how often did you yourself skip entire meals because there was not enough food?

NEVER 1
RARELY (1-6 TIMES THIS YEAR) 2
SOMETIMES (7-12 TIMES THIS YEAR) 3
OFTEN (FEW TIMES EACH MONTH) 4

1003) In the last 12 months how often did you personally eat less food in a meal because there was not enough food?

NEVER 1
RARELY (1-6 TIMES THIS YEAR) 2
SOMETIMES (7-12 TIMES THIS YEAR) 3
OFTEN (FEW TIMES EACH MONTH) 4

1004) In the last 12 months, how often did you or any of your family have to eat wheat (or another grain) although you wanted to eat rice (not including when you were sick)?

NEVER 1
RARELY (1-6 TIMES THIS YEAR) 2
SOMETIMES (7-12 TIMES THIS YEAR) 3
OFTEN (FEW TIMES EACH MONTH) 4

1005) In the past 12 months how often did your family have to ask food from relatives or neighbors to make a meal?

NEVER 1
RARELY (1-6 TIMES THIS YEAR) 2
SOMETIMES (7-12 TIMES THIS YEAR) 3
OFTEN (FEW TIMES EACH MONTH) 4

1006) RECORD THE TIME.

HOUR ___________
MINUTES ___________

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: ___________________

INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX.
COLUMN 1 REQUIRES A CODE IN EVERY MONTH.

INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE **
B BIRTHS
P PREGNANCIES
T TERMINATIONS

0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
L RHYTHM METHOD
M WITHDRAWAL

X OTHER (SPECIFY) ___________

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE
0 INFREQUENT SE/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALISTIC
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
X OTHER (SPECIFY) _______________________

Z DON'T KNOW

2011

12 DEC 01
1________
2________

11 NOV 02
1________
2________

10 OCT 03
1________
2________

09 SEP 04
1________
2________

08 AUG 05
1________
2________

07 JUL 06
1________
2________

06 JUN 07
1________
2________

05 MAY 08
1________
2________

04 APR 09
1________
2________

03 MAR 10
1________
2________

02 FEB 11
1________
2________

01 JAN 12
1________
2________

2010

12 DEC 13
1________
2________

11 NOV 14
1________
2________

10 OCT 15
1________
2________

09 SEP 16
1________
2________

08 AUG 17
1________
2________

07 JUL 18
1________
2________

06 JUN 19
1________
2________

05 MAY 20
1________
2________

04 APR 21
1________
2________

03 MAR 22
1________
2________

02 FEB 23
1________
2________

01 JAN 24
1________
2________

2009

12 DEC 25
1________
2________

11 NOV 26
1________
2________

10 OCT 27
1________
2________

09 SEP 28
1________
2________

08 AUG 29
1________
2________

07 JUL 30
1________
2________

06 JUN 31
1________
2________

05 MAY 32
1________
2________

04 APR 33
1________
2________

03 MAR 34
1________
2________

02 FEB 35
1________
2________

01 JAN 36
1________
2________

2008

12 DEC 37
1________
2________

11 NOV 38
1________
2________

10 OCT 39
1________
2________

09 SEP 40
1________
2________

08 AUG 41
1________
2________

07 JUL 42
1________
2________

06 JUN 43
1________
2________

05 MAY 44
1________
2________

04 APR 45
1________
2________

03 MAR 46
1________
2________

02 FEB 47
1________
2________

01 JAN 48
1________
2________

2007

12 DEC 49
1________
2________

11 NOV 50
1________
2________

10 OCT 51
1________
2________

09 SEP 52
1________
2________

08 AUG 53
1________
2________

07 JUL 54
1________
2________

06 JUN 55
1________
2________

05 MAY 56
1________
2________

04 APR 57
1________
2________

03 MAR 58
1________
2________

02 FEB 59
1________
2________

01 JAN 60
1________
2________

2006

12 DEC 61
1________
2________

11 NOV 62
1________
2________

10 OCT 63
1________
2________

09 SEP 64
1________
2________

08 AUG 65
1________
2________

07 JUL 66
1________
2________

06 JUN 67
1________
2________

05 MAY 68
1________
2________

04 APR 69
1________
2________

03 MAR 70
1________
2________

02 FEB 71
1________
2________

01 JAN 72
1________
2________