IDENTIFICATION

CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
NAME OF THE HOUSEHOLD HEAD _____
NAME AND LINE NUMBER OF ELIGIBLE WOMAN ________________

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER'S NAME ___________
RESULT _____

NEXT VISIT:
DATE _____
TIME _____

FINAL VISIT:
DAY _____
MONTH _____
YEAR _____
INT. CODE ____
RESULT ___

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 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.
In case you need more information about the survey, you may contact Mr. S. N. Mitra, Executive Director, Mitra and Associates, 2/17 Iqbal Road, Block A, Mohammadpur, Dhaka 1207, Bangladesh. Telephone number are 8118065, 9115503, 01711278663.

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

NAME OF INTERVIEWER: ___________
DATE: _____

101. RECORD THE TIME.

102. In what month and year were you born?

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

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

104. Have you ever attended school/madrasha?

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

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

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

107. CHECK 105:

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?

109. CHECK 108:

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

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

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

113. What is your religion?

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

Grameen Bank?
BRAC?
BRDB?
ASHA?
PROSHIKA?
Mother's Club?
Any other organization (such as micro credit)?

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?

202. Do you have any sons or daughters to whom you have given birth 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 to whom you have given birth 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 given birth to a boy or girl 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:
Just to make sure that I have this right: you have had in TOTAL ______ births during your life. Is that correct?

210. CHECK 208:

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?
RECORD NAME. BIRTH HISTORY NUMBER

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

214. Were any of these births twins?

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

216. Is (NAME) still alive?

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

218. IF ALIVE:
Is (NAME) living with you?

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

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.

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

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

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

224. CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2009 OR LATER.

225. (C) FOR EACH BIRTH SINCE JANUARY 2009, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT 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?

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

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

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

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

229B. Have you ever used MR?

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

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

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

231. When did the last such pregnancy end?

232. CHECK 231:

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.

234. Since January 2009, have you had any other pregnancies that did not result in a live birth?

235. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2009.
(C) ENTER 'T' IN THE CALENDAR IN THE 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 2009?

237. When did the last such pregnancy that terminated before 2009 end?

238. When did your last menstrual period start?

239. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

240. Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?

SECTION 3. CONTRACEPTION

Now I would like to talk about family planning -- the various ways or methods that a couple can use to delay or avoid a pregnancy.

301A. Have you heard about EMERGENCY CONTRACEPTION PILLS (ECP)? As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within three days to prevent pregnancy.

301B. Have you ever used EC?

301C. Did you use EC in last 12 months?

301D. Have you heard about LACTATIONAL AMENORRHEA METHOD (LAM)? Up to 6 months after child birth, a woman can use a method that requires she breastfeeds frequently, day and night, and that her menstrual period has not returned.

301E. Have you ever used LAM?

302. CHECK 103A:

302A. CHECK 226:

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

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

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?
SHOW AND WRITE THE BRAND NAME OF THE PILLS.

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?
SHOW AND WRITE THE BRAND NAME OF CONDOMS.

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

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

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

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?

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

310. CHECK 308/308A:

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 2009.
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 CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.
ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.
ILLUSTRATIVE QUESTIONS:
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

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

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

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.

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

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.

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 past three months, was there any such clinic in this village or mohalla?

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

325C. What services did you recieve?

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

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

325F. What services did you receive?

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

326A. Who visited you to talk about family planning or to give you family planning methods?

Anyone else?

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?

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'

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 215:

402. CHECK 215:
ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2011 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 three years. (We will talk about each separately.)

403. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

404. FROM 212 AND 216

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

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

407. How much longer did you want to wait?

408. Did you see anyone for antenatal care for this pregnancy?

409. Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
IF 'D' MENTIONED WRITE THE NAME OF THE CSBA.

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

412. How many times did you receive antenatal care during this pregnancy?

413. As part of your antenatal care during this pregnancy, were any of the following done at least once?
Was your weight measured?
Was your blood pressure measured?
Did you have a urine test?
Did you have a blood test?
Did you have an ultrasonography?
Did you counsel about danger signs?

414. During (any of) your antenatal care visit(s), were you told about signs of pregnancy complications?

415. When you got pregnant with (NAME), did any fieldworker/community worker visited you at your home to counsel on health pregnancy or checkup?

416. Who visited?

417. What did they do:
Did s/he measure your weight?
Did s/he measure your blood pressure?
Did s/he do a urine test?
Did s/he do a blood test?
Did s/he counsel about danger signs?

418. How many home visits did you receive during the last pregnancy?

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

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.

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.

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

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

435A. What day of the week was the birth delivered by caesarean section?

435B. At what time of day was the caesarean section or operation done?

435C. How many days before the delivery was the decision to have caesarean section made?

435D. Who proposed first to have the birth delivered by caesarean section, you, a family member or a doctor?

435E. Were you or your family told the reasons for having the operation?

435F. What were the reasons for making the decision to have the operation?
Any other reason?
CIRCLE ALL MENTIONED.

435G. CHECK 212:

435H. Did you have caesarean section before this birth?

435i. Did you or any of your family member ever used a mobile phone to get health services or advice for you or (NAME) during pregnancy or delivery?

435ii. What was the reason the mobile phone was used?
Any other reason?
CIRCLE ALL MENTIONED.

435iii. Who did you call?
Any other person?
CIRCLE ALL MENTIONED.

435iv. How much did you pay in total for your last delivery?
IF MORE THAN 999995, WRITE 999995

435v. Where did you get the money for (NAME's) delivery?
Any other source?
CIRCLE ALL MENTIONED.

435AA. CHECK 434:
DELIVERED AT HOME?

435AB. Now I would like to ask you some specific questions about what was done with (NAME) during and immediately following delivery. Was a Clean Delivery Kit used during the delivery of (NAME)?
SHOW THE DELIVERY KIT.

435AC. What was used to cut the cord?

435AD. Was the (INSTRUMENT IN 435AC) boiled before the cord was cut?

435AE. Was anything applied to the cord immediately after cutting and tying it?

435AF. What was applied to the cord after it was cut and tied?
Anything else?

435AG. How long after delivery was (NAME) bathed for the first time?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD IN DAYS.

435AH. How long after birth was (NAME) dried?

435AI. After the birth, was (NAME) put directly on the bare skin of your chest?
Show the woman a picture of skin-to-skin position.

435AJ. CHECK 434:
DELIVERED AT HOME?

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?

437. Did anyone check on your health after you left the facility?

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

439. Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
IF '14' IS CIRCLED, WRITE THE NAME OF THE CSBA.

439A. Where did this first check take place?

440. How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

440A. During the first two days after delivery, did any health care provider either do the following for you at home or at a health facility:
Breast examination?
Check vaginal discharge?
Check temperature?
Counsel on danger signs?

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

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.

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

445. Where did this first check of (NAME) take place?
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.

445A. During the first two days after delivery, did any health care provider do the following for (NAME) either at home or at a facility:
Examine the cord?
Counsel on danger signs?
Assess temperature?
Counsel you on breastfeeding?
Observe breastfeeding?
Assess weight?

445B. During the first month of (NAME)'s birth, did s(he) experience any illness?

445C. Did you seek advice or treatment for the illness from any source?

445D. Where did you seek advice or treatment?
Any other place?

445E. Who provided the care?

446. In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

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

448. Did your period return between the birth of (NAME) and your next pregnancy?

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

450. CHECK 226:
IS RESPONDENT PREGNANT?

451. Have you had sexual intercourse since the birth of (NAME)?

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

453. Did you ever breastfeed (NAME)?

454. CHECK 404:
IS CHILD LIVING?

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

456. In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

457. What was (NAME) given to drink?
Anything else?
RECORD ALL LIQUIDS MENTIONED.

458. CHECK 404:
IS CHILD LIVING?

459. Are you still breastfeeding (NAME)?

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

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

461. GO BACK TO 405 IN NEXT COLUMN; 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 2009 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).

502. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

503. FROM 212 AND 216

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

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

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.

506A. DATE OF BIRTH

507. CHECK 506A:

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.

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

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 a scar?

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

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

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

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

510F. How many times was the Pentavalent vaccination given?

510G. A measles injection or a measles and rubella (MR) injection -- that is, a shot in the arm at the age of 9 months or older -- to prevent him/her from getting measles and/or rubella?

510H. A measles injection, that is, a shot in the arm at the age of 15 months or older -- to prevent him/her from getting measles?

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

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

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

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.

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

514. Has (NAME) had diarrhea in the last 2 weeks? (PLEASE USE THE LOCAL NAME)

515. Was there any blood in the stools?

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, 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?

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?

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

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.

522. Was he/she given any of the following 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?

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

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

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

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

530. CHECK 525:
HAD FEVER?

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?

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?

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

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

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

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

539. Did anybody prescribe the drug?

540. Who prescribed the drug?

541. Where did you get the drug?

552. GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 557.

557. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2012 OR LATER LIVING WITH THE RESPONDENT

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

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

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

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?

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'.

SECTION 6. MARRIAGE

601. CHECK 103A:

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

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

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'.

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

610. CHECK 609:

MARRIED ONLY ONCE:
In what month and year did you start living with your (husband/partner)?

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?

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

611A. Do you think you got married at an age that was right for you, or would you have preferred to marry earlier or later?

611B. At what age would you have preferred to get married?

611C. Were you studying or attending school just before you got married?

611D. Did you continue your studies after marriage?
IF YES: For how long?

611E. Were you working outside home just before you got married?

611F. Did you continue working after marriage?
IF YES: For how long?

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?

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 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.

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.

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'.

SECTION 7. FERTILITY PREFERENCES

701. CHECK 103A:

701A. CHECK 304:

702. CHECK 226:

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?

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?

705. CHECK 226:

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

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

706. CHECK 226:

707. CHECK 303:
USING A CONTRACEPTIVE METHOD?

708. CHECK 705:

709. CHECK 703 AND 704:

WANTS TO HAVE A/ANOTHER CHILD:
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?

WANTS NO MORE/NONE:
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.

710. CHECK 303:
USING A CONTRACEPTIVE METHOD?

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

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

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

712. CHECK 216:

HAS LIVING CHILDREN:
If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

NO LIVING CHILDREN:
If you could choose exactly the number of children to have in your whole life, how many would that be?

PROBE FOR A NUMERIC RESPONSE.

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?

714. In the last month have you:
Heard about family planning on the radio?
Seen anything about family planning on the television?
Read about family planning in a newspaper or magazine?
Read about family planning in a poster, billboard, or leaflet?
Heard about family planning from a community event?

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

714B. Were these government or non-government worker?

716. CHECK 103A:

717. CHECK 303: USING A CONTRACEPTIVE METHOD?

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

719. CHECK 304:

720. Does your (husband/partner) want the same number of children that you want, or does he want more or fewer than you want?

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801. CHECK 103A:

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

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

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

804. What level of schooling did he last attend?

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

806. CHECK 801:

CURRENTLY MARRIED/LIVING WITH A MAN:
What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?

FORMERLY MARRIED/LIVED WITH A MAN:
What was your (last) (husband's/partner's) occupation? That is, what kind of work did he mainly do?

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

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?

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?

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

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

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

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

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

815. CHECK 103A:

816. CHECK 814:

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

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

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

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

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

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

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

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

826. In your opinion, is a hand 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?

SECTION 9. HIV/AIDS

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

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

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

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

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

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

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

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

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

908. Can the virus that causes AIDS be transmitted from a mother to her baby:
During pregnancy?
During delivery?
By breastfeeding?

937. CHECK 901:

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?

937A. Have you heard about:
a) Syphilis?
b) Gonorrhea?

938: CHECK 613:

939. CHECK 937 AND 937A:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

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?

941. Sometimes women experience a bad-smelling abnormal genital discharge.
During the last 12 months, have you had a bad-smelling abnormal genital discharge?

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

943. CHECK 940, 941, AND 942:

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

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.

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?

946. RECORD THE TIME.

947. Thank you for taking the time to answer these questions. I would like to inform you that additional information on family planning and antenatal care for women who give birth in the past five years will be collected in the near future in order to find better ways to provide health services for women and families.
Another member of our team may return in a few days or weeks to ask you a few additional questions about these topics.
Do you agree to allow another member of our team to contact you about participating in a short interview?
Your responses will remain confidential.

SIGNATURE OF INTERVIEWER: ________________
DATE: __________

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: ________________