MINISTRY OF PLANNING
CONGO DEMOCRATIC REPUBLIC

IDENTIFICATION

RESPONDENT POOL _________

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) _________

NAME OF HOUSEHOLD HEAD ___________

CLUSTER NUMBER _____

HOUSEHOLD NUMBER ______

PROVINCE _____

URBAN/RURAL

RESIDENCE:

NAME AND LINE NUMBER OF WOMAN _____

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: WAS THIS HOUSEHOLD SELECTED FOR THE QUESTIONS ON "DOMESTIC VIOLENCE"?
IF NO, RECORD '2' IN THE SPACE ON THE RIGHT.
IF YES, CHECK SCHEDULE 500B FOR THE SELECTION OF ELIGIBLE WOMEN IN THE SECTION ON "DOMESTIC VIOLENCE". WAS THE WOMAN YOU ARE INTERVIEWING SELECTED? IF YES, RECORD '1' IN THE SPACE ON THE RIGHT; IF NO, RECORD '2'.

INTERVIEWER VISITS

FIRST VISIT: (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME _______________
RESULT* _____

NEXT VISIT: (FOR INTERVIEWS 1 AND 2)
DATE _____
TIME _____

FINAL VISIT:
DAY _____
MONTH _____
YEAR 2007
INT. NUMBER ____
RESULT* ___

RESULT CODES*:

TOTAL NUMBER OF VISITS ____

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF INTERVIEW: _________

INTERPRETER

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 ___ and I am working with the Ministry of Planning. We are conducting a national survey about women and children's health. We would very much appreciate your participation in this survey. I would like to ask you some questions about your health (and your children's health). The information will help the government to plan health services. The questions usually take about 20 to 45 minutes. Whatever information you provide will be kept strictly confidential and will not be shared with anyone.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: _______________
DATE: ________

101) RECORD THE TIME.

102) First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a large city, a city, or a rural location?

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

104) Just before you moved here, did you live in a large city, a city, or a rural location?

105) In what month and year were you born?

106) How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

107) Have you ever attended school?

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

109) What is the highest (grade/form/year) you completed at this level?

110) CHECK 108:

111) Now I would like you to read this sentence out loud to me; read as much as you can.

SHOW CARD TO RESPONDENT:

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

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

113) CHECK 111:

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

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

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

117) In the last 12 months, how many times have you traveled outside of your community and slept somewhere other than your home?

118) In the last 12 months, have you been away from home for more than one month at a time?

119) What is your religion?

120) What is your tribe?

120A) I would like to ask you a question about the tribe of your biological parents. Do (did) they belong to the same tribe?

SECTION 2. REPRODUCTION

201) Now I would like to ask you 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) ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'

209) CHECK 208:
Just to makes 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 Q212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

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

213) Were any of these births twins?

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

215) In what month and year was (NAME) born?
PROBE: What 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 YEAR', 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)?

222) Have you had any live births since the birth of (NAME OF LAST BIRTH)?

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

224) CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE 2002 OR LATER. IF NONE, RECORD '0'.

226) Are you pregnant now?

227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.

228) At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

229) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

230) When did the last such pregnancy end?

231) CHECK 230:

232) How many months pregnant were you when the last such pregnancy ended?
RECORD THE NUMBER OF COMPLETED MONTHS.

233) Have you had any other pregnancies that did not result in a live birth?

235) Have you had any pregnancies that ended before January 2002 that did not result in a live birth?

236) When did the last such pregnancy end before 2002?

237) When did you last menstrual period start?

238) From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

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

240) Are there any children who depend primarily on you?

241) Among these children who depend primarily on you, are there any that are 18 years old or younger?

242) Now I would like to talk about the children ages 18 and under who depend primarily on you.

Have you made any arrangements for someone to take care of these children if you were to get sick or if you were no longer able to take care of them?

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.

CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN CONTINUE DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '1' IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

301) Which ways or methods have you heard about? FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you heard of (METHOD)?

302) Have you ever used (METHOD)?

303) CHECK 302:

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

306) What have you used or done?
CORRECT 302 AND 303 (AND 301 IF NECESSARY)

307) Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.

How many living children did you have at that time, if any?
IF NONE, RECORD '00'.

308) CHECK 302 (01):

309) CHECK 226:

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

311) Which method are you using?
311A) CIRCLE 'A' FOR FEMALE STERILIZATION.

IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD ON LIST.

312) Why do you use the pill over another method?

313) In what facility did the sterilization take place?

SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

314) CHECK 311:

CODE 'A' CIRCLED: Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

CODE 'B' CIRCLED: Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?

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

316A) Since what month and year have you been using (FIRST METHOD FROM Q311) without stopping? PROBE: In what month and year did you start using (FIRST METHOD FROM Q311) now without stopping?

316B) CHECK 316/316A, 215, and 230:

THERE WAS A BIRTH IN 215 OR A PREGNANCY IN 230 THAT ENDED IN A MISCARRIAGE, AN ABORTION, OR A STILLBIRTH AFTER THE MONTH AND THE YEAR OF THE START OF THE USE OF CONTRACEPTION BASED ON 316/316A.
IF YES: GO BACK TO 316/316A TO CORRECT, PROBE TO RECORD THE MONTH AND THE YEAR OF THE START OF THE CONTINUED USE OF THE CURRENT METHOD. (DATE MUST BE AFTER THAT OF THE LAST BIRTH OR THE LAST PREGNANCY).

317) CHECK 316/316A:

319) CHECK 311/311A:
CIRCLE THE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD IN 311/311A.

320) Where did you obtain (CURRENT METHOD) when you started using it?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

321) CHECK 311/311A:
CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD IN 311/311A.

322) You obtained (CURRENT METHOD) from (SOURCE OF METHOD 313 OR 320).
At that time, were you told about side effects or problems you might have with the method?

323) Were you ever told by a health worker or family planning worker about side effects or problems you might have with the method?

324) Were you told what to do if you experienced side effects or problems?

325) CHECK 322:

CODE '1' CIRCLED: At that time, were you told about other methods of family planning that you could use?

CODE '1' NOT CIRCLED: You obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM 313 OR 320). Were you told about other methods of family planning that you could use?

326) Were you ever told by a health worker or family planning worker about other methods of family planning that you could use?

327) CHECK 311/311A:

CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD IN 311/311A.

328) Where did you obtain (CURRENT METHOD) last time?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

330) Where is this?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

Another place?
RECORD ALL MENTIONED.

331) In the last 12 months, were you visited by a field worker who talked to you about family planning?

332) In the last 12 months, have you visited a health facility for care for yourself (or your children)?

333) Did any staff member at the health facility speak to you about family planning methods?

SECTION 4A. PREGNANCY, POSTNATAL CARE, AND BREASTFEEDING

401) CHECK 224:

402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST TWO COLUMNS OF ADDITIONAL QUESTIONNAIRE).

Now I would like to ask you some questions about the health of all your children born in the last five years. (We will talk about each separately).

403) LINE NUMBER FROM Q212.

404) FROM Q212 AND Q216

405) At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

406) How much longer would you have liked to wait?

407) Did you see anyone for antenatal care for this pregnancy? IF YES: Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

[ASK FOR MOST RECENT BIRTH ONLY]

IF NO, CIRCLE CODE 'Y'.

408) How many months pregnant were you when you first received antenatal care for this pregnancy? [ASK FOR MOST RECENT BIRTH ONLY]

409) How many times did you receive antenatal care during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

410) CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE.
[ASK FOR MOST RECENT BIRTH ONLY]

411) How many months pregnant were you the last time you received antenatal care?
[ASK FOR MOST RECENT BIRTH ONLY]

412) During this pregnancy, were any of the following done at least once?
[ASK FOR MOST RECENT BIRTH ONLY]

Were you weighed?
Was your height measured?
Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?

413) Were you told about the signs of pregnancy complications?
[ASK FOR MOST RECENT BIRTH ONLY]

414) Were you told where to go if you had any of these complications?
[ASK FOR MOST RECENT BIRTH ONLY]

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

416) During this pregnancy, how many times did you get this tetanus injection?

417) During this pregnancy, were you given or did you buy iron tablets?
SHOW TABLETS. [ASK FOR MOST RECENT BIRTH ONLY]

418) During the whole pregnancy, for how many days did you take the iron tablets?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
[ASK FOR MOST RECENT BIRTH ONLY]

419) During this pregnancy, did you have difficulty with your vision during the daylight?
[ASK FOR MOST RECENT BIRTH ONLY]

420) During this pregnancy, did you suffer form night blindness?
[ASK FOR MOST RECENT BIRTH ONLY]

421) During this pregnancy, did you take any drugs in order to keep you from getting malaria?
[ASK FOR MOST RECENT BIRTH ONLY]

422) What drugs did you take? Any other drugs?
[ASK FOR MOST RECENT BIRTH ONLY]

RECORD ALL MENTIONED. IF THE TYPE OF DRUG CANNOT BE DETERMINED SHOW THE ANTIMALARIALS TO THE RESPONDENT.

422A) CHECK 422:
TYPE OF DRUG TAKEN DURING PREGNANCY TO PREVENT MALARIA
[ASK FOR MOST RECENT BIRTH ONLY]

422B) How many times did you take SP/FANSIDAR during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

422C) CHECK 407:
PRENATAL CARE DURING THIS PREGNANCY
[ASK FOR MOST RECENT BIRTH ONLY]

422D) When you were pregnant with (NAME), did you get SP/FANSIDAR during an prenatal visit, during a different visit in a heath care facility, or from another source?
[ASK FOR MOST RECENT BIRTH ONLY]

422E) CHECK 422:
TYPE OF DRUG TAKEN DURING PREGNANCY TO AVOID MALARIA
[ASK FOR MOST RECENT BIRTH ONLY]

422F) How many times did you take CHLOROQUINE during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

422G) CHECK 407:
PRENATAL CARE DURING THIS PREGNANCY
[ASK FOR MOST RECENT BIRTH ONLY]

422H) When you were pregnant with (NAME), did you get the CHLOROQUINE during a prenatal visit, during a different visit to a health facility, or from another source?
[ASK FOR MOST RECENT BIRTH ONLY]

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

424) Was (NAME) weighed at birth?

425) How much did (NAME) weigh?
RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

425A) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

425B) Why wasn't (NAME)'s birth declared to the state?

426) Who assisted with the delivery of (NAME)?
Anyone else?

PROBE FOR THE TYPE OF PERSON. RECORD ALL PERSONS MENTIONED.
IF RESPONDENT SAYS NO ONE ASSISTED HER, PROBE TO DETERMINE IF ANY ADULT WAS PRESENT AT BIRTH.

427) Where did you give birth to (NAME)?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

428) Was (NAME) delivered by cesarean section?

429) After (NAME) was born, did a health professional or village birth attendant give you an exam?

430) How many days or weeks after delivery did the first check take place?
RECORD '00' DAYS IF SAME DAY.
[ASK FOR MOST RECENT BIRTH ONLY]

431) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[ASK FOR MOST RECENT BIRTH ONLY]

432) Where did this first check take place?
[ASK FOR MOST RECENT BIRTH ONLY]

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

433) In the first two months after delivery, did you receive a vitamin A dose like this?
SHOW CAPSULE. [ASK FOR MOST RECENT BIRTH ONLY]

434) Has your period returned since the birth of (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

435) Did your period return between the birth of (NAME) and your next pregnancy?
[DO NOT ASK FOR MOST RECENT BIRTH]

436) How many months after the birth of (NAME) did you not have a period?

437) CHECK 226:
IS RESPONDENT PREGNANT?
[ASK FOR MOST RECENT BIRTH ONLY]

438) Have you resumed sexual intercourse since the birth of (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

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

440) Did you ever breastfeed (NAME)?

441) 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.

442) In the first three days after delivery, before your milk began flowing regularly, was (NAME) given anything to drink other than breast milk?

443) What was (NAME) given to drink before your milk began flowing regularly?
Anything else? RECORD ALL LIQUIDS MENTIONED.

444) CHECK 404:
IS CHILD LIVING?

445) Are you still breastfeeding (NAME)?

446) For how many months did you breastfeed (NAME)?

447) CHECK 404:
IS CHILD LIVING?

448) How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

449) How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

450) Did (NAME) drink anything form a bottle with a nipple yesterday or last night?

451) Was sugar added to any of the foods or liquids given to (NAME) yesterday?

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

453) GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 454.

SECTION 4B. VACCINATION, HEALTH, AND NUTRITION

454) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH OCCURRING IN 2002 OR LATER. ASK THE QUESTIONS FOR ALL BIRTHS. START WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE THE LAST TWO COLUMNS OF THE ADDITIONAL QUESTIONNAIRE).

455) LINE NUMBER FROM Q212.

456) FROM Q212 AND Q216.

458) Do you have a pre-schooling card where (NAME)'s vaccination are written down?
IF YES: May I please see it?

459) Have you ever had a pre-schooling vaccination card for (NAME)?

460) (1) COPY VACCINATION DATES FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.

461) Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DTcoq 1-3, MEASLES, AND/OR YELLOW FEVER.

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

463) Please tell me if (NAME) received any of the following vaccinations:

463A) A BCG vaccination against tuberculosis, that is, an injection in the forearm that usually causes a scar?

463B) Polio vaccine, that is, drops in the mouth?

463C) When was the first polio vaccine received, just after birth or later?

463D) How many times was the polio vaccine received?

463E) A DTcoq vaccination, that is, an injection in the thigh sometimes given at the same time as polio drops?

463F) How many times?

463G) A malaria vaccine, meaning an injection in the left arm around the age of 9 months?

463H) An injection to prevent yellow fever, meaning an injection done in the arm around the age of 9 months?

464) Did (NAME) receive any of these vaccinations during the last two years in a national immunization day campaign?

465) During the national immunization day campaign, did (NAME) get any of these vaccinations?
RECORD ALL MENTIONED.

465A) Did (NAME) get a dose of vitamin A like this one during the last 6 months?
Show capsule

465B) When did (NAME) get the vitamin A?

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

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

468) When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths?

469) CHECK 466 AND 467:
FEVER OR COUGH?

470) Did you seek advice or treatment for the fever/cough?

471) Where did you seek advice or treatment?
Anywhere else?
RECORD ALL SOURCES MENTIONED.

472) CHECK 466:
HAD A FEVER?

472A) Does (NAME) currently have a fever?

472B) Has (NAME) had convulsions at any time in the last 2 weeks?

472C) CHECK 466 AND 472B:
FEVER OR CONVULSIONS?

473) Did (NAME) take any drugs to treat the fever?

474) What drugs did (NAME) take?
RECORD ALL MENTIONED.
ASK TO SEE THE DRUGS IF TYPE OF DRUG IS UNKNOWN. IF THE TYPE OF DRUG CANNOT BE DETERMINED, SHOW THE RESPONDENT TYPICAL ANTIMALARIALS.

474A) Did (NAME) get an injection or suppository to treat (the fever/convulsions)?

474B) CHECK 474:
TYPE OF DRUG?

474C) How long after the (fever/convulsions) started did (NAME) first take SP/Fansidar?

474D) How many days in a row did (NAME) take SP/Fansidar?
IF 7 DAYS OR MORE, RECORD '7'.

474E) Did you have the SP/Fansidar in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the SP/Fansidar the first time?

474F) CHECK 474:
TYPE OF DRUG?

474G) How long after the (fever/convulsions) started did (NAME) first take Chloroquine?

474H) How many days in a row did (NAME) take Chloroquine?
IF 7 DAYS OR MORE, RECORD '7'.

474I) Did you have the Chloroquine in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the Chloroquine the first time?

474J) CHECK 474:
TYPE OF DRUG?

474K) How long after the (fever/convulsions) started did (NAME) first take Amodiaquine?

474L) How many days in a row did (NAME) take Amodiaquine?
IF 7 DAYS OR MORE, RECORD '7'

474M) Did you have the Amodiaquine in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the Amodiaquine the first time?

474N) CHECK 474:
TYPE OF DRUG?

474O) How long after the (fever/convulsions) started did (NAME) first take quinine?

474P) How many days in a row did (NAME) take quinine?
IF 7 DAYS OR MORE, RECORD '7'.

474Q) Did you have the quinine in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the quinine the first time?

474R) Was anything else done to treat (NAME)'s (fever/convulsions)?

474S) What was done for (NAME)'s (fever/convulsions)?
Anything else?
RECORD ALL MENTIONED.

474SA) How much in total did you pay for the care for (NAME)'s fever?

474T) Was (NAME) given any drug for intestinal worms in the last six months?

475) Has (NAME) had diarrhea in the last two weeks?

476) Now I would like to know how much (NAME) was given to drink during the diarrhea. 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?

477) 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?

478) Was he/she given any of the following to drink?

a) A fluid made from a special packet called [local name of ORS packet]?
b) A government recommended homemade fluid?

479) Was anything (else) given to treat the diarrhea?

480) What (else) was given to treat the diarrhea?
Anything else?

RECORD ALL TREATMENTS GIVEN.

481) Did you seek advice or treatment for the diarrhea?

482) Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

482A) How much in total did you pay for the care for (NAME)'s diarrhea?

483) GO BACK TO 456 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 484.

484) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2002 OR LATER LIVING WITH THE RESPONDENT

485) What do you usually do with your (youngest) child's stools when he/she doesn't use the toilet?

486) CHECK 478A FOR ALL COLUMNS:

487) Have you ever heard of a special product called Orasel you can get for the treatment of diarrhea? SHOW ORS PACKET.

488) CHECK 218:

488A) Sometimes children have serious illnesses and they must be taken to a health care establishment immediately. What types of symptoms would prompt you to take your child to a health care establishment immediately?

489) When (your child/one of your children) is seriously ill, can you yourself decide that he/she needs to be taken somewhere for medical treatment?

IF THE RESPONDENT ANSWERS THAT NONE OF HER CHILDREN HAVE BEEN SERIOUSLY ILL, ASK: If (your child/one of your children) is seriously ill, could you yourself decide that he/she needs to be taken somewhere for medical treatment?

490) Now I would like to ask you questions about health care for yourself.

There are different reasons that prevent women from getting advice or medical treatment for themselves. When you are ill and want advice or medical treatment, which of the following are a serious problem or not?

Knowing where to go.
Getting permission to go.
Getting money for treatment.
Not close to a health care establishment.
Having to take transportation.
Not wanting to go alone.
Worrying that there is no female health care professional.

491) CHECK 215 AND 218:

492) Now I would like to ask you about the liquids (NAME FROM Q491) drank over the last 7 days, including yesterday. How many days in the last 7 did (NAME FROM Q491) drink one or several of the following liquids?

FOR EACH LIQUID DRANK AT LEAST ONCE IN THE LAST 7 DAYS, ASK:
How many times total did (name from q. 491) drink during the day or night?

IF 7 TIMES OR MORE, RECORD '7'.
IF DON'T KNOW, RECORD '8'.

493) Now I would like to ask you about the foods (NAME FROM Q491) ate over the last 7 days, including yesterday. How many times in the last 7 days did (NAME FROM Q491) eat one or several of the following foods?

FOR EACH FOOD EATEN AT LEAST ONCE IN THE LAST 7 DAYS, ASK:
How many times total did (NAME FROM Q491) eat during the day or night?

IF 7 TIMES OR MORE, RECORD '7'.
IF DON'T KNOW, RECORD '8'.

494) How many meals do you usually eat per day?

495) Did you wash your hands before the last time you prepared a meal for your family?

496) Do you currently smoke cigarettes or tobacco?
IF YES: What do you smoke?
RECORD ALL MENTIONED.

498) How many cigarettes have you smoked in the last 24 hours?

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

501) Are you currently married or living with a man as if married?

502) Have you ever been married or lived with a man?

503) What is your current marital status: are you widowed, divorced, or separated?

504) Is your husband/partner living with you now or is he staying elsewhere?

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

506) How old was your husband/partner at his last birthday?

507) Other than yourself, does your husband/partner have other wives or does he live with other women as if married?

508) Including yourself, in total, how many other wives or partners does your husband currently have?

509) Are you the first, second?wife?

510) Have you been married or have you lived with a man only once or more than once?

511) CHECK 510:

MARRIED/LIVED WITH MAN ONLY ONCE: In what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH MAN MORE THAN ONCE: I would like to talk about the first time you were married or started living with a man as if married. In what month and year were you married or did you start living with a man as if married for the first time?

512) How old were you when you started living with him?

513) CHECK 503: IS RESPONDENT CURRENTLY WIDOWED?

514) CHECK 510:

515) How did your previous marriage/union end?

516) To whom did most of your late husband's property go to?

517) Did you receive any of your late husband's assets or valuables?

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

519) Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.

How old were you when you had sexual intercourse for the very first time (if ever)?

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

521) CHECK 106:

522) The first time you had sexual intercourse, was a condom used?

523) How old was the person you first had sexual intercourse with?

524) Was this person older than you, younger than you, or about the same age as you?

525) Would you say this person was ten or more years older than you or less than ten years older than you?

526) When was the last time you had sexual intercourse?
IF 12 MONTHS OR MORE, ANSWER MUST BE CONVERTED AND RECORDED IN YEARS.

526A) 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.

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

528) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

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

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

531) What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married?
IF YES, CIRCLE '02'
IF NO, CIRCLE '03'

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

533) CHECK 106:

534) How old is this person?

535) Was this person older than you, younger than you, or about the same age as you?

536) Would you say this person was ten or more years older than you or less than ten years older than you?

537) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

538) In total, how many different people have you had sexual intercourse with in the last 12 months?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

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

539A) CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR MEN'S SURVEY?

540) CHECK 106:

541) CHECK FOR PRESENCE OF OTHER PEOPLE.
DO NOT CONTINUE UNTIL YOU ARE COMPLETELY ALONE WITH RESPONDENT.

541A) Has anyone ever forced you to have sexual intercourse against your will?

542) The first time you had sexual intercourse, did you want to have sexual intercourse, or were you forced against your will?

543) Did anyone make you have sexual intercourse against your will in the last 12 months?

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

545) Where is that?
Any other place?
RECORD ALL MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

546) If you wanted to, could you yourself get a condom?

547) CHECK 527 FOR ALL COLUMNS:

548) Where did you get the condom last time?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

SECTION 6. FERTILITY PREFERENCES

601) CHECK 311/311A:

602) CHECK 226:

NOT PREGNANT OR UNSURE: Now I have some question about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

PREGNANT: Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

603) 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 this child you are expecting now, how long would you like to wait before the birth of another child?

604) CHECK 226:

605) CHECK 310:
USING A CONTRACEPTIVE METHOD?

606) CHECK 603:

607) CHECK 602:

WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy.
Can you tell me why you are not using a method? Any other reason?

WANTS NO MORE/NONE: You have said that you do not want any (more) children, but you are not using any method to avoid pregnancy.
Can you tell me why you are not using a method? Any other reason?

RECORD ALL REASONS MENTIONED.

608) In the next few weeks, if you discovered that you were pregnant, would that be a big problem, a small problem, or no problem at all?

609) CHECK 310:
USING A CONTRACEPTIVE METHOD?

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

611) Which method would you prefer to use?

612) What is the main reason that you think you will never use a contraceptive method at any time in the future?

613) Would you ever use a contraceptive method if you were married?

614) 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.

615) 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?

616) Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?

617) In the last few months have you heard about family planning:

On the radio?
On the television?
In a newspaper or magazine?

619) In the last few months, have you discussed the practice of family planning with your friends, your neighbors, or your relatives?

620) With whom? Anyone else?
RECORD ALL PERSONS MENTIONED.

621) CHECK 501:

622) CHECK 311/311A:

623) You say that you are currently using a contraception method. Would you say that using contraception is mainly your decision, your husband's/partner's decision, or did you both decide together?

624) Now I want to ask you about your husband's/partner's views on family planning.

Do you think your husband/partner approves or disapproves of couples using a contraceptive method to avoid pregnancy?

625) How many times in the last year have you talked to your husband/partner about family planning?

626) CHECK 311/311A:

627) Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer than you want?

628) Husband and wives do not always agree in everything. Please tell me if you think a woman is justified refusing to have sex with her husband when:

She knows her husband has a disease that she can get during sexual intercourse?
She knows her husband has sex with women other than his wives?
She recently gave birth?
She is tired or not in the mood?

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

630) CHECK 501:

631) Can you refuse sexual intercourse with your husband when you do not wish to have intercourse?

632) Can you ask your husband to use a condom if you want him to use one?

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701) CHECK 501 AND 502:

703) Did your (last) husband/partner ever attend school?

704) What was the highest level of school he attended: primary, secondary, or higher?

705) What was the highest (grade/form/year) he completed at that level?

706) CHECK 701:

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?

707) Aside from your own housework, are you currently working?

708) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business.
Are you currently doing any of these things or any other work?

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

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

711) CHECK 710:

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

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

714) Do you usually work at home or away from home?

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

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

717) Who mainly decides how the money you earn will be used?

718) On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

719) Who in your household usually has the final say on the following decisions?

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

721) Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

722) Were you sick at any time in the last two weeks?

723) Did you receive medical care?

724) How much did you pay for the medical care (consultations, drugs, etc)?

725) Why did you not received medical care?
Any other reason?
RECORD ALL MENTIONED.

726) Do you know of an illness called "fistula," meaning, when a woman has constant leakage of urine or stool?

726A) What do you think is the main cause for this problem?

727) Are you currently experiencing urine and/or stool leakage from your vagina outside of "urination/defecation"?

728) Have you ever experienced urine and/or stool leakage from your vagina outside of "urination/defecation"?

729) How did this problem start?

730) You said that this happened after childbirth. Was it from your 1st, 2nd, 3rd... delivery?

731) How old were you when this happened (for the first time)?

732) Have you ever received (are you currently getting) treatment?

SECTION 8. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

801) Now I would like to talk about something else.

Have you ever heard of an illness called AIDS?

802) Can people reduce their chance of getting the AIDS virus by having just one sex partner who is not infected and who has no other sex partners?

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

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

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

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

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

808) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

809) What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.

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

811) Can the virus that causes AIDS be transmitted from a mother to a child:

During pregnancy?
During delivery?
By breastfeeding?

812) CHECK 811:

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

814) Are there any special drugs that people infected with the AIDS virus can get from a doctor or nurse?

815) CHECK 215:

816) CHECK 407:

817) Now I would like to ask you questions about your last birth. You told me that you saw someone for antenatal care during this pregnancy. During any of the antenatal visits for this pregnancy, did anyone talk to you about:

Babies getting the AIDS virus from their mother?
Things that you can do to prevent getting the AIDS virus?
Getting tested for the AIDS virus?

818) Were you offered a test for that AIDS virus as part of your antenatal care?

819) I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

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

821) Where was the test done?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

822) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

823) When was the last time you were tested for the AIDS virus?

824) I don't want to know the result, but have you ever been tested to see if you have the AIDS virus?

825) When was the last time you were tested?

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

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

828) Where was the test done?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

830) Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

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

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

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

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

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

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

838) CHECK 835, 836, AND 837:

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

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

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

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

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

850) CHECK 801:

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?

851) If a man has a sexually transmitted disease, what symptoms might he have?
Any other signs or symptoms?
RECORD ALL SYMPTOMS MENTIONED.

852) If a woman has a sexually transmitted disease, what symptoms might she have?
Any other signs or symptoms?
RECORD ALL SYMPTOMS MENTIONED.

853) CHECK 519:

854) CHECK 850:

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

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

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

858) CHECK 855, 856, 857:

859) The last time you had (INFECTION FROM 855/856/857), did you seek any kind of advice or treatment?

860) Where did you go?
Any other place?
CIRCLE ALL MENTIONED.

861) The last time you had (INFECTION FROM 855/856/857), did your partner seek any kind of advice or treatment?

862) Where did he go?
Any other place?
CIRCLE ALL MENTIONED.

SECTION 9. MATERNAL MORTALITY

901A) Now, I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your biological mother.

Did your mother give birth to any children other than yourself?

901B) How many boys did your mother have who are still living?

901C) Other than yourself, how many girls did your mother have who are still living?

901D) How many boys did your mother have who died?

901E) How many girls did your mother have who died?

901F) Did your mother give birth to any other children, who you don't know if they are living or dead?

901G) How many other children did your mother give birth do, who you don't know if they are living or dead?

901H) ADD THE ANSWERS FROM 901B, C, D, E, and G, ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

901I) CHECK 901H:
Just to make sure that I've understood, including yourself, your mother give birth to _____ children total. Is that correct?

902) CHECK 901H:

903) How many of these births did your mother have before you were born?

Now I would like to make a list of all your sisters and brothers, whether they are still alive or not, starting with the oldest. RECORD THE NAME OF ALL THE SISTERS AND BROTHERS.

904) What was the name given to your oldest (next oldest) brother or sister?

905) Is (NAME) male or female?

906) Is (NAME) still alive?

907) How old is (NAME)?

908) How many years ago did (NAME) die?

909) How old was (NAME) when he/she died?

IF DON'T KNOW, PROBE: Did (NAME) die before he/she was 12 years old?

IF YES, RECORD '95'. IF NO, ASK OTHER QUESTIONS TO OBTAIN AN ESTIMATE. FOR EXAMPLE: Did (NAME) die before getting married?

910) Was (NAME) pregnant when she died?

911) Did (NAME) die during childbirth?

912) Did (NAME) die within two months after the end of a pregnancy or childbirth?

913) How many living children did (NAME) give birth to in her life?

IF NO MORE BROTHERS OR SISTERS, GO TO 1001.

SECTION 10. DOMESTIC VIOLENCE

1001) CHECK THE FRONT COVER PAGE: THE WOMAN YOU ARE SURVEYING WAS SELECTED FOR THE QUESTIONS ON "DOMESTIC VIOLENCE"?

1002) CHECK FOR THE PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.
CIRCLE THE CODE CORRESPONDING TO THE SITUATION AND FOLLOW THE CONTINUATION INSTRUCTIONS.

READ TO ALL RESPONDENTS:
Now I would like to ask you questions about some certain parts of your life as part of a relationship. I know that some of these questions are very personal. However, your answers are crucial for helping to understand the condition of women in the Democratic Republic of Congo. Let me assure you that your answers are completely confidential and will not be told to anyone. Additionally, you are the only person in your household that is being asked these questions and no one will know that you were asked these questions. If someone arrives while we are talking, we will talk about something else.

1003) CHECK 501, 502, AND 504:

1004) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.

4A) (Does/did) your last husband/partner ever:

4B) How many times did this happen during the last 12 months?

1005) 5A) (Does/did) your (last) husband/partner ever:

5B) How many times did this happen during the last 12 months?

1006) Does (did) your (last) husband/partner drink alcohol?

1007) How often does (did) he get drunk: very often, only sometimes, or never?

1008) CHECK 1003:

MARRIED/LIVING WITH A MAN/SEPARATED/DIVORCED/WIDOWED: From the time you were 15 years old has anyone other than your (current/last) husband/partner hit, slapped, kicked, or done anything else to hurt you physically?

NEVER MARRIED/NEVER LIVED WITH A MAN: From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you physically?

1008A) Who has physically hurt you in this way?
PROBE: Anyone else?
RECORD ALL MENTIONED.

1008B) CHECK 1008A:

1009) Who has hit, slapped, kicked or done something to physically hurt you most often?

1010) In the last 12 months, how many times has this person hit, slapped, kicked, or done anything else to physically hurt you?

1011) CHECK Q201, Q226, AND Q229: LIVE BIRTHS, PREGNANCIES, STILLBIRTHS

1012) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

1013) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED.

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1014) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE ONE OF THE FOLLOWING PERSONS WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

1015) INTERVIEWER COMMENTS:
IF QUESTIONS 1003 TO 1014 WERE NOT ASKED, EXPLAIN THE REASONS

COMMENTS________________________________________________________

1016) RECORD THE TIME.

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: _________