CONFIDENTIAL

IDENTIFICATION

RESPONDENT POOL

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) ____

NAME OF HEAD OF HOUSEHOLD ____

CLUSTER NUMBER

HOUSEHOLD NUMBER

FORMER PROVINCE

NEW PROVINCE

URBAN/RURAL

KINSHASA - MAIN CITY OF PROVINCE - OTHER CITY - CITY - STATE - RURAL

NAME AND LINE NUMBER OF WOMAN ____

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: WAS THE HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, THE ANEMIA, MALARIA, HIV, AND VACCINATIONS TESTS, AND THE ANTHROPOMETRIC MEASUREMENTS? (YES 1, NO 2)

IF NO ( 2) CHECK QUESTION 293A OF THE HOUSEHOLD QUESTIONNAIRE FOR THE SELECTION OF THE WOMAN ELIGIBLE FOR THE SECTION ON "DOMESTIC VIOLENCE." IF THE WOMAN WHO YOU ARE SURVEYING WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE, RECORD 1 IN THE SPACE TO THE RIGHT; OTHERWISE RECORD 2 (YES 1, NO 2).

INTERVIEWER VISITS
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
INTERVIEWER'S NAME ____
RESULT*

THIRD VISIT DATE ____
INTERVIEWER'S NAME ____
RESULT*

FINAL VISIT
DAY ____
MONTH ____
YEAR 201_
INTERVIEWER CODE ____
RESULT

TOTAL NUMBER OF VISITS ____

*RESULT CODES:

LANGUAGE OF QUESTIONNAIRE ____

LANGUAGE CODES:

LANGUAGE OF INTERVIEW ____

LANGUAGE CODES:

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 ___. I am working with the Ministry of Planning and the Ministry of Health. We are conducting a survey about health all over the Democratic Republic of Congo. The information we collect will help the government to improve health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. Based on the terms of article 8 and 9 of the Decree of February 11, 2010, 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 the person listed on the card that has been given to your household.

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

SIGNATURE 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

104) Have you ever attended school?

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

106) What is the highest (grade/form/year) you completed at this level?*
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

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?

113A) Are you Congolese?

114) What is your tribe?
RECORD NAME OF TRIBE

115) In the last 12 months, how many times have you been away from for one or more nights?

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

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, RECODE '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 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 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 you (first/next) baby?

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: 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), 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 2008 OR LATER.

226) Are you pregnant now?

227) How many months pregnant are you?

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?

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

231) When did the last such pregnancy end?

232) CHECK 231:
LAST PREGNANCY ENDED IN JAN 2008 OR LATER

LAST PREGNANCY ENDED BEFORE JAN. 2008 (GO TO 238)

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

234) Since January 2008, have you had any other pregnancies that did not result in a live birth?

236) Did you have any miscarriages, abortions or stillbirths that ended before 2008?

237) When did the last such pregnancy that terminated before 2008 end?

238) When did you last menstrual period start?
(DATE, IF GIVEN)

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

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

Have you ever heard of (Method)?

302) 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) What is the brand name of the pills you are using?
IF DON'T KNOW BRAND, ASK TO SEE THE PACKAGE.

306) What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

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 did you start using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD FIRST MENTIONED) now without stopping?

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.

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?

315A) Where did you learn how to use the rhythm/lactational amenorrhea method?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

317) At that time, where you told about side effects or problems you might have with the method?

317A) When you got sterilized, were you told about side effects or problems you might have with the method?

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

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

320) CHECK 317:
CODE 1 CIRCLED
At that time, were you told about other methods of family planning that you could use?

CODE '2' CIRCLED
When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

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

322) 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 IDENTITY 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 you can obtain a method of family planning?

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

326) In the last 12 months, were you visited by a fieldworker who talked to you about family planning?

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

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

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2008 OR LATER. ASK THE QUESTIONS ABOUT ALL 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

404) FROM 212 AND 216:

405) When you got pregnant with (NAME), did you want to become 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.

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

411) How many months pregnant were you when you first received antenatal care for this pregnancy?

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

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?

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 a tetanus injection?

417) CHECK 416:

418) At any time before this pregnancy, did you receive any tetanus injections?

419) Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD 7

420) How many years ago did you receive the last tetanus injection before this pregnancy?

421) During this pregnancy, were you given or did you buy iron tablets or iron syrup?
SHOW TABLES/SYRUP

422) During the whole pregnancy, for how many days did you take the tables or syrup?
IF ANSWER NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

423) During this pregnancy, did you take any drug for intestinal worms?

424) During this pregnancy, did you take any drugs to keep you from getting malaria?

425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION

427) How many times did you take (SP/Fansidar) during this pregnancy?

428) CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility, or from another source?

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

431) Was (NAME) weighed at birth?

432) How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE

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

434) Where did you give birth to (NAME)?
PROBE TO IDENTITY 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, that is, did they cut your belly open to take the baby out?

436) I would like to talk to you about check 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 check 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)?

439) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.

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

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 IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

444) Who checked on (NAME)'s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.

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

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/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: CHILD IS 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)?

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 2008 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.

507) CHECK 506:

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

509) Did (NAME) ever receive 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 left forearm that usually causes a scar?

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

510C) Was the first polio vaccine given just after birth or later?

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

510E) A DTC/HepB/Hib 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 DTC/HepB/Hib vaccination given?

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

510H) A yellow fever vaccination, that is, a shot in the right arm at the age of 9 months or older,- to prevent him/her from getting yellow fever?

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

513A) In the last six months, was (NAME) given a mebendazole table like this one?
SHOW 500 MG TABLET FOR CHILDREN AGE 12-59 MONTHS

513B) Has (NAME) ever had the measles?

513C) How old was (NAME) when he/she had the measles?

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

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 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?

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.

520) CHECK 519:

521) Where did you first seek advice or treatment?

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 packet called (Local Name for ORS Packet)?
b) A pre-packaged ORS liquid?
c) A government-recommended homemade fluid?

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

524) What (else) was given to treat the diarrhea?
Anything else?
RECORD ALL TREATMENTS GIVEN.

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

526) At any time during the illness, did (NAME) have blood taken from his/her finger or heal for testing?

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 breath 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?

534) 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.

535) CHECK 534:

536) Where did you first seek advice or treatment?

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) CHECK 538:
ANY CODE A-L CIRCLED?

540) CHECK 538:
SP/FANSIDAR (A) GIVEN

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

542) CHECK 538:
CHLOROQUINE (B) GIVEN

543) How long after the fever started did (NAME) first take Chloroquine?

544) CHECK 538:
AMODIAQUINE (C) GIVEN

545) How long after the fever started did (NAME) first take Amodiaquine?

546) CHECK 538:

547) How long after the fever started did (NAME) first take Quinine?

548) CHECK 538:
COMBINATION WITH ARTEMISININ (CTA) PROTO. RDC: ARTESUNATE/AMODIAQUINE, ARTEMETHER/LUMEFANTRINE (E) GIVEN

549) How long after the fever started did (NAME) first take (Combination with artemisinin (CTA) Proto. RDC)?

549A) CHECK 538:
OTHER CTA: ARSUCAM/CO-ARINATE/ETC (F) GIVEN

549B) How long after the fever started did (NAME) first take Other CTA: Arsucam/Co-Arinate/etc?

550) CHECK 538:
OTHER ANTIMALARIAL GIVEN

551) How long after the fever started did (NAME) first take (Other antimalarial)?

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2008 OR LATER LIVING WITH THE RESPONDENT

554) The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

555) CHECK 522A AND 522B, ALL COLUMNS:

556) Have you ever heard of a special product called ORS, for example Orasel, you can get for the treatment of diarrhea?

557) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2011 OR LATER LIVING WITH 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):

a) Plain water?
b) Juice or juice drinks?
c) Clear broth?
d) Milk such as tinned, powdered, or fresh animal milk? IF YES: How many times did (NAME) drink milk?
e) Infant formula? IF YES: How many times did (NAME) drink infant formula?
f) Any other liquids?
g) Yogurt? IF YES: How many times did (NAME) eat yogurt?
h) Any commercially fortified baby food like [brand name of commercially fortified baby food, e.g. Cerelac]?
i) Rice, corn, millet, sorghum, noodles, porridge, or other foods made from grains?
j) Pumpkin, yams or red or yellow squash, carrots, sweet potatoes that are yellow or orange inside?
k) White potatoes, white yams, manioc, cassava, white sweet potatoes or any other foods made from roots?
l) Any dark green, leafy vegetables?
m) Ripe mangoes, papayas?
n) Any other fruits or vegetables (for example: banana, apple, applesauce green beans, avocado, tomato)?
o) Liver, kidney, heart or any other organ meats?
p) Any meat, such as beef, pork, lamb, goat, chicken or duck?
q) Eggs?
r) Fresh or dried fish or shellfish?
s) Other foods based in beans, soy, peas, lentils, or nuts?
t) Cheese or other food made from milk?
u) Any other solid, semi-solid, or soft food?

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 FROM 557) 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 AND SEXUAL ACTIVITY

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

602) Have you ever been married or lived together with a man as if married?

603) What is your current marital status: are you a widow, divorced, or separated?

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

605) RECORD THE LINE NUMBER OF HER HUSBAND/PARTNER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT A LISTED IN THE HOUSEHOLD, RECORD '00'.

606) Does your husband/partner have other wives or does he live with other women as if married?

607) Including yourself, in total how many wives or live-in partners does he have?

608) Are you the first, second?wife?

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

610) CHECK 609:
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: Now I would like to talk about the 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?

612) CHECK for the presence of others. Before continuing, make every effort to ensure privacy.

613) 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?

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

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

618) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

619) 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 2
IF NO, CIRCLE 3

620) CHECK 609:

621) CHECK 613

622) How long ago did you first have sexual intercourse with this (second/third) person?

623) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 96 OR MORE, WRITE 95.

624) How old is this person?

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

626) 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

627) 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

628) PRESENCE OF OTHERS DURING THIS SECTION:

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

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

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

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

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

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

SECTION 7. FERTILITY PREFERENCES

701) 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 question 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 NOT SURE: 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?

706) CHECK 226:

707) CHECK 303:
USING A CONTRACEPTIVE METHOD?

708) CHECK 705:

709) CHECK 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 method to delay or avoid pregnancy 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 few months have you:
a) Heard about family planning on the radio?
b) Seen anything about family planning on the television?
c) Read about family planning in a newspaper or magazine?

716) CHECK 601:

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 601 and 602:

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

AGE IN COMPLETED YEARS ____

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

804) What is the highest level of school you attended: Primary, Secondary, or higher?

805) What is the highest (grade/form/year) you completed at this level?*
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

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 or do you ear in cash or in kind for this work or are you not paid at all?

815) CHECK 601:

816) CHECK 814:

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

818) Would you say that the money that you earn is more than what your (husband/partner) earns, less than what he earns, or about the same?

819) Who usually decides how the money your (husband/partner) earnings will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

820) Who usually makes decisions about health care for yourself: you, your (husband/partner), you and your (husband/partner) 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) Do you own this or any other house either alone or jointly with someone else?

824) Do you own any land either alone or jointly with someone else?

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

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?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

DON'T KNOW 8

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?

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 a baby?
a) During pregnancy?
b) During delivery?
c) By breastfeeding?

909) CHECK 908:

910) 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?

911) CHECK 208 and 215:

912) CHECK 408 FOR LAST BIRTH:

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

914) During any of the antenatal visits for your last birth were you given any information about:
a) Babies getting HIV from their mother?
b) Things that you can do to prevent getting HIV?
c) Getting tested for HIV?

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

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

917) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

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

919) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

920) CHECK 434 FOR LAST BIRTH

921) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

922) I don't want to know the results, but were you tested for the AIDS virus at that time?

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

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

925) How many months ago was your most recent HIV test?

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

927) How many months ago was your most recent HIV test?

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

929) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

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

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

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

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

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

935) 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?

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

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?

938) CHECK 613:

939) CHECK 937: 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 (infection from 940/941/942), did you seek any kind of advice or treatment?

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

RECORD ALL MENTIONED.

946) 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?

947) Is a wife justified in refusing to have sex with her husband when she knows he has sex with (another woman, women other than his wife/wives)?

948) CHECK 601:

949) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?

950) Could you ask your (husband/partner) to use a condom if you wanted him to?

SECTION 10. OTHER HEALTH ISSUES

1001) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?
IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

1003) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

1004) Do you currently smoke cigarettes?

1005) In the last 24 hours, how many cigarettes did you smoke?

1005A) The last time you bought cigarettes for personal use, how many cigarettes did you buy?

1005B) In total, how much did you spend on this purchase?
AMOUNT IN CONGOLESE FRANCS

1006) Do you currently smoke or use any (other) type of tobacco?

1007) What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

1007A) Do you currently consume non-smoking tobacco every day, less than every day, or not at all?

EVERY DAY 1
LESS THAN EVERY DAY 2
NOT AT ALL 3

1007B) CHECK 1004 and 1006:

1007C) In the last 12 months, have you tried to stop smoking?

1007D) In the last 30 days, has anyone smoked inside of the places where you work?

1008) Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?

a) Getting permission to go to the doctor?
b) Getting money needed for advice or treatment?
c) The distance to the health facility?
d) Not wanting to go alone?

1009) Are you covered by any health insurance?

1010) What type of health insurance are you covered by?
RECORD ALL MENTIONED

SECTION 11. MATERNAL MORTALITY

1101) Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother.
Did your mother give birth to any children other than yourself?

1101B) How many boys did your mother have who are still living?

1101C) Other than yourself, how many girls did your mother have who are still living?

1101D) How many boys did your mother have who died?

1101E) How many girls did your mother have who died?

1101F) Did your mother give birth to any other children, who you don't know if they are living or dead?

1101G) How many other children did your mother give birth to, who you don't know if they are living or dead?

1101H) ADD THE ANSWERS FORM 1101, 1102, 1103, 1104, AND 1106
ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL

1101I) CHECK 1101H:
Just to make sure that I've understood, including yourself, your mother gave birth to _____ children total. Is that correct?

1102) CHECK 1101h:

1103) How many of these births did your mother have before you were born?

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

1104) What was the name given to your oldest (next oldest) brother or sister?

1105) Is (NAME) male or female?

1106) Is (NAME) still alive?

1107) How old is (NAME)?

1108) How many years ago did (NAME) die?

1109) How old was (NAME) when he/she died?
IF DON'T KNOW, PROBE:
Did (NAME) die before the age of 12?
IF YES, RECORD 95.
IF NO, ASK OTHER QUESTIONS TO GET AN ESTIMATE, FOR EXAMPLE: Did (NAME) die before getting married?

IF MAN, OR WOMAN DECEASED BEFORE AGED 12, GO TO NEXT SIBLING.

1110) Was (NAME) pregnant when she died?

1111) Did (NAME) die during childbirth?

1112) Did (NAME) die within two months after the end of a pregnancy or childbirth?

1113) How many live born children did (NAME) give birth to during her lifetime?

SECTION 12. CHILD DEVELOPMENT AND EARLY LEARNING

1201) CHECK COVER PAGE OF QUESTIONNAIRE:
HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANEMIA, MALARIA, HIV, AND VACCINES TESTS AND ANTHROPOMETRIC MEASUREMENTS

1201A) CHECK QUESTIONS 217 and 218:
DOES A CHILD BETWEEN AGES 0 AND 4 LIVE IN THIS HOUSEHOLD (217 IS 0-4 YEARS COMPLETED AND 218 IS 1)?

1202) CHECK QUESTION 217:
SELECT THE YOUNGEST CHILD BETWEEN AGES 0 AND 4, RECORD HIS/HER NAME AND LINE NUMBERS

1203) Now I would like to ask you some questions about (NAME OF CHILD FROM QUESTION 1202), your youngest child between ages 0 and 4.

1203A) Does (NAME) have a birth certificate?

1203B) Why doesn't (NAME) have a birth certificate?

1204) How many children's books and picture books do you have for (NAME)?

1205) I would like to ask you what objects (NAME) uses to play with while at home.
Does he/she play with:
a) Homemade toys (like dolls, cars, or other homemade toys)?
b) Toys from a store or a manufacture?
c) Household objects (like bowls or pots), or objects found outside (like sticks, stones, animals, shells, or leaves)?

IF THE RESPONDENT SAYS "YES" TO ONE OF THE ABOVE CATEGORIES, PROBE TO DETERMINE PRECISELY WHAT THE CHILD PLAYS WITH TO BE CERTAIN OF THE RESPONSE.

1206) Sometimes the adults who take care of the children have to leave the house to go shopping, do the laundry, or for other reasons and have to leave the young children.
During the last week, how many days was (NAME):
a) Left alone for more than one hour?
b) Left in the care of another child (meaning someone under 10 years old) for more than one hour?

1207) CHECK QUESTION 217 and 218:
DOES A CHILD AGES 3 OR 4 LIVE IN THIS HOUSEHOLD (217 IS 3 OR 4 YEARS COMPLETED AND 218 IS 1)?

1208) CHECK 217:
SELECT THE YOUNGEST CHILD OF 3 OR 4 YEARS, RECORD HIS/HER NAME AND LINE NUMBERS

1209) Now I would like to ask you some questions about (name of child from QUESTION 1208), your youngest child of 3 or 4 years.

1210) Is (NAME) in a preschool education program or an early learning class, in a public or private establishment, including nursery school or a community child-care center?

1211) Within the last seven days, about how many hours did (NAME) go to that place?

1212) During the last three days did you or a member of your family age 15 or old participate with (NAME) in one of the following activities:
IF YES, ASK: Who participated in this activity with (NAME)?
CIRCLE ALL MENTIONED.

a) Read books or looked at illustrated books with (NAME)?
b) Told stories to (NAME)?
c) Sang songs to (NAME), or with (NAME), including lullabies?
d) Took (NAME) for a walk outside of the house, the residence, the courtyard or the enclosure wall?
e) Played with (NAME)?
f) Spent time with (NAME), naming, counting, and/or drawing?

1213) Now I would like to ask you some questions about the health and development of your child. Children do not all develop in the same manner and at the same speed. Some, for example, walk earlier than others. These questions relate to several aspects of your child's development.

Does (NAME) know or can he/she recite at least ten letters from the alphabet?

1214) Can (NAME) read at least four simple, common words?

1215) Can (NAME) list and recognize all digits from 1 to 10?

1216) Can (NAME) grasp with two fingers a small object from the ground, like a stick or a pebble?

1217) Is (NAME) ever too sick to play?

1218) Is (NAME) able to follow simple instructions to do something correctly?

1219) When you give (NAME) something to do, is he/she able to do it independently?

1220) Does (NAME) get along well with other children?

1221) Does (NAME) kick, bit, or hit other children or adults?

1222) Is (NAME) easily distracted?

SECTION 13. DOMESTIC VIOLENCE

1300) CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE

1301) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

READ TO THE RESPONDENT:
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in the Democratic Republic of Congo. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.

1302) CHECK 601 and 602:

1303) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?
a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your female friends?
d) He (tries/tried) to limit your contact with your family?
e) He (insists/insisted) on knowing where you (are/where) at all times?

1304) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.
A) (Does/did) your last husband/partner ever:

B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

1305) A) Did your (last) (husband/partner) ever do any of the following things to you:

B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

1306) CHECK 1305 (A-J):

1307) How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD 00.

1308) Did the following ever happen as a result of what your (last) husband/partner did to you:
a) You had cuts, bruises, or aches?
b) You had eye injuries, sprains, dislocations, or burns?
c) You had deep wounds, broken bones, broken teeth, or any other serious injury?

1309) Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?

1310) In the last 12 months, how often have you done this to your (last) husband/partner: often, only sometimes, or not at all?

1311) Does (did) your husband/partner drink (alcohol)?

1312) How often does (did) he get drunk: often, only sometimes, or never?

1313) Are (were) you afraid of your (last) (husband/partner): many times, sometimes, or never?

1314) CHECK 609:

1315) A) So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

B) How long ago did this last happen?

1316) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN:
From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, or done anything else to hurt you physically?

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

1317) Who has physically hurt you in this way? Anyone else?
RECORD ALL MENTIONED

1318) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

1319) CHECK 201, 226, and 230:

1320) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

1321) Who has done any of these things to physically hurt you while you were pregnant? Anyone else?
RECORD ALL MENTIONED

1322) CHECK 601 AND 602:

1323) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).

At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

1324) At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

1325) Who was the person who was forcing you the first time?

1326) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?

1327) CHECK 1305a (H-J) AND 1315A (B):

1328) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: How old were you the first time someone including (your/any) (husband/partner) forced you to have sexual intercourse or perform any other sexual?

NEVER MARRIED/NEVER LIVED WITH A MAN: How old were you the first time someone forced you to have sexual intercourse or perform any other sexual acts?

1329) CHECK 1305 (A-J), 1315A (A,B), 1316, 1320, 1323, AND 1324:

1330) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

1331) From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.

1332) Have you ever told anyone about this?

1333) As far as you know, did your father ever beat your mother?

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.

1334) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

1335) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

1336) 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: ____