IDENTIFICATION

DEPARTMENT NAME_______

LOCATION NAME_______

NAME OF HEAD OF HOUSEHOLD_______

CLUSTER NUMBER_______

STRUCTURE NUMBERS_______

HOUSEHOLD NUMBER_______

NAME AND LINE NUMBER OF MAN_______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISIT)
INTERVIEWER'S NAME_______
RESULT______

NEXT VISIT
DATE_______
TIME_______

FINAL VISIT
DAY_______
MONTH_______
YEAR _______
INT. NUMBER_______
RESULT______

RESULT CODES:

TOTAL NO. OF VISITS_______

SUPERVISOR
NAME_______
DATE_______

FIELD EDITOR
NAME_______
DATE_______

OFFICE EDITOR_______

KEYED BY_______

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT:

Hello. My name is _______. I am working for the Demographic and Health Survey, supported by the government and its partners. We are conducting a survey about health all over 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 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has already 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 almost every day, at least once a week, less than once a week or not at all?

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

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

113) What is your religion?

114) What is your ethnicity?

Circle the code for the large ethnic group.
For foreigners, circle foreigner

SECTION 2. REPRODUCTION

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

Have you ever fathered any children with any woman?

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

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

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

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

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

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

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

209) CHECK 208:
HAS HAD MORE THAN ONE CHILD

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

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

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

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)?

307) CHECK 301 (07): KNOW MALE CONDOM

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

309) Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.

310) If you wanted, could you yourself get a condom?

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

405) Do you have other wives or do you live with other women as if married?

406) Altogether, how many wives or live-in partners do you have?

407) CHECK 405:

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

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

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

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

409) CHECK 407:

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

411) In what month and year did you start living with your (wife/partner)?

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

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

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

414) Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues.

How old were you when you had sexual intercourse for the very first time?

415) 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.

416) 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.

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

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

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

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

421) CHECK 410:

422) CHECK 414:

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

424) 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 the number of times is 95 or more, write 95.

425) How old is this person?

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

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

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

428) CHECK 420 (ALL COLUMNS):

429) CHECK 420 AND 418 (ALL COLUMNS):

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

431) Have you ever paid anyone in exchange for having sexual intercourse?

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

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

434) In total, with how many different people have you had sexual intercourse in your life?

IF NON-NUMERIC NUMBER, PROBE TO GET AN ESTIMATE
IF THE NUMBER IF MORE THAN 95, WRITE '95'.

435) CHECK 418: MOST RECENT PARTNER (FIRST COLUMN):

437) From where did you obtain the condom the last time?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

SECTION 5. FERTILITY PREFERENCES

501) CHECK 401:

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

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

505) Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

506) CHECK 407:

507) CHECK 503:

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

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

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

509) CHECK 203 AND 205:

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

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

Probe for a numeric response.

510) 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?

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

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

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

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

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

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

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

If she is not faithful?
If she goes out without telling him?
If she refuses to have sex with him?
If she isn't respectful to him?
If she isn't respectful to his family?
If she neglects the children?
If she neglects her housework?
If she spends money without his authorization?

SECTION 7. HIV/AIDS

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

701A) Where did you hear about AIDS?

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

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

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

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

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

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

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

During pregnancy?
During delivery?
By breastfeeding?

709) CHECK 708:

710) 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?

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

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

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

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

715) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

717) Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

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

720) 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?

721) 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?

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

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

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

724) CHECK 414:

725) CHECK 723: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

726) 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?

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

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

729) CHECK 726, 727, AND 728:

730) The last time you had (infection from 726/727/728), did you seek any kind of advice or treatment?

731) Where did you go? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.

732) 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?

733) Is a wife justified in refusing to have sex with her husband when she knows he has sex with women other than his wives?

SECTION 8. OTHER HEALTH ISSUES

801) Some men are circumcised, that is, the foreskin is completely removed from the penis. Are you circumcised?

802) How old were you when you got circumcised?

803) Who did the circumcision?

805) 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.

806) 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.

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

808) Do you currently smoke cigarettes?

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

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

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

812) Are you covered by any health insurance?

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

814) Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a sexual assault or after pelvic surgery. [##translator note: The top line of this question was cut off, but I used the question from the woman's survey to provide what should be an accurate translation]

Have you ever heard of this problem, that is to say, when a woman has constant leakage of urine or stool form her vagina during the day and night?

815) Where did you hear about this problem?
Any other information source?
RECORD ALL MENTIONED.

816) Do you personally know a woman who has or had this problem?

817) In your opinion, can you get this problem through witchcraft or other supernatural means?

818) In your opinion, can this problem be cured?

819) If a woman in your family had constant leakage of urine or stool from her vagina during the day and night, would you allow her to live in your household?

819) 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_________