IDENTIFICATION

PLACE NAME___
NAME OF HOUSEHOLD HEAD___
CLUSTER NUMBER___
HOUSEHOLD NUMBER___
NAME AND LINE NUMBER OF WOMAN___

INTERVIEWER VISITS

FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT* ___

NEXT VISIT
DATE___
TIME___

FINAL VISIT
DAY___
MONTH___
YEAR___
INT. NO.___
RESULT___

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE___

LANGUAGE OF INTERVIEW ___
NATIVE LANGUAGE OF RESPONDENT___
TRANSLATED USED___

SUPERVISOR
NAME___
NUMBER___

FIELD EDITOR
NAME___
NUMER___

OFFICE EDITOR
NUMBER___

KEYED BY
NUMBER___

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the Ethiopian Public Health Institute. We are conducting a survey about health and other topics all over Ethiopia. The Information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.

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

SIGNATURE OF INTERVIEWER___
DATE___

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO SECTION 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 1 (GO TO END)

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME

101A. Before I begin the interview, could you please bring your and your children's Birth Certificate, Maternal and Child Immunization Card, and any immunization record from a private health provider, or any other documents where the date of birth is officially registered for yourself or your children? We will need to refer to those documents.

105. In what month and year were you born?

106. How old were you at 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 or number of years you completed at that level?

IF ATTENDED PRIMARY OR SECONDARY, RECORD COMPLETED GRADE COMPLETED AT THAT LEVEL. IF ATTENDED TECHNICAL/VOCATIONAL OR HIGHER, RECORD YEARS COMPLETED AT THAT IF COMPLETED LESS THAN ONE UYEAR AT THAT LEVEL, RECORD '00'.

110. CHECK 108:

111. 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?

122. What is your religion?

SECTION 2. REPRODUCTION

201. Now I would like to ask about all the births you have had during your life. Have you ever given birth?

202. Do you have any sons or daughters to whom you have given birth who are now living with you?

203.
a) How many sons live with you?

b) And how many daughters live with you?

IF NONE, RECORD '00'

204. Do you have any sons are daughters to whom you have given birth are alive but do not live with you?

205.
a) How many sons are alive but do not live with you?

b) 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, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

207.
a) How many boys have died?

b) And how many girls have died?

IF NONE, RECORD '00'.

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

209. CHECK 208:
Just to make sure that I have this right: you have had in TOTAL ___births during your life. Is that correct?

210. CHECK 208:

211. Now I would like to record the names of all births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD THE TWINS AND TRIPLETS ON SEPARATE ROWS. IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

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

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

214. Were any of these births twins?

215. On what day, month, and year was (NAME) born?

216. Is (NAME) still alive?

217. IF ALIVE: How old was (NAME) at (NAME)'s 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 '12 MONTHS' OR '1 YR', ASK: Did (NAME) have (his/her) first birthday?

THEN ASK: Exactly how many months old was (NAME) when (he/she) died?

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)?

223. COMPARE 208 WITH NUMBER OF BIRTHS IN BIRTH HISTORY

224. CHECK 215: ENTER THE NUMER OF BIRTHS IN 2006-2011 E.C.

226. Are you pregnant now?

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

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 or your partner currently doing something or using any method to delay or avoid getting pregnant?

304. Which method are you using?
RECORD ALL MENTIONED.

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

304.
A. Where did you obtain (METHOD FROM Q. 304) the last time?
IF MORE THAN ONE METHOD CIRCLED IN Q. 3O4, ASK ABOUT THE METHOD THAT IS HIGHEST IN LIST.

PROBE TO IDENTIFY THE TYPE OF COURSE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRTIE THE NAME OF THE PLACE

(NAME OF PLACE) ____

B. Where did you learn to use (METHOD FROM Q. 304)?

305. Are you currently married or living together with a man as if married?

306. Have you ever been married or lived together with a man as if married?

307. What is your marital status now: are you widowed, divorced, or separated?

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 224:

402. CHECK 215. RECORD THE BIRTH HISTORY NUMBER IN 403 AND THE NAME AND SURVIVAL STATUS IN 404 FOR EACH BIRTH IN 2006-2011 E.C. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRE(S).

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:

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 antenatal care for this pregnancy?
Anywhere else?

PROBE TO IDENTIFY 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:

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

415. Which signs of pregnancy complications were you told about?

420. During this pregnancy, were you given or did you buy any iron tablets?

SHOW TABLETS.

421. During the whole pregnancy, for how many days did you take the tablets?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

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

PROBE FOR THE TYPE(S) OF ALL PERSON(S) AND RECORD ALL MENTIONED.

IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT DELIVERY.

430. Where did you give birth to (NAME)?

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

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

435. I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility?

436. How long after delivery did the first check take place?

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

437. Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

438. Now I would like to talk to you about checks on (NAME)'s health after delivery-- for example, someone examining (NAME), checking the cord, or seeing if (NAME) is OK. Did anyone check on (NAME)'s health while you were still in the facility?

439. How long after delivery was (NAME)'s health first checked?

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

440. Who checked on (NAME)'s health at that time?

PROBE FOR MOST QUALIFIED PERSON.

441. Now I want to talk to you about what happened after you left the facility. Did anyone check on your health after you left the facility?

442. How long after delivery did that check take place?

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

443. Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

444. Where did the check take place?

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

445. I would like to talk to you about checks on (NAME)'s health after you left (FACILITY IN 430). Did any health care provider or a traditional birth attendant check on (NAME)'s health in the two months after you left (FACILITY IN 430)?

446. How many hours, days or weeks after the birth of (NAME) did that check take place?

IF LESS THAN ONE DAY, RECORD HOURS; IF LESS THAN ONE WEEK, RECORD DAYS.

447. Who checked on (NAME)'s health at that time?

PROBE FOR MOST QUALIFIED PERSON.

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

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

ALL SKIP TO 457.

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

450. How long after delivery did the first check take place?

IF LESS THAN ONE DAY, RECORD HOURS; IF LESS THAN ONE WEEK, RECORD DAYS.

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

452. Where did this first check take place?

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

453. I would like to talk to you about checks on (NAME)'s health after delivery -- for example, someone examining (NAME), checking the cord, or seeing if (NAME) is OK. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on (NAME)'s health?

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

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

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

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

457. During the first two days after (NAME)'s birth, did any health care provider do the following:

464. Did you ever breastfeed (NAME)?

465. CHECK 404: IS CHILD LIVING?

466. 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.

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

468. CHECK 404: IS CHILD LIVING?

469. Are you still breastfeeding (NAME)?

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

471. GO BACK TO 429 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 479.

479. CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2009-2011 E.C. LIVING WITH THE RESPONDENT

480. Now I would like to ask you about liquids or foods that (NAME FROM 479) 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 479) drink or eat:

481. CHECK 480 (CATGORIES 'g' THROUGH 'u'):

482. Did (NAME FROM 479) eat any solid, semi-solid, or soft foods yesterday during the day or at night?
IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

483. How many times did (NAME FROM 479) eat solid, semisolid, or soft foods yesterday during the day or at night?

IF 7 OR MORE TIMES, RECORD '7'.

SECTION 5A. CHILD IMMUNIZATION (LAST BIRTH)

501A. CHECK 215 IN THE BIRTH HISTORY: ANY BIRTHS IN 2008-2011 E.C.?

502A. RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN IN 2008-2011 E.C

503A. CHECK 216 FOR CHILD:

504A. Do you have a card, mother and child book, or other document where (NAME)'s vaccinations are written down?

505A. Did you ever have a vaccination card or mother and child book for (NAME)?

506A. CHECK 504A:

507A. May I see the card, mother and child book, or other document where (NAME)'s vaccinations are written down?

508A. COPY DATES FROM THE CARD. WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

509A. CHECK 508A: 'BCG' TO 'MEASLES 2' ALL RECORDED?

510A. In addition to what is recorded on (this document/these documents), did (NAME) receive any other vaccinations, including vaccinations received in campaigns or immunization days or child health days?

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 508A THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

511A. Did (NAME) ever receive any vaccinations to prevent (NAME) from getting diseases, including vaccinations received in campaigns or immunization days or child health days?

512A. Has (NAME) ever received a BCG vaccination against tuberculosis, that is, an injection in the right arm or shoulder that usually causes a scar?

514A. Has (NAME) ever received oral polio vaccine, that is, about two drops in the mouth to prevent polio?

515A. Did (NAME) receive the first oral polio vaccine in the first two weeks after birth or later?

516A. How many times did (NAME) receive the oral polio vaccine?

516A1. The last time (NAME) received the polio drops, did (NAME) also get an IPV injection in the right thigh to protect against polio?

517A. Has (NAME) ever received a DPT-HEP.BHIB/Pentavalent vaccination, that is, an injection given in the left thigh sometimes at the same time as polio

518A. How many times did (NAME) receive the DPT-HEP.BHIB/Pentavalent vaccine?

519A. Has (NAME) ever received a PCV/Pneumoccal vaccination, that is, an injection in the right thigh to prevent pneumonia?

520A. How many times did (NAME) receive the PCV/Pneumoccal vaccine?

521A. Has (NAME) ever received a rotavirus vaccination, that is, liquid in the mouth to prevent diarrhea?

522A. How many times did (NAME) receive the rotavirus vaccine?

523A. Has (NAME) ever received a measles vaccination, that is, an injection in the left arm to prevent measles?

524A. How many times did (NAME) receive the measles vaccine?

525A. In the last six months, was (NAME) given a vitamin A dose like [this/any of these]?

526A. CONTINUE WITH 501B (REPEAT QUESTIONS WITH NEXT CHILD.)

SECTION 6. INFORMATION ABOUT HEALTH FACILITY WHERE VACCINATION CARDS ARE KEPT

600. CHECK 504A, 507A, 504B AND 507B: VACCINATION CARD SEEN?

601. Did any of your children born in 2008 E.C. or later ever receive any vaccination at a health facility (including government hospitals, health centers/posts, NGO facilities, or private hospitals/clinics)?

602. ASK RESPONDENT FOR CONSENT TO COPY VACCINATION DATES FROM THE CHILDREN'S HEALTH CARDS OR FAMILY FOLDER OR IMMUNISATION REGISTRATION BOOK KEPT IN A HEALTH FACILITY.

As part of this survey, we would like to visit the health facility in which your children got vaccinated. With your permission, our health facility team will visit the health center and copy the vaccination records from the health cards, family folder or immunization registration book directly to the same questionnaire I am using right now for our interview. The information will be kept confidential and will not be shared with anyone other than members of our survey team. We hope you will allow access to the health card, family folder or immunization registration book because information about your children's vaccinations is very important. The information will complement the information that we obtained from you in this interview. Many dangerous childhood illnesses such as measles or tetanus can be prevented through timely and effective vaccination. The information from the cards will assist the government to develop programs to protect children from vaccine preventable diseases and reduce childhood mortality and morbidity in Ethiopia

Do you have any questions?

Will you allow (NAME OF CHILD) to have his/her vaccination records copied from his/her health card, family folder or immunization registration book kept at the health facility?

603. CIRCLE THE CODE AND SIGN YOUR NAME.

RECORD CHILD'S FULL NAME, MOTHER'S FULL NAME, FATHER'S FULL NAME, CHILD'S KEBELE, TOWN, AND REGION, AND NAME OF HEALTH FACILITY WHERE CHILD'S LAST VACCINATION WAS ADMINISTERED. BE SURE TO TAKE ADDRESS AND LOCATION DESCRIPTION OF HEALTH FACILITY.

604. BIRTH HISTORY NUMBER OF EACH CHILD BORN IN 2008 E.C. OR LATER FROM 212 IN BIRTH HISTORY.

605. CHILD'S FULL NAME FROM 212

606. CHILD'S DATE OF BIRTH FROM 215

607. CHILD'S AGE FROM 217

607A. Insert health card number for (NAME OF CHILD)
IF UNAVAILABLE WRITE '00'

609. What is your first and last name?

610. What is the first and last name of (NAME)'s father?

611. What is the name of the health facility where (NAME)'s last vaccination was administered?

612. What is the location (Kebele, Town, Woreda), where (NAME)'s last vaccination was administered?

613. Can you describe the location of the health facility?

ADD TO THE DESCRIPTION ALL LANDMARKS (SUCH AS A PARK), PUBLIC STRUCTURES (SUCH AS SCHOOL OR CHURCH), AND STREETS OR ROADS.

614. What is the name of the doctor/health officer that vaccinated (NAME) at the health facility?

615. GO BACK TO 604 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 616.

616. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW___
COMMENTS ON SPECIFIC QUESTIONS___
ANY OTHER COMMENTS___

SUPERVISOR'S OBSERVATIONS___

EDITOR'S OBSERVATIONS___