IDENTIFICATION

LOCAL GOVERNMENT AREA: ____

DISTRICT NAME: ________
DISTRICT CODE: _____

SETTLEMENT NAME: ______
SETTLEMENT CODE: ______

NAME AND LINE NUMBER OF WOMAN: _____________

TELEPHONE NUMBER: __________________

EA NUMBER: _______________

CLUSTER NUMBER: ______

HOUSEHOLD NUMBER: ______

AREA OF RESIDENCE: ____

RESPONDENT'S LINE NUMBER ____

CHECK SELECTION TABLE IN HOUSEHOLD QUESTIONNAIRE; RESPONDENT WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE _____

INTERVIEWER VISITS

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

THIRD VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

FINAL VISIT
DAY ____
MONTH ____
YEAR 2013
INT. NUMBER ____
RESULT*

RESULT CODES:

NEXT VISIT
DATE ____
TIME ____

SUPERVISOR
NAME ____

FIELD EDITOR
NAME ____

OFFICE EDITOR ____

KEYED BY ____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ______________. I am working with The Gambia Bureau of Statistics and the Ministry of Health and Social Welfare. We are conducting a survey about health all over the Gambia. 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: ____________

101) RECORD THE TIME.

101A) COLLECT ANY RELEVANT DOCUMENTS THAT MAY HAVE INFORMATION ON THE RESPONDENTS AND HER CHILDREN'S AGE AND IMMUNIZATIONS.

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 type of school system did you attend?

105A) What is the highest level of school you attended: primary (lower basic), secondary, or higher?

106) What is the highest (grade/form/year) you completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

107) CHECK 105A:

108) Now I would like you to read these sentences to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentences 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) What is your nationality?

114) What is your ethnicity?

115) In the last 12 months, how many times have you been away from home 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 about all the birth you have had during your life. Have you ever given birth?

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

203) How many sons live with you?
And how many daughters live with you?

IF NONE, RECORD '00'.

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

205) How many sons are alive but do not live with you?
And how many daughters are alive but do not live with you?

IF NONE, RECORD '00'.

206) Have you ever given birth to a boy or girl who was born alive but later died?

IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

207) How many boys have died? And how many girls have died?

IF NONE, RECORD '00'.

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

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

210) CHECK 208:

211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.

RECORD THE NAMES OF ALL THE BIRTHS IN 212.

RECORD TWINS AND TRIPLETS ON SEPARATE ROWS.
(IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

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

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

214) Were any of these births twins?

215) In what month and year was (NAME) born?

PROBE: When is his/her birthday?

216) Is (NAME) still alive?

217) IF ALIVE: How old was (NAME) at his/her last birthday?

RECORD AGE IN COMPLETED YEARS.

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

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

220) IF DEAD: How old was (NAME) when he/she died?

IF '1 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.

225) C:

FOR EACH BIRTH SINCE JANUARY 2008, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

C:
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

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:

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

C:
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

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

235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2008

C:
ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

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

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

238) When did your last menstrual period start?

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

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

SECTION 3. CONTRACEPTION

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?

WRITE THE BRAND NAME. 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 was the sterilization performed?

308A) Since what month and year have you been using (CURRENT METHOD) without stopping?

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

308B) CHECK 308A, 215, 231:

308C) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO MESKEREM 1998.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

C:
IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH. IN COLUMN 2, ENTER REASON FOR DISCONTINUATION OF A METHOD IN THE LAST MONTH THE METHOD WAS USED.

ILLUSTRATIVE QUESTIONS:

When was the last time you used a method? Which method was that?
When did you start using that method? How long after the birth of (NAME)?
How long did you use the method then?

308D) CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

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

314) CHECK 304:

CIRCLE METHOD CODE:

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

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 IDENTIFY 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, were you told about side effects or problems you might have 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 '1' NOT 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 IDENTIFY THE TYPE OF SOURCE.

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

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

325) Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE.

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

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 OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

Now I would like to ask some questions about your children 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 get pregnant at that time?

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

407) How much longer did you want to wait?

408) Did you see anyone for antenatal care for this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

409) Whom did you see? Anyone else?
[ASK FOR MOST RECENT BIRTH ONLY]

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

410) Where did you receive antenatal care for this pregnancy?
Anywhere else? [ASK FOR MOST RECENT BIRTH ONLY]

PROBE TO IDENTIFY EACH 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? [ASK FOR MOST RECENT BIRTH ONLY]

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

413) As part of your antenatal care during this pregnancy, were any of the following done at least once:

a) Was your blood pressure measured?
b) Did you give a urine sample?
c) Did you give a blood sample?

[ASK FOR MOST RECENT BIRTH ONLY]

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?
[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?
[ASK FOR MOST RECENT BIRTH ONLY]

416) During this pregnancy, how many times did you get a tetanus injection?
[ASK FOR MOST RECENT BIRTH ONLY]

417) CHECK 416:
[ASK FOR MOST RECENT BIRTH ONLY]

418) At any time before this pregnancy, did you receive any tetanus injections?
[ASK FOR MOST RECENT BIRTH ONLY]

419) Before this pregnancy, how many times did you receive a tetanus injection?
[ASK FOR MOST RECENT BIRTH ONLY]

IF 7 OR MORE TIMES, RECORD '7'.

420) How many years ago did you receive the last tetanus injection before this pregnancy? [ASK FOR MOST RECENT BIRTH ONLY]

421) During this pregnancy, were you given or did you buy any iron tablets or iron syrup? [ASK FOR MOST RECENT BIRTH ONLY]

SHOW TABLETS/SYRUP.

422) During the whole pregnancy, for how many days did you take the tablets or syrup?
[ASK FOR MOST RECENT BIRTH ONLY]

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

423) During this pregnancy, did you take any drug for intestinal worms?
[ASK FOR MOST RECENT BIRTH ONLY]

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

425) What drugs did you take?
[ASK FOR MOST RECENT BIRTH ONLY]

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.
[ASK FOR MOST RECENT BIRTH ONLY]

427) How many times did you take (SP/Fansidar) during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

428) CHECK 409: ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY [ASK FOR MOST RECENT BIRTH ONLY]

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility or from another source? [ASK FOR MOST RECENT BIRTH ONLY]

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(S) OF PERSON(S) AND RECORD ALL MENTIONED.

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

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

434A) How long after you felt you were ready to give birth to (NAME) did you go there?
[ASK FOR MOST RECENT BIRTH ONLY]

IF 24 HOURS OR MORE, WRITE "24"

434B) How long after (NAME) was delivered did you stay there?
[ASK FOR MOST RECENT BIRTH ONLY]

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 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? [ASK FOR MOST RECENT BIRTH ONLY]

437) Did anyone check on your health after you left the facility?
[ASK FOR MOST RECENT BIRTH ONLY]

438) I would like to talk to you about checks on your health after delivery, for example, some, asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

439) Who checked on your health at that time?
[ASK FOR MOST RECENT BIRTH ONLY]

PROBE FOR MOST QUALIFIED PERSON.

440) How long after delivery did the first check take place?
[ASK FOR MOST RECENT BIRTH ONLY]

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

441) CHECK 434:
[ASK FOR MOST RECENT BIRTH ONLY]

442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?
[ASK FOR MOST RECENT BIRTH ONLY]

443) How many hours, days, or weeks after the birth of (NAME) did the first check take place? [ASK FOR MOST RECENT BIRTH ONLY]

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

444) Who checked on (NAME)'s health at that time?
[ASK FOR MOST RECENT BIRTH ONLY]

PROBE FOR MOST QUALIFIED PERSON.

445) Where did this first check of (NAME) take place?
[ASK FOR MOST RECENT BIRTH ONLY]

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

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

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)? [ASK FOR MOST RECENT BIRTH ONLY]

SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

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

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?
[ASK FOR MOST RECENT BIRTH ONLY]

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

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

453) Did you ever breastfeed (NAME)?

454) CHECK 404: IS CHILD LIVING?
[ASK FOR MOST RECENT BIRTH ONLY]

455) How long after birth did you first put (NAME) to the breast?
[ASK FOR MOST RECENT BIRTH ONLY]

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? [ASK FOR MOST RECENT BIRTH ONLY]

457) What was (NAME) given to drink? Anything else?
[ASK FOR MOST RECENT BIRTH ONLY]

RECORD ALL LIQUIDS MENTIONED.

458) CHECK 404: IS CHILD LIVING?

459) Are you still breastfeeding (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

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

GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501.

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 DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

507) CHECK 506:

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

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATION IN 506 THAT ARE NOT RECORDED AS HAVE BEEN GIVEN.

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

510) Please tell me if (NAME) had any of the following vaccinations:

510A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

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

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

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

510E) A DPT-HepB-Hib vaccination, that is an injection given in the thigh or buttockss, sometimes at the same time as polio drops?

510F) How many times was the DPT-HepB-Hib vaccination given?

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

510H) A yellow fever injection - that is, a shot in the 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 AMPULES/CAPSULES/SYRUPS.

512) In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)?

SHOW COMMON TYPES OF PILLS/ SPRINKLES/ SYRUPS.

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

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

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 to 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?
USE LETTER CODE FROM 519.

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 packed called [LOCAL NAME FOR ORS PACKET]?
b) 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 heel 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 breathe faster than usual with short, rapid breaths or have difficulty breathing?

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

530) CHECK 525: HAD FEVER?

531) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same, 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? USE LETTER CODE FROM 534.

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-F 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: QUININE ('D') GIVEN

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

548) CHECK 538: COMBINATION WITH ARTEMISININ ('E') GIVEN

549) How long after the fever started did (NAME) first take (COMBINATION WITH ARTEMISININ- COARTEM))?

550) CHECK 538: OTHER ANTIMALARIAL ('F') 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 533.

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

554) The last time (NAME FROM 533) passed stools, what was done to dispose of the stools?

555) CHECK 522(a) AND 522(b). ALL COLUMNS:

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

557) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2010 OR LATER LIVING WITH THE RESPONDENT

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

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

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

560) Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?

IF 'YES' PROBE: What kind of solid, semi-solid, or soft foods did (NAME) eat?

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?

IF 7 OR MORE TIMES, RECORD '7'.

SECTION 6. MARRIAGE 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 marital status now: are you widowed, divorced, or separated?

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

605) RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE.

IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

605) RECORD THE HUSBAND'S PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE.

IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

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 lived with a man only once or more than once?

610) CHECK 609:

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

MARRIED/LIVED WITH A MAN MORE THAN ONCE: b) Now I would like to ask about your first (husband/partner). In what month and year did you start living with him?

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

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

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

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

614) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to nay 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?
[SECOND TO LAST SEXUAL PARTNER AND THIRD-TO-LAST SEXUAL PARTNER ONLY]

617) The last time you had sexual intercourse with this (second/third) person, was a male condom or female 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 NOT, 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 95 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 person in the last 12 months? [ANSWER FOR LAST AND SECOND-TO-LAST PARTNER ONLY]

626) In total, with how many different people have you had sexual intercourse in the last 12 months? [ANSWER FOR THIRD-TO-LAST PARTNER ONLY]

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

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

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

628) PRESENCE OF OTHERS DURING THIS SECTION

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

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

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

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

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

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

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE 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 questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

705) CHECK 226:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child? (GO TO 707)

PREGNANT: After the birth of the child you are expecting now, how long would you like to wait before the birth of another child? (GO TO 711)

706) CHECK 226:

707) CHECK 303: USING A CONTRACEPTIVE METHOD?

708) CHECK 705:

709) CHECK 704:

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

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

RECORD ALL REASONS MENTIONED.

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

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

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? PROBE FOR A NUMERIC RESPONSE. (GO TO 713)

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. (GO TO 713)

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?
d) Hear about family planning through peer health education?
e) Heard about family planning from friends/relatives?
f) Read about family planning from traditional communicators?
g) Read about family planning from the internet?
h) Heard about family planning from a health personnel/worker?

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?

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

804A) What type of school system did your (last) (husband/partner) attend?

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

805) What was the highest (grade/form/year) he completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

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 do?

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

808) As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?

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

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

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

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

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

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

815) CHECK 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 your (husband's/partner's) 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 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) 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:

a) If she goes out without telling him?
b) If she neglects the children?
c) If she argues with him?
d) If she refuses to have sex with him?
e) If she burns the food?
f) Using contraceptives without the consent of the husband?
g) If she argues with the husband/partner's relatives?

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 change 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 her 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 give any information about:

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

915) Were you offered a test for the 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 IDENTITY 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 EACH 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 AIDS, would you be willing to care for her to him in her own household?

935) In your opinion, if a female teacher has the AIDS virus but it 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:

HEARING ABOUT AIDS: a) Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

NOT HEARD ABOUT AIDS: b) 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 (PROBLEM FROM 940/941/942), did you seek any kind of advice or treatment?

945) Where did you go? Any other place?

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

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 other women other than his 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

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 any other health worker?

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.

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

1004) Do you currently smoke cigarettes?

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

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

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

1008) Many different factors can prevent woman 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.

1011) Have you ever heard of female circumcision?

1012) In some countries, there is a practice in which a girl may have part of her genitals cut when she's still young. Have you ever heard about this practice?

1013) Have you ever been circumcised?

1014) I would like to ask you what was done to you at that time. Was any flesh removed from the genital area?

1015) Was the genital area just nicked without removing any flesh?

1016) How old were you when you were circumcised?

IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE PROBE TO GET AN ESTIMATE

1017) Who performed the circumcision?

1018) Do you approve of having young girls in your family being circumcised?

1019) Would you prefer that the practice of circumcising young women in your community continue or is brought to an end?

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, including those who are living with you, those living elsewhere and those who have died.

How many children did your mother give birth to, including you?

1102) CHECK 1101:

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

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?

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 of childbirth?

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

IF NO MORE BROTHERS OR SISTERS, GO TO 1200; IF THE RESPONDENT WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE IF THE WOMAN IS NOT SELECTED GO 1233.

DOMESTIC VIOLENCE MODULE

1200) CHECK HOUSEHOLD QUESTIONNAIRE, [COVER PAGE].

1201) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

1202) CHECK 601 AND 602:

1203) 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 you (are/were) at all times?

1204) Now I need to ask some more questions about your relationship with your (last) (husband/partner).

1204A) Did your (last) (husband/partner) ever:

1204B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

1205A) Did your (last) (husband/partner) ever do any of the following things to you:

1206) CHECK 1205A (a-j):

1207) How long after you first (got married/started living together) with your (last) (husband/partner) did (this/any of these things) first happen?

IF LESS THAN ONE YEAR, RECORD '00'.

1208) Did the following ever happen as a result of what your (last) (husband/partner) did you to you:

1209) 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?

1210) In the last 12 months, how often have you done this to your (last) (husband/partner): often, only sometimes, or not at all?

1211) Does (did) your (last) (husband/partner) drink alcohol?

1212) How often does (did) he get drunk: often, only sometimes, or never?

1213) Are (Were) you afraid of your (last) (husband/partner): most of the time, sometimes, or never?

1214: CHECK 609:

1215A) 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).

1215B) How long ago did this last happen?

1216) 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?

1217) Who has hurt you in this way? Anyone else?

RECORD ALL MENTIONED.

1218) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

1219) CHECK 201, 226, AND 230:

1220) Has any one ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?

1221) Who has done any of these things to physically hurt you while pregnant?
Anyone else?

RECORD ALL MENTIONED.

1222) CHECK 601 AND 602:

1222A) 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?

1222B) 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?

1223) Who was the person who was forcing you at that time?

1224) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN: In the last 12 months, has anyone other than (your/any) (husband/partner) 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?

1224A) CHECK 1205A (h-j) and 1215A(b)

1225) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN: How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts by anyone, including (your/any) husband/partner?

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

1226) CHECK 1205A (a-j), 1215A (a,b), 1216, 1220, 1222A, AND 1222B:

1227) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

1228) From whom have you sought help? Anyone else?

RECORD ALL MENTIONED.

1229) Have you ever told anyone about this?

1230) 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 THIS DOMESTIC VIOLENCE MODULE ONLY.

1231) 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?

1232) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE _____________________________________
________________________________________________________________________

1233) RECORD THE TIME

CALENDAR

INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX
ALL MONTHS SHOULD BE FILLED IN.
INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE:

INFORMATION TO BE CODED FOR RELEVANT BOX IN COLUMN 2.
DISCONTINUATION OF CONTRACEPTIVE USE:

2013:
12 DEC 01 ____ ____
11 NOV 02 ____ ____
10 OCT 03 ____ ____
09 SEP 04 ____ ____
08 AUG 05 ____ ____
07 JUL 06 ____ ____
06 JUN 07 ____ ____
05 MAY 08 ____ ____
04 APR 09 ____ ____
03 MAR 10 ____ ____
02 FEB 11 ____ ____
01 JAN 12 ____ ____

2012:
12 DEC 13 ____ ____
11 NOV 14 ____ ____
10 OCT 15 ____ ____
09 SEP 16 ____ ____
08 AUG 17 ____ ____
07 JUL 18 ____ ____
06 JUN 19 ____ ____
05 MAY 20 ____ ____
04 APR 21 ____ ____
03 MAR 22 ____ ____
02 FEB 23 ____ ____
01 JAN 24 ____ ____

2011:
12 DEC 25 ____ ____
11 NOV 26 ____ ____
10 OCT 27 ____ ____
09 SEP 28 ____ ____
08 AUG 29 ____ ____
07 JUL 30 ____ ____
06 JUN 31 ____ ____
05 MAY 32 ____ ____
04 APR 33 ____ ____
03 MAR 34 ____ ____
02 FEB 35 ____ ____
01 JAN 36 ____ ____

2010:
12 DEC 37 ____ ____
11 NOV 38 ____ ____
10 OCT 39 ____ ____
09 SEP 40 ____ ____
08 AUG 41 ____ ____
07 JUL 42 ____ ____
06 JUN 43 ____ ____
05 MAY 44 ____ ____
04 APR 45 ____ ____
03 MAR 46 ____ ____
02 FEB 47 ____ ____
01 JAN 48 ____ ____

2009:
12 DEC 49 ____ ____
11 NOV 50 ____ ____
10 OCT 51 ____ ____
09 SEP 52 ____ ____
08 AUG 53 ____ ____
07 JUL 54 ____ ____
06 JUN 55 ____ ____
05 MAY 56 ____ ____
04 APR 57 ____ ____
03 MAR 58 ____ ____
02 FEB 59 ____ ____
01 JAN 60 ____ ____

2008:
12 DEC 61 ____ ____
11 NOV 62____ ____
10 OCT 63 ____ ____
09 SEP 64 ____ ____
08 AUG 65 ____ ____
07 JUL 66 ____ ____
06 JUN 67 ____ ____
05 MAY 68 ____ ____
04 APR 69 ____ ____
03 MAR 70 ____ ____
02 FEB 71 ____ ____
01 JAN 72 ____ ____

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 _____