9 JUNE 2007
Department of Statistics
Household Survey Directorate

The Hashemite Kingdom of Jordan

WOMAN'S QUESTIONNAIRE

Survey Contents Confidential by Statistical Law

IDENTIFICATION

GOVERNORATE ____

DISTRICT______

SUB-DISTRICT _____

LOCALITY ______

AREA ____

SUB-AREA ______

STRATUM ______

URBAN/ RURAL

QUESTIONNAIRE NUMBER______

BLOCK NUMBER ______

BUILDING NUMBER _____

HOUSING UNIT NUMBER ________

CLUSTER NUMBER ________

HOUSEHOLD NUMBER _______

TELEPHONE/ MOBILE NUMBER (if available) __________

NAME AND LINE NUMBER OF WOMAN: ____________

WOMAN SELECTED FOR DOMESTIC VIOLENCE SECTION

INTERVIEWER VISITS

FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

NEXT VISIT:
DATE__
TIME__

SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

NEXT VISIT:
DATE__
TIME__

THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

FINAL VISIT
DAY__
MONTH__
YEAR 2007
INT. NUMBER__
RESULT:

TOTAL NUMBER OF VISITS__

SUPERVISOR
NAME_______
DATE ________

FIELD EDITOR
NAME________
DATE________

OFFICE EDITOR ___

KEYED BY____

SECTION 1: RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is______________ and I am working with the Department of Statistics. We are conducting a national survey that asks women about the health of women and their children. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The interview usually takes about 40 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

Participation in this survey is voluntary, and if we should come to 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. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ________________ Date: ________________

101) RECORD THE TIME.

101A) What is your marital status now: are you married, widowed, divorced, or separated?

IF THE WOMAN IS NOT MARRIED, WIDOWED, DIVORCED, OR SEPARATED, END THE INTERVIEW, AND CORRECT MARITAL STATUS AND ELIGIBILITY IN THE HOUSEHOLD QUESTIONNAIRE

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

104) In what month and year were you born?

105) How old were you at your last birthday?
COMPARE AND CORRECT 104 AND/OR 105 IF CONSISTENT.

106) Have you ever attended school?

107) What is the highest level of school you attended: Old elementary, old preparatory, old secondary, new basic, new secondary, intermediate diploma, bachelor, or higher?

108) What is the highest grade you completed at that level?

113) Do you read a newspaper or magazine almost every day, 3-5 times a week, once or twice a week, once a month, few times a year, or never?

114) Do you listen to the radio almost every day, at least once a week, once or twice a month, few times a year, or never?

115) Do you watch television almost every day, at least once a week, once or twice a month, few times a year, or never?

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) 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 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 our 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 LINES.
(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) Were any of these births twins?

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

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

PROBE: What is his/her birthday?

216) Is (NAME) still alive?

217) IF ALIVE:

How old was (NAME) at his/her last birthday?

RECORD AGE IN COMPLETED YEARS. IF LESS THAN 1 YEAR, RECORD '00'

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).

LINE NUMBER ____ (NEXT BIRTH)

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? (NOT APPLICABLE TO FIRST CHILD)

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:

CHECK:

224) CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2002 OR LATER.
IF NONE, RECORD '0' AND SKIP TO 226.

225) FOR EACH BIRTH SINCE JANUARY 2002, ENTER 'B' IN THE MONTH OF BIRTH IN COLUMN 1 OF 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?

227) How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS.
ENTER 'P' S IN THE COLUMN 1 OF THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

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

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

229A) The last time you had such a pregnancy, did the pregnancy end in a miscarriage, an induced abortion or a stillbirth?

230) When did the last such pregnancy end?

231) CHECK 230:

231A) Did this (MISCARRIAGE/ ABORTION/ STILLBIRTH - FROM Q.229A) last such pregnancy take place in a health facility, at home, or in another place?

231B) Did you seek care for this (MISCARRIAGE/ ABORTION/ STILLBIRTH - FROM Q.229A)?

231C) Where did you go for this (MISCARRIAGE/ ABORTION/ STILLBIRTH - FROM Q.229A)?

231D) In which type of health facility did you go?

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

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN COLUMN 1 OF THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

233) Since January 2002, have you had any other pregnancies that did not result in a live birth?

233A) Since January 2002, how many mother pregnancies that did not result in a live birth have you had?

234) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2002.

ENTER 'T' IN COLUMN 1 OF THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPETED MONTHS.

235) Did you have any miscarriages, abortions, or stillbirths that ended before 2002?

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

237) When did your last menstrual period start?

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

239) 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.

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

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

302) Have you ever used (METHOD)?

303) CHECK 302:

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

305) ENTER '0' IN COLUMN 1 OF THE CALENDAR IN EACH BLANK MONTH (GO TO 333)

306) What you used or done?

CORRECT 302 AND 303 (AND 301 IF NECESSARY).

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

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

308) CHECK 302(01):

309) CHECK 226:

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

311) Which method are you using?

CIRCLE ALL MENTIONED.

311A) CIRCLE 'A' FOR FEMALE STERILIZATION.

311B) Who advised you to use this method?

IF MORE THAN ONE METHOD CIRCLED IN 311/311A, THIS QUESTION SHOULD REFER TO THE HIGHEST METHOD IN THE LIST.

311C) CHECK 311/311A:

CIRCLE METHOD(S) CODE

312) May I see the package of pills you are using?
IF PACKAGE SEEN RECORD CODE OF BRAND USING THE FIRST LIST OF CODES

IF PACKAGE NOT SEEN, ASK:
Do you know the brand name of the pills you are using?
RECORD CODE OF BRAND USING THE SECOND LIST OF CODES.

314) RECORD IF CODE 'C' FOR PILL IS CIRCLED IN 311.

YES (USING PILL)
The last time you obtained the pills, how many pill cycles did you get?

NO(USING CONDOM BUT NOT PILL)
The last time you obtained the condoms, how many condoms did you get?

315) The last time you obtained (HIGHEST METHOD ON LIST IN 311), how much did you pay in total, including the cost of the method and any consultation you may have had?

IF MORE THAN 990 JD, RECORD 990

315A) CHECK 311:

315B) Who inserted your IUD?

316) In what facility did the sterilization take place?

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

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

317) CHECK 311/311A:

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

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

318) How much was paid in total for the sterilization, including any consultation you (he) may have had?

IF MORE THAN 990 JD, RECORD 990

318A) Do you regret that you had the operation not to have any (more) children?

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

319A) 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?

320) CHECK 319/319A, 215, AND 230:

ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 319/319A

321) CHECK 319/319A:

YEAR IS 2002 OR LATER:
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN COLUMN 1 OF THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING.

YEAR IS 2001 OR EARLIER:
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN COLUMN 1 OF THE CALENDAR AND EACH MONTH BACK TO JANUARY 2002 (GO TO 331)

322) I would like to ask you some questions about the times you or your husband 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 JANUARY 2002.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1: ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:
COLUMN 1:
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?

IN COLUMN 2: ENTER CODES FOR DISCONTINUATION NEXT TO LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.

ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.

ILLUSTRATIVE QUESTIONS:
COLUMN 2:
Why did you start using that method?
Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?

IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK:
How many months did it take you to get pregnant after you stopped using (METHOD)?
AND ENTER '0' IN EACH SUCH MONTH IN COLUMN 1

323) CHECK 311/311A:

CIRCLE METHOD CODE:

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

324) Where did you obtain (CURRENT METHOD) when you started using it?
324A) Where did you learn how to use periodic abstinence/ the lactational amenorrhea method?

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

325) CHECK 311/311A:

CIRCLE METHOD CODE:

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

326) You obtained (CURRENT METHOD FROM 323) from (SOURCE OF METHOD FROM 316 OR 324) in (DATE FROM 319/319A). At that time, were you told about side effects or problems you might have with the method?

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

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

329) CHECK 326:

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 323) from (SOURCE OF METHOD FROM 316 OR 324) were you told about other methods of family planning that you could use?

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

331) CHECK 311/311A:

CIRCLE METHOD CODE:

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

332) Where did you obtain (CURRENT METHOD) the last time?

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

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

334) Where is that?

Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

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

337) 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 LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

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

403) LINE NUMBER FROM 212

404) FROM 212 AND 216

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

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

407) Did you see anyone for antenatal care for this pregnancy? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

IF YES: Whom did you see? Anyone else?

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

408) Where did you receive antenatal care for this pregnancy? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

Anywhere else?

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

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

409) How many months pregnant were you when you first received antenatal care for this pregnancy? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

410) How many times did you receive antenatal care during this pregnancy? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

411) As part of your antenatal care during this pregnancy, were any of the following done at least once? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

412) During (any of ) your antenatal care visit(s), were you told about the sings of pregnancy complications? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

413) Were you told where to go if you had any of these complications? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

413A) During (any of) your antenatal care visit(s), were you told about the signs of complications during the postnatal period? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

413B) During (any of) your antenatal care visit(s) were you told about having postnatal care visits one week and 30 days after delivery? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

414) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

415) During this pregnancy, how many times did you get this tetanus injection?( ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

416) CHECK 415:

417) At any time before this pregnancy did you receive any tetanus injections, either to protect yourself or another baby? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

418) Before this pregnancy, how many other times did you receive a tetanus injection? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

IF 7 OR MORE TIMES, RECORD '7'.

419) In what month and year did you receive the last tetanus injection before this pregnancy? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

420) How many years ago did you receive that tetanus injection? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

421) During this pregnancy, were you given or did you buy any iron tablets or iron syrup? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

422) During the whole pregnancy, for how many days did you take the tables or syrup? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

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

427) Was (NAME) weighed at birth?

428) How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

429) 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.

429A) How much did you pay the service provider for this delivery?

RECORD TOTAL COST IN DINARS

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

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

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE)______________

431) How long after (NAME) was delivered did you stay there?

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

432) Was (NAME) delivered by caesarean section?

432A) When you were discharged after (NAME) was born, were you given any free sample of infant formula by the health facility staff?

432B) Before you were discharged after (NAME) was born, did anyone in the health facility talk to you or advise you about family planning?

433) Before you were discharged after (NAME) was born, did any health care provider check on your health?

434) How long after delivery did the first check take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

435) Who checked on your health at that time? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

PROBE FOR MOST QUALIFIED PERSON

436) After you were discharged, did any health care provider check on your health?

436A) What is the main reason you did not seek a health professional check on your health after (NAME) was born? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

437) Why didn't you deliver in a health facility? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

PROBE: Any other reason?

RECORD ALL MENTIONED

438) After (NAME) was born, did any health care provider check on your health?

438A) What is the main reason you did not seek a health professional check on your health after (NAME) was born? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

439) How long after delivery did the first check take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

439A) How long after delivery did this check take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

440) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

441) Where did this (first) check take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE)___________

441A) How much did you pay for this (first) postnatal visit? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

RECORD THE TOTAL COST IN DINARS

441B) After this (first) visit, did you come back a second time for a health care provider to check on your health? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

441C) How long after delivery did this check take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

441D) Did anyone at the health facility talk to you or advise you about family planning during any of your postnatal check? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

442) CHECK 436: (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

443) In the two months after (NAME) was born, did any health care provider check on his/her health? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

444) How many hours, days, or weeks after the birth of (NAME) did the first check take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

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

PROBE FOR MOST QUALIFIED PERSON.

446) Where did this first check of (NAME) take place? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE)____________

448) Has your menstrual period returned since the birth of (NAME)? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

449) Did your period return between the birth of (NAME) and your next pregnancy? (ASK FOR ALL, EXCEPT THE MOST RECENT BIRTH IN THE LAST FIVE YEARS)

450) For how many months after the birth of (NAME) did you not have a period?

451) CHECK 226: IS RESPONDENT PREGNANT? (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

452) Have you begun to have sexual intercourse again since the birth of (NAME)? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

IF LESS THAN 1 MONTH, RECORD '00'

454) Did you ever breastfeed (NAME)?

455) How long after birth did you first put (NAME) to the breast? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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 ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

457) What was (NAME) given to drink? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

Anything else?

RECORD ALL LIQUIDS MENTIONED.

458) CHECK 404: IS CHILD LIVING? (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

459) Are you still breastfeeding (NAME)? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

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

461) CHECK 404: IS CHILD LIVING?

462) How many times did you breastfeed last night between sunset and sunrise? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

463) How many times did you breastfeed yesterday during the daylight hours? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

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

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

SECTION 5: CHILD IMMUNIZATION AND HEALTH AND CHILD'S AND WOMAN'S NUTRITION

501) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES.)

502) LINE NUMBER FROM 212

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

507) Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in an immunization campaign?

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 1-4, POLIO BOOSTER, DPT 1-3, DPT BOOSTER, HEPATITIS 1-3, HIB 1-3, MEASLES, AND/OR MMR.

508) Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in an immunization campaign?

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

509A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

509B) Polio vaccine, that is, usually drops in the mouth or sometimes an injection in the thigh?

509C) How many times was the polio vaccine received?

509D) A DPT vaccination, that is, an injection given in the thigh, sometimes at the same times as polio to prevent diphtheria, pertussis, and tetanus. Sometimes, DPT is part of the TETRA or PENTA vaccine.

)

509E) How many times was a DPT vaccination received?

509F) An injection to prevent Hepatitis, that is an injection given sometimes at the same times as polio and DPT injections. Sometimes, DPT is part of the TETRA or PENTA vaccine.

509G) How many times was a Hepatitis vaccination received?

509H) A Hib vaccination, that is an injection given sometimes at the same times as polio, DPT, and Hepatitis to prevent meningitis. Sometimes, DPT is part of the TETRA or PENTA vaccine.

509I) How many times was a Hib vaccination received?

509J) A measles injection, that is a shot in the arm at the age of 9 months or older to prevent measles?

509K) A MMR vaccination, that is an injection to prevent Measles, Mumps, and Rubella, usually given at the age of 18 months.

510A) CHECK 506 AND 509E: DPT INJECTION (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510B) Where did (NAME) receive the first vaccination to prevent DPT? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510C) CHECK 506 AND 509E: DPT INJECTION (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510D) Where did (NAME) receive the second vaccination to prevent DPT? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510E) CHECK 506 AND 509E: DPT INJECTION (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510F) Where did (NAME) receive the third vaccination to prevent DPT? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510G) CHECK 506 AND 509J: MEASLES INJECTION (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510H) Where did (NAME) receive the vaccination to prevent measles? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510I) CHECK 506 AND 509K: MMR INJECTION (ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

510J) Where did (NAME) receive the vaccination to prevent measles, mumps, and rubella? (ASK ONLY FOR MOST RECENT BIRTH IN THE LAST FIVE YEARS)

514) Has (NAME) ever received a vitamin A dose (like this/ any of these)?
SHOW COMMON TYPES OF CAPSULES.

515) Did (NAME) receive a vitamin A dose within the last six months?

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

519) Was there any blood in the stools?

520) 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?

521) 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?

522) Did you seek advice or treatment for the diarrhea from any source?

523) Where did you seek advice or treatment?

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

524) CHECK 523:

525) Where did you first seek advice or treatment?

USE LETTER CODE FROM 523

526) How many days after the diarrhea began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY, RECORD '00'.

527) Does (NAME) still have diarrhea?

528) Was he/she given any of the following to drink at any time since he/she started having the diarrhea:

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

530) What (else) was given to treat the diarrhea?

Anything else?
RECORD ALL TREATMENTS GIVEN/

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

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

533) When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

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

535) CHECK 531: HAD FEVER?

536) Now I would like to know how much (NAME) was given to drink (including breast milk) 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?

537) 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?

538) Did you seek advice or treatment from any source for the illness with a (fever/cough)?

539) Where did you seek advice or treatment?

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

540) CHECK 539:

541) Where did you first seek advice or treatment?

USE LETTER CODE FROM 539

542) How many days after the illness began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY, RECORD '00'.

543) Is (NAME) still sick with a (fever/cough)?

544) At any time during the illness, did (NAME) take any drugs for the illness?

545) What drugs did (NAME) take?

Any other drugs?

RECORD ALL MENTIONED.

546) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 547.

547) CHECK 528(A), ALL COLUMNS:

548) Have you ever heard of a special product called Aquacell or Paralait you can get for the treatment of diarrhea?

549) Have you had fever at any time in the last 6 months?

IF YES: When was the last time you had fever?

IF NO FEVER, RECORD '4'

550) The last time you had a fever, did you get medicine to treat the fever?

IF YES: How much did you spend to obtain the medicine?

RECORD THE TOTAL COST IN DINARS
IN NO MEDICINE OBTAINED, RECORD '995'

550A) Have you performed a breast cancer self-exam to detect breast cancer in yourself within the last 12 months?

550B) Have you had a breast cancer clinical exam to detect breast cancer in the last 12 months?

550C) Have you ever heard of a pap smear, that is, an exam that consists of removing cells from the cervix to detect changes that can suggest the presence of cancer in a woman's womb?

550D) Have you ever had such an exam in your life time?

550E) Do you smoke:

551) CHECK 215 AND 218, ALL ROWS:

NUMBER OF CHILDREN BORN IN 2004 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER (AND CONTINUE WITH 552)

552) Now I would like to ask you about liquids or foods (NAME FROM 551) had yesterday during the day or at night.

Did (NAME FROM 551) (drink/eat):

553) Now I would like to ask you about (other) liquids or foods that (NAME FROM 551)/you may have had yesterday during the day or at night. I am interested in whether your child/you had the item even if it was combined with other foods.

Did (NAME FROM 551)/you drink (eat):

554) CHECK 552 (LAST CATEGORY: PORRIDGE/GRUEL) AND 553 (CATEGORIES f THROUGH r FOR CHILD):

555) How many times did (NAME FROM 551) eat solid, semisolid, or soft foods yesterday during the day or at night?

IF 7 OR MORE TIMES, RECORD '7'

SECTION 6: MARRIAGE AND SEXUAL ACTIVITY

601) CHECK 101A:

602) Is your husband living with you now or is he staying elsewhere?

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

604) Does your husband have another wife (other wives) besides you?

605) Including yourself, in total, how many wives does your husband have?

606) Have you been married only once or more than once?

607) CHECK 606:

MARRIED ONLY ONCE:
In what month and year did you start living with your husband (consummate marriage)?

MARRIED MORE THAN ONCE:
Now I would like to ask about your first husband. In what month and year did you start living with him (consummate marriage)?

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

609) Before you got married, was your [first] husband related to you in any way?

610) What type of relation was it?

611) CHECK 609:

MARRIED ONLY ONCE:
Did your husband have a premarital medical exam?

MARRIED MORE THAN ONCE:
Now I would like to ask about your last marriage. Did your husband have a premarital medical exam?

611A) Did you have a premarital medical exam?

611B) Where did you go for the premarital medical exam?

612) When was the last time you had sexual intercourse?

IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MOTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

613) The last time you had sexual intercourse, was a condom used?

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

615) Where is that?

Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF PLACE.

SECTION 7: FERTILITY PREFERENCES

700) CHECK 101A:

701) CHECK 311/311A:

702) CHECK 226:

NOT PREGNANT OR UNSURE:
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?

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

703) CHECK 226:

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

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

704) CHECK 226:

705) CHECK 310: USING A CONTRACEPTIVE METHOD?

706) CHECK 703:

707) CHECK 702 AND 703:

WANTS TO HAVE A/ANOTHER CHILD BUT NOT BEFORE 2 YEARS:
You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy.

Can you tell me why you are not using a method?

Any other reason?

WANTS NO MORE/NONE
You have said that you do not want (a/another) child, but you are not using any method to avoid pregnancy.

Can you tell me why you are not using a method?

Any other reason?

RECORD ALL REASONS MENTIONED.

708) CHECK 310: USING A CONTRACEPTIVE?

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

710) Which contraceptive method would you prefer to use?

711) What is the main reason that you think you will not use a contraceptive method at any time in the future?

711A) Why does your husband disapprove of using contraception?

RECORD ALL REASONS MENTIONED.

713) 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

714) How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?

715) In the last 6 months have you:

716) Where and form whom would you prefer to get information about family planning?

CIRCLE ONLY ONE ANSWER.

717) CHECK 101A:

718) CHECK 311/311A:

719) Does your husband know that you are using a method of family planning?

720) Would you say that using contraception is mainly your decision, mainly your husband's decision, or did you both decide together?

720A) Now I want to ask you about our husband's view on family planning. Do you think that your husband approves or disapproves of couples using a contraceptive method to avoid pregnancy?

721) CHECK 311/311A:

722) Does your husband 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 101A:

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

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

804) What is the highest level of school he attended: Old elementary, old preparatory, old secondary, new basic, new secondary, intermediate diploma, bachelor, or higher?

805) What was the highest grade he completed at that level?

806) CHECK 101A:

807) Has your husband done any work in the last seven days, even for one hour? By "work", I mean any paid work, any work in a business completely or partially owned by your husband, any work in a business owned by the household without payment, or work in other business?

808) Does your husband have any job, but he did not practice it during the last seven days for a reason such as vacation, travel, or illness?

809) What is your husband's current occupation, that is, what kind of work does he mainly do?

810) What is your husband's employment status: is he an employee, an employer, is he self-employed, is he working for his family without payment, or is he working for someone else without payment?

811) Have you done any work in the last seven days, even for one hour? By "work", I mean any paid work, any work in a business completely or partially owned by yourself, any work in a business owned by the household without payment, or work in other business?

812) Do you have any job, but he did not practice it during the last seven days for a reason such as vacation, travel, or illness?

813) What is your current occupation, that is, what kind of work does he mainly do?

814) What is your employment status: are you an employee, an employer, are you self-employed, are you working for your family without payment, or are you working for someone else without payment?

818) CHECK 101A:

819) CHECK 814:

820) Who usually decides how the money you earn will be used: mainly you, mainly your husband, or you and your husband jointly?

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

822) Who usually decides how your husband's earnings will be used: you, your husband, or you and your husband jointly?

822A) CHECK 814:

CODES 1, 2, OR 3 CIRCLED:
In addition to your employment income, do you have income from any other sources, such as real estate, retirement, allowances, etc.?

CODES 4, OR 5 CIRCLED OR 814 NOT ASKED:
Do you have income from any source such as real estate, retirement, allowances, etc.?

822B) Who usually decides how the (additional) money you earn will be used: mainly you, mainly your husband, or you and your husband jointly?

823) Who usually makes decisions about health care for yourself: you, your husband, you and your husband jointly, or someone else?

824) Who usually makes decisions about making major household purchases?

825) Who usually makes decisions about making purchases for daily household needs?

826) Who usually makes decisions about visits to your family or relatives?

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

828) 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:

828A) In your opinion, what do you consider to be violence against women?

CIRCLE CODE '1' FOR EACH SPONTANEOUS ANSWER, THEN FOR EACH CASE NOT MENTIONED SPONTANEOUSLY, ASK: "In your opinion do you consider (ITEM NOT MENTIONED SPONTANEOUSLY) to be violence against women"?

IF 'YES' CIRCLE 2 (YES PROBE), IF NO, CIRCLE '3' (NO).

:

SECTION 9: HIV/AIDS AND STI

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

901A) Is there anything a person can do to avoid getting the AIDS virus?

901B) What can a person do?

Anything else?

RECORD ALL WAYS MENTIONED

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

907) Can people get the AIDS virus by shaking hands with or hugging a person who has AIDS?

907A) Can people get the AIDS virus by sharing razors or blades when shaving their beard or having their hair cut?

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

909) Can the virus that causes AIDS be transmitted from a mother to her baby:

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

911) Where is that ?

Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VOLUNTARY COUNSELING AND TESTING CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

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

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

915) 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?

915A) CHECK 101A:

915B) Have you ever talked about ways to prevent ways to prevent getting the virus that causes AIDS with your husband?

915C) In the last 6 months have you heard, seen, or received any information about HIV/AIDS?

916) 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?

916A) If a man has a sexually transmitted disease, what symptoms might he have?

Any other symptoms?

RECORD ALL MENTIONED

916A) If a woman has a sexually transmitted disease, what symptoms might he have?

Any other symptoms?

RECORD ALL MENTIONED

917) Husbands and wives do not always agree on everything. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

918) 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?

919) Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

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

SECTION 10: OTHER HEALTH ISSUES

1001) Have you heard of an illness called tuberculosis?

1002) How does spread from one person to another?

PROBE: Any other ways?

RECORD ALL MENTIONED.

1003) Can tuberculosis be cured?

1003A) Would you be willing to take a test for tuberculosis?

1013) Now I would like to ask you some questions about medical care for yourself.

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?

SECTION 11: DOMESTIC VIOLENCE

1101) CHECK DOMESTIC VIOLENCE BOX ON COVER PAGE: IS THIS WOMAN SELECTED FOR THE DOMESTIC VIOLENCE MODULE?

1102) CHECK FOR PRESENCE OF OTHERS: DO NOT CONTINUE UNTIL EFFECTIVE 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. I know that some of these questions are very personal. However, your answers are crucial for helping to understand the condition of women in Jordan. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else will know that you were asked these questions.

1103) CHECK 101A:

1104) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband. If we should come to any question that you do not want to answer, just let me know and we will go on to the next question.

(Does/ did) your (last) husband ever:

1105)

(Does/ did) your (last) husband ever do any of the following to you:

1106) CHECK 1105:

1107) Did the following ever happen as a result of what your (last) husband did to you:

1108) From the time you were 15 years old has anyone other than your (last) husband hit, slapped, kicked, or done anything else to hurt you physically?

1109) Who has hurt you in this way?

Anyone else?

RECORD ALL MENTIONED.

1110) In the last 12 months, how often have you been hit, slapped, kicked, or physically hurt by this/these person(s): often, only sometimes, or not at all?

1111) CHECK 201, 226, AND 229:

1112) Has anyone ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?

1113) Who has done any of these things to physically hurt you while you were pregnant?

Anyone else?

RECORD ALL MENTIONED.

1114) CHECK 1105:

1115) At any time during the last 12 months when your (last) husband did something to physically hurt you, did you try to get help to prevent or stop him from hurting you?

1116) From whom have you sought help?

Anyone else?

RECORD ALL MENTIONED.

1117) 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?

1118) INTERVIEWER'S COMMENTS / EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

SECTION 12: EARLY CHILDHOOD DEVELOPMENT

1201) CHECK 217: ANY LIVING CHILD 3-8 YEARS OLD?

1202) CHECK 217:

SELECT THE YOUNGEST CHILD AGED 3-8 YEARS AND RECORD NAME AND LINE NUMBER

NAME OF THE YOUNGEST CHILD FROM Q.212

LINE NUMBER OF THE YOUNGEST CHILD FROM Q.212

READ TO THE RESPONDENT

Now I would like to ask you questions about (NAME OF THE CHILD FORM 1202), your youngest child who is 3-8 years old.

1203) Can (CHILD'S NAME FROM 1202) count?

IF YES, ASK: To which number can he/she count?

RECORD THE NUMBER

IF '97' OR MORE, RECORD 97

1204) Can (CHILD'S NAME FROM 1202) identify his/her own name, or the names of his/her siblings or friends when he/she sees them in a story, a book, or elsewhere?

1205) How does (CHILD'S NAME FROM 1202) manage a misunderstanding with his/her friends in the neighborhood?

1206) Does (CHILD'S NAME FROM 1202) brush his/her teeth?

1207) Does (CHILD'S NAME FROM 1202) wash his/her hands after using the toilet?

1208) During the last month, has (CHILD'S NAME FROM 1202) read or has anyone read him/her magazines, stories, or books other than his/her school books?

IF YES, ASK: How often?

1209) Does (CHILD'S NAME FROM 1202) participate in family discussions?

1210) 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:

CALENDAR

INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX. IN COLUMN 1, ALL MONTHS SHOULD BE FILLED IN.

INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE

NOTE: In case of a multiple birth which ended with live and non-live birth outcomes record BIRTH to calendar

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE

2007

2006

2005

2004

2003

2002