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9 JUNE 2007
Department of Statistics
Household Survey Directorate

The Hashemite Kingdom of Jordan


JORDAN POPULATION AND FAMILY HEALTH SURVEY 2007

WOMAN'S QUESTIONNAIRE

Survey Contents Confidential by Statistical Law

IDENTIFICATION

GOVERNORATE ____

DISTRICT______

SUB-DISTRICT _____

LOCALITY ______

AREA ____

SUB-AREA ______

STRATUM ______

URBAN/ RURAL

URBAN 1
RURAL 2

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 (YES = 1; NO = 2) ____

INTERVIEWER VISITS

FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ___________

NEXT VISIT:
DATE__
TIME__

SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ___________

NEXT VISIT:
DATE__
TIME__

THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ___________

FINAL VISIT
DAY__
MONTH__
YEAR 2007
INT. NUMBER__
RESULT:

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ___________

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: ________________

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101) RECORD THE TIME.

HOUR___
MINUTES___

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

MARRIED 1
DIVORCED 2
WIDOWED 3
SEPARATED 4
NEVER MARRIED 5 (END)

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

YEARS ___
ALWAYS 95
VISITOR 96

104) In what month and year were you born?

MONTH___
DON'T KNOW MONTH 98
YEAR _____
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS ___

106) Have you ever attended school?

YES 1
NO 2 (GO TO 113)

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?

OLD SYSTEM
ELEMENTARY 1
PREPARATORY 2
SECONDARY 3
NEW SYSTEM
BASIC 4
SECONDARY 5
INTERMEDIATE DIPLOMA 6
BACHELOR 7
HIGHER 8

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

GRADE ____

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?

ALMOST EVERY DAY 1
3-5 TIMES A WEEK 2
ONCE OR TWICE A WEEK 3
ONCE A MONTH 4
FEW TIMES A YEAR 5
NEVER 6
CANNOT READ/ ILLITERATE 7

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?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
AT LEAST ONCE A MONTH 3
FEW TIMES A YEAR 4
NEVER 5

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

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
AT LEAST ONCE A MONTH 3
FEW TIMES A YEAR 4
NEVER 5

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?

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

203) How many sons live with you?

SONS AT HOME ___

And how many daughters live with you?

DAUGHTERS AT HOME ____

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?

YES 1
NO 2 (GO TO 206)

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

SONS ELSEWHERE____

And how many daughters are alive but do not live with you?

DAUGHTERS ELSEWHERE____

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?

YES 1
NO 2 (GO TO 208)

207) How many boys died?

BOYS DEAD ___

And how many girls have died?

GIRLS DEAD ___

IF NONE, RECORD '00'.

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

TOTAL ___

209) CHECK 208:

Just to make sure that I have this right: you have had in TOTAL ___ births during your life. Is that correct?

YES (GO TO 210)
NO (PROBE AND CORRECT 201-208 AS NECESSARY.)

210) CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 226)

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?

(NAME)____

213) Were any of these births twins?

SINGLE 1
MULTIPLE 2

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

BOY 1
GIRL 2

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

PROBE: What is his/her birthday?

MONTH___
YEAR_____

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

217) IF ALIVE:

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

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

AGE IN YEARS___

218) IF ALIVE:

Is (NAME) living with you?

YES 1
NO 2

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.

DAYS 1___
MONTHS 2____
YEARS 3_____

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)

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

222) Have you had any live births since the birth of (NAME OF LAST BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

223) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

NUMBERS ARE SAME (GO TO CHECK)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

CHECK:

FOR EACH BIRTH: YEAR OF BIRTH IS RECORDED __
FOR EACH BIRTH SINCE JANUARY 2002: MONTH AND YEAR OF BIRTH ARE RECORDED. ___
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED. ___
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED.____
FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS. __

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?

YES 1
NO 2 (GO TO 229)
UNSURE 8 (GO TO 229)

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.

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?

THEN 1
LATER 2
NOT AT ALL 3

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

YES 1
NO 2 (237)

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

MISCARRIAGE 1
INDUCED ABORTION 2
STILLBIRTH 3

230) When did the last such pregnancy end?

MONTH __
YEAR____

231) CHECK 230:

LAST PREGNANCY ENDED IN JAN. 2002 OR LATER (GO TO 231A)
LAST PREGNANCY ENDED BEFORE JAN.2002 (GO TO 237)

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

HEALTH FACILITY 1 (231D)
YOUR HOME/ OTHER HOME 2
OTHER PLACE (SPECIFY) _______ 6

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

YES 1
NO 2 (GO TO 232)

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

PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
UNIVERSITY HOSPITAL 13
ROYAL MEDICAL HOSPITAL 14
OTHER PUBLIC (SPECIFY) _______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
OTHER PRIVATE MEDICAL (SPECIFY) _________26

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.

(NAME OF PLACE)______________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
UNIVERSITY HOSPITAL 13
ROYAL MEDICAL HOSPITAL 14
OTHER PUBLIC (SPECIFY) _______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
OTHER PRIVATE MEDICAL (SPECIFY) _________26

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.

NUMBER OF MONTHS____

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

YES 1
NO 2 (GO TO 235)

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

NUMBER OF PREGNANCIES ____

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?

YES 1
NO 2 (GO TO 237)

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

MONTH____
YEAR_____

237) When did your last menstrual period start?

(DATE, IF GIVEN)____________
DAYS AGO 1______
WEEKS AGO 2_____
MONTHS AGO 3______
YEARS AGO 4__________

IN MENOPAUSE/ HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

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?

YES 1
NO (GO TO 301)
DON'T KNOW (GO TO 301)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) _________ 6
DON'T KNOW 8

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.

01 FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2
02 MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2
03 PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
04 IUD: Women can have a loop or coil placed inside them by a doctor or a midwife.
YES 1
NO 2
05 INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant usually for 3 months.
YES 1
NO 2
06 IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy usually for 3 years.
YES 1
NO 2
07 CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08 FEMALE CONDOM: Women can place a plastic sheath in their vagina before sexual intercourse.
YES 1
NO 2
09 LACTATIONAL AMENORRHEA METHOD (LAM)
YES 1
NO 2
10 PERIODIC ABSTINENCE: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
11 WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2
12 EMERGENCY CONTRACEPTION: As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within five days to prevent pregnancy.
YES 1
NO 2
13: Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1
(SPECIFY)_______
(SPECIFY)________
NO 2

302) Have you ever used (METHOD)?

01 FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
Have you ever had an operation to avoid having any more children?
YES 1
NO 2
02 MALE STERILIZATION: Men can have an operation to avoid having any more children.
Has your husband ever had an operation to avoid having any more children?
YES 1
NO 2
03 PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
04 IUD: Women can have a loop or coil placed inside them by a doctor or a midwife.
YES 1
NO 2
05 INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant usually for 3 months.
YES 1
NO 2
06 IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy usually for 3 years.
YES 1
NO 2
07 CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08 FEMALE CONDOM: Women can place a plastic sheath in their vagina before sexual intercourse.
YES 1
NO 2
09 LACTATIONAL AMENORRHEA METHOD (LAM)
YES 1
NO 2
10 PERIODIC ABSTINENCE: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
11 WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2
12 EMERGENCY CONTRACEPTION: As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within five days to prevent pregnancy.
YES 1
NO 2
13: Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
(SPECIFIED IN 301)___________
YES 1
NO 2
(SPECIFIED IN 301)____________
YES 1
NO 2

303) CHECK 302:

NOT A SINGLE "YES" (NEVER USED) (GO TO 304)
AT LEAST ONE "YES" (EVER USED) (GO TO 307)

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

YES 1 (GO TO 306)
NO 2

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'.

NUMBER OF CHILDREN______

308) CHECK 302(01):

WOMAN NOT STERILIZED (GO TO 309)
WOMAN STERILIZED (GO TO 311A)

309) CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 310)
PREGNANT (GO TO 322)

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

YES 1
NO 2 (GO TO 322)

311) Which method are you using?

CIRCLE ALL MENTIONED.

311A) CIRCLE 'A' FOR FEMALE STERILIZATION.

FEMALE STERILIZATION A
MALE STERILIZATION B
PILL C
IUD D
INJECTABLES E
IMPLANTS F
CONDOM G
FEMALE CONDOM H
DIAPHRAGM I
FOAM/ JELLY J
LACTATIONAL AMEN. METHOD K
PERIODIC ABSTINENCE L
WITHDRAWAL M
OTHER (SPECIFY)________ X

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.

NO ONE 01
DOCTOR 02
NURSE 03
MIDWIFE 04
HUSBAND 05
MOTHER/MOTHER IN LAW 06
OTHER RELATIVE 07
FRIENDS 08
NEIGHBORS 09
OTHER (SPECIFY)_________ 96

311C) CHECK 311/311A:

CIRCLE METHOD(S) CODE

FEMALE STERILIZATION A (GO TO 316)
MALE STERILIZATION B (GO TO 316)
PILL C
IUD D (GO TO 315)
INJECTABLES E (GO TO 315)
IMPLANTS F (GO TO 315)
CONDOM G (GO TO 314)
FEMALE CONDOM H (GO TO 315)
DIAPHRAGM I (GO TO 315)
FOAM/ JELLY J (GO TO 315)
LACTATIONAL AMEN. METHOD K (GO TO 319A)
PERIODIC ABSTINENCE L (GO TO 319A)
WITHDRAWAL M (GO TO 319A)
OTHER (SPECIFY)________ X (GO TO 319A)

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.

PACKAGE SEEN
CERAZETTE 11
OVRETTE 12
LOFEMENAL 13
MICROGYNON 14
YASMIN 15
OTHER 16
PACKAGE NOT SEEN
CERAZETTE 21
OVRETTE 22
LOFEMENAL 23
MICROGYNON 24
YASMIN 25
OTHER 26
DON'T KNOW 98

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?

NUMBER OF PILL CYCLES/CONDOMS_______
DON'T KNOW 998

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

COST IN JD_____
FREE 995
DON'T KNOW 998

315A) CHECK 311:

USING IUD CODE 'D' CIRCLED (GO TO 315B)
NOT USING IUD CODE 'D' NOT CIRCLED (GO TO 319A)

315B) Who inserted your IUD?

MALE DOCTOR 1
FEMALE DOCTOR 2
MIDWIFE 3
OTHER (SPECIFY)__________6

(GO TO 319A FOR ALL ANSWERS)

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.

(NAME OF PLACE)___________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 11
UNIVERSITY HOSPITAL 12
ROYAL MEDICAL SERVICES 13
OTHER PUBLIC (SPECIFY)_______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
OTHER PRIVATE MEDICAL (SPECIFY)________26
DON'T KNOW 98

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?

YES 1
NO 2
DON'T KNOW 8

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

COST IN JD ________
FREE 995
DON'T KNOW 998

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

YES 1
NO 2

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

MONTH ____
YEAR ____

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?

MONTH______
YEAR _______

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

YES:
GO BACK TO 319/319A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).
NO (GO TO 321)

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.

NO CODE 00 (GO TO 333)
FEMALE STERILIZATION 01 (GO TO 326)
MALE STERILIZATION 02 (GO TO 335)
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 324A)
PERIODIC ABSTINENCE 12 (GO TO 324A)
WITHDRAWAL 13 (GO TO 335)
OTHER METHOD 96 (GO TO 335)

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.

(NAME OF PLACE)________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
GOVERNMENT MOTHER AND CHILD HEALTH CENTER 13
UNIVERSITY HOSPITAL 14
ROYAL MEDICAL SERVICES 15
OTHER PUBLIC (SPECIFY)_________ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/ CLINIC 21
PRIVATE DOCTOR 22
PHARMACY 23
JORDANIAN ASSOCIATION OF FAMILY PLANNING AND PROTECTION (JAFPP) 24
UNITED NATIONS RELIEF AND WORKS AGENCY CLINIC 25
OTHER NON-GOVERNMENT ORGANIZATION 26
OTHER PRIVATE MEDICAL (SPECIFY)_________ 96

325) CHECK 311/311A:

CIRCLE METHOD CODE:

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

PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07 (GO TO 332)
FEMALE CONDOM 08 (GO TO 329)
DIAPHRAGM 09 (GO TO 329)
FOAM/ JELLY 10 (GO TO 329)
LACTATIONAL AMEN. METHOD 11 (GO TO 335)
PERIODIC ABSTINENCE 12 (GO TO 335)

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?

YES 1 (GO TO 328)
NO 2

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

YES 1
NO 2 (GO TO 329)

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

YES 1
NO 2

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?

YES 1 (GO TO 331)
NO 2

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

YES 1
NO 2

331) CHECK 311/311A:

CIRCLE METHOD CODE:

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

FEMALE STERILIZATION 01 (GO TO 335)
MALE STERILIZATION 02 (GO TO 335)
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 335)
PERIODIC ABSTINENCE 12 (GO TO 335)
WITHDRAWAL 13 (GO TO 335)
OTHER METHOD 96 (GO TO 335)

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.

(NAME OF PLACE)__________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HOSPITAL 12
GOVERNMENT MOTHER AND CHILD HEALTH CENTER 13
UNIVERSITY HOSPITAL/CLINIC 14
ROYAL MEDICAL SERVICES 15
OTHER PUBLIC (SPECIFY)____________ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL CLINIC/CLINIC 21
PRIVATE DOCTOR 22
PHARMACY 23
JORDANIAN ASSOCIATION. OF FAMILY PLANNING AND PROTECTION (JAFPP) 24
UNITED NATIONS RELIEF AND WORKS AGENCY CLINIC 25
OTHER NON-GOVERNMENT ORGANIZATION 26
OTHER PRIVATE MEDICAL (SPECIFY)_________ 27
OTHER SOURCE
FRIEND/RELATIVE 33
OTHER (SPECIFY)_______ 96
(GO TO 335 FOR ALL)

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

YES 1
NO 2
(GO TO 335 FOR ALL ANSWERS)

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.

(NAME OF PLACE(S))________________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT MOTHER AND CHILD HEALTH CENTER C
UNIVERSITY HOSPITAL/CLINIC D
ROYAL MEDICAL SERVICES E
OTHER PUBLIC (SPECIFY)______________ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PRIVATE DOCTOR H
PHARMACY I
JORDANIAN ASSOCIATION OF FAMILY PLANNING AND PROTECTION (JAFPP) J
UNITED NATIONS RELIEF AND WORKS AGENCY CLINIC K
OTHER NON- GOVERNMENT ORGANIZATION L
OTHER PRIVATE MEDICAL (SPECIFY) __________ M
OTHER SOURCE
FRIEND/ RELATIVE N
OTHER (SPECIFY)____________ X

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4: PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2002 OR LATER (GO TO 402)
NO BIRTHS IN 2002 OR LATER (GO TO 548)

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

LINE NUMBER_____________

404) FROM 212 AND 216

NAME_________
LIVING __ (GO TO 405)
DEAD___ (GO TO 405)

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?

THEN 1 (SKIP TO 407)
LATER 2
NOT AT ALL (SKIP TO 407)

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

MONTHS 1______
YEARS 2______
DON'T KNOW 998

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.

HEALTH PERSONNEL DOCTOR A
NURSE/ MIDWIFE B
OTHER PERSON (SPECIFY)____________ X
NO ONE Y (GO TO 414)

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.

(NAME OF PLACE(S))______________
HOME
YOUR HOME A
OTHER HOME B
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL C
GOVERNMENT HEALTH CENTER D
UNIVERSITY HOSPITAL E
ROYAL MEDICAL SERVICES F
OTHER PUBLIC (SPECIFY)___________ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
UNITED NATIONS RELIEF AND WORKS AGENCY HEALTH CENTER I
OTHER PRIVATE MEDICAL (SPECIFY)__________ J
OTHER (SPECIFY)_________ X

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)

NUMBER OF MONTHS ______
DON'T KNOW 98

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

NUMBER OF TIMES _________
DON'T KNOW 98

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)

Were you weighed?

WEIGHT:
YES 1
NO 2
Was your blood pressure measured?

BP:
YES 1
NO 2
Did you give a urine sample?

URINE:
YES 1
NO 2
Did you give a blood sample?

BLOOD:
YES 1
NO 2

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)

YES 1
NO 2 (GO TO 413A)
DON'T KNOW 8 (GO TO 413A)

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)

YES 1
NO 2
DON'T KNOW 8

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)

YES 1
NO 2
DON'T KNOW 8

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)

YES 1
NO 2
DON'T KNOW 8

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)

YES 1
NO 2(GO TO 417)
DON'T KNOW 8 (GO TO 417)

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

TIMES ____
DON'T KNOW 8

416) CHECK 415:

2 OR MORE TIMES (GO TO 421)
1 OR DON'T KNOW (GO TO 417)

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)

YES 1
NO 2 (GO TO 421)
DON'T KNOW 8

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'.

TIMES ___
DON'T KNOW 8

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)

MONTH_____
DON'T KNOW MONTH 98
YEAR ______ (GO TO 421)
DON'T KNOW YEAR 9998

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

YEARS AGO _______

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)

YES 1
NO 2 (GO TO 426)
DON'T KNOW 8 (GO TO 426)

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.

DAYS ______
DON'T KNOW 998

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

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8

427) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 429)
DON'T KNOW 8 (GO TO 429)

428) How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

KILOGRAMS FROM CARD 1______________
KILOGRAMS FROM RECALL 2___________
DON'T KNOW 99998

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.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
OTHER PERSON X (SPECIFY)________ (GO TO 430)
NO ONE Y (GO TO 430)

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

RECORD TOTAL COST IN DINARS

COST IN JD_________
FREE 9995
DON'T KNOW 9998

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)______________

HOME
YOUR HOME 11 (GO TO 437)
OTHER HOME 12 (GO TO 437)
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
UNIVERSITY HOSPITAL 23
ROYAL MEDICAL SERVICES 24
OTHER PUBLIC (SPECIFY)________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY)_______ 36
OTHER (SPECIFY)_________ 96 (GO TO 437)

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.

HOURS 1_____
DAYS 2______
WEEKS 3______
DON'T KNOW 998

432) Was (NAME) delivered by caesarean section?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 436)

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.

HOURS 1_____
DAYS 2_____
WEEKS 3_____
DON'T KNOW 998

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

HEALTH PERSONNEL
DOCTOR 1
NURSE/MIDWIFE 2
OTHER PERSON (SPECIFY)_________ 6

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

YES 1 (GO TO 439A)
NO 2

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)

NO NEED/ NO SICKNESS 01
NOT AWARE AVAILABILITY OF POSTNATAL SERVICE 02
NOT SUPPOSED TO GO OUT DURING THIS PERIOD 03
NO ONE TO TAKE CARE OF MY BABY DURING VISIT 04
TOO FAR 05
TOO EXPENSIVE 06
NO QUALIFIED PERSONNEL 07
HUSBAND OPPOSED 08
OTHER (SPECIFY)_________ 96 (GO TO 448)

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

COST TOO MUCH A
FACILITY NOT OPEN B
TOO FAR/ NO TRANSPORTATION C
DON'T TRUST FACILITY/ POOR QUALITY SERVICE D
NO FEMALE PROVIDER AT FACILITY E
HUSBAND/ FAMILY DID NOT ALLOW F
NOT NECESSARY G
NOT CUSTOMARY H
OTHER (SPECIFY)________ X

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

YES 1 (GO TO 439)
NO 2

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)

NO NEED/ NO SICKNESS 01
NOT AWARE AVAILABILITY OF POSTNATAL SERVICE 02
NOT SUPPOSED TO GO OUT DURING THIS PERIOD 03
NO ONE TO TAKE CARE OF MY BABY DURING VISIT 04
TOO FAR 05
TOO EXPENSIVE 06
NO QUALIFIED PERSONNEL 07
HUSBAND OPPOSED 08
OTHER (SPECIFY)_________ 96 (GO TO 443)

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

HOURS 1____
DAYS 2____
WEEKS 3_____
DON'T KNOW 998

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.

HOURS 1_______
DAYS 2______
WEEKS 3______
DON'T KNOW 998

440) Who checked on your health at that time?

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 1
NURSE/MIDWIFE 2
OTHER PERSON (SPECIFY)________ 6

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)___________

HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT MOTHER CHILD HEALTH CENTER 23
UNIVERSITY HOSPITAL 24
ROYAL MEDICAL SERVICES 25
OTHER PUBLIC (SPECIFY)_________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
UNITED NATIONS RELIEF AND WORKS AGENCY HEALTH CENTER 32
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
OTHER (SPECIFY)__________ 96

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

COST IN JD______
FREE 995
DON'T KNOW 998

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)

YES 1
NO 2 (GO TO 441D)

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.

HOURS 1______
DAYS 2______
WEEKS 3_________
DON'T KNOW 998

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)

YES 1
NO 2

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

YES (GO TO 448)
NOT ASKED (GO TO 443)

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)

YES 1
NO 2 (GO TO 448)
DON'T KNOW 8 (GO TO 448)

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.

HOURS AFTER BIRTH 1 ________
DAYS AFTER BIRTH 2________
WEEKS AFTER BIRTH 3_____
DON'T KNOW 998

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

PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 1
NURSE/ MIDWIFE 2
OTHER PERSON (SPECIFY)_________ 6

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)____________

HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT MOTHER CHILD HEALTH CENTER 23
UNIVERSITY HOSPITAL 24
ROYAL MEDICAL SERVICES 25
OTHER PUBLIC (SPECIFY)_________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
UNITED NATIONS RELIEF AND WORKS AGENCY HEALTH CENTER 32
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
OTHER (SPECIFY)__________ 96

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

YES 1 (GO TO 450)
NO 2 (GO TO 451)

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)

YES 1
NO 2 (GO TO 453)

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

MONTHS ____
DON'T KNOW 98

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

NOT PREGNANT (GO TO 452)
PREGNANT (GO TO 453)

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)

YES 1
NO 2 (GO TO 454)

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

IF LESS THAN 1 MONTH, RECORD '00'

MONTHS ____
DON'T KNOW 98

454) Did you ever breastfeed (NAME)?

YES 1
NO 2 (GO TO 461)

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.

IMMEDIATELY 000
HOURS 1___
DAYS 2_____

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)

YES 1
NO 2 (GO TO 458)

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

Anything else?

RECORD ALL LIQUIDS MENTIONED.

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
HONEY I
OTHER (SPECIFY)_______ X

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

LIVING (GO TO 459)
DEAD (GO TO 460)

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

YES 1 (GO TO 462)
NO 2

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

MONTHS____
DON'T KNOW 98

461) CHECK 404: IS CHILD LIVING?

LIVING (GO TO 464)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

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.

NUMBER OF NIGHTTIME FEEDINGS _____

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.

NUMBER OF DAYLIGHT FEEDINGS_____

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

YES 1
NO 2
DON'T KNOW 8

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

LINE NUMBER_______

503) FROM 212 AND 216

NAME_______
LIVING (GO TO 504)
DEAD (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 547)

504) Do you have a card where (NAME'S) vaccinations are written down?
IF YES: May I see it please?

YES, SEEN 1 (GO TO 506)
YES, NOT SEEN 2 (GO TO 508)
NO CARD 3

505) Did you ever have a vaccination card for (NAME)?

YES 1 (GO TO 508)
NO 2 (GO TO 508)

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.

BCG
DAY_____
MONTH_____
YEAR_____
POLIO(IPV/OPV) 1
DAY_____
MONTH_____
YEAR_____
POLIO (IPV/OPV) 2
DAY_____
MONTH_____
YEAR_____
POLIO (OPV) 3
DAY_____
MONTH_____
YEAR_____
POLIO (OPV) 4
DAY_____
MONTH_____
YEAR_____
POLIO BOOSTER
DAY_____
MONTH_____
YEAR_____
DPT (TETRA/ PENTA) 1
DAY_____
MONTH_____
YEAR_____
DPT (TETRA/PENTA) 2
DAY_____
MONTH_____
YEAR_____
DPT (TETRA/ PENTA) 3
DAY_____
MONTH_____
YEAR_____
DPT BOOSTER
DAY_____
MONTH_____
YEAR_____
HEPATITIS (TETRA/PENTA) 1
DAY_____
MONTH_____
YEAR_____
HEPATITIS (TETRA/PENTA) 2
DAY_____
MONTH_____
YEAR_____
HEPATITIS (TETRA/PENTA) 3
DAY_____
MONTH_____
YEAR_____
HIB (TETRA/PENTA) 1
DAY_____
MONTH_____
YEAR_____
HIB (TETRA/PENTA) 2
DAY_____
MONTH_____
YEAR_____
HIB (TETRA/PENTA) 3
DAY_____
MONTH_____
YEAR_____
MEASLES
DAY_____
MONTH_____
YEAR_____
MMR (MEASLES/ MUMPS/ RUBELLA)
DAY_____
MONTH_____
YEAR_____

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.

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 506) (GO TO 510A)
NO 2 (GO TO 510A)
DON'T KNOW 8 (GO TO 510A)

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

YES 1
NO 2 (GO TO 514)
DON'T KNOW 8 (GO TO 514)

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?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 509D)
DON'T KNOW 8 (GO TO 509D)

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

NUMBER OF TIMES____

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.

YES 1
NO 2 (GO TO 509F)
DON'T KNOW 8 (GO TO 509F

)

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

NUMBER OF TIMES ___

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.

YES 1
NO 2 (GO TO 509H)
DON'T KNOW 8 (GO TO 509H)

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

NUMBER OF TIMES___

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.

YES 1
NO (GO TO 509J)
DON'T KNOW 8

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

NUMBER OF TIMES____

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

AT LEAST ONE (GO TO 510B)
NONE OR DON'T KNOW (GO TO 510G)

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

PUBLIC FACILITY 1
PRIVATE FACILITY 2
UNITED NATIONS RELIEF AND WORKS AGENCY 3
OTHER 6
DON'T KNOW 8

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

AT LEAST TWO (GO TO 510D)
ONLY ONE (GO TO 510G)

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

PUBLIC FACILITY 1
PRIVATE FACILITY 2
UNITED NATIONS RELIEF AND WORKS AGENCY 3
OTHER 6
DON'T KNOW 8

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

AT LEAST THREE (GO TO 510F)
ONLY TWO (GO TO 510G)

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

PUBLIC FACILITY 1
PRIVATE FACILITY 2
UNITED NATIONS RELIEF AND WORKS AGENCY 3
OTHER 6
DON'T KNOW 8

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

YES (GO TO 510H)
NO OR DON'T KNOW (GO TO 510I)

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

PUBLIC FACILITY 1
PRIVATE FACILITY 2
UNITED NATIONS RELIEF AND WORKS AGENCY 3
OTHER 6
DON'T KNOW 8

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

YES (GO TO 510J)
NO OR DON'T KNOW (GO TO 514)

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

PUBLIC FACILITY 1
PRIVATE FACILITY 2
UNITED NATIONS RELIEF AND WORKS AGENCY 3
OTHER 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 518)
DON'T KNOW 8 (GO TO 518)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 531)
DON'T KNOW 8

519) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 527)

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.

(NAME OF PLACE(S))_________________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT MOTHER AND CHILD HEALTH CENTER C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
OTHER PUBLIC (SPECIFY)_________ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/ CLINIC G
PHARMACY H
PRIVATE DOCTOR I
UNITED NATIONS RELIEF AND WORKS AGENCY HEALTH CENTER J
OTHER PRIVATE MEDICAL (SPECIFY)__________ K
OTHER (SPECIFY)___________ X

524) CHECK 523:

TWO OR MORE CODES CIRCLED (GO TO 525)
ONLY ONE CODE CIRCLED (GO TO 526)

525) Where did you first seek advice or treatment?

USE LETTER CODE FROM 523

FIRST PLACE __

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

DAYS ______

527) Does (NAME) still have diarrhea?

YES 1
NO 2
DON'T KNOW 8

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

a) A fluid made from a special packet called Aquacell or Paralait?

AQUACELL/PARALAIT:
YES 1
NO 2
DON'T KNOW 8
b) Thin watery gruel made from rice, carrot, wheat, etc.?

GRUEL:
YES 1
NO 2
DON'T KNOW 8
c) Soup?

SOUP:
YES 1
NO 2
DON'T KNOW 8
d) Homemade sugar-salt-water solution?

SUGAR-SALT-WATER SOLUTION:
YES 1
NO 2
DON'T KNOW 8
e) Milk or infant formula?

MILK/FORMULA:
YES 1
NO 2
DON'T KNOW 8
f) Yoghurt-based drink?

YOGHURT:
YES 1
NO 2
DON'T KNOW 8
g) Water?

WATER:
YES 1
NO 2
DON'T KNOW 8
h) Any other liquid?

OTHER LIQUID:
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO (GO TO 531)
DON'T KNOW (GO TO 531)

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

Anything else?
RECORD ALL TREATMENTS GIVEN/

PILL OR SYRUP
ANTIBIOTIC A
NON-ANTIBIOTIC B
UNKNOWN PILL OR SYRUP C
INJECTION
ANTIBIOTIC D
NON-ANTIBIOTIC E
UNKNOWN INJECTION F
(IV) INTRAVENOUS G
HOME REMEDY/ HERBAL MEDICINE H
OTHER (SPECIFY)_______ X
DON'T KNOW Z

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 535)
DON'T KNOW (GO TO 535)

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

YES 1
NO 2 (GO TO 536)
DON'T KNOW (GO TO 536)

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

CHEST ONLY 1
NOSE ONLY 2
BOTH 3
OTHER (SPECIFY)_______ 6
DON'T KNOW 8
(FOR ALL ANSWERS GO TO 536)

535) CHECK 531: HAD FEVER?

YES (GO TO 536)
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 547)

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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 543)

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.

(NAME OF PLACE(S))_________________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT MOTHER AND CHILD HEALTH CENTER C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
OTHER PUBLIC (SPECIFY)_________ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/ CLINIC G
PHARMACY H
PRIVATE DOCTOR I
UNITED NATIONS RELIEF AND WORKS AGENCY HEALTH CENTER J
OTHER PRIVATE MEDICAL (SPECIFY)__________ K
OTHER (SPECIFY)___________ X

540) CHECK 539:

TWO OR MORE CODES CIRCLED (GO TO 541)
ONLY ONE CODE CIRCLED (GO TO 542)

541) Where did you first seek advice or treatment?

USE LETTER CODE FROM 539

FIRST PLACE __

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

DAYS ______

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

FEVER ONLY 1
COUGH ONLY 2
BOTH FEVER AND COUGH 3
NO, NEITHER 4
DON'T KNOW 8

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

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 547)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 547)

545) What drugs did (NAME) take?

Any other drugs?

RECORD ALL MENTIONED.

PILL OR SYRUP
ANTIBIOTIC A
NON-ANTIBIOTIC B
UNKNOWN PILL OR SYRUP C
INJECTION
ANTIBIOTIC D
NON-ANTIBIOTIC E
UNKNOWN INJECTION F
(IV) INTRAVENOUS G
HOME REMEDY/ HERBAL MEDICINE H
OTHER (SPECIFY)_______ X
DON'T KNOW Z

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

547) CHECK 528(A), ALL COLUMNS:

NO CHILD RECEIVED AQUACELL OR PARALAIT (GO TO 548)
ANY CHILD RECEIVED AQUACELL OR PARALAIT (GO TO 549)

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

YES 1
NO 2

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'

WITHIN PAST TWO WEEKS 1
MORE THAN 2 WEEKS BUT LESS THAN ONE MONTH 2
ONE MONTH OR MORE 3
NO 4 (GO TO 550A)

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'

COST _________
FREE 994
NO MEDICINE 995
DON'T KNOW 998

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

YES 1
NO 2
DON'T KNOW BREAST CANCER/DON'T KNOW SELF EXAM 8

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

YES 1
NO 2
NOT SURE 8

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?

YES 1
NO 2 (GO TO 550E)

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

YES 1
NO 2

550E) Do you smoke:

Cigarettes?

CIGARETTES:
YES 1
NO 2
Nargilla?

NARGILLA:
YES 1
NO 2

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)

(NAME)_______________

NONE (GO TO 601)

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):

Plain water?

PLAIN WATER:
YES 1
NO 2
DON'T KNOW 8
Commercially produced infant formula?

FORMULA:
YES 1
NO 2
DON'T KNOW 8
Any (other) porridge or gruel?

OTHER PORRIDGE/GRUEL
YES 1
NO 2
DON'T KNOW 8

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):

a) Milk such as tinned, powdered, or fresh animal milk?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
b) Fruit juice?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
c) Soup broth?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
d) Tea?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
e) Any other liquids such as sugar water or carbonated drinks?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
f) Bread, pasta, rice, maize, or any other food made from grains?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
g) Carrots, red sweet potatoes, or pumpkin?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
h) Any other food made from roots or tubers, such as white potatoes, or other roots/tubers?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
i) Any green leafy vegetables, such as spinach, or mouloukia?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
j) Apricot, palm nuts, or yellow melon?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
k) Any other fruits or vegetables?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
l) Meat, poultry, fish, or eggs?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
m) Any food made from legumes, such as lentils, beans, or chickpeas?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
n) Any type of nuts or seeds, such as pistachio, almonds, cashew, peanuts, or sesame seeds?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
o) Cheese or yoghurt?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
p) Any oil, fats, or butter, or foods made with any of these?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
q) Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8
r) Any other solid or semi-solid food?

CHILD:
YES 1
NO 2
DON'T KNOW 8
MOTHER:
YES 1
NO 2
DON'T KNOW 8

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

AT LEAST ONE 'YES' (GO TO 555)
NOT A SINGLE 'YES' (GO TO 601)

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'

NUMBER OF TIMES ______
DON'T KNOW 8

SECTION 6: MARRIAGE AND SEXUAL ACTIVITY

601) CHECK 101A:

CURRENTLY MARRIED (GO TO 602)
WIDOWED/SEPARATED/DIVORCED (GO TO 606)

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

LIVING WITH HER 1
STAYING ELSEWHERE 2

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

NAME _____________
LINE NUMBER __________

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

YES 1
NO 2 (GO TO 606)

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

TOTAL NUMBER OF WIVES ___
DON'T KNOW 8

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

ONLY ONCE 1
MORE THAN ONCE 2

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)?

MONTH____
DON'T KNOW MONTH 98
YEAR____ (GO TO 609)
DON'T KNOW YEAR 9998

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

AGE ______

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

YES 1
NO 2 (GO TO 611)

610) What type of relation was it?

FIRST COUSIN ON BOTH FATHER AND MOTHER'S SIDE 01
FIRST COUSIN ON BOTH MOTHER AND FATHER'S SIDE 02
FIRST COUSIN ON FATHER'S SIDE (IBN AL AMM) 03
FIRST COUSIN ON MOTHER'S SIDE (IBN AL KHAL) 04
FIRST COUSIN ON FATHER'S SIDE (IBN AL AMMAH) 05
FIRST COUSIN ON MOTHER'S SIDE (IBN AL KHALAH) 06
SECOND COUSIN (FATHER'S SIDE) 07
SECOND COUSIN (MOTHER'S SIDE) 08
OTHER RELATIVE 09
DON'T KNOW 98

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?

YES 1
NO 2
DON'T KNOW 8

611A) Did you have a premarital medical exam?

YES 1
NO 2 (GO TO 612)

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

PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
GOVERNMENT MOTHER AND CHILD HEALTH CENTER 13
UNIVERSITY HOSPITAL 14
ROYAL MEDICAL SERVICES 15
OTHER PUBLIC (SPECIFY)________ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR 22
JORDANIAN ASSOCIATION OF FAMILY PLANNING AND PROTECTION (JAFPP) 23
UNITED NATIONS RELIEF AND WORKS AGENCY HEALTH CENTER 24
OTHER NON-GOVERNMENT ORGANIZATION 25
OTHER PRIVATE MEDICAL (SPECIFY)___________ 26
OTHER (SPECIFY)_____________ 96

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.

DAYS AGO 1______
WEEKS AGO 2______
WEEKS AGO 3__________
YEARS AGO 4 ________ (GO TO 614)

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 700)

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.

(NAME OF PLACE(S)) ____________________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT MOTHER AND CHILD HEALTH CENTER C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
OTHER PUBLIC (SPECIFY)________ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PRIVATE DOCTOR H
PHARMACY I
JORDANIAN ASSOCIATION OF FAMILY PLANNING AND PROTECTION (JAFPP) J
UNITED NATIONS RELIEF AND WORKS AGENCY CLINIC K
OTHER NON-GOVERNMENT ORGANIZATION L
OTHER PRIVATE MEDICAL (SPECIFY)___________ M
OTHER SOURCE
FRIEND/ RELATIVE N
OTHER (SPECIFY)_____________ X

SECTION 7: FERTILITY PREFERENCES

700) CHECK 101A:

CURRENTLY MARRIED (GO TO 701)
CURRENTLY WIDOWED, DIVORCED, OR SEPARATED (GO TO 713)

701) CHECK 311/311A:

NEITHER STERILIZED (GO TO 702)
HE OR SHE STERILIZED (GO TO 713)

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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 704)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 713)
UNDECIDED/ DON'T KNOW AND PREGNANT 4 (GO TO 709)
UNDECIDED/ DON'T KNOW AND NOT PREGNANT OR UNSURE (GO TO 708)

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?

MONTHS 1___
YEARS 2___
SOON/NOW 993 (GO TO 708)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 713)
OTHER (SPECIFY)_____________ 996 (GO TO 708)
DON'T KNOW 998 (GO TO 708)

704) CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 705)
PREGNANT (GO TO 709)

705) CHECK 310: USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 706)
NOT CURRENTLY USING (GO TO 706)
CURRENTLY USING (GO TO 713)

706) CHECK 703:

NOT ASKED (GO TO 707)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 707)
00-23 MONTHS OR 00-01 YEAR (GO TO 709)

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.

FERTILITY-RELATED REASONS
NOT HAVING SEX A
INFREQUENT SEX B
MENOPAUSAL/ HYSTERECTOMY C
SUBFECUND/INFECUND D
POSTPARTUM AMENORRHEIC E
BREASTFEEDING F
DIFFICULT TO GET PREGNANT G
OPPOSITION TO USE
RESPONDENT OPPOSED H
HUSBAND OPPOSED I
OTHERS OPPOSED J
RELIGIOUS PROHIBITION K
RUMORS L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS O
FEAR OF SIDE EFFECTS P
LACK OF ACCESS/ TOO FAR Q
COSTS TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY'S NORMAL PROCESSES T
OTHER (SPECIFY)___________ X
DON'T KNOW Z

708) CHECK 310: USING A CONTRACEPTIVE?

NOT ASKED (GO TO 709)
NO, NOT CURRENTLY USING (GO TO 709)
YES, CURRENTLY USING (GO TO 713)

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

YES 1
NO 2 (GO TO 711)
DON'T KNOW 8 (GO TO 713)

710) Which contraceptive method would you prefer to use?

FEMALE STERILIZATION 01
MALE STERILIZATION 02
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11
PERIODIC ABSTINENCE 12
WITHDRAWAL 13
OTHER (SPECIFY)_________ 96
DON'T KNOW/ UNSURE 98
(GO TO 713 FOR ALL ANSWERS)

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

FERTILITY-RELATED REASONS
INFREQUENT SEX/ NO SEX 11
MENOPAUSAL/ HYSTERECTOMY 12
SUBFECUND/INFECUND 13
WANTS AS MANY CHILDREN AS POSSIBLE 14
OPPOSITION TO USE
RESPONDENT OPPOSED 21
HUSBAND OPPOSED 22
OTHERS OPPOSED 23
RELIGIOUS PROHIBITION 24
RUMORS 25
LACK OF KNOWLEDGE
KNOWS NO METHOD 31
KNOWS NO SOURCE 32
METHOD-RELATED REASONS
HEALTH CONCERNS 41
FEAR OF SIDE EFFECTS 42
LACK OF ACCESS/ TOO FAR 43
COSTS TOO MUCH 44
INCONVENIENT TO USE 45
INTERFERES WITH BODY'S NORMAL PROCESSES 46
OTHER (SPECIFY)___________ 96
DON'T KNOW 98
(FOR ALL ANSWERS EXCEPT '22' ('HUSBAND OPPOSED) GO TO 713)

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

RECORD ALL REASONS MENTIONED.

AGAINST RELIGION A
CAUSE HEALTH PROBLEMS B
FEAR OF SIDE EFFECTS C
COST TOO MUCH D
INTERFERES WITH THE BODY'S NORMAL PROCESSES E
FATALISTIC F
OTHER (SPECIFY) __________ X
DON'T KNOW Z

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

NONE 00 (GO TO 715)
NUMBER _____
OTHER (SPECIFY)__________ 96 (GO TO 715)

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?

NUMBER OF BOYS_____
NUMBER OF GIRLS ____
NUMBER OF EITHER____
OTHER (SPECIFY)________________ 96

715) In the last 6 months have you:

Heard about family planning on the radio?

RADIO:
YES 1
NO 2
Seen about family planning on the television?

TELEVISION:
YES 1
NO 2
Read about family planning in a newspaper or magazine?

NEWSPAPER OR MAGAZINE:
YES 1
NO 2
Seen or read about family planning on posters?

POSTER:
YES 1
NO 2
Read about family planning on in bulletins/booklets?

BULLETIN/BOOKLET:
YES 1
NO 2
Heard about family planning in lectures?

LECTURES:
YES 1
NO 2
Heard about family planning from women you associate with?

WOMEN:
YES 1
NO 2
Heard about family planning from any other people you associate with?

OTHER PEOPLE:
YES 1
NO 2

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

CIRCLE ONLY ONE ANSWER.

INTERPERSONAL
GOVERNMENT HEALTH WORKER 11
PRIVATE DOCTOR/NURSE 12
JAFPP STAFF 13
HUSBAND 14
OTHER RELATIVES 15
FRIENDS 16
MEDIA
RADIO 21
TV 22
PRINT MATERIALS 23
SCHOOL, LIBRARY/ACADEMIC 24
COMMUNITY/PUBLIC MEETING 25
LECTURES 26
OTHER (SPECIFY) __________________ 96
DON'T KNOW 98

717) CHECK 101A:

CURRENTLY MARRIED (GO TO 718)
CURRENTLY WIDOWED, DIVORCED, OR SEPARATED (GO TO 801)

718) CHECK 311/311A:

CODE B, G, OR M (GO TO 720)
OTHER CODES CIRCLED (GO TO 719)
NO CODE CIRCLED (GO TO 720A)

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

YES 1
NO 2
DON'T KNOW 8

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

MAINLY RESPONDENT 1
MAINLY HUSBAND 2
JOINT DECISION 3
OTHER (SPECIFY) _____________ 6

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?

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

721) CHECK 311/311A:

NEITHER STERILIZED (GO TO 722)
HE OR SHE STERILIZED (GO TO 801)

722) Does your husband want the same number of children that you want, or does he want more or fewer than you want?

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8

SECTION 8: HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 101A:

CURRENTLY MARRIED (GO TO 802)
CURRENTLY WIDOWED, DIVORCED, OR SEPARATED (GO TO 803)

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

AGE IN COMPLETED YEARS ____

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

YES 1
NO 2 (GO TO 806)

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?

OLD SYSTEM
ELEMENTARY 01
PREPARATORY 02
SECONDARY 03
NEW SYSTEM
BASIC 04
SECONDARY 05
INTERMEDIATE DIPLOMA 06
BACHELOR 07
HIGHER 08
DON'T KNOW 98 (GO TO 806)

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

GRADE ______
DON'T KNOW 98

806) CHECK 101A:

CURRENTLY MARRIED (GO TO 807)
CURRENTLY WIDOWED, DIVORCED, OR SEPARATED (GO TO 811)

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?

YES 1 (GO TO 809)
NO 2

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?

YES 1
NO 2 (GO TO 811)

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?

EMPLOYEE 1
EMPLOYER 2
SELF-EMPLOYED 3
UNPAID FAMILY WORKER 4
UNPAID WORKER 5

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?

YES 1 (GO TO 813)
NO 2

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?

YES 1
NO 2 (GO TO 818)

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?

EMPLOYEE 1
EMPLOYER 2
SELF-EMPLOYED 3
UNPAID FAMILY WORKER 4
UNPAID WORKER 5

818) CHECK 101A:

CURRENTLY MARRIED (GO TO 819)
CURRENTLY WIDOWED, DIVORCED, OR SEPARATED (GO TO 827)

819) CHECK 814:

CODE 1, 2, OR 3 CIRCLED (GO TO 820)
CODE 4 OR 5 CIRCLED OR 814 NOT ASKED (GO TO 822)

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
OTHER(SPECIFY)___________ 6

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?

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND DOESN'T BRING IN ANY MONEY 4 (GO TO 822A)
DON'T KNOW 8

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
HUSBAND HAS NO EARNINGS 4
OTHER (SPECIFY) ________ 6

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.?

YES 1
NO 2 (GO TO 823)

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
OTHER 6

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________ 6

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________ 6

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________ 6

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY)_____________ 6

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

CHILDREN LESS THAN TEN:
PRESENT LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3
HUSBAND:
PRESENT LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3
OTHER MALES:
PRESENT LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES:
PRESENT LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 3

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:

If she goes out without telling him?

GOES OUT:
YES 1
NO 2
DON'T KNOW 8
If she neglects the children?

NEGLECTING CHILDREN:
YES 1
NO 2
DON'T KNOW 8
If she burns the food?

BURNS FOOD:
YES 1
NO 2
DON'T KNOW 8
If she insults him?

INSULTS:
YES 1
NO 2
DON'T KNOW 8
If she disobeys him?

DISOBEYS:
YES 1
NO 2
DON'T KNOW 8
If she argues with him?

DISOBEYS:
YES 1
NO 2
DON'T KNOW 8
If she argues with him?

ARGUES:
YES 1
NO 2
DON'T KNOW 8
If she has relations with another man?

ANOTHER MAN:
YES 1
NO 2
DON'T KNOW 8

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).

Beating?

BEATING:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Physical threats?

PHYSICAL THREATS:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Insults?

INSULTS:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Rape?

RAPE:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Sexual harassment?

SEXUAL HARASSMENT:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Early marriage?

EARLY MARRIAGE:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Compulsory marriage?

COMPULSORY MARRIAGE

:

YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
Unwanted sexual intercourse?

UNWANTED SEXUAL INTERCOURSE:
YES SPONTANEOUSLY 1
YES PROBE 2
NO 3
OTHER(SPECIFY)_______________ 1

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?

YES 1
NO 2 (GO TO 916)

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

YES 1
NO 2 (GO TO 902)
DON'T KNOW 8 (GO TO 902)

901B) What can a person do?

Anything else?

RECORD ALL WAYS MENTIONED

ABSTAIN FROM SEXUAL INTERCOURSE A
USE CONDOMS B
LIMIT SEX TO SPOUSE/ STAY FAITHFUL TO SPOUSE C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING RAZOR/ BLADES K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____________ W
OTHER (SPECIFY) ________________ X
DON'T KNOW Z

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

During pregnancy?

DURING PREGNANCY:
YES 1
NO 2
DON'T KNOW 8
During delivery?

DURING DELIVERY:
YES 1
NO 2
DON'T KNOW 8
By breastfeeding?

BREASTFEEDING:
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 912)

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.

(NAME OF PLACE(S)) _______________________
PUBLIC MEDICAL SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT MOTHER AND CHILD HEALTH CENTER C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
TESTING AND COUNSELING CENTER F
OTHER PUBLIC (SPECIFY)_____________ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
PRIVATE DOCTOR I
JORDANIAN ASSOCIATION OF FAMILY PLANNING AND PROTECTION (JAFPP) J
PRIVATE LABORATORY K
OTHER NON GOVERNMENT ORGANIZATION L
OTHER PRIVATE MEDICAL (SPECIFY)________ M
OTHER (SPECIFY)________________ X

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

YES 1
NO 2
DON'T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DON'T KNOW/ NOT SURE/ DEPENDS 8

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?

YES 1
NO 2
DON'T KNOW/ NOT SURE/ DEPENDS 8

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?

SHOULD BE ALLOWED 1
SHOULD NOT BE ALLOWED 2
DON'T KNOW/ NOT SURE/ DEPENDS 8

915A) CHECK 101A:

CURRENTLY MARRIED (GO TO 915B)
WIDOWED/ DIVORCED/ SEPARATED (GO TO 915C)

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 916)

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?

YES 1
NO 2 (GO TO 917)

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

Any other symptoms?

RECORD ALL MENTIONED

ABDOMINAL PAIN A
GENITAL DISCHARGE/ DRIPPING B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/ INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
IMPOTENCE L
FEVER M
OTHER (SPECIFY)_________________ X
NO SYMPTOMS Y
DON'T KNOW Z

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

Any other symptoms?

RECORD ALL MENTIONED

ABDOMINAL PAIN A
GENITAL DISCHARGE/ DRIPPING B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/ INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
HARD TO GET PREGNANT/ HAVE A CHILD L
FEVER M
OTHER (SPECIFY)_________________ X
NO SYMPTOMS Y
DON'T KNOW Z

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?

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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?

YES 1
NO 2
DON'T KNOW 8

SECTION 10: OTHER HEALTH ISSUES

1001) Have you heard of an illness called tuberculosis?

YES 1
NO 2 (GO TO 1013)

1002) How does spread from one person to another?

PROBE: Any other ways?

RECORD ALL MENTIONED.

THROUGH THE AIR WHEN COUGHING OR SNEEZING A
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TUBERCULOSIS C
THROUGH FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER (SPECIFY)__________________ X
DON'T KNOW Z

1003) Can tuberculosis be cured?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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?

Knowing where to go?

WHERE TO GO:
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Getting permission to go?

PERMISSION TO GO:
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Getting money needed for treatment?

GETTING MONEY:
BIG PROBLEM 1
NOT A BIG PROBLEM 2
The distance to the health facility?

DISTANCE:
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Having to take transport?

TAKING TRANSPORT:
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Not wanting to go alone?

GO ALONE:
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Concern that there may not be a female health provider?

NO FEMALE PROVIDER:
BIG PROBLEM 1
NOT A BIG PROBLEM 2

SECTION 11: DOMESTIC VIOLENCE

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

YES (GO TO 1102)
NO (GO TO 1201)

1102) CHECK FOR PRESENCE OF OTHERS: DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

PRIVACY OBTAINED 1 (CONTINUE)
PRIVACY NOT POSSIBLE 2 (GO TO 1118)

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:

CURRENTLY MARRIED (READ 1104)
WIDOWED/ SEPARATED/ DIVORCED (READ 1104 IN THE PAST TENSE)

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:

a) say or do something to humility you in front of others?
YES 1
NO 2 (GO TO 1104b)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
b) threaten to hurt or harm you or someone close to you?
YES 1
NO 2 (GO TO 1105)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4

1105)

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

1) push you, shake you, or throw something at you?
YES 1
NO 2 (GO TO 1105(2))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
2) slap you or twist your arm?
YES 1
NO 2 (GO TO 1105(3))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
3) punch you with his fist or with something that could hurt you?
YES 1
NO 2 (GO TO 1105(4))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
4) kick you, drag you, or beat you up?
YES 1
NO 2 (GO TO 1105(5))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
5) try to choke you or burn you on purpose?
YES 1
NO 2 (GO TO 1105(6))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
6) threaten you with a knife, gun, or any other weapon?
YES 1
NO 2 (GO TO 1105(7))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
7) attack you with a knife, gun, or any other weapon?
YES 1
NO 2 (GO TO 1105(8))
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4
8) physically force you to have sexual intercourse with him even when you did not want to?
YES 1
NO 2 (GO TO 1106)
How often did this happen during the last 12 months: often only sometimes, or not at all?
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
NOT APPLICABLE 4

1106) CHECK 1105:

AT LEAST ONE 'YES' (GO TO 1107)
NOT A SINGLE 'YES' (GO TO 1108)

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

a) You had cuts, bruises, or aches?

BRUISES/ ACHES:
YES 1
NO 2
b) You had an injury or a broken bone?

INJURY/ BROKEN BONE:
YES 1
NO 2
c) You went for treatment?

WENT FOR TREATMENT:
YES 1
NO 2

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?

YES 1
NO 2 (GO TO 1111)
REFUSED TO ANSWER/ NO ANSWER 3 (GO TO 1111)

1109) Who has hurt you in this way?

Anyone else?

RECORD ALL MENTIONED.

MOTHER A
FATHER B
STEP-MOTHER C
STEP-FATHER D
BROTHER E
SISTER F
SON G
DAUGHTER H
EX-HUSBAND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
OTHER FEMALE RELATIVE/IN-LAW L
OTHER MALE RELATIVE/ IN-LAW M
FEMALE FRIEND/ACQUAINTANCE N
MALE FRIEND/ACQUAINTANCE O
FEMALE TEACHER P
MALE TEACHER Q
FEMALE EMPLOYER R
MALE EMPLOYER S
FEMALE STRANGER T
MALE STRANGER U
POLICE/SOLDIER V
OTHER (SPECIFY)_______ X

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?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1111) CHECK 201, 226, AND 229:

EVER BEEN PREGNANT (YES ON 201, 226, OR 229) (GO TO 1112)
NEVER BEEN PREGNANT (GO TO 1114)

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

YES 1
NO 2 (GO TO 1114)

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

Anyone else?

RECORD ALL MENTIONED.

CURRENT HUSBAND A
MOTHER B
FATHER C
STEP-MOTHER D
STEP-FATHER E
BROTHER F
SISTER G
SON H
DAUGHTER I
EX-HUSBAND J
MOTHER-IN-LAW K
FATHER-IN-LAW L
OTHER FEMALE RELATIVE/IN-LAW M
OTHER MALE RELATIVE/ IN-LAW N
FEMALE FRIEND/ACQUAINTANCE O
MALE FRIEND/ACQUAINTANCE P
FEMALE TEACHER Q
MALE TEACHER R
FEMALE EMPLOYER S
MALE EMPLOYER T
FEMALE STRANGER U
MALE STRANGER V
POLICE/SOLDIER W
OTHER (SPECIFY)_______ X

1114) CHECK 1105:

CODE '1' (OFTEN) OR CODE '2' (SOMETIMES) CIRCLED FOR AT LEAST ONE ITEM (GO TO 1115)
NOT A SINGLE CODE '1' OR '2' CIRCLED (GO TO 1117)

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?

YES 1
NO 2 (GO TO 1117)

1116) From whom have you sought help?

Anyone else?

RECORD ALL MENTIONED.

MOTHER A
FATHER B
BROTHER C
SISTER D
MOTHER-IN-LAW E
FATHER-IN-LAW F
OTHER FEMALE RELATIVE/IN-LAW G
OTHER MALE RELATIVE/ IN-LAW H
FRIEND I
NEIGHBOR J
TEACHER K
EMPLOYER L
RELIGIOUS FIGURE M
DOCTOR/ MEDICAL PERSONNEL N
POLICE O
LAWYER P
SOCIAL SERVICE ORGANIZATION Q
OTHER (SPECIFY)_______ X

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?

HUSBAND:
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT:
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT:
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3

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?

YES (GO TO 1202)
NO (GO TO 1210)

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

CANNOT COUNT 00
CAN COUNT (NUMBER) __________
CAN COUNT TO 97 OR MORE 97
DON'T KNOW 98

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?

YES 1
NO 2
DON'T KNOW 8

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

DISCUSSES DISAGREEMENT WITH FRIENDS IN A POSITIVE WAY 1
WITHDRAWS FROM THE SITUATION 2
RESORTS TO SHOUTING AND VIOLENCE 3
OTHER (SPECIFY)_________________ 4
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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?

YES ALWAYS: MORE THAN 12 TIMES 1
YES SOMETIMES: AROUND 4 TIMES 2
NO STORY READ 3
NO BOOK READ 4
DON'T KNOW 8

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

YES 1
NO 2
NOT ALLOWED TO PARTICIPATE 3

1210) RECORD THE TIME

HOUR ____________
MINUTE___________

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

B BIRTHS
P PREGNANCIES
T TERMINATIONS
0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 PILL
4 IUD
5 INJECTABLES
6 IMPLANTS
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM/ JELLY
K LACTATIONAL AMENORRHEA METHOD
L PERIODIC ABSTINENCE
M WITHDRAWAL
X OTHER (SPECIFY)________

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

0 INFREQUENT SEX/HUSBAND AWAY
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 HEALTH CONCERNS
6 SIDE EFFECTS
7 LACK OF ACCESS/ TOO FAR
8 COSTS TOO MUCH
9 INCONVENIENT TO USE
F FATALISTIC
A DIFFICULT TO GET PREGNANT/ MENOPAUSAL
D WIDOW/ DIVORCE/ SEPARATION
R RAMADAN
X OTHER (SPECIFY)_________________
Z DON'T KNOW

2007

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_ _

2006

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_ _

2005

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_ _

2004

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_ _

2003

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_ _

2002

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 71_ _
02 FEB 71_ _
01 JAN 72_ _