March 5, 2012
Department of Statistics
Household Survey Directorate

Survey Contents Confidential by Statistical Law

IDENTIFICATION:

QUESTIONNAIRE NUMBER _____
GOVERNORATE ____
DISTRICT _____
SUB-DISTRICT _____
LOCALITY ____
AREA _____
SUB-AREA _____
STRATUM _____
URBAN/RURAL

BLOCK NUMBER _____
BUILDING NUMBER _____
HOUSING UNIT NUMBER _____
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
TELEPHONE/MOBILE NUMBER (if available) _______________

NAME AND LINE NUMBER OF WOMAN

WOMAN SELECTED FOR DOMESTIC VIOLENCE SECTION

INTERVIEWER VISITS (REPEAT FOR SECOND AND THIRD VISITS)

DATE __________
INTERVIEWER'S NAME __________
RESULT*

*RESULT CODES

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY ____
MONTH _____
YEAR _____
INTERVIEW NUMBER _____
RESULT____

TOTAL NUMBER OF VISITS ____

SUPERVISOR
NAME __________
DATE __________

FIELD EDITOR
NAME __________
DATE __________

OFFICE EDITOR _____

KEYED BY _____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ______________ and I am working with the Department of Statistics. We are conducting a national survey that asks women about the health of women and their children. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The interview usually takes about 40 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary, and if we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
May I begin the interview now?

Signature of interviewer: _______________
Date: __________

101. RECORD THE TIME.

101A. What is your marital status now: are you married, widowed, divorced, or separated?
IF THE WOMAN IS NOT MARRIED, WIDOWED, DIVORCED OR SEPARATED, END THE INTERVIEW, AND CORRECT MARITAL STATUS AND ELIGIBILITY IN THE HOUSEHOLD QUESTIONNAIRE.

102. In what month and year were you born?

103. How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104. Have you ever attended school?

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

106. What is the highest grade you completed at that level?

110. 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?

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

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

SECTION 2. REPRODUCTION

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

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

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

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

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

206. Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

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

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

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

210: CHECK 208:

211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

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

213. Were any of these births twins?

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

215. In what month and year was (NAME) born?
PROBE: When is his/her birthday?

216. Is (NAME) still alive?

217. IF ALIVE:
How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS. IF LESS THAN 1 YEAR, RECORD '00'.

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

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

220. IF DEAD:
How old was (NAME) when he/she died?
IF '1 YR', PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

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

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

224. CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2007 OR LATER.

225. FOR EACH BIRTH SINCE JANUARY 2007, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226. Are you pregnant now?

227. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

228. When you got pregnant, did you want to get pregnant at that time?

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

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

230A. The last time you had a such pregnancy, did the pregnancy end in a miscarriage, an induced abortion or a stillbirth?

231. When did the last such pregnancy end?

232. CHECK 231:

232A. Did this (MISCARRIAGE/ABORTION/STILLBIRTH -- FROM Q. 230A) last such pregnancy take place in a health facility, at home, or in another place?

232B. Did you seek care for this (MISCARRIAGE/ABORTION/STILLBIRTH -- FROM Q. 230A)?

232C. Where did you go for this (MISCARRIAGE/ABORTION/STILLBIRTH -- FROM Q. 230A)?

232D. What type of health facility was this?
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.

232E. Before you were discharged, did anyone in the health facility talk to you or advise you about family planning?

233. How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

234. Since January 2007, have you had any other pregnancies that did not result in a live birth?

234A. Since January 2007, how many other pregnancies that did not result in a live birth have you had?

235. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2007.
ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236. Did you have any miscarriages, abortions, or stillbirths that ended before 2007?

237. When did the last such pregnancy that terminated before 2007 end?

238. When did your last menstrual period start?

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

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

SECTION 3. CONTRACEPTION

301. Now I would like to talk about family planning -- the various ways or methods that a couple can use to delay or avoid a pregnancy.
Have you ever heard of (METHOD)?

302. CHECK 226:

303. Are you currently doing something or using any method to delay or avoid getting pregnant?

304. Which method are you using?
CIRCLE ALL MENTIONED.
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

304A. Who advised you to use this method?
IF MORE THAN ONE METHOD CIRCLED IN 304, THIS QUESTION SHOULD REFER TO THE HIGHEST METHOD IN THE LIST.

304B. CHECK 304:
CIRCLE METHOD(S) CODE

305. What is the brand name of the pills you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

305A. The last time you obtained the pills, how many pill cycles did you get?

305B. How much did you pay for the pills?

306A. The last time you obtained the condoms, how many condom did you get?

306B. How much did you pay for the condoms?

306C. Who inserted your IUD?

306D. How much did you pay in total for the IUD, including the cost of the IUD and the consultation?

306E. Is the IUD you are using hormonal or non-hormonal?
CIRCLE ONE RESPONSE ONLY

307. In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

307A. When you got sterilized, were you told that you would not be able to have any (more) children because of the operation?

307B. How much was paid in total for the sterilization, including any consultation you (he) may have had?
IF MORE THAN 990 JD, RECORD 990

307C. Do you regret that you had the operation not to have any (more) children?

308. In what month and year was the sterilization performed?

308A. Since what month and year have you been using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

309: CHECK 308/308A, 215 AND 231:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A.

310. CHECK 308/308A:

311. I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2007.
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:
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 THE 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:
Why did you stop using the (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.

312. CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH.

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

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

315. You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?

315A. Where did you learn to use the rhythm/lactational amenorrhea method?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

316. CHECK 204:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

317. At that time, were you told about side effects or problems you might have with the method?

317A. When you got sterilized, were you told about side effects or problems you might have with the method?

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

319. Were you told what to do if you experienced side effects or problems?

320. CHECK 317:

CODE '1' CIRCLED:
At that time, were you told about other methods of family planning that you could use?

CODE '1' NOT CIRCLED:
When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

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

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

323. Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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

325. Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

326. In the last 12 months, were you visited by a fieldworker who talked to you about family planning?

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

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

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 224:

402. CHECK 215: ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 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. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

404. FROM 212 AND 216

405. When you got pregnant with (NAME), did you want to get pregnant at that time?

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

407. How much longer would you have liked to wait?

408. Did you see anyone for antenatal care for pregnancy?

409. Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

410. Where did you receive antenatal care for this pregnancy?
Anywhere else?
PROBE TO IDENTIFY 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.

411. How many months pregnant were you when you first received antenatal care for this pregnancy?

412. How many times did you receive antenatal care during this pregnancy?

413. As part of your antenatal care during this pregnancy, were any of the following done at least once?
Was your blood pressure measured?
Were you weighted?
Did you give a urine sample?
Did you give a blood sample?

413A. CHECK Q413. IF 'YES' CIRCLED FOR 'BP' ONLY ASK:
How many times was your blood pressure checked?

414. During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?

414A. Were you told where to go if you had any of these complications?

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

414C. During (any of) your antenatal care visit(s), were you told about having postnatal care visits one week and 30 days after delivery?

415. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

416. During this pregnancy, how many times did you get this tetanus injection?

417. CHECK 416:

418. At any time before this pregnancy, did you receive any tetanus injections, either to protect yourself or another baby?

419. Before this pregnancy, how many other times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'.

420. How many years ago did you receive that tetanus injection?

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

422. During the whole pregnancy, for how many days did you take the tablets or syrup?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

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

431. Was (NAME) weighed at birth?

432. How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

433. Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.
IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

433A. How much did you pay the service provider for this delivery?
RECORD THE TOTAL COST IN DINARS

434. 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.

434A. How long after (NAME) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

DON'T KNOW 998

434B. When you were discharged after (NAME) was born, were you given any free sample of infant formula by the health facility staff?

434C. Before you were discharged after (NAME) was born, did anyone in the health facility talk to you or advise you about family planning?

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

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

437. Did anyone check on your health after you left the facility?

437A. What is the main reason you did not seek a health professional check on your health after (NAME) was born?

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

438A. What is the main reason you did not seek a health professional check on your health after (NAME) was born?

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

440. How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

440A. How much did you pay for this (first) postnatal visit?
RECORD THE TOTAL COST IN DINARS

440B. After this (first) visit, did you come back a second time for a health care provider to check on your health?

440C. How long after delivery did this check take place?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

440D. Did anyone at the health facility talk to you or adbise you about family planning during any of your postnatal check?

442. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?

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

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

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

446A. During this check did (NAME) receive a heel prick?

446B. During this check did (NAME) have his/her hearing tested?

447. Has your menstrual period returned since the birth of (NAME)?

448. Did your period return between the birth of (NAME) and your next pregnancy?

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

450. CHECK 226:
IS RESPONDENT PREGNANT?

451. Have you had sexual intercourse since the birth of (NAME)?

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

453. Did you ever breastfeed (NAME)?

454. CHECK 404:
IS CHILD LIVING?

455. How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD '00' HOURS.
IF LESS THAN 24 HOURS, RECORD HOURS.
OTHERWISE, RECORD DAYS.

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

457. What was (NAME) given to drink?
Anything else?
RECORD ALL LIQUIDS MENTIONED.

458. CHECK 404:
IS CHILD LIVING?

459. Are you still breastfeeding (NAME)?

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

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

SECTION 5. CHILD IMMUNIZATION AND HEALTH AND CHILD'S NUTRITION

501. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502. BIRTH HISTORY LINE NUMBER FROM 212

503. FROM 212 AND 216

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

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

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

507. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in an immunization campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 1-4, POL. Booster DPT 1-3, DPT Booster, HEPATITIS 1-3, Hib 1-3, MEASLES AND/OR MMR.

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

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

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

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

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

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

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

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

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

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

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

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

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

510. Did (NAME) receive an anemia test?

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

511A. Did (NAME) receive a vitamin A dose within the last six months?

512. In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)?
SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.

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

515. Was there any blood in the stools?

516. Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk).
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

517. When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

518. Did you seek advice or treatment for the diarrhea from any source?

519. Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

520. CHECK 519:

521. Where did you first seek advice or treatment?
USE LETTER CODE FROM 519.

521A. How many days after the diarrhea began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY, RECORD '00'.

521B. Does (NAME) still have diarrhea?

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

a) A fluid made from a special packet called Aquacell or Paralait?
b) Thin watery gruel made from rice, carrots, wheat, etc.?
c) Soup?
d) Homemade sugar-salt-water solution?
e) Milk or infant formula?
f) Yoghurt-based drink?
g) Water
h) Any other liquid?

523. Was anything (else) given to treat the diarrhea?

524. What (else) was given to treat the diarrhea?
Anything else?
RECORD ALL TREATMENTS GIVEN.

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

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

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

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

530. CHECK 525:
HAD FEVER?

531. Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough).
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

532. When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

533. Did you seek advice or treatment for the illness from any source?

534. Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

535. CHECK 534:

536. Where did you first seek advice or treatment?
USE LETTER CODE FROM 534.

536A. How many days after the illness began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD '00'.

536B. Is (NAME) still sick with a (fever/cough)?

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

538. What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED.

552. GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555.

555. CHECK 522(a), ALL COLUMNS:

556. Have you ever heard of a special product Aquacell or Paralait you can get for the treatment diarrhea?

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

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

a) Plain water?

b) Juice or juice drinks?

c) Clear broth?

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

e) Infant formula?

f) Any other liquids?

g) Yogurt?

h) Any commercially fortified baby food, e.g. Cerelac?

i) Bread, pasta, rice, maize, or other food made from grains?

j) Carrots, red sweet potatoes, or pumpkin?

k) Any other food made from roots or tubers, such as white potatoes, or other roots/tubers?

l) Any green leafy vegetables, such as spinach, or mouloukia?

m) Apricot, palm nuts, or yellow melon?

n) Any other fruits or vegetables?

o) Liver, kidney, heart or other organ meats?

p) Any meat, such as beef, lamb, goat, chicken, or duck?

q) Eggs?

r) Fresh or dried fish or shellfish?

s) Any foods made from beans, peas, lentils, chickpeas or nuts?

t) Cheese or other food made from milk?

u) Any type of nuts or seeds, such as pistachio, almonds, cashew, peanuts, or sesame seeds?

v) Any other solid, semi solid, or soft food?

559. CHECK 558 (CATEGORIES "g" THROUGH "v"):

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

561. How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night? IF 7 OR MORE TIMES, RECORD '7'.

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

601. CHECK 101A:

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

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

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

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

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

607. CHECK 606:

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

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

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

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

610. What type of relation was it?

611. CHECK 606:

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

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

611A. Did you have a premarital medical exam?

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

612. When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

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

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

615. Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

615A. Have you performed a breast cancer self exam to detect breast cancer in yourself within the last 12 months?

615B. Have you had a breast cancer clinical exam to detect breast cancer in the last 12 months?

615C. 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?

615D. Have you ever had such an exam in your lifetime?

SECTION 7. FERTILITY PREFERENCES

700. CHECK 101A:

701. CHECK 304:

702. CHECK 226:

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

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

705. CHECK 226:

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

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

706. CHECK 226:

707. CHECK 303: USING A CONTRACEPTIVE METHOD?

708. CHECK 705:

709. CHECK 704:

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

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

RECORD ALL REASONS MENTIONED.

710. CHECK 303: USING A CONTRACEPTIVE METHOD?

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

711A. Which contraceptive method would you prefer to use?

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

711C. Why does your husband disapprove of using contraception?
RECORD ALL REASONS MENTIONED.

711D. Why do you disapprove of using contraception?
RECORD ALL REASONS MENTIONED.

712. CHECK 216:

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

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.

713. How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or a girl?

713A. If you could choose exactly the number of months to wait between the birth of one child and the birth of another, how many months would that be?
PROBE FOR A NUMERIC RESPONSE.

714. In the last few months have you:

Heard about family planning on the radio?
Seen about family planning on the television?
Read about family planning in a newspaper or a magazine?
Seen or read about family planning on posters?
Read about family planning in bulletins/booklets?
Heard about family planning in lectures?
Heard about family planning from women you associate with?
Heard about family planning from any other people you associate with?
Heard about family planning at a community event?

714A. In the last few months have you seen, heard or read about Hayatee Ahla?

714B. In the last few months have you ever seen this logo for the Hayatee Ahla campaign?
SHOW THE HOT BALLOON CARD

714C. What does Hayatee Ahla mean to you?
PROBE: Anything else?
CIRCLE ALL RESPONSES.

715. Where and form whom would you prefer to get information about family planning?
CIRCLE ONLY ONE ANSWER.

716. CHECK 601:

716A. CHECK 304:

716B. Does your husband know that you are using a method of family planning?

717. CHECK 303: USING A CONTRACEPTIVE METHOD?

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

718A. Now I want to ask you about your husband's views on family planning. Do you think that your husband approves or disapproves of couples using a contraceptive method to avoid pregnancy?

719. CHECK 304:

720. Does your (husband/partner) want the same number of children that you want, or does he want more or fewer than you want?

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

801. CHECK 101A:

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

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

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

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

806. CHECK 101A:

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

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

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

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

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

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

812A. Have you ever done any work before?

812B. Why did you stop working?

813. What is your current occupation, that is, what kind of work do you mainly do?

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

818. CHECK 101A:

819. CHECK 814:

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

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

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

822A. CHECK 814:

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

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

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

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

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

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

826A. Do you own this or any other house either alone or jointly with someone else?

826B. Do you own any land either alone or jointly with someone else?

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

828. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:
If she goes out without telling him?
If she neglects the children?
If she burns the food?
If she insults him?
If she disobeys him?
If she argues with him?
If she has relation with another man?

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?

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

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

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

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

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

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

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

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

909. Can the virus that causes AIDS be transmitted from a mother to her baby:
During pregnancy?
During delivery?
By breastfeeding?

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

911. Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

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

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

915. In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

915A. CHECK 101A:

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

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

915D. Where did you hear or see that information?
Anywhere else?
RECORD ALL MENTIONED

916. CHECK 901:

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

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

916A. What (other) sexually transmitted infections have you heard about?
Anything else?
RECORD ALL MENTIONED

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

918. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

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

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

SECTION 10. OTHER HEALTH ISSUES

1001. Have you ever heard of an illness called tuberculosis?

1002. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

1003. Can tuberculosis be cured?

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

1004. Do you currently smoke cigarettes?

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

1006. Do you smoke narglia?

1007. Now I would like to ask you some questions about medical care for you 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?
Getting permission to go?
Getting money needed for treatment?
The distance to the health facility?
Having to take transport?
Not wanting to go alone?
Concern that there may not be a female health provider?

SECTION 11. EARLY CHILDHOOD DEVELOPMENT

1101. CHECK 217 AND 218:
ANY LIVING CHILD 0-4 YEARS OLD LIVING WITH HIS/HER MOTHER?

1102. CHECK 217:
SELECT THE YOUNGEST CHILD AGED 0-4 LIVING WITH HIS/HER MOTHER AND RECORD NAME AND LINE NUMBER.

1103. READ TO THE RESPONDENT
Now I would like to ask you some questions about (NAME OF CHILD FROM 1102), your youngest child living with you who is 0-4 years old.

1104. How many children's books or picture books do you have for (NAME)?

1105. I am interested in learning about the things that (NAME) plays with when he/she is at home. Does he/she plays with:

a) homemade toys (such as dolls, cars, or other toys made at home)?
b) toys from a shop or manufactured toys?
c) household objects (such as bowls or pots) or objects found outside (such as sticks, rocks, animal shells or leaves)?
IF THE RESPONDENT SAYS "YES" TO THE CATEGORIES ABOVE, THEN PROBE TO LEARN SPECIFICALLY WHAT THE CHILD PLAYS WITH TO ASCERTAIN THE RESPONSE.

1106. Sometimes adults taking care of children have to leave the house to go shopping, wash clothes, or for other reasons and have to leave young children.
On how many days in the past week was (NAME):
a) left alone for more than an hour?
b) left in the care of another child, that is, someone less than 10 years old, for more than an hour?
IF 'NEVER', WRITE '0'. IF DOESN'T KNOW WRITE '8'.

1107. VERIFY 217: AGE OF THE CHILD

1108. VERIFY 217 AND 218:
ANY LIVING CHILD 3-4 YEARS OLD LIVING WITH HIS/HER MOTHER?

1109. VERIFY 217:
SELECT THE YOUNGEST CHILD AGE 3-4 LIVING WITH HIS/HER MOTHER AND RECORD THE NAME AND LINE NUMBER.

1110. Now, I would like to ask you some questions concerning (NAME)/(NAME OF THE CHILD IN 1109), your youngest child age 3-4 years.

1111. Does (NAME) attend any organized learning or early childhood education programme, such as a private or government facility, including kindergarten or community child care?

1112. Within the last seven days, about how many hours did (NAME) attend?

1113. In the past 3 days, did you or any household member over 15 years of age engage in any of the following activities with (NAME)?
IF YES, ASK: Who engaged in this activity with (NAME)?
CIRCLE ALL THAT APPLY

a) Read books to or look at picture books with (NAME)
b) Told stories to (NAME)?
c) Sang songs to (NAME) or with (NAME), including lullabies?
d) Took (NAME) outside of the home, compound, yard or enclosure?
e) Played with (NAME)?
f) Named, counted, or drew things to or with (NAME)?

I would like to ask you some questions about the health and development of your child. Children do not all develop and learn at the same rate. For example, some walk earlier than others. These questions are related to several aspects of your child's development.

1114. Can (NAME) identify or name at least ten letters of the alphabet?

1115. Can (NAME) read at least four simple, popular words?

1116. Does (NAME) know the name and recognize the symbol of all numbers from 1 to 10?

1117. Can (NAME) pick up a small object with two fingers, like a stick or a rock from the ground?

1118. Is (NAME) sometimes too sick to play?

1119. Does (NAME) follow simple directions on how to do something correctly?

1120. When given something to do, is (NAME) able to do it independently?

1121. Does (NAME) get along well with other children or adults?

1122. Does (NAME) kick, bite, or hit other children or adults?

1123. Does (NAME) get distracted easily?

SECTION 12. DOMESTIC VIOLENCE MODULE

1200. CHECK HOUSEHOLD QUESTIONNAIRE.

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

READ TO THE RESPONDENT

Now I would like to ask you some questions about some other important aspects of a woman's life. You may find some of these questions 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 in your household will know that you were asked these questions.

1202. CHECK 602 AND 602:

1203. First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband?

a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your female friends?
d) He (tries/tried) to limit your contact with your family?
e) He (insists/insisted) on knowing where you (are/were) at all times?

1204. Now I need to ask some more questions about your relationship with your last husband.
A. Did your husband ever:
B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

1205.
A. Did your (last) husband ever do any of the following things to you:
B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

1206. CHECK 1205A (a-h):

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

a) You had cuts, bruises or aches?

b) You had eye injuries, sprains, dislocations, or burns?

c) You had deep wounds, broken bones, broken teeth, or any other serious injury?

1213. Are (were) you afraid of your (last) husband: most of the time, sometimes, or never?

1214. CHECK 606:

1215.
A. So far we have been talking about the behavior of your (current/last) husband. Now I want to ask you about the behavior of any previous husband?
B. How long ago did this last happen?

1216. From the time you were 15 years old has anyone other than (your/any) husband hit you, slapped you, kicked you, or done anything else to hurt you physically?

1217. Who has hurt you in this way?
Anyone else?
RECORD ALL MENTIONED.

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

1219. CHECK 201, 226, AND 230:

1220. Has anyone ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?

1221. Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED.

1226. CHECK 1205A (a-h), 1215, 1216, AND 1220:

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

1228. From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.

1229. Have you ever told anyone about this?

1230. As far as you know, did your father ever beat your mother?

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1231. DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

1232. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

1233. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

SUPERVISOR'S OBSERVATIONS: _________________________________________
NAME OF SUPERVISOR: __________
DATE: _____

EDITOR'S OBSERVATIONS: ___________________________________________
NAME OF EDITOR: _____________
DATE: _____

(SEE PDF FOR CALENDAR)