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March 5, 2012
Department of Statistics
Household Survey Directorate

The Hashemite Kingdom of Jordan
JORDAN POPULATION AND FAMILY HEALTH SURVEY 2012 - WOMAN'S QUESTIONNAIRE

Survey Contents Confidential by Statistical Law

IDENTIFICATION:

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

URBAN 1
RURAL 2

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

NAME AND LINE NUMBER OF WOMAN

NAME_________________
LINE NUMBER ____

WOMAN SELECTED FOR DOMESTIC VIOLENCE SECTION

YES 1
NO 2

INTERVIEWER VISITS (REPEAT FOR SECOND AND THIRD VISITS)

DATE __________
INTERVIEWER'S NAME __________
RESULT*

*RESULT CODES

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

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: __________

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

101. RECORD THE TIME.

HOUR ______
MINUTE ______

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. In what month and year were you born?

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

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

AGE IN COMPLETED YEARS ____

104. Have you ever attended school?

YES 1
NO 2 (GO TO 110)

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?

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

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

GRADE ___

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?

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

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?

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

112. Do you watch television almost every day, at least once a week, at least once 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?
And how many daughters live with you?
IF NONE, RECORD '00'.

SONS AT HOME _____
DAUGHTERS AT HOME _____

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

SONS ELSEWHERE _____
DAUGHTERS ELSEWHERE _____

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

BOYS DEAD _____
GIRLS DEAD _____

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

TOTAL BIRTHS _____

209. CHECK 208:
Just to make sure 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 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?

RECORD NAME ___________

BIRTH HISTORY NUMBER _____

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: When 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 ____ (GO TO NEXT BIRTH)

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.

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?

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 224)
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

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

NUMBER OF BIRTHS ____
NONE 0 (GO TO 226)

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?

YES 1
NO 2 (GO TO 230)
UNSURE 8 (GO TO 230)

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.

MONTHS _____

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

YES 1 (GO TO 230)
NO 2

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

LATER 1
NO MORE 2

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

YES 1
NO 2 (GO TO 238)

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

MISCARRIAGE 1
INDUCED ABORTION 2
STILLBIRTH 3

231. When did the last such pregnancy end?

MONTH _____
YEAR ______

232. CHECK 231:

LAST PREGNANCY ENDED IN JAN. 2007 OR LATER (GO TO 232A)
LAST PREGNANCY ENDED BEFORE JAN. 2007 (GO TO 238)

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

HEALTH FACILITY 1 (GO TO 232D)
YOUR HOME/OTHER HOME 2
OTHER PLACE (SPECIFY) _____ 6

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

YES 1
NO 2 (GO TO 233)

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.

(NAME OF PLACE) _____________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL 11
GOVT. 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

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

YES 1
NO 2

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.

MONTHS _____

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

YES 1
NO 2 (GO TO 236)

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

NUMBER OF PREGNANCIES _____

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?

YES 1
NO 2 (GO TO 238)

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

MONTH ____
YEAR _____

238. 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

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

YES 1
NO 2 (GO TO 301)
DON'T KNOW 8 (GO TO 301)

240. 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.
Have you ever heard of (METHOD)?

01. Female Sterilization. PROBE: Women can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO 02)
02. Male Sterilization. PROBE: Men can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO 03)
03. IUD. PROBE: Women can have a loop or coil placed inside them by a doctor or a midwife.
YES 1
NO 2 (GO TO 04)
04. Injectables. PROBE: Women can have an injection by a health provider that stops them from becoming pregnant usually for 3 months.
YES 1
NO 2 (GO TO 05)
05. Implants. PROBE: Women can have one or more small rods placed in their upper arm by a doctor which can prevent pregnancy usually for 3 years
YES 1
NO 2 (GO TO 06)
06. Pill. PROBE: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2 (GO TO 07)
07. Condom. PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2 (GO TO 08)
08. Female Condom. PROBE: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2 (GO TO 09)
09. Lactational Amenorrhea Method (LAM)
YES 1
NO 2 (GO TO 10)
10. Rhythm Method. PROBE: To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
YES 1
NO 2 (GO TO 11)
11. Withdrawal. PROBE: Men can be careful and pull out before climax.
YES 1
NO 2 (GO TO 12)
12. Emergency Contraception. PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2 (GO TO 13)
13. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1 (SPECIFY) ______
NO 2

302. CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 303)
PREGNANT (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

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

FEMALE STERILIZATION A
MALE STERILIZATION B
IUD C
INJECTABLES D
IMPLANTS E
PILL F
CONDOM G
FEMALE CONDOM H
DIAPHRAGM I
FOAM/JELLY J
LACTATIONAL AMEN. METHOD K
RHYTHM METHOD L
WITHDRAWAL M
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y

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.

NO ONE 01

DOCTOR 02
NURSE 03
MIDWIFE 04
HUSBAND 05
MOTHER/FATHER IN LAW 06
OTHER RELATIVE 07
FRIENDS 08
NEIGHBOURS 09
SOCIAL WORKER 10
OTHER (SPECIFY) _____ 96

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

FEMALE STERILIZATION A (GO TO 307)
MALE STERILIZATION B (GO TO 307)
IUD C (GO TO 306C)
INJECTABLES D (GO TO 308A)
IMPLANTS E (GO TO 308A)
PILL F
CONDOM G (GO TO 306A)
FEMALE CONDOM H (GO TO 308A)
DIAPHRAGM I (GO TO 308A)
FOAM/JELLY J (GO TO 30A)
LACTATIONAL AMEN. METHOD K (GO TO 308A)
RHYTHM METHOD L (GO TO 308A)
WITHDRAWAL M (GO TO 308A)
OTHER MODERN METHOD X (GO TO 308A)
OTHER TRADITIONAL METHOD Y (GO TO 308A)

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

CERAZETTE 11
GRACIAL 12
MARVELON TAB 13
MIRCRONOR 14
CELIST 15
MICROGYNON 16
EXLUTEN 17
BELARA 18
YASMIN 19
OTHER (SPECIFY) _____ 96
DON'T KNOW 98

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

NUMBER OF PILL CYCLES _____
DON'T KNOW 998

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

COST IN JD ____ (GO TO 308A)

FREE 95 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

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

NUMBER OF CONDOMS _____
DON'T KNOW 998

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

COST IN JD _____ (GO TO 308A)

FREE 95 (GO TO 308A)
DON'T KNOW (GO TO 308A)

306C. Who inserted your IUD?

MALE DOCTOR 1
FEMALE DOCTOR 2
MIDWIFE 3
OTHER (SPECIFY) _____ 6

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

COST IN JD _____

FREE 995
DON'T KNOW 998

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

HORMONAL 1 (GO TO 308A)
NON-HORMONAL 2 (GO TO 308A)
DON'T KNOW 8 (GO TO 308A)

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.

(NAME OF PLACE) ___________
PUBLIC MEDICAL SECTOR
GOVT. 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

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

YES 1
NO 2

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

COST IN JD ______

FREE 995
DON'T KNOW 998

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

YES 1
NO 2

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?

MONTH _____
YEAR _____

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.

YES (GO BACK TO 308/308A, 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 310)

310. CHECK 308/308A:

YEAR IS 2007 OR LATER (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING.)
YEAR IS 2006 OR EARLIER (ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2007. THEN SKIP TO 322)

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.

NO METHOD USED (GO TO 313)
ANY METHOD USED (GO TO 314)

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

YES 1 (GO TO 324)
NO 2 (GO TO 324)

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

NO CODE CIRCLED 00 (GO TO 324)
FEMALE STERILIZATION 01 (GO TO 317A)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 315A)
RHYTHM METHOD 12 (GO TO 315A)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD (GO TO 326)

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.

(NAME OF PLACE) ___________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL 11
GOVT. HEALTH CENTER 12
GOVT. MCH 13
UNIVERSITY HOSPITAL/CLINIC 14
ROYAL MEDICAL SERVICES 15
OTHER PUBLIC (SPECIFY) ______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR 22
PHARMACY 23
JORDANIAN AS. OF FP AND PROTECTION (JAFPP) 24
UNRWA CLINIC 25
OTHER NON-GOV ORGANIZATION 26
OTHER PRIVATE MEDICAL (SPECIFY) _____ 27
OTHER SOURCE
FRIEND/RELATIVE 33
OTHER (SPECIFY) _____ 96

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

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 (GO TO 323)
FEMALE CONDOM 08 (GO TO 320)
DIAPHRAGM 09 (GO TO 320)
FOAM/JELLY 10 (GO TO 320)
LACTATIONAL AMEN. METHOD 11 (GO TO 326)
RHYTHM METHOD 12 (GO TO 326)

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?

YES 1 (GO TO 319)
NO 2

318. 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 320)

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

YES 1
NO 2

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?

YES 1 (GO TO 322)
NO 2

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

YES 1
NO 2

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

FEMALE STERILIZATION 01 (GO TO 326)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 326)
RHYTHM METHOD 12 (GO TO 326)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

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.

(NAME OF PLACE) __________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL 11 (GO TO 326)
GOVT. HEALTH CENTER 12 (GO TO 326)
GOVT. MCH 13 (GO TO 326)
UNIVERSITY HOSPITAL/CLINIC 14 (GO TO 326)
ROYAL MEDICAL SERVICES 15 (GO TO 326)
OTHER PUBLIC (SPECIFY) _____ 16 (GO TO 326)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 326)
PRIVATE DOCTOR 22 (GO TO 326)
PHARMACY 23 (GO TO 326)
JORDANIAN AS. OF FP AND PROTECTION (JAFPP) 24 (GO TO 326)
UNRWA CLINIC 25 (GO TO 326)
OTHER NON-GOV ORGANIZATION 26 (GO TO 326)
OTHER PRIVATE MEDICAL (SPECIFY) _____ 27 (GO TO 326)
OTHER SOURCE
FRIEND/RELATIVE 33 (GO TO 326)
OTHER (SPECIFY) _____ 96 (GO TO 326)

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

YES 1
NO 2 (GO TO 326)

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.

(NAME OF PLACE(S)) __________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GOVT. MCH 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 AS. OF FP AND PROTECTION (JAFPP) J
UNRWA CLINIC K
OTHER NON-GOV ORGANIZATION L
OTHER PRIVATE MEDICAL (SPECIFY) _____ M
OTHER SOURCE
FRIEND/RELATIVE N
OTHER (SPECIFY) _____ X

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

YES 1
NO 2

327. 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)

328. 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 2007 OR LATER (GO TO 402)
NO BIRTHS IN 2007 OR LATER (GO TO 556)

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

BIRTH HISTORY NUMBER _____

404. FROM 212 AND 216

NAME __________

LIVING (GO TO 405)
DEAD (GO TO 405)

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

YES 1 (GO TO 408)
NO 2

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

LATER 2
NOT AT ALL 3 (GO TO 408)

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

MONTHS 1 _____
YEARS 2 _____
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 415)

409. 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

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.

(NAME OF PLACE(S)) __________
HOME
YOUR HOME A
OTHER HOME B
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL C
GOVT. HEALTH CENTER D
UNIVERSITY HOSPITAL E
ROYAL MEDICAL SERVICES F
OTHER PUBLIC (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
UNRWA HEALTH CENTER I
OTHER PRIVATE MEDICAL (SPECIFY) _____ J
OTHER (SPECIFY) _____ X

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

NUMBER OF MONTHS _____
DON'T KNOW 98

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

NUMBER OF TIMES _____
DON'T KNOW 98

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?

BP
YES 1
NO 2
WEIGHT
YES 1
NO 2 (GO TO 414)
URINE
YES 1
NO 2 (GO TO 414)
BLOOD
YES 1
NO 2 (GO TO 414)

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

NUMBER OF TIMES _____
DON'T KNOW 98

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?

YES 1
NO 2 (GO TO 414B)
DON'T KNOW 8 (GO TO 414B)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 418)
DON'T KNOW 8 (GO TO 418)

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

TIMES ____
DON'T KNOW 8

417. CHECK 416:

2 MORE TIMES (GO TO 421)
OTHER (GO TO 418)

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

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

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

TIMES _____
DON'T KNOW 8

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

YEARS AGO ___

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

YES 1
NO 2 (GO TO 430)
DON'T KNOW 8 (GO TO 430)

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.

DAYS _____
DON'T KNOW 998

430. 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

431. Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 433)
DON'T KNOW 8 (GO TO 433)

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

KG FROM CARD 1 __.______
KG FROM RECALL 2 __.______
DON'T KNOW 99998

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.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE B
OTHER PERSON (SPECIFY) _____ X (GO TO 434)
NO ONE Y (GO TO 434)

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

COST IN JD _____

FREE 9995
DON'T KNOW 9998

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.

(NAME OF PLACE) ___________
HOME
YOUR HOME (GO TO 438)
OTHER HOME (GO TO 438)
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL 21
GOVT. 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 438)

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.

HOURS 1 _____
DAYS 2 _____
WEEKS 3 ______

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?

YES 1
NO 2
DON'T KNOW 8

434C. 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

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

YES 1
NO 2

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?

YES 1 (GO TO 439)
NO 2

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

YES 1 (GO TO 439)
NO 2

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

NO NEED/NO SICK 01 (GO TO 442)
NOT AWARE AVAILABILITY OF POST-NATAL SERVICE 02 (GO TO 442)
NOT SUPPOSED TO GO OUT DURING THIS PERIOD 03 (GO TO 442)
NO ONE TO TAKE CARE OF MY BABY DURING VISIT 04 (GO TO 442)
TOO FAR 05 (GO TO 442)
TOO EXPENSIVE 06 (GO TO 442)
NO QUALIFIED PERSONNEL 07 (GO TO 442)
HUSBAND OPPOSED 08 (GO TO 442)
OTHER (SPECIFY) _____ 96 (GO TO 442)

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)?

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?

NO NEED/NO SICK 01 (GO TO 442)
NOT AWARE AVAILABILITY OF POST-NATAL SERVICE 02 (GO TO 442)
NOT SUPPOSED TO GO OUT DURING THIS PERIOD 03 (GO TO 442)
NO ONE TO TAKE CARE OF MY BABY DURING VISIT 04 (GO TO 442)
TOO FAR 05 (GO TO 442)
TOO EXPENSIVE 06 (GO TO 442)
NO QUALIFIED PERSONNEL 07 (GO TO 442)
HUSBAND OPPOSED 08 (GO TO 442)
OTHER (SPECIFY) _____ 96 (GO TO 442)

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

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

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.

HOURS 1 _____
DAYS 2 _____
WEEKS 3 _____

DON'T KNOW 998

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

COST IN JD _____

FREE 995
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 440D)

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

HOURS 1 _____
DAYS 2 _____
WEEKS 3 _____

DON'T KNOW 998

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 447)
DON'T KNOW 8 (GO TO 447)

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.

HOURS AFTER BIRTH 1 _____
DAYS AFTER BIRTH 2 _____
WEEKS AFTER BIRTH 3 _____

DON'T KNOW 998

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

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

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.

(NAME OF PLACE) ____________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL 21
GOVT. HEALTH CENTER 22
GOVT. MCH 23
UNIVERSITY HOSPITAL 24
ROYAL MEDICAL SERVICES 25
OTHER PUBLIC (SPECIFY) _____ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
UNRWA HEALTH CENTER 32
OTHER PRIVATE MEDICAL (SPECIFY) _____ 36
OTHER (SPECIFY) _____ 96

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 449)
NO 2 (GO TO 450)

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

YES 1
NO 2 (GO TO 452)

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

MONTHS _____
DON'T KNOW 98

450. CHECK 226:
IS RESPONDENT PREGNANT?

NOT PREGNANT (GO TO 451)
PREGNANT OR UNSURE (GO TO 452)

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

YES 1
NO 2 (GO TO 453)

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

MONTHS _____
DON'T KNOW 98

453. Did you ever breastfeed (NAME)?

YES 1 (GO TO 455)
NO 2

454. CHECK 404:
IS CHILD LIVING?

LIVING (GO TO 460)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OF IF NO MORE BIRTHS, GO TO 501)

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.

IMMEDIATELY 000

HOURS 1 ______
DAYS 2 ______

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

YES 1
NO 2 (GO TO 458)

457. What was (NAME) given to drink?
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?

LIVING (GO TO 459)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

459. Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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

BIRTH HISTORY 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 555)

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, POL. 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 510)
NO 2 (GO TO 510)
DON'T KNOW 8 (GO TO 510)

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 510)
DON'T KNOW 8 (GO TO 510)

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 (GO TO 509D)
DON'T KNOW (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 injection. Sometimes, DPT is part of 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, Hib is part of the TETRA or PENTA vaccine.

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

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

510. Did (NAME) receive an anemia test?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 512)
DON'T KNOW 8 (GO TO 512)

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

YES 1
NO 2
DON'T KNOW 8

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.

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

515. Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

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?

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

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?

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

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

YES 1
NO 2 (GO TO 521B)

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.

(NAME OF PLACE(S)) _______________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GOVT. MCH C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
OTHER PUBLIC (SPECIFY) _____ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
UNRWA HEALTH CENTER J
OTHER PRIVATE MEDICAL (SPECIFY) _____ K
OTHER (SPECIFY) _____ X

520. CHECK 519:

TWO OR MORE CODES CIRCLED (GO TO 521)
ONE ONE CODE CIRCLED (GO TO 521A)

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

FIRST PLACE _____

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

DAYS _____

521B. Does (NAME) still have diarrhea?

YES 1
NO 2
DON'T KNOW 8

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?

AQUACELL/PARALAIT
YES 1
NO 2
DON'T KNOW 8
GRUEL
YES 1
NO 2
DON'T KNOW 8
SOUP
YES 1
NO 2
DON'T KNOW 8
SU-SALT
YES 1
NO 2
DON'T KNOW 8
MILK/FOR.
YES 1
NO 2
DON'T KNOW 8
YOGHURT
YES 1
NO 2
DON'T KNOW 8
WATER
YES 1
NO 2
DON'T KNOW 8
OTH. LIQ.
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

524. 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

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 530)
DON'T KNOW 8 (GO TO 530)

528. 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 531)
DON'T KNOW 8 (GO TO 531)

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

CHEST ONLY 1 (GO TO 531)
NOSE ONLY 2 (GO TO 531)
BOTH 3 (GO TO 531)
OTHER (SPECIFY) _____ 6 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

530. CHECK 525:
HAD FEVER?

YES (GO TO 531)
NO OR DK (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555)

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?

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

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?

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

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

YES 1
NO 2 (GO TO 536B)

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.

(NAME OF PLACE(S)) _______________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GOVT. MCH C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
OTHER PUBLIC (SPECIFY) _____ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
UNRWA HEALTH CENTER J
OTHER PRIVATE MEDICAL (SPECIFY) _____ K
OTHER (SPECIFY) ______ X

535. CHECK 534:

TWO OR MORE CODES CIRCLED (GO TO 536)
ONLY ONE CODE CIRCLED (GO TO 536A)

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

FIRST PLACE ____

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

DAYS ____

536B. 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

537. 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 555)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 555)

538. 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

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

555. CHECK 522(a), ALL COLUMNS:

NO CHILD RECEIVED AQUACELL OR PARALAIT (GO TO 556)
ANY CHILD RECEIVED AQUACELL OR PARALAIT (GO TO 557)

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

YES 1
NO 2

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

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 558. (NAME) __________
NONE (GO TO 601)

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?

YES 1
NO 2
DON'T KNOW 8

b) Juice or juice drinks?

YES 1
NO 2
DON'T KNOW 8

c) Clear broth?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8
IF YES: How many times did (NAME) drink milk? IF 7 OR MORE TIMES, RECORD '7'.
NUMBER OF TIMES DRANK MILK _____

e) Infant formula?

YES 1
NO 2
DON'T KNOW 8
IF YES: How many times did (NAME) drink infant formula? IF 7 OR MORE TIMES, RECORD '7'.
NUMBER OF TIMES DRANK FORMULA ____

f) Any other liquids?

YES 1
NO 2
DON'T KNOW 8

g) Yogurt?

YES 1
NO 2
DON'T KNOW 8
IF YES: How many times did (NAME) eat yogurt? IF 7 OR MORE TIMES, RECORD '7'.
NUMBER OF TIMES ATE YOGURT _____

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

j) Carrots, red sweet potatoes, or pumpkin?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

m) Apricot, palm nuts, or yellow melon?

YES 1
NO 2
DON'T KNOW 8

n) Any other fruits or vegetables?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

q) Eggs?

YES 1
NO 2
DON'T KNOW 8

r) Fresh or dried fish or shellfish?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

t) Cheese or other food made from milk?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

NOT A SINGLE "YES" (GO TO 560)
AT LEAST ONE "YES" (GO TO 561)

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?

YES 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY)
NO 2 (GO TO 601)

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'.

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 NO. _____

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 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?

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
GOVT. HOSPITAL 11
GOVT. HEALTH CENTER 12
GOVT. MCH 13
UNIVERSITY HOSPITAL 14
ROYAL MEDICAL SERVICES 15
OTHER PUBLIC (SPECIFY) _____ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR 22
JORDANIAN AS. OF FP AND PROTECTION (JAFPP) 23
UNRWA HEALTH CENTER 24
OTHER NON GOV. 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 MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO 1 _____
WEEKS AGO 2 _____
MONTHS 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 615A)

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.

(NAME OF PLACE(S)) _______________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GOVT. MCH 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 AS. OF FP AND PROTECTION (JAFPP) J
UNRWA CLINIC K
OTHER NON-GOV ORGANIZATION L
OTHER PRIVATE MEDICAL (SPECIFY) _____ M
OTHER SOURCE
FRIEND/RELATIVE N
OTHER (SPECIFY) _____ X

615A. 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

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

YES 1
NO 2
NOT SURE 8

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?

YES 1
NO 2 (GO TO 700)

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

YES 1
NO 2

SECTION 7. FERTILITY PREFERENCES

700. CHECK 101A:

CURRENTLY MARRIED (GO TO 701)
CURRENTLY WIDOWED, DIVORCED, OR SEPARATED (GO TO 712)

701. CHECK 304:

NEITHER STERILIZED (GO TO 702)
HE OR SHE STERILIZED (GO TO 712)

702. CHECK 226:

PREGNANT (GO TO 702)
NOT PREGNANT OR UNSURE (GO TO 704)

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?

HAVE ANOTHER CHILD 1 (GO TO 705)
NO MORE 2 (GO TO 711)
UNDECIDED/DON'T KNOW 8 (GO TO 711)

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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 707)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 712)
UNDECIDED/DON'T KNOW 8 (GO TO 710)

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?

MONTHS 1_____
YEARS 2_____

SOON/NOW 993 (GO TO 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
OTHER (SPECIFY) _____ 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)

706. CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 707)
PREGNANT (GO TO 711)

707. CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING (GO TO 708)
CURRENTLY USING (GO TO 712)

708. CHECK 705:

NOT ASKED (GO TO 709)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 709)
00-23 MONTHS OR 00-01 YEAR (GO TO 711)

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.

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

710. CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 711)
NO, NOT CURRENTLY USING (GO TO 711)
YES, CURRENTLY USING (GO TO 712)

711. 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 711B)
DON'T KNOW 8 (GO TO 712)

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

FEMALE STERILIZATION 01 (GO TO 712)
MALE STERILIZATION 02 (GO TO 712)
PILL 03 (GO TO 712)
IUD 04 (GO TO 712)
INJECTABLES 05 (GO TO 712)
IMPLANTS 06 (GO TO 712)
CONDOM 07 (GO TO 712)
FEMALE CONDOM 08 (GO TO 712)
DIAPHRAGM 09 (GO TO 712)
FOAM/JELLY 10 (GO TO 712)
LACTATIONAL AMEN. METHOD 11 (GO TO 712)
RHYTHM METHOD/PERIOD. ABSTIN. 12 (GO TO 712)
WITHDRAWAL 13 (GO TO 712)
OTHER (SPECIFY) _____ 96 (GO TO 712)
DON'T KNOW/UNSURE 98 (GO TO 712)

711B. 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 (GO TO 712)
MENOPAUSAL/HYSTERECTOMY 12 (GO TO 712)
SUBFECUND/INFECUND 13 (GO TO 712)
WANTS AS MANY CHILDREN AS POSSIBLE 14 (GO TO 712)
OPPOSITION TO USE
RESPONDENT OPPOSED 21 (GO TO 711D)
HUSBAND OPPOSED 22
OTHERS OPPOSED 23 (GO TO 712)
RELIGIOUS PROHIBITION 24 (GO TO 712)
RUMORS 25 (GO TO 712)
LACK OF KNOWLEDGE
KNOWS NO METHOD 31 (GO TO 712)
KNOWS NO SOURCE 32 (GO TO 712)
METHOD-RELATED REASONS
HEALTH CONCERNS 41 (GO TO 712)
FEAR OF SIDE EFFECTS 42 (GO TO 712)
LACK OF ACCESS/TOO FAR 43 (GO TO 712)
COSTS TOO MUCH 44 (GO TO 712)
INCONVENIENT TO USE 45 (GO TO 712)
INTERFERES WITH BODY'S NORMAL PROCESSES 46 (GO TO 712)
OTHER (SPECIFY) ____ 96 (GO TO 712)
DON'T KNOW 98 (GO TO 712)

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

AGAINST RELIGION A (GO TO 712)
CAUSE HEALTH PROBLEMS B (GO TO 712)
FEAR OF SIDE EFFECTS C (GO TO 712)
COST TOO MUCH D (GO TO 712)
INTERFERES WITH BODY'S NORMAL PROCESSES E (GO TO 712)
FATALISTIC F (GO TO 712)
OTHER (SPECIFY) _____ X (GO TO 712)
DON'T KNOW Z (GO TO 712)

711D. Why do you 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 BODY'S NORMAL PROCESSES E
FATALISTIC F
OTHER (SPECIFY) _____ X
DON'T KNOW Z

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.

NONE 00 (GO TO 714)
NUMBER _____
OTHER (SPECIFY) _____ 96 (GO TO 714)

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?

NUMBER OF BOYS _____
NUMBER OF GIRLS _____
NUMBER OF EITHER _____
OTHER (SPECIFY) _____ 96

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.

NUMBER _____
OTHER (SPECIFY) _____ 96

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?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
BULLETIN/BOOKLET
YES 1
NO 2
LECTURE
YES 1
NO 2
WOMEN
YES 1
NO 2
OTHER PEOPLE
YES 1
NO 2
COMMUNITY EVENT
YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 715)
DON'T KNOW 8 (GO TO 715)

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

FAMILY PLANNING A
USING CONTRACEPTIVES B
ADVANTAGE OF MODERN CONTRA. C
HAPPY SMALL FAMILY D
SPACING AT LEAST 3 YEARS BETWEEN PREGNANCIES E
QUALITY OF LIFE/WELL BEING/PROSPERITY F
SUPPORT OF GENDER EQUALITY BY ISLAM G
LIFE PLANNING H
REPRODUCTIVE HEALTH I
APPROVAL OF USING MODERN CONTRACEPTIVES BY ISLAM J
APPROVAL OF ON SPACING PREG. BY AT LEAST 3 YEARS K
OTHER (SPECIFY) _____ X
DON'T KNOW Y

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

INTERPERSONAL
GOVERN. 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

716. CHECK 601:

YES, CURRENTLY MARRIED (GO TO 716A)
CURRENT WIDOWED, DIVORCED, OR SEPARATED (GO TO 801)

716A. CHECK 304:

OTHER CODES CIRCLED (GO TO 716B)
CODE B, G, OR M CIRCLED (GO TO 718)
NO CODE CIRCLED (GO TO 718A)

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

YES 1
NO 2
DON'T KNOW 8

717. CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING (GO TO 718)
NOT CURRENTLY USING OR NOT ASKED (GO TO 718A)

718. 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/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) _____ 6

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?

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

719. CHECK 304:

NEITHER STERILIZED (GO TO 720)
HE OR SHE STERILIZED (GO TO 801)

720. Does your (husband/partner) 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?

OCCUPATION ________________________

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 you did not practice it during the last seven days for a reason such as vacation, travel, or illness?

YES 1 (GO TO 813)
NO 2

812A. Have you ever done any work before?

YES 1
NO 2 (GO TO 818)

812B. Why did you stop working?

GOT MARRIED A (GO TO 818)
BECAME PREGNANT B (GO TO 818)
BECAME ILL C (GO TO 818)
HUSBAND OPPOSED D (GO TO 818)
OTHER OPPOSED E (GO TO 818)
DIDN'T NEED TO WORK F (GO TO 818)
DIDN'T NEED MONEY G (GO TO 818)
CAN'T FIND A JOB H (GO TO 818)
I LOST MY JOB I (GO TO 818)
I GOT FIRED J (GO TO 818)
OTHER (SPECIFY) _____ X (GO TO 818)
DON'T KNOW Y (GO TO 818)

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

OCCUPATION _____________________

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 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.?

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 (SPECIFY) _____ 6

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

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

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

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

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

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

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

CHILDREN UNDER 10
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER FEMALES
PRESENT/LISTENING 1
PRESENT/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?
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?

GOES OUT
YES 1
NO 2
DON'T KNOW 8
NEGLECTS CHILDREN
YES 1
NO 2
DON'T KNOW 8
BURNS FOOD
YES 1
NO 2
DON'T KNOW 8
INSULTS
YES 1
NO 2
DON'T KNOW 8
DISOBEYS
YES 1
NO 2
DON'T KNOW 8
ARGUES
YES 1
NO 2
DON'T KNOW 8
ANOTHER MAN
YES 1
NO 2
DON'T KNOW 8

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)

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 delivery?
By breastfeeding?

DURING PREGNANCY
YES 1
NO 2
DON'T KNOW 8
DURING DELIVERY
YES 1
NO 2
DON'T KNOW 8
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, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) _______________
PUBLIC MEDICAL SECTOR
GOVT. HOSPITAL A
GOVT. HEALTH CENTER B
GOVT. MCH C
UNIVERSITY HOSPITAL D
ROYAL MEDICAL SERVICES E
TESTING AND COUNCELING CENTER F
OTHER PUBLIC (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
PRIVATE DOCTOR I
JORDANIAN AS. OF FP AND PROTECTION (JAFPP) J
PRIVATE LABORATORY K
OTHER NON GOV. ORGANIZATION L
OTHER PRIVATE MEDICAL (SPECIFY) _____ M
OTHER (SPECIFY) _____ X

912. Would you buy fresh vegetables 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 your 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 AIDS, 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 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)

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

TELEVISION A
RADIO B
NEWSPAPER/MAGAZINE C
PAMPHLET/BROCHURE D
POSTER E
COMMUNITY MEETING F
HOME VISIT BY HEALTH WORKER G
HEALTH FACILITY STAFF H
HUSBAND I
OTHER RELATIVES/FRIENDS/NEIGHBORS J
OTHER (SPECIFY) _____ X

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

GENITAL HERPES A
GENITAL WARTS/HPV B
HEPATITIS C
CHLAMYDIA D
SYPHILIS E
HIV/AIDS INFECTION F
TRICHOMONIASIS G
CHANCROID H
YEAST INFECTION I
OTHER (SPECIFY) _____ X
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 ever heard of an illness called tuberculosis?

YES 1
NO 2 (GO TO 1004)

1002. How does tuberculosis 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 TB 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

1004. Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1006)

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

NUMBER OF CIGARETTES _____

1006. Do you smoke narglia?

YES 1
NO 2

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?

WHERE TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
GETTING MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
TAKING TRANSPORT
BIG PROBLEM 1
NOT A BIG PROBLEM 2
GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NO FEMALE PROVIDER
BIG PROBLEM 1
NOT A BIG PROBLEM 2

SECTION 11. EARLY CHILDHOOD DEVELOPMENT

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

YES (GO TO 1102)
NO (GO TO 1200)

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

NAME OF THE YOUNGEST CHILD FROM Q. 212 __________
LINE NUMBER OF THE YOUNGEST CHILD FROM Q. 219 _____

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)?

NONE 00
NUMBER OF BOOKS FOR CHILDREN ____
TEN BOOKS OR MORE 10

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.

HOMEMADE TOYS
YES 1
NO 2
DON'T KNOW 8
TOYS FROM A SHOP
YES 1
NO 2
DON'T KNOW 8
HOUSEHOLD OBJECTS OR OUTSIDE OBJECTS
YES 1
NO 2
DON'T KNOW 8

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'.

NUMBER OF DAYS LEFT ALONE FOR MORE THAN AN HOUR _____
NUMBER OF DAYS LEFT TO ANOTHER CHILD FOR MORE THAN AN HOUR _____

1107. VERIFY 217: AGE OF THE CHILD

CHILD OF 0, 1 OR 2 YEARS (GO TO 1108)
CHILD OF 3 OR 4 YEARS (GO TO 1111)

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

YES (GO TO 1109)
NO (GO TO 1200)

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

NAME OF THE YOUNGEST CHILD 3-4 YEARS FROM Q. 212 __________
LINE NUMBER OF THE YOUNGEST CHILD FROM Q. 219 _____

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?

YES 1
NO 2 (GO TO 1113)
DON'T KNOW 8 (GO TO 1113)

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

NUMBER OF HOURS _____

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)?

READ BOOKS
MOTHER A
FATHER B
OTHER X
NO ONE Y
TOLD STORIES
MOTHER A
FATHER B
OTHER X
NO ONE Y
SANG SONGS
MOTHER A
FATHER B
OTHER X
NO ONE Y
TOOK OUTSIDE
MOTHER A
FATHER B
OTHER X
NO ONE Y
PLAYED WITH
MOTHER A
FATHER B
OTHER X
NO ONE Y
NAMED/COUNTED
MOTHER A
FATHER B
OTHER X
NO ONE Y

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?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

1123. Does (NAME) get distracted easily?

YES 1
NO 2
DON'T KNOW 8

SECTION 12. DOMESTIC VIOLENCE MODULE

1200. CHECK HOUSEHOLD QUESTIONNAIRE.

WOMAN SELECTED FOR THIS SECTION (GO TO 1201)
WOMAN NOT SELECTED (GO TO 1233)

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

PRIVACY OBTAINED 1 (CONTINUE)
PRIVACY NOT POSSIBLE 2 (GO TO 1232)

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:

CURRENTLY MARRIED (GO TO 1203)
WIDOWED/SEPARATED/DIVORCED (READ IN PAST TENSE AND USE 'LAST' WITH HUSBAND)

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?

JEALOUS
YES 1
NO 2
DON'T KNOW 8
ACCUSES
YES 1
NO 2
DON'T KNOW 8
NOT MEET FRIENDS
YES 1
NO 2
DON'T KNOW 8
NO FAMILY
YES 1
NO 2
DON'T KNOW 8
WHERE YOU ARE
YES 1
NO 2
DON'T KNOW 8

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?

a) say or do something to humiliate you in front of others?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) threaten to hurt or harm you or someone you care about?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) insult you or make you feel bad about yourself?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

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?

a) push you, shake you, or throw something at you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) slap you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) twist your arm or pull your hair?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
d) punch you with his fist or with something that could hurt you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) kick you, drag you, or beat you up?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) try to choke you or burn you on purpose?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) threaten or attack you with a knife, gun, or other weapon?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) physically force you to have sexual intercourse with him when you did not want to?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1206. CHECK 1205A (a-h):

AT LEAST ONE 'YES' (GO TO 1208)
NOT A SINGLE 'YES' (GO TO 1213)

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

a) You had cuts, bruises or aches?

YES 1
NO 2

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

YES 1
NO 2

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

YES 1
NO 2

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

MOST OF THE TIME AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1214. CHECK 606:

MARRIED MORE THAN ONCE (GO TO 1215)
MARRIED ONLY ONCE (GO TO 1216)

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?

a) Did any previous husband ever hit, slap, kick, or do anything else to hurt you physically?
YES 1
NO 2
0-11 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3
b) Did any previous husband physically force you to have intercourse against your will?
YES 1
NO 2
0-11 MONTHS AGO 1
12+ MONTHS AGO 2
DON'T REMEMBER 3

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?

YES 1
NO 2 (GO TO 1219)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1219)

1217. 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
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

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

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1219. CHECK 201, 226, AND 230:

EVEN BEEN PREGNANT (YES ON 201 OR 226 OR 230) (GO TO 1220)
NEVER BEEN PREGNANT (GO TO 1226)

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

YES 1
NO 2 (GO TO 1226)

1221. 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

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

AT LEAST ONE 'YES' (GO TO 1227)
NOT A SINGLE 'YES' (GO TO 1230)

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

YES 1
NO 2 (GO TO 1229)

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

MOTHER A (GO TO 1230)
FATHER B (GO TO 1230)
SISTER C (GO TO 1230)
BROTHER D (GO TO 1230)
MOTHER-IN-LAW E (GO TO 1230)
FATHER-IN-LAW F (GO TO 1230)
OTHER FEMALE RELATIVE/IN-LAW G (GO TO 1230)
OTHER MALE RELATIVE/IN-LAW H (GO TO 1230)
FRIEND I (GO TO 1230)
NEIGHBOR J (GO TO 1230)
TEACHER K (GO TO 1230)
EMPLOYER L (GO TO 1230)
RELIGIOUS FIGURE M (GO TO 1230)
DOCTOR/MEDICAL PERSONNEL N (GO TO 1230)
POLICE O (GO TO 1230)
LAWYER P (GO TO 1230)
SOCIAL SERVICE ORGANIZATION Q (GO TO 1230)
OTHER (SPECIFY) _____ X (GO TO 1230)

1229. Have you ever told anyone about this?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

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?

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

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

______________________________________________________________

1233. 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: _____

(SEE PDF FOR CALENDAR)