DEPARTMENT OF CENSUS AND STATISTICS OF SRI LANKA
DEMOGRAPHIC AND HEALTH SURVEY

ZONE____
DISTRICT____
SECTOR:

WARD/GS DIV/ESTATE____
SURVEY BLOCK NUMBER____
HOUSING UNIT NUMBER____
HOUSEHOLD NUMBER____

LINE NUMBER OF ELIGIBLE WOMAN____

INTERVIEWER VISITS

FIRST VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*

NEXT VISIT
DATE____
TIME____

SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*

NEXT VISIT
DATE____
TIME____

FINAL VISIT
DATE____
INTERVIEWER'S NAME____
RESULT*

TOTAL NUMBER OF VISITS____

FIELD EDITED BY
NAME____
DATE____

OFFICE EDITED BY
NAME____
DATE____

KEYED BY
NAME____
DATE____

SECTION 1: RESPONDENT'S BACKGROUND

101) RECORD NUMBER OF PEOPLE LISTED IN THE HOUSEHOLD SCHEDULE.

102) RECORD NUMBER OF CHILDREN AGE 5 AND UNDER LISTED IN THE HOUSEHOLD SCHEDULE AND WHO USUALLY LIVE IN THE HOUSEHOLD.

103) RECORD THE TIME.

104) First I would like to ask some questions about yourself and your household. For most of the time until you were 12 years old, did you live in metropolitan Colombo, another urban area, in a village, or on an estate?

105) How long have you been living continuously in the (URBAN AREA, VILLAGE, OR ESTATE)?

106) Just before you moved here, did you live in metropolitan Colombo, another urban area, in a village, or on an estate?

107) In what month and year were you born?

108) How old were you at your last birthday? COMPARE AND CORRECT 107 AND/OR 108 IF INCONSISTENT.

109) Have you ever attended school?

110) What was the highest grade in school you completed? CIRCLE BOTH LEVEL AND GRADE.

111) What was the highest exam you passed?

112) CHECK 110:

113) Can you read a letter or newspaper easily, with difficult, or not at all?

114) Do you read a newspaper or magazine at least once a week?

115) Do you usually watch television every week?

116) Do you usually listen to a radio every day?

117) What is the major source of drinking water for members of your household?

118) What is the major source of water for household use OTHER than drinking (e.g., handwashing, cooking) for members of your household?

119) How long does it take to go there, get water, and come back?

120) What kind of toilet facility is available for use by members of this household?

121) Is this facility for the exclusive use of members of this household, or is it shared?

122) Do you have, right now, a cake of bath soap on the premises?

123A) Does your house have:

123B) Does any member of your household own:

124) MAIN MATERIAL OF THE FLOOR. (INTERVIEWER: RECORD OBSERVATION)

125) MAIN MATERIAL OF THE ROOF. (INTERVIEWER: RECORD OBSERVATION)

126) MAIN MATERIAL OF THE WALLS. (INTERVIEWER: RECORD OBSERATION)

127) What religion do you belong to?

128) RECORD ETHNICITY. (INTERVIEWER: RECORD OBSERVATION)

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 son or daughter you have given birth to who is now living with you?

203) How many sons live with you? And how many daughters live with you? IF NONE ENTER ZEROS (00).

204) Do you have any sons or daughter you have given birth to who is alive but does not live with you?

205) How many sons live elsewhere? How many daughters live elsewhere? IF NONE ENTER ZEROS (00).

206) Have you ever given birth to a boy or a girl who was born alive but later died? IF NO, PROBE: Any (other) boy or girl who cried or showed any signs of life but only survived a few hours or days?

207) How many boys have died? And how many girls have died? IF NONE, ENTER ZEROS (00).

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

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

210) CHECK 208:

211) Now I would like to talk to you about all of your births. It is important that you begin with your first birth and then report subsequent births in the order that they occurred. Now, please tell me the name of your first birth.

INTERVIEWER: FIRST, RECORD THE NAMES OF ALL BIRTHS THE WOMAN MENTIONS BY PROGRESSING DOWN COLUMN 212. SECOND, ASK QUESTIONS 213 THROUGH 218, AS APPROPRIATE FOR EACH BIRTH. THIRD, RECORD TWINS ON SEPARATE LINES, AND CONNECT WITH A BRACKET.

212) What is the name of your (FIRST, SECOND, etc.) birth?

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

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

215) Is (NAME) still alive?

216) IF DEAD: How old was (NAME) when he/she died? RECORD DAYS IF LESS THAN 1 MONTH (31 DAYS); MONTHS IF LESS THAN 2 YEARS.

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

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

219) COMPARE 208 WITH NUMBERS OF BIRTHS IN HISTORY ABOVE AND MARK CORRECT BOX.

220) How long ago did your last menstrual period start?

221) CHECK 220:

222) Why did your last menstruation occur so long ago?

223) Are you pregnant now?

224) For how many months have you been pregnant?

225) Have you had a tetanus injection since you have been pregnant?

226) Did you see anyone for a check on this pregnancy?

227) Whom did you see? PROBE FOR TYPE OF PERSON AND RECORD MOST QUALIFIED.

228) When during her monthly cycle do you think a woman has the greatest chance of becoming pregnant? PROBE: What are the days during the month when a woman has to be careful to avoid becoming pregnant?

229) PRESENCE OF OTHERS AT THIS POINT:

SECTION 3: CONTRACEPTION

301) Now I would like to talk about a different topic. There are various ways that a couple can delay or avoid a pregnancy. Which of these methods have you heard of?

INTERVIEWER:
A) CIRCLE CODE 1 IN 302 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
B) THEN PROCEED DOWN THE COLUMN, CONTINUING QUESTION 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED.
C) THEN FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN QUESTION 302, ASK QUESTION 303 THROUGH 305 BEFORE PROCEEDING TO THE NEXT METHOD.

302. Have you ever heard of (READ METHOD AND DESCRIPTION)?

303. Have you ever used (METHOD)?

304. Where would you go to obtain (METHOD) if you wanted to use it?

305. What would you say is the main problem, if any, in getting or using (METHOD)?

306) CHECK 303: EVER USED A METHOD?

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

308) What have you used or done? CORRECT 302 AND 303 AND OBTAIN INFORMATION FOR 304 TO 306 AS NECESSARY.

309) CHECK 303:

310) The last time you used the safe period, how did you determine on which days you had to abstain?

311) How many living children, if any, did you already have when you first did something to avoid getting pregnant? IF NONE ENTER ZEROS (00).

312) CHECK 223:

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

314) Have you done something or used a method in the past month to avoid getting pregnant?

315) Some women abstain from sexual relations completely for more than one or two months for the following reasons: 1: To avoid pregnancy. 2: Because the eldest child is of marriage age. 3: Because the husband is away. 4: A women has just had a baby or is breastfeeding. 5: Illness. 6: Religious reasons. Have you ever abstained for any of these reasons?

316) Are you currently abstaining for any of these reasons?

317) Which reason?

319) Which method are you using?

320) Please show me the package of pills you are now using. (RECORD NAME OF BRAND.)

321) How much does one packet (cycle) of pills cost you?

322) In what month and year did you (he) have the operation?

323) CHECK 306:

323A) CHECK 317:

324) Have you obtained a method to avoid pregnancy in the last twelve months from a hospital, a clinic, a doctor, or a fieldworker?

325) Which method did you obtain?

326) Have you obtained instructions for using the safe period in the last twelve months from a hospital, clinic, a doctor, or a fieldworker?

327) Where did you obtain (METHOD) the last time?

327A) Where did the sterilization take place?

328) Was there anything you disliked about the service you received there? IF YES: What?

329) CHECK 223:

330) CHECK 319:

331) For how long have you been using (CURRENT METHOD) continuously?

332) Have you experienced any problem from using (CURRENT METHOD)?

333) What is the main problem you experienced?

334) At any time during the same month, do you regularly use any other method than (CURRENT METHOD)?

335) Which method is that? CHECK 302 THROUGH 333 AND CORRECT AS NECESSARY

336) Have you ever used any other method before (CURRENT METHOD) (since your last birth) to avoid getting pregnant?

337) Which method did you use before (CURRENT METHOD)?

338) In what month and year did you start using (METHOD BEFORE CURRENT) (the last time)?

339) For how long had you been using (METHOD BEFORE CURRENT) before you stopped using it (last time)?

340) What was the main reason you stopped using (METHOD BEFORE CURRENT) then?

341) CHECK 208: ANY BIRTHS?

342) Since your last birth have you used any method to avoid getting pregnant?

343) Which was the last method you used?

344) In what month and year did you start using that method (the last time)?

345) For how long had you been using (LAST METHOD) before you stopped using it (last time)?

346) What was the main reason you stopped using (LAST METHOD) then?

347) Do you intend to use a method to avoid pregnancy at any time in the future?

348) Which method would you prefer to use?

349) Do you intend to use (PREFERRED METHOD) in the next 12 months?

350) In the last month, have you heard or seen a message about family planning on the radio or on tv?

351) Did you hear it once or more than once?

352) Do you think that it is acceptable or not acceptable for family planning information to be provided on radio? On television?

353) When do you listen to the radio?

354) What progress do you listen to? (CIRCLE ALL MENTIONED.)

355) CHECK 223:

355A) CHECK 214:

356) Now I would like to get some more information about (your pregnancy and) the children you had in the last five years.

INTERVIEWER: FIRST, MARK PREGNANCY STATUS, AND FROM PAGE 10 RECORD NAMES OF BIRTHS SINCE 1982. SECOND, MARK APPROPRIATE BOX IN 357, AND ASK THE APPROPRIATE QUESTIONS FOR EACH COLUMN FOR WHICH THE HEADING IS FILLED OUT.

357) CHECK 306:

358) Before you became pregnant (with NAME) and after the birth of (NAME) did you do anything to avoid getting pregnant, even for a short time?

359) Which was the last method you used then? (CODES BELOW)

360) Any method before that? (RECORD CODE) (IF NONE, ENTER 00)

361) For how long had you used (LAST METHOD) that time?

362) Did you become pregnant while you were still using (LAST METHOD)?

363) What was the main reason you stopped using (LAST METHOD)? IF RESPONSE IS ?Ç£TO GET PREGNANT?Ç¥ CIRCLE 1 AND GO TO NEXT COLUMN. IF NOT, SEE CODES BELOW.

364) At the time you became pregnant (with NAME) did you want to have that child then, to wait until later, or to have no (more) children at all?

365) Did you want to have that child, but at a later time, or not have another child at all?

SECTION 4: HEALTH OF CHILDREN

401) CHECK 214:

402) FROM QUESTION 212 ON PAGE 10, RECORD THE NAMES AND LINE NUMBERS OF ALL BIRTHS SINCE JANUARY 1982 IN THE FOLLOWING TABLE. FOR EACH BIRTH, CHECK IF ALIVE OR DEAD, AND MARK THE APPROPRIATE BOX.

403) Did you receive a tetanus injection when you were pregnant with (NAME)?

404) Did you receive a tetanus injection when you were pregnant with (NAME)?

405) Did you visit a doctor or a clinic for a check on this pregnancy?

406) In what type of place was (NAME) born?

407) Who assisted with the delivery of (NAME)? PROVE AND RECORD MOST QUALIFIED PERSON.

408) Did you ever feed (NAME) at the breast?

409) How many days after birth did you begin feeding (NAME) at the breast?

410) Was the colostrum (the first milk produced) given to (NAME) or was it thrown away?

411) Why did you throw it away?

412) Are you still breastfeeding (NAME)? IF DEAD, CIRCLE ?Çÿ3'.

413) At what age did you totally stop breastfeeding (NAME)?

414) What is the main reason you (never breastfed/stopped breastfeeding)(NAME)?

415) At what age did you begin to give the following foods to (NAME)? READ OUT CATEGORIES. Powdered milk: half cream, powdered milk: full cream, cow/goat milk, cungee, eggs, mashed potatoes/cereal, fruit/juice/soup
00 IF GIVEN IN FIRST MOTH
96 IF NEVER GIVEN
98 IF DON'T KNOW

416) At what age did you start at least one food on a daily basis?

417) CHECK 416:

418) Why did you wait so long to begin daily supplemental feeding of (NAME)?

419) When you began daily supplemental feeding of (NAME), did you continue full breastfeeding, did you reduce; or did you stop completely?

420) How many months after the birth of (NAME) did your period return?

421) Have you resumed sexual relations since the birth of (NAME)?

422) How many months after the birth of (NAME) did you not have sexual relations?

423) FROM PAGE 10, RECORD THE NAMES OF ALL BIRTHS SINCE JANUARY 1982 IN THE FOLLOWING TABLE. FOR EACH BIRTH, CHECK IF ALIVE OR DEAD, AND MARK THE APPROPRIATE BOX.
ASK QUESTIONS 424 HROUGH 434 FOR ALL SURVIVING BIRTHS

424) Do you have a clinic card, a child growth card or any other document showing what immunizations (NAME) was given?

425) RECORD THE DATES OF INJECTIONS FROM THE CARD. CIRCLE ?Ç£1?Ç¥ IF NOT GIVEN.

426) Has (NAME) ever had an immunization to prevent him/her from getting diseases?

427) Please tell me if (NAME) has had any of the following injections:

428) At what age was (NAME) given the last of these immunizations?

429) Was (NAME) given a measles vaccine?

430) Has (NAME) had diarrhea in the last 24 hours?

431) Has (NAME) had diarrhea in the last two weeks?

432) Did you take (NAME) to a government hospital or clinic, to a Western doctor, or to an Ayurvetic doctor to treat the diarrhea (the last time)? IF YES: Where did you take him/her?

433) Was (NAME) given any packet of Jeevanee or UNICEF salts to treat the diarrhea (the last time)?

434) Was there anything (else) you or somebody did to treat the diarrhea? IF YES: What was done? CIRCLE CODE 1 FOR ALL MENTIONED

435) CHECK 433: ?Ç£1?Ç¥ MARKED FOR ANY BIRTH? IF 433 IS EMPTY, MARK ?Ç£NO?Ç¥.

436) Have you ever heard of JEEVANEE or UNICEF Salts which you can give to a child with diarrhea?

437) INTERVIEWER: SHOW JEEVANEE AND UNICEF PACKETS. ASK: Have you ever seen either or both packets before?

438) Have you ever given either JEEVANEE or UNICEF Salts to any of your children?

439) Where did you obtain the packet (the last time)?

440) How much did one packet cost? IF FREE, ENTER RS.00.00.

441) I now have some questions about how to prepare Jeevanee.

442) Please describe the type of water used to mix Jeevanee.

443) Describe how the powder is mixed.

444) How do you measure the water?

445) How long can you keep the solution once it has been mixed?

446) CHECK 412 FOR LAST BIRTH:

447) How many times did you breastfeed (NAME OF LAST BIRTH) last night, between sundown and sunrise?

448) How many times did you breastfeed (NAME OF LAST BIRTH ) yesterday during the daylight hours?

449) At any time yesterday or last night, was (NAME OF LAST BIRTH) given any of the following? READ OUT CODING CATEGORIES

450) CHECK 449:

451) Were any of these given in a bottle with a nipple?

452) CHECK 430 AND 431 FOR LAST BIRTH:

453) When (NAME) had diarrhea recently, did you continue (full) breastfeeding, did you reduce, or did you stop completely?

454) Why did you (reduce/stop)?

SECTION 5: MARRIAGE

501) Are you currently married, or are you widowed, divorced, or separated?

501A) Are you and your husband currently living together?

502) Have you been married once, or more than once?

503) In what month and year did you start living with your (first) husband as husband and wife?

504) How old were you when you started living with him?

505) Where did you live before you began living with your husband: in metropolitan Colombo, another urban area, in a village, or on an estate?

506) Did your (first) husband live in the same place before marriage, or in a different urban area, village, or estate?

507) How many miles was his place from yours?

508) Are your mother and father still alive?

509) Are your first husband's parents still alive?

510) CHECK 508 AND 509:

511) FOR EACH ?Ç£1?Ç¥ CIRCLED IN 508 AND 509, CIRCLE A ?Ç£1?Ç¥ FOR THE CORRESPONDING PARENT IN 512. THEN ASK 512 FOR THOSE PARENTS NOT HAVING A ?Ç£1?Ç¥ CIRCLED.

512) Was (MENTION PARENTS NOT ALIVE NOW) alive at the time you began living with your (first) husband?

513) CHECK 512:

514) At the time you began living with your (first) husband, did you and he live with any of these parents for at least 6 months?

515) For about how many years did you live with your parents at this time?

516) Are you now living either with your parents or with your husband's parents?

517) CHECK 501:

518) Have you had sexual intercourse in the last four weeks?

519) How many times?

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

521) CHECK 223:

522) CHECK 315:

523) If you became pregnant in the next few weeks, would you feel happy, unhappy, or would it not matter very much?

524) What is the main reason that you are not using a method to avoid pregnancy?

525) PRESENCE OF OTHERS AT THIS POINT:

SECTION 6: FERTILITY PREFERENCES

601) CHECK 319:

602) CHECK 501:

603) Now I have some questions about the future. CHECK 223:

604) Would you say that you definitely do not want to have (more) children, or are you not sure?

605) Are you more inclined toward having a (another) child, or toward not having a (another) child?

606) Would you say that you definitely want a (another) child, or are you not sure?

607) How long would you like to wait from now before the birth of a (another) child?

608) How old would your youngest child be? IF NO LIVING CHILDREN, CIRCLE ?Çÿ96'.

609) Was your last child born by caesarean section?

610) Do you regret that you (your husband) had the operation not to have any more children?

611) Would you like to have another child or would you prefer not to have any more children?

612) CHECK 202 AND 204 AND MARK CORRECT BOX. RECORD SINGLE NUMBER, RANGE OR OTHER ANSWER.

SECTION 7: HUSBAND'S BACKGROUND AND WORK

701) Now I have some questions about your (most recent) husband, his background, and his work.

702) Did your husband ever attend school?

703) What was the highest grade in school he completed? CIRCLE BOTH LEVEL AND GRADE.

704) What was the highest exam he passed?

705) CHECK 703:

706) Can (could) he read a letter or newspaper easily, with difficulty, or not at all?

707) What kind of work does (did) your husband mainly do?

708) Does (did) he earn a regular wage or salary?

709) Does (did) your husband work mainly on his or his family's or on someone else's land?

709A) Does (did) he hire others to work the land or his?

710) Does (did) he work mainly for money or does (did) he work for a share of the crops?

711) Now I have some questions about your work.

712) Before you married your (first) husband, did you ever work regularly to earn money, other than on a farm or in a business run by your family?

713) When you were earning money then, did you turn most of it over to your family or did you keep most of it for yourself?

714) Since you were first married, have you ever worked regularly to earn money other than on a farm or in a business run by your family?

715) Are you now working to earn money, other than on a farm or in a business run by your family?

716) Are you now working to earn money on a farm or in a business run by your family?

717) What kind of work do you mainly do?

SECTION 8: SOCIOECONOMIC INDICATORS

801) Has your household experienced any food shortages in the past 6 months?

802) Has your household experienced any food shortages in the past 2 weeks?

803) INTERVIEWER: DO MEMBERS OF THE HOUSEHOLD APPEAR WEALTHY ENOUGH TO OWN A CHANGE OF CLOTHES?

804) RECORD THE TIME.

SECTION 9: LENGTH AND WEIGHT

INTERVIEWER: FROM PAGE 10, RECORD NAMES AND LINE NUMBERS OF ALL LIVING CHILDREN BORN SINCE JANUARY 1, 1984. START WITH THE YOUNGEST CHILD. RECORD DATE OF BIRTH IN 901 AND CHECK AGE IN 902. THEN GO TO TEAR-OFF SHEET.

901) DATE OF BIRTH

902) CHECK AGE: 3 TO 36 MONTHS?

903) LENGTH (IN CENTIMETERS)

904) WEIGHT (IN KILOGRAMS)

905) STATE REASON IF UNABLE TO RECORD

906) NAME OF MEASURER____
NAME OF ASSISTANT____

INTERVIEWER'S OBSERVATIONS

(To be filled in after completing interview.)

Person Interviewed____

Specific Questions____

Other Aspects____

Name of Interviewer____

Date____

SUPERVISOR'S OBSERVATIONS.

Name of Supervisor____

Date____

EDITOR'S OBSERVATIONS.

Name of Field Editor____

Date____

Name of Keyer____

Date____