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REPUBLIC OF MALI
DEMOGRAPHIC AND HEALTH SURVEY IN MALI WOMAN'S QUESTIONNAIRE - FRENCH 1987

IDENTIFICATION:

FIRST AND LAST NAME OF WOMAN__
NUMBER OF QUESTIONNAIRE__

REGION__
CLUSTER__
ARRONDISSEMENT/COMMUNE__
VILLAGE CODE__
VILLAGE NEIGHBORHOOD__
NAME OF HEAD OF COMPOUND__
NAME OF HEAD OF HOUSEHOLD__
LINE NUMBER OF WOMEN IN THE HOUSEHOLD ____

INTERVIEWER VISITS:

INTERVIEWER 1(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
MONTH__
YEAR 1987
INTERVIEWER NAME____

RESULTS___

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 OTHER (SPECIFY)__

NEXT VISIT [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__
RESULTS___

FINAL VISIT
DATE ___
MONTH ___
YEAR 1987
RESULTS ___

TOTAL NUMBER OF VISITS ___

SUPERVISOR
NAME___
DATE___

FIELD EDITOR
NAME__
DATE__

OFFICE EDITOR__
KEYED BY___

SECTION 1. RESPONDENT'S BACKGROUND

100. RECORD THE NUMBER OF PEOPLE LISTED IN THE HOUSEHOLD

NUMBER OF PEOPLE__

101. NUMBER OF CHILDREN UNDER 5 YEARS RECORDED ON THE HOUSEHOLD SURVEY AND WHO USUALLY LIVE IN THE HOUSEHOLD

NUMBER OF CHILDREN__

102. RECORD THE TIME

HOUR____
MINUTES____

To begin, I would like to ask you questions about yourself and your household.

103. How long have you been living continuously in (NAME OF VILLAGE, TOWN, CITY)?

YEARS__

ALWAYS 95 (GO TO 106)
VISITOR 96
DOESN'T KNOW 98

104. For the majority of the 12 first years of your life, did you live in Bamako, in another city or in countryside?

NAME OF LOCALITY_____
BAMAKO 1
KAYES, SIKASSO, SEGOU, NOULIKORO, MOPTI, TOMBOUCTOU, GAO 2
OTHER CITIES 3
COUNTRYSIDE 4
OTHER COUNTRIES 5

105. Just before you moved here (or came here to visit) did you live in Bamako, in another city or in countryside?

NAME OF LOCALITY_____
BAMAKO 1
KAYES, SIKASSO, SEGOU, NOULIKORO, MOPTI, TOMBOUCTOU, GAO 2
OTHER CITIES 3
COUNTRYSIDE 4
OTHER COUNTRIES 5

106. In which month and in which year were you born?
IF ONLY THE YEAR IS KNOWN, PROBE TO GET THE SEASON IF NOT THE MONTH

MONTH _____
DOESN'T KNOW MONTH 98
YEAR _____
DOESN'T KNOW YEAR 98

107. How old were you at your last birthday?

IF THE BIRTH DATE AND SEASON ARE NOT KNOWN, ESTIMATE AGE ACCORDING TO AN HISTORIC EVENT OR ACCORDING TO A PERSON WHOSE AGE IS KNOWN. COMPARE AND CORRECT IF 105 AND/OR 106 ARE/IS INCONSISTENT

AGE IN COMPLETED YEARS____

108. Did you go to school?

YES 1
NO 2 (GO TO 112)

109. What is the highest level of school you attended: primary, secondary or superior?

PRIMARY 1
SECONDARY 2
SUPERIOR 3

110. What is the last (year/grade) that you achieved at this level?

YEAR/GRADE ____

111. CHECK 109:

PRIMARY (GO TO 112)
SECONDARY OR HIGHER (GO TO 113)

112. Can you read and understand a letter or a newspaper easily, with difficulty or not at all?

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3
INCAPABLE/BLIND 4

113. Do you listen to the radio at least once a week?

YES 1
NO 2

114. What is your religion?

MUSLIM 1
CHRISTIAN 2
OTHERS 3

115. Are you Malian?

YES 1
NO 2 (GO TO 117)

116. What is your ethnicity?

BAMBARA 01
PEUL OR TOUCOULEUR 02
MALINKE 03
TOUAREG 04
MAURE 05
SARAKOLE OR SOLINKE 06
SONGHAI 07
DOGON 08
BOZO 09
SENOUFO/MINIANKA 10
BOBO 11
KASSONKE 12
OTHER (SPECIFY)__88

117. Are you a member of a woman's association or a woman's cooperation?

COOP. OF COMMSUPTION 01
WORKER'S COOP. 02
AGRICULTURE COOP. 03
AGRO-PASTORAL COOP. 04
BREEDER'S COOP. 05
OTHER COOP. OR ASSOCIATION (SPECIFY) _____06
NOT A MEMBER 97 (GO TO 119)

118. What is your role in this organization?

BOARD MEMBER 1
JUST A MEMBER 2
OTHERS (SPECIFY) _____3

119. What is the main source of drinking water for members of your household?

INSIDE THE DWELLING
RUNNING WATER 01
WELL 02
OTHER (SPECIFY) _____03
OUTSIDE OF THE DWELLING
STONE FOUNTAIN 04
WELL 05
BOREHOLE WELL 06
RIVER OR STREAM 07
PONDS OR LAKES 08
OTHER (SPECIFY) _____09

120. What is the main source of water for bathing, dish/clothes-washing for the members (usual) of your household?

INSIDE THE DWELLING
RUNNING WATER 01
WELL 02
OTHER (SPECIFY)__03
OUTSIDE OF THE DWELLING
STONE FOUNTAIN 04
WELL 05
BOREHOLE WELL 06
RIVER OR STREAM 07
PONDS OR LAKES 08
OTHER (SPECIFY) _____09

121. What kind of toilet facility is there in this household?

FLUSH 1
LATRINE 2
OTHER (SPECIFY) _____3
NO TOILET FACILITY 4

122. What kind of toilette facility do children 3 to 5 years use?

FLUSH 1
LATRINE 2
POT THEN TOILET 3
YARD THEN TOILET 4
OTHER (SPECIFY) _____5
NO CHILDREN 6

123. Does your household have:

Electricity?
Radio?
Television?
Refrigerator or freezer?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
REFRIGERATOR/FREEZER
YES 1
NO 2

124. Is there anyone in your household who owns:

A bicycle?
A motorcycle?
A car?

BICYCLE?
YES 1
NO 2
MOTORCYCLE?
YES 1
NO 2
CAR ?
YES 1
NO 2

125. What type of floor do the rooms where you live in your household have?

TILE 1
CEMENT 2
EARTH 3
OTHER (SPECIFY) _____4

126. What type of roof does your dwelling have?

CONCRETE, TILE, SLATE 1
SHEET METAL AND CEILING 2
TOLE SANS PLAFOND 3
CLAY 4
STRAW 5
OTHERS (SPECIFY) _____6

127. Do you usually have soap for hand washing in this household?

YES 1
NO 2
DOESN'T KNOW 8

SECTION 2. REPRODUCTION

Now I would like to ask about all of the births you have had during your life.

201. Have you ever given birth to a living child?

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

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

SONS ELSEWHERE ____
DAUGHTERS ELSEWHERE____

206. Have you given birth to a son or daughter who was born alive but later died?
IF NO, PROBE: Any who cried and showed signs of life at birth but did not survive more than a couple hours or days?

YES 1
NO 2 (GO TO 208)

207. How many sons have died?
And how many daughters have died?
IF NONE, RECORD '00'

SONS DEAD____
DAUGHTERS DEAD____

208. Have you had any still born babies?

YES 1
NO 2 (GO TO 211)

209. Among these are there any who breathed and showed signs of life after birth?

YES 1
NO 2 (GO TO 211)

210. Among these still born babies:
How many boys showed signs of life?
How many girls showed signs of life?

BOYS BORN ALIVE_____
GIRLS BORN ALIVE_____

211. SUM ANSWERS TO Q.203, 205, 207 AND 210 AND RECORD THE TOTAL.
IF NONE, RECORD '00'

TOTAL__

211A. CHECK: Just to be sure that I have this right: You have had in TOTAL___ births during your life. Is that correct?

YES (GO TO 212)
NO: PROBE AND CORRECT 203-211 AS NECESSARY.

212. CHECK 211:

ONE OR MORE BIRTH:
Now I would like to make a list of all your births, whether still alive or not, starting with the first one you had.

RECORD THE NAMES OF ALL THE BIRTHS IN Q.212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES
NONE (GO TO 220)

213. What name was given to your first/next baby?
RECORD TWINS RECORD ON SEPARATE LINES AND REUNITE WITH A LINE ON THE LEFT.

NAME__

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

BOY 1
GIRL 2

215. Is (NAME) still alive?

YES 1
NO 2

216. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
OR: In which season?

MONTH____
YEAR 19___

217. IF DEAD: How old was (NAME) when he/she died?
IF '1 YEAR' PROBE: How old was (NAME) in months?

RECORD IN DAYS IF LESS THAN 1 MONTH; IN MONTHS IF LESS THAN 2 YEARS; OR
IN YEARS

DAYS 1__
MONTHS 2__
YEARS 3__

218. IF ALIVE: How old is (NAME)?
RECORD AGE IN COMPLETED YEARS

AGE IN YEARS__

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

YES 1
NO 2

220. CHECK THAT THE NUMBER OF RECORDED BIRTHS CORRESPONDS TO 211.

221. Have you had your period in the last 4 weeks?

YES 1
NO 2 (GO TO 223)

222. How many days since your period started?

DAYS__ (GO TO 230)

223. Are you pregnant?

YES 1
NO 2 (GO TO 229)
NOT SURE 8 (GO TO 229)

224. How many months pregnant are you?

MONTHS____

225. Since you became pregnant, have you ever received an injection to protect your baby from tetanus, that is to say, convulsions after birth?

YES 1
NO 2
DOESN'T KNOW 8

226. Have you had a prenatal visit for your current pregnancy?

YES 1
NO 2 (GO TO 230)

227. Who did you consult the first time?

PROBE AND RECORD THE CODE FOR THE MOST QUALIFIED PERSON.

DOCTOR 1
MID-WIFE, NURSE, AUX. 2
HOSPITAL, DISPENS, PMI 3
DOULA 4
TRADITIONAL BIRTHER 5
OTHER (SPECIFY) ____6

228. At how many months of pregnancy did you have your first prenatal visit?

MONTH _____ (GO TO 230)
DOESN'T KNOW 98 (GO TO 230)

229. When did your last menstrual period start?

MONTHS AGO _____
BEFORE LAST PREGNANCY 95
NEVER MENSTRUATED 96
DOESN'T KNOW 98

230. During the menstrual cycle, are there certain days when a woman is more likely to become pregnant?

DURING HER PERIOD 1
JUST AFTER THE END OF HER PERIOD 2
HALFWAY BETWEEN TWO PERIODS 3
JUST BEFORE HER PERIOD BEGINS 4
OTHER (SPECIFY) ____6
DOESN'T KNOW 8

231. PEOPLE PRESENT (DURING THIS FIRST PART OF THE INTERVIEW):

CHILDREN LESS THAN 10 YEARS
YES 1
NO 2
HUSBAND
YES 1
NO 2
OTHER MEN
YES 1
NO 2
OTHER WOMEN
YES 1
NO 2

SECTION 3. CONTRACEPTION

Now I would like to talk to you about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy
.

CIRCLE CODE '1' ON LINE 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN CONTINUE DOWN COLUMN 301 READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '2' IF THE METHOD IS RECOGNIZED. THEN, FOR EACH METHOD WITH CODE '1' OR '2' CIRCLED IN 302, ASK 303-305.

301. Which methods have you heard about?
302. Have you ever heard of (METHOD)?

PILL Women can take a pill every day to avoid becoming pregnant.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
IUD Women can have a loop or a coil in plastic or metal placed inside their uterus by a doctor or a nurse to avoid becoming pregnant.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
INJECTIONS Women can have an injection by a health provider to avoid becoming pregnant during one or more months.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
CREAM, JELLY, SPONGE Some women put a diaphragm, a sponge, effervescent pills, jelly or cream before having sexual intercourse to avoid getting pregnant.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
FEMALE STERILIZATION Women can have an operation to avoid having any more children.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
MALE STERILIZATION Men can have an operation to avoid having any more children.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having intercourse on the days of the month she is most likely to get pregnant.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
WITHDRAWAL Men can be careful to pull out before climax.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
ABSTINENCE Some couples, in addition to post natal abstinence, avoid having sexual intercourse so that the woman does not get pregnant.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
MEDICINAL PLANTS (stem, root, leaves) are products that can be used to delay pregnancy.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
AMULET (cord with a knot) are things couples can use to delay pregnancy.
SPONTANEOUS YES 1
YES DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
OTHER METHODS Have you heard of other ways or methods including traditional methods that women or men can use to avoid pregnancy?
(SPECIFY)__
YES SPONTANEOUS 1
NO 3

303. Have ever used (METHOD)?

PILL Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
IUD Women can have a loop or a coil in plastic or metal placed inside their uterus by a doctor or a nurse to avoid becoming pregnant.
YES 1
NO 2
INJECTIONS Women can have an injection by a health provider to avoid becoming pregnant during one or more months.
YES 1
NO 2
CREAM, JELLY, SPONGE Some women put a diaphragm, a sponge, effervescent pills, jelly or cream before having sexual intercourse to avoid getting pregnant.
YES 1
NO 2
CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
FEMALE STERILIZATION Women can have an operation to avoid having any more children. Are you sterilized?
YES 1
NO 2
MALE STERILIZATION Men can have an operation to avoid having any more children.
Have you ever had a partner who had an operation to avoid having any more children?
YES 1
NO 2
PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
WITHDRAWAL Men can be careful to pull out before climax.
YES 1
NO 2
ABSTINENCE Some couples, in addition to post natal abstinence, avoid having sexual intercourse so that the woman does not get pregnant.
YES 1
NO 2
MEDICINAL PLANTS (stem, root, leaves) are products that can be used to delay pregnancy.
YES 1
NO 2
AMULET (cord with a knot) are things couples can use to delay pregnancy.
YES 1
NO 2
OTHER METHOD (SPECIFY) ____
YES 1
NO 2

304. Where can you get (METHOD)?
OR Where would you go to get advice on (METHOD)?

PILL Women can take a pill every day to avoid becoming pregnant.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
IUD Women can have a loop or a coil in plastic or metal placed inside their uterus by a doctor or a nurse to avoid becoming pregnant.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
INJECTIONS Women can have an injection by a health provider to avoid becoming pregnant during one or more months.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
CREAM, JELLY, SPONGE Some women put a diaphragm, a sponge, effervescent pills, jelly or cream before having sexual intercourse to avoid getting pregnant.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
FEMALE STERILIZATION Women can have an operation to avoid having any more children. Or is it possible to get sterilized?
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
MALE STERILIZATION Men can have an operation to avoid having any more children. Or is it possible to get sterilized?
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having intercourse on the days of the month she is most likely to get pregnant. Or is it possible to get advice on using the rhythm method?
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
MEDICINAL PLANTS (stem, root, leaves) are products that can be used to delay pregnancy.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
AMULET (cord with a knot) are things couples can use to delay pregnancy.
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW
OTHER METHOD (SPECIFY) ____
1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC
3 AMPPF (Malian Association of Family Protection and Promotion)
4 HEALTH CENTER
5 PHARMACY
6 OTHER (SPECIFY) ____
8 DOESN'T KNOW

305. What is the major problem (if there is one) with using (METHOD)?

PILL Women can take a pill every day to avoid becoming pregnant.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
IUD Women can have a loop or a coil in plastic or metal placed inside their uterus by a doctor or a nurse to avoid becoming pregnant.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
INJECTIONS Women can have an injection by a health provider to avoid becoming pregnant during one or more months.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
CREAM, JELLY, SPONGE Some women put a diaphragm, a sponge, effervescent pills, jelly or cream before having sexual intercourse to avoid getting pregnant.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
FEMALE STERILIZATION Women can have an operation to avoid having any more children.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
MALE STERILIZATION Men can have an operation to avoid having any more children.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid pregnancy by not having intercourse on the days of the month she is most likely to get pregnant.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
MEDICINAL PLANTS (stem, root, leaves) are products that can use to delay pregnancy.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
AMULET (cord with a knot) are things couples can use to delay pregnancy.
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW
OTHER METHOD (SPECIFY) _____
01 NOTHING
02 ACCESSIBILITY/AVAILABILITY
03 COST
04 SECONDARY EFFECTS
05 INEFFECTIVE METHOD
06 HUSBAND OPPOSED
07 OTHER (SPECIFY) _____
98 DOESN'T KNOW

306. CHECK 303:

NOT A SINGLE "YES" (NEVER USED) IN 302 OR NO "YES" IN 303 (NEVER USED) (GO TO 307)
AT LEAST ONE "YES" (EVER USED) (GO TO 309)

307. Have you ever used anything or tried in any way to delay or avoid pregnancy?

YES 1
NO 2 (GO TO 312)

308. What did you do or use?
CORRECT 302-303 AND GET INFORMATION FOR 304 (AND 305 IF NECESSARY).

(SPECIFY) ____

309. CHECK 303:

USED RHYTHM METHOD (GO TO 310)
NEVER USED RHYTHM METHOD (GO TO 311)

310. When you used the rhythm method the last time, how did you measure to determine the days when you should abstain?

CALCULATED THE DAYS ON A CALENDAR 1
BASED ON BODY TEMPERATURE 2
BASED ON THE CERVICAL MUCOUS METHOD 3
BASED ON BODY TEMPERATURE AND BASED ON THE CERVICAL MUCOUS METHOD 4
OTHER (SPECIFY) _____5

311. How many living children did you have when you used a method to avoid becoming pregnant for the first time?
IF NONE RECORD '00'

NUMBER OF CHILDREN _____

312. CHECK 227 AND 303:

PREGNANT (GO TO 317)
NOT PREGNANT AND NOT USING (GO TO 316)
NOT PREGNANT AND USING (GO TO 313)

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

YES 1
NO 2 (GO TO 316)

314. What method(s) are you using?

PILL 01
IUD 02
INJECTIONS 03
CREAM/FOAM/JELLY 04
CONDOM 05
FEMALE STERILIZATION 06 (GO TO 315A)
MALE STERILIZATION 07 (GO TO 315A)
RHYTHM METHOD 08
WITHDRAWAL 09 (GO TO 321)
ABSTINENCE 10 (GO TO 321)
MEDICINAL PLANTS 11
AMULET 12
OTHER (SPECIFY) ____13 (GO TO 321)
DOESN'T KNOW/NOT SURE 98 (GO TO 321)

315. Where did you (your partner) get (advice for) (CURRENT METHOD) the last time?

1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC (GO TO 321)
3 AMPPF (Malian Association of Family Protection and Promotion) (GO TO 321)
4 HEALTH CENTER (GO TO 321)
5 PHARMACY (GO TO 321)
6 OTHER (SPECIFY) _____ (GO TO 321)
8 DOESN'T KNOW (GO TO 321)

315A. Where did you (or your partner) get sterilized?

1 PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers)
2 FREE CLINIC (GO TO 321)
3 AMPPF (Malian Association of Family Protection and Promotion) (GO TO 321)
4 HEALTH CENTER (GO TO 321)
5 PHARMACY (GO TO 321)
6 OTHER (SPECIFY) _____ (GO TO 321)
8 DOESN'T KNOW (GO TO 321)

316. Why don't you use one of the methods I just described to delay or space your pregnancies?

BAD FOR HEALTH 01
BREAST FEEDING 02
STERILIZED OR MENOPAUSAL 03
LACK OF INFORMATION 04
DIFFICULTY ACCESSING 05
HUSBAND OPPOSED 06
RELIGION 07
POLYGAMOUS HUSBAND 08
HAS NOT YET KNOWN A MAN 09
FEAR OF BEING JUDGED BADLY 10
DIVORCED, SEPARATED, WIDOW 11
UNDECIDED 12
HUSBAND ABSENT 13
WANTS A CHILD 14
STERILE 15
OTHER (SPECIFY) _____16

317. Do you intend to use a method or a way to avoid getting pregnant in the future?

YES 1
NO 2 (GO TO 321)
DOESN'T KNOW 8 (GO TO 321)

318. Which method do you prefer to use?

PILL 01
IUD 02
INJECTIONS 03
CREAM/FOAM/JELLY 04
CONDOM 05
FEMALE STERILIZATION 06
MALE STERILIZATION 07
RHYTHM METHOD 08
WITHDRAWAL 09
ABSTINENCE 10
MEDICINAL PLANTS 11
AMULET 12
OTHER (SPECIFY) ____88
DOESN'T KNOW/NOT SURE 98

319. Do you intend to use a method or a way to avoid getting pregnant in the next 12 months?

YES 1
NO 2
DOESN'T KNOW 8

320. Where would you go to get advice or to get materials for (PREFERRED METHOD)?

PMI (protection maternelle et infantile - a program created in France to give free care to expecting/recent mothers) 1
FREE CLINIC 2
AMPPF (Malian Association of Family Protection and Promotion) 3
HEALTH CENTER 4
PHARMACY 5
OTHER (SPECIFY) ____ 6

321. There are women who do not want to get pregnant but do not use any methods (that I've just cited) to delay or space pregnancies. In your opinion, what are the main reasons for this?
CIRCLE ALL THE RESPONSES GIVEN.
PROBE: Other reasons?

LACK OF INFORMATION 1
TOO EXPENSIVE 1
OPPOSITION TO FAMILY PLANNING 1
LACK OF INFORMATION 1
DIFFICULTY ACCESSING 1
HUSBAND OPPOSED 1
RELIGION 1
FATALISM/LACK OF INTEREST 1
OTHER PEOPLE OPPOSED 1
FEAR OF BEING JUDGED BADLY 1
DIVORCED, SEPARATED, WIDOW 11
OTHER (SPECIFY) _____1
DOESN'T KNOW 1

322. Do you think that it is acceptable that information about spacing of births be provided on radio or television?

YES 1
NO 2
DOESN'T KNOW 8

SECTION 4. HEALTH AND BREAST FEEDING OF CHILDREN UNDER 5 YEARS

401. CHECK 216:

ONE OF MORE BIRTHS SINCE MARCH 1982. WRITE THE LINE NUMBER, THE NAME AND THE SURVIAL STATE OF EACH BIRTH SINCE MARCH 1982 IN TABLE 3 BEGINNING WITH THE LAST BIRTH.

REPEAT SECTION 4 FOR THE FOUR MOST RECENT BIRTHS SINCE MARCH 1982
NO LIVE BIRTH SINCE MARCH 1982 (GO TO SECTION 5)

LINE NUMBER ____
NAME____
LIVING____
DEAD____

402. When you were pregnant with (NAME) did you have a prenatal consultation?
IF YES: Who did you consult the first time?
PROBE AND CIRCLE THE CODE OF THE MOST QUALIFIED PERSON

DOCTOR 1
MID-WIFE, NURSE, AUX. 2
HOSPITAL, PMI, FREE CLINIC 3
DOULA 4
TRADITIONAL BIRTHER 5
OTHER (SPECIFY) ______6

403. When you were pregnant with (NAME) did you receive an injection to protect your child from tetanus?

YES 1
NO 2
DOESN'T KNOW 8

404. Who assisted when you delivered (NAME)?
PROBE AND CIRCLE THE CODE OF THE MOST QUALIFIED PERSON.

DOCTOR 1
MID-WIFE, NURSE, AUX. 2
HOSPITAL, PMI, FREE CLINIC 3
DOULA 4
TRADITIONAL BIRTHER 5
OTHER (SPECIFY) _____6
NO ASSISTANCE 8

405. Have you ever breast fed (NAME)?

YES 1 (GO TO 406)
NO 2 (GO TO 408)

406. IF ALIVE: Do you still breast feed (NAME)?
(ONLY FOR MOST RECENT BIRTH)

YES 1 (GO TO 408)
NO 2 (GO TO 407)

407. How many months did you breast feed (NAME)?

MONTHS____
UNTIL DEATH 96

408. Has your period started again?
(ONLY FOR MOST RECENT BIRTH)

YES 1 (GO TO 409)
NO 2 (GO TO 410)

409. How long after (NAME'S) birth did you start having your period?

MOST RECENT BIRTH:
MONTHS__ (GO TO 411)
OTHER BIRTHS:
NEVER STARTED AGAIN 96
MONTHS__ (GO TO 411)

410. Have you begun having sexual intercourse again since the birth of (NAME)?
(ONLY FOR MOST RECENT BIRTH)

IF NO MORE BIRTHS (GO TO 412)

YES 1 (GO TO 411)
NO 2 (GO TO 402 FOR NEXT BIRTH)

411. How many months after the birth of (NAME) did you have sex?
GO TO 402 FOR THE NEXT BIRTH OR GO TO 412 IF THERE ARE NO MORE BIRTHS

MONTHS____

412. CHECK 406 FOR THE LAST BIRTH:

STILL BREAST FEEDING (GO TO 413)
OTHER CASES (GO TO 418)

413. How many times did you breastfeed last night between sunset and sunrise?

NUMBER OF TIMES____

WHEN THE CHILD CRIED 96
DOESN'T KNOW 98

414. How many times did you breastfeed your child during the day?

NUMBER OF TIMES____

WHEN THE CHILD CRIED 96
DOESN'T KNOW 98

415. Did you feed (NAME OF LAST CHILD) any of the following liquids last night or yesterday? READ THE LIST OF CATEGORIES.

Water?
Juice?
Powdered milk?
Cow or goat milk?
Quinqueliba?
Other liquid? (SPECIFY) ____
Grain broth?
Solid food?

WATER
YES 1
NO 2
JUICE
YES 1
NO 2
POWDERED MILK
YES 1
NO 2
COW OR GOAT MILK
YES 1
NO 2
QUINQUELIBA
YES 1
NO 2
OTHER LIQUID (SPECIFY) ____
YES 1
NO 2
GRAIN BROTH
YES 1
NO 2
SOLID FOOD
YES 1
NO 2

416. CHECK 415:

OTHER FOOD OR LIQUID WAS GIVEN (AT LEAST ONE "YES" IN 415) (GO TO 417)
NO OTHER FOOD OR LIQUID WAS GIVEN (NO "YES" IN 415) (GO TO 418)

417. Did you give these liquids in a bottle?

YES 1
NO 2

418. When you were pregnant with (NAME OF LAST CHILD) did you want to have this child at that time, or wait until later, or not have other children at all?

AT THAT TIME 1
LATER 2
NOT HAVE ANY 3

419. CHECK 401:

WRITE THE NAME AND THE SURVIVAL STATE OF EACH BIRTH SINCE MARCH 1982 IN TABLE 4, BEGINNING WITH THE LAST BIRTH. THE FIRST LINE OF TABLE 4 SHOULD BE EXACTLY THE SAME AS THAT OF TABLE 3. ONLY ASK QUESTIONS OF LIVING CHILDREN.

(REPEAT FOR 4 BIRTHS)

LINE NUMBER_____
NAME_____
LIVING____
DEAD____

420. Has (NAME) ever been vaccinated against illnesses?

YES 1
NO 2
DOESN'T KNOW 8

421. Do you have a health card for (NAME)?
IF YES: May I see it?

YES, SEEN 1
YES, NOT SEEN 2
NO CARD 3 (GO TO 423)

422. THE DATES FOR EACH VACCINATION FROM THE CARD.

BCG
DAY____
MONTH____
YEAR____
DPT 1
DAY____
MONTH____
YEAR____
POLIO 1
DAY____
MONTH____
YEAR____
DPT 2
DAY____
MONTH____
YEAR____
POLIO 2
DAY____
MONTH____
YEAR____
DPT 3
DAY____
MONTH____
YEAR____
POLIO 3
DAY____
MONTH____
YEAR____
MEASLES
DAY____
MONTH____
YEAR____
TET 1
DAY____
MONTH____
YEAR____
TET2
DAY____
MONTH____
YEAR____
TETR
DAY____
MONTH____
YEAR____
YELLOW FEVER
DAY____
MONTH____
YEAR____
MEN
DAY____
MONTH____
YEAR____

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

YES 1 (GO TO 425)
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2 (GO TO 427)
DOESN'T KNOW 8 (GO TO 427)

425. Did you or someone else do something to treat the diarrhea?

YES 1
NO 2 (GO TO 427)
DOESN'T KNOW 8 (GO TO 427)

426. What was done to treat the diarrhea?
RECORD '1' FOR ALL THE TREATMENTS MENTIONED.

ORT 1
SUGARY-SALTY SOLUTION (HOMEMADE) 1
RICE BROTH 1
INTREVEINOUS FOOD 1
BAOBAB FRUIT 1
MEDICINAL PLANTS 1
GANIDAN SYRUP AND OTHER PHARMACEUTICAL PRODUCTS 1
HOSPITAL, PMI, FREE CLINIC 1
OTHER 1
DOESN'T KNOW 1

427. Has (NAME) had a fever in the last four weeks?

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

428. Did you do something to treat the fever?

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

429. What was done to treat the fever?
CODE '1' FOR ALL THE TREATMENTS MENTIONED.

NIVAQUINE/CH. 1
ASPIRIN 1
OTHER PILL 1
INJECTION 1
HOSPITAL/PMI/FREE CLINIC 1
MEDICINAL PLANTS 1
CINALES 1
OTHERS (SPECIFY) ____1
DOESN'T KNOW 1

430. Did (NAME) have difficulty breathing or rapid breathing in the last four weeks?

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

431. Did you or someone else do something to treat the problem?

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

432. What was done to treat the problem?

ANTIBIOTIC 1
SYRUP 1
PILL 1
INJECTION 1
HOSPITAL/PMI/FREE CLINIC 1
OTHERS (SPECIFY) ____1
DOESN'T KNOW 1

433. Has (NAME) had the measles?

YES 1
NO 2 (GO TO 436)
DOESN'T KNOW 8 (GO TO 436)

434. Did you or someone else do something to treat the measles?

YES 1
NO 2 (GO TO 436)
DOESN'T KNOW 8 (GO TO 436)

435. What was done to treat the measles?

ANTIBIOTIC 1
SYRUP 1
PILL 1
INJECTION 1
HOSPITAL/PMI/FREE CLINIC 1
OTHERS (SPECIFY) _____1
DOESN'T KNOW 1

436. Does (NAME) have one of the following handicaps?

ONE UPPER OR LOWER LIMB SHORT OR PARALYZED 1
TWO UPPER OR LOWER LIMBS SHORT OR PARALYZED 2
SUFFERS FROM LAMENESS 3
NOTHING 4 (GO TO NEXT BIRTH OR IF NO MORE GO TO 438)

437. Did this handicap follow:

AN ILLNESS 1
AN ILLNESS AND INJECTION 2
BIRTH 3

GO TO THE NEXT BIRTH OR IF NO MORE (GO TO 438)

438. CHECK 426:

NO CHILD GOT TRO (GO TO 439)
AT LEAST ONE CHILD GOT TRO (GO TO SECTION 5)

439. Have you ever heard about a product called (ORT) that you can get to treat diarrhea?

YES 1
NO 2

SECTION 5. MARRIAGE

501. Have you ever been or are you currently married or you live with a man?

YES 1
NO 2 (GO TO 511)

502. Are you married, widowed, divorced or separated, do you live with or have you lived with someone?

MARRIED/LIVES WITH SOMEONE 1 (GO TO 508)
WIDOWED 2 (GO TO 508)
DIVORCED 3 (GO TO 508)
SEPARATED 4 (GO TO 508)
HAS LIVED WITH SOMEONE 5 (GO TO 508)

503. Is your husband/partner living with you now or is he staying elsewhere?

LIVE TOGETHER 1
LIVES ELSEWHERE 2

504. Besides yourself, does your husband/partner have other wives or does he live with other women as if he were married?

YES 1
NO 2 (GO TO 507)

505. How many wives or partners does your husband currently have?
(6=6 AND MORE)

NUMBER OF WIVES OR PARTNERS____
DOESN'T KNOW 8

506. What is your rank: Are you the first, second, third...wife?

RANK____ (GO TO 508)
DOESN'T KNOW RANK 8

507. At the beginning of this marriage or union did your husband/partner have other wives besides yourself?

IF THERE WERE NO OTHER WIVES, RECORD '0'. IF 6 OR MORE, RECORD '6'.

NUMBER____
DOESN'T KNOW 8

508. Is this/was this your first marriage (union)?

YES 1
NO 2

509. In which month and in which year did you begin to live with your husband/partner?

MONTH_____
DOESN'T KNOW MONTH 98
YEAR_____ (GO TO 512)
DOESN'T KNOW YEAR 98
MARRIAGE NOT CONSUMMATED 96 (GO TO 512)

510. How old were you when you began living with him?

AGE YEARS____ (GO TO 512)

511. Did you already have a boyfriend?

YES 1
NO 2 (GO TO 516)

512. How old were you when you had sexual intercourse for the first time?

AGE_____
NEVER HAD 96 (GO TO 516)

513. How long has it been since you last had sexual intercourse (if you already had it)?

NUMBER OF DAYS 1____
NUMBER OF WEEKS 2____
NUMBER OF MONTHS 3____
BEFORE THE LAST BIRTH 996 (GO TO 516)

514. CHECK 223 AND 313:

PREGNANT (GO TO 516)
NOT PREGNANT (GO TO 515)

515. Would you be upset if you found out that you were pregnant in the coming weeks?

YES 1
NO 2

516. PRESENCE OF OTHER PEOPLE:

CHILDREN LESS THAN 10 YEARS
YES 1
NO 2
HUSBAND
YES 1
NO 2
OTHER MEN
YES 1
NO 2
OTHER WOMEN
YES 1
NO 2

SECTION 6. FERTILITY PREFERENCES

601. CHECK 502:

CURRENTLY IN UNION (GO TO 602)
OTHER CASE (GO TO 610)

Now I would like to ask you questions about the future.

602. CHECK 223:

NOT PREGNANT OR NOT SURE: Would you like to have (a/another) child,?

PREGNANT: After the child that you are expecting, would you like to have (a/another) child?

YES 1
NO 2 (GO TO 604)
NOT SURE/DOESN'T KNOW 8 (GO TO 604)

603. How long would you like to wait from now before the birth of (a/another) child (outside of the current pregnancy)?

NUMBER OF MONTHS ____
OTHER (SPECIFY) ____96
DOESN'T KNOW 98

604. In your opinion what is the best interval between two births?

NUMBER OF MONTHS____
OTHER (SPECIFY) ____96
DOESN'T KNOW 98

605. After a birth, how long should a couple wait before having sexual intercourse again?

NUMBER OF DAYS 1_____
NUMBER OF MONTHS 2_____
NUMBER OF YEARS 3_____
OTHER (SPECIFY) ____996
DOESN'T KNOW 998

606. In your opinion should a mother wait until she is no longer breastfeeding to have sexual intercourse again?

YES 1
NO 2
DOESN'T KNOW 8

607. Would you say that your husband approves or disapproves of couples that use a method to delay or space pregnancies?

APPROVES 1
DISAPPROVES 2
NO OPINION 3

608. How many times during the past 12 months did you speak with your partner/husband about
methods to delay or space pregnancies?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

609. Would you say that you approve or disapprove of couples that use a method to avoid to delay or space pregnancies?

APPROVE 1
DISAPPROVE 2
NO OPINION 3

610. CHECK 211:

NO CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?

HAS 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?

NUMBER____
OTHER (SPECIFY) ____

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

NUMBER OF BOYS ____
NUMBER OF GIRLS ____
GIRLS DEPEND ON GOD 94
BOYS DEPEND ON GOD 95
OTHER (SPECIFY) ____96
DOESN'T KNOW 98

612. In your opinion, what are the advantages of having many children? (CITE 3)

(SPECIFY)____

613. What are the disadvantages of having many children? (CITE 3)

(SPECIFY)____

614. In your opinion, how many children are considered as a lot for a woman?

NUMBER ____
DOESN'T KNOW 98

615. Which do you prefer, many children or fewer children?

MANY CHILDREN 1
FEWER CHILDREN 2

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S PROFESSIONAL ACTIVITY

701. CHECK 501 AND 502:

NOT SINGLE OR LIVED WITH A MAN: ASK QUESTIONS ABOUT THE CURRENT /MOST RECENT HUSBAND/PARTNER (GO TO 702)
OTHER CASES (GO TO 715)

702. Did your (last) husband/partner attend school?

YES 1
NO 2 (GO TO 706)
DOESN'T KNOW 8 (GO TO 706)

703. What was the highest level of school that he achieved?

PRIMARY 1
SECONDARY 2
SUPERIOR 3
DOESN'T KNOW 8 (GO TO 706)

704. What was the last year that he achieved at this level?

YEAR___
DOESN'T KNOW 98

705. CHECK 703:

PRIMARY (GO TO 706)
SECONDARY OR HIGHER (GO TO 707)

706. Can he read a letter or a newspaper in any language?

YES 1
NO 2
DOESN'T KNOW 8

707. What kind of work did/does he mainly do?

_____

708. CHECK 707:

DOES NOT/DID NOT WORK IN AGRICULTURE (GO TO 709)
WORKS/WORKED IN AGRICULTURE (GO TO 709)
NEVER WORKED (GO TO 712)

709. Does/did he receive a regular weekly or monthly salary?

YES 1
NO 2 (GO TO 712)
DOESN'T KNOW 8 (GO TO 712)

710. Does your husband/partner work mainly on his own land or on family land, or does he work on land that he rents from someone else, or does he work on someone else's land?

OWN/FAMILY LAND 1
SOMEONE ELSE'S LAND 2

711. Does or did he work mainly to be paid in money or in kind?

MONEY 1
KIND 2
DOESN'T KNOW 8

712. Before marriage (living regularly with a partner), did you work regularly to earn money other than working in a family field or business?

YES 1
NO 2 (GO TO 714)
DOESN'T KNOW 8 (GO TO 714)

713. Did you give most of the money you earned to your family or did you keep most of it for yourself?

FAMILY 1
HERSELF 2
EQUALLY 3

714. (Since you started living with a partner), have you worked regularly to earn money other than working in a family field or business?

YES 1 (GO TO 717)
NO 2 (GO TO 718)

715. Have you ever worked regularly to earn money other than working in a family field or business?

YES 1
NO 2 (GO TO 718)

716. Did you give most of the money you earned to your family or did you keep most of it for yourself?

FAMILY 1
HERSELF 2
EQUALLY 3

717. Outside of working the field or in a family business, do you work to make money?

YES 1
NO 2

718. RECORD THE TIME:

HOUR____
MINUTE____

SECTION 8. WEIGHT AND HEIGHT

801. CHECK TABLE 1:

FOR EACH LIVING CHILD BORN SINCE MARCH 1984 (THAT IS TO SAY 3 TO 36 MONTHS OLD) RECORD THE LINE NUMBER, THE BIRTH DATE, THE WEIGHT AND THE HEIGHT.

FIRST NAME AND LAST NAME____
LINE NUMBER____
MONTH/BIRTH____
YEAR/BIRTH 19____
HEIGHT IN CM____
WEIGHT IN GR____

OBSERVATIONS____

INTERVIEWER'S OBSERVATIONS

RESPONDENT COMMENTS ____

SPECIFIC QUESTIONS ____

OTHER ASPECTS ____

INTERVIEWER
NAME____
DATE____

SUPERVISOR'S OBSERVATIONS_____
NAME____
DATE____

OFFICE EDITOR'S OBSERVATIONS ____
NAME ____
DATE____

KEYED BY____
DATE____