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DEMOGRAPHIC AND HEALTH SURVEYS - MOZAMBIQUE 1997 -WOMEN'S QUESTIONNAIRE

IDENTIFICATION

PLACE NAME ________
NAME OF HOUSEHOLD HEAD_______
CLUSTER NUMBER_______
HOUSEHOLD NUMBER_______
PROVINCE_______

URBAN/RURAL:

URBAN 1
RURAL 2

LARGE CITY/SMALL CITY/VILLAGE/RURAL AREA:

LARGE CITY 1
SMALL CITY 2
VILLAGE 3
RURAL AREA 4

NAME AND LINE NUMBER OF WOMAN______

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE______
INTERVIEWER'S NAME_____

RESULT______

1 COMPLETED
2 ABSENT
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED/INCOMPLETE
6 INCAPACITATED
7 OTHER (SPECIFY) _____

NEXT VISIT
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR_____
NAME______
RESULT_____

TOTAL NUMBER OF VISITS______

LANGUAGE OF SURVEY: PORTUGUESE 01

LANGUAGE OF THE INTERVIEW______

WAS IT NECESSARY TO HAVE AN INTERPRETER?

YES 1
NO 2

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____

KEYED BY_____

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME:

HOUR_____
MINUTES____

102. For most of the time until you were 12 years old, did you live in a city, village or rural area?

CITY 1
VILLAGE 2
RURAL AREA 3

103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

YEARS____

ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)

104. Before you moved here, did you live in a city, village or rural area?

CITY 1
VILLAGE 2
RURAL AREA 3

105. In what month and year were you born?

MONTH_____
DOESN'T KNOW MONTH 98
YEAR_____
DOESN'T KNOW YEAR 98

106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

AGE COMPLETED IN YEARS ______

107. Have you attended school?

YES 1 (GO TO 108)
NO 2

107A. Have you attended a literacy course?

YES 1 (GO TO 114)
NO 2 (GO TO 114)

108. What is the highest level of school you attended?

PRIMARY 1
SECONDARY 2
HIGH SCHOOL 3
HIGHER/ TEACHER PREP 4
TECHNICAL ELEMENTARY 5
TECHNICAL BASIC 6
TECHNICAL ADVANCED 7

109. What is the highest grade/year you completed at that level?

GRADE_____

110. CHECK 106:

AGE 24 OR YOUNGER (GO TO 111)
AGE 25 OR OLDER (GO TO 113)

111. Are you currently attending school?

YES 1 (GO TO 113)
NO 2

112. What was the main reason you stopped attending school?

GOT PREGNANT 01
GOT MARRIED 01
TO CARE FOR YOUNGER CHILDREN 03
FAMILY NEEDED HELP ON FARM/PLANTATION OR IN BUSINESS 04
DOESN'T HAVE MONEY 05
NEEDED TO EARN MONEY 06
HAD ENOUGH SCHOOLING 07
DID NOT PASS ENTRANCE EXAMS 08
DIDN'T LIKE TO STUDY 09
SCHOOL NOT ACCESSIBLE/TOO FAR 10
SCHOOL WAS DESTROYED DURING WAR 11
FAMILY DISLOCATED DURING WAR 12
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98

113. CHECK 108:

PRIMARY (GO TO 114)
SECONDARY OR HIGHER (GO TO 115)

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

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 116)

115. Do you usually read a newspaper or magazine at least once a week?

YES 1
NO 2

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

YES 1
NO 2

117. Do you usually watch television at least once a week?

YES 1
NO 2

118. What is your religion?

RELIGION (SPECIFY) _____

119. What language did you grow up speaking?

LANGUAGE (SPECIFY) _____

120. CHECK QUESTION 4 IN THE HOUSEHOLD QUESTIONNAIRE:

THE WOMAN INTERVIEWED IS NOT A USUAL RESIDENT (GO TO 121)
THE WOMAN INTERVIEWED IS A USUAL RESIDENT (GO TO 201)

Now I would like to ask about the place in which you usually live.

121. What is the name of the place in which you usually live?
Is that a city, village or rural area?

NAME OF PLACE_____
CITY 1
VILLAGE 2
RURAL AREA 3

122. In which province is that located?

NIASSA 01
CABO DELGADO 02
NAMPULA 03
ZAMBÉZIA 04
TETE 05
MANICA 06
SOFALA 07
INHAMBANE 08
GAZA 09
MAPUTO 10
CIDADE DE MAPUTO 11

123. Now I would like to ask about the household in which you usually live.
What is the main source of drinking water for members of your household?

PIPED WATER
INTO RESIDENCE/YARD 11 (GO TO 124A)
INTO NEIGHBOR'S RESIDENCE/YARD 12
PUBLIC TAP 13
WELL WATER
WELL IN YARD/PLOT 21 (GO TO 124A)
WELL IN NEIGHBOR'S YARD/PLOT 22
PUBLIC WELL 23
SURFACE WATER
CREEK 31
RIVER 32
LAKE 33
DAM 34
RAINWATER 41 (GO TO 124A)
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 124A)
OTHER (SPECIFY) ___ 96

124. How long does it take to go there, get water, and come back?

MINUTES____
ON PREMISES 996

124A. How much did you pay for that water in the last month?

COST (BY 1000 M) 1 _____

FREE 9996

DOESN'T KNOW 9998

125. What kind of toilet facility does your household have?

FLUSH TOILET 1
TOILET WITHOUT FLUSHING SYSTEM 2
LATRINE 3
NO FACILITY/BUSH 31 (GO TO 20)
OTHER (SPECIFY) _____ 96

125A. Is the bathroom used by only the members of your household or other people?

ONLY BY MEMBERS 1
OTHER PEOPLE 2

126. Does your household have:

Electricity?
Radio?
Television?
A telephone?
A refrigerator?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2

127. What is the main material of the floor of your home?

NATURAL FLOOR
EARTH 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
ADOBE 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 33
OTHER (SPECIFY) _____ 96

128. Does any member of your household own:

A bicycle?
A motorcycle?
A car?

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

TABLE OF LEVEL OF EDUCATION OF IDSM CODES (DEMOGRAPHIC AND HEALTH SURVEYS OF MOZAMBIQUE):

CURRENT SYSTEM:
1 PRIMARY 1ST GRADE 1-5
1 PRIMARY 2ND GRADE 6-7
2 SECONDARY 8-10
3 HIGH SCHOOL 11-12
4 HIGHER/ TEACHING PREP 1-7
5 TECHNICAL ELEMENTARY 1-3
6 TECHNICAL BASIC 1-3
7 TECHNICAL ADVANCED 1-3
OLD SYSTEM:
1 PRIMARY 0-4
1 PREPARATORY CYCLE 5-6
2 SECONDARY 7-9
3 HIGH SCHOOL 10-11
4 HIGHER/ TEACHING PREP 1-7
5 TECHNICAL ELEMENTARY 1-3
6 TECHNICAL BASIC 1-3
7 TECHNICAL ADVANCED 1-3
COLONIAL SYSTEM:
PRIMARY 0-4
PREPARATORY CYCLE 1-2
SECONDARY 2ND CYCLE 3-5
SECONDARY 3RD CYCLE 6-7
HIGHER/ TEACHING PREP 1-7
TECHNICAL ELEMENTARY 1-3
PREPARATORY SECTION 1-3
INSTITUTE/COLLEGE 1-3

SECTION 2. REPRODUCTION

Now I would like to ask about all the births you have had during your life (and if the children are still alive).

201. 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 live in another place?

YES 1
NO 2 (GO TO 206)

205. How many sons are living somewhere else?
And how many daughters are living somewhere else?
IF NONE RECORD '00'

SONS ELSEWHERE_____
DAUGHTERS ELSEWERE_____

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

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______

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

YES
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210. CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 227)

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.

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

NAME _____

213. Where any of these births twins?
IF YES, which ones?

SINGULAR 1
MULTIPLE 2

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

MALE 1
FEMALE 2

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

MONTH____
YEAR____

216. Is (NAME) still alive?

YES 1
NO 2 (GO TO 219)

217. IF ALIVE: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS_____

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

YES 1 (FIRST BIRTH, GO TO NEXT BIRTH; OTHER BIRTHS, GO TO 220)
NO 2 (FIRST BIRTH, GO TO NEXT BIRTH; OTHER BIRTHS, GO TO 220)

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

DAYS 1 _____
MONTHS 2 _____
YEARS 3 _____

220. FROM YEAR OF BIRTH OF (NAME) SUBTRACT YEAR OF PREVIOUS BIRTH. IS THE DIFFERENCE 4 YEARS OR MORE?
[FOR ALL BIRTHS EXCEPT FOR FIRST BIRTH]

YES 1
NO 2 (GO TO NEXT BIRTH)

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?
[FOR ALL BIRTHS EXCEPT FOR FIRST BIRTH]

YES 1
NO 2

222. FROM YEAR OF INTERVIEW SUBTRACT YEAR OF LAST BIRTH. IS THE DIFFERENCE 4 YEARS OR MORE?

YES 1 (GO TO 223)
NO 2 (GO TO 224)

223. Have you had any live births since the birth of (NAME OF LAST BIRTH)?

YES 1
NO 2

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

NUMBERS ARE SAME:
CHECK: FOR EACH BIRTH: YEAR OF BIRTH RECORDED
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED
FOR AGE AT DEATH 12 MONTHS OR 1 YEAR: PROBE TO DETERMINE EXACT NUMBER OF MONTHS
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

225. CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1994. IF NONE, RECORD '0' AND GO TO 227.

227. Are you pregnant now?

YES 1
NO 2 (GO TO 236)
UNSURE 8 (GO TO 236)

228. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS

MONTHS_______

229. At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to have any more children at all?

THEN 1
LATER 2
DID NOT WANT MORE CHILDREN 3

236. What is the day when your last menstrual period started?

DATE, IF GIVEN _____
DAYS AGO 1____
WEEKS AGO 2____
MONTHS AGO 3 _____
YEARS AGO 4____

IN MENOPAUSE 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

237. Do you think that, between the first day of a woman's period and the first day of her next period, are there certain times when she has a greater chance of becoming pregnant than other times?

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

238. During which times of the monthly cycle does a woman have the greatest chance of becoming pregnant?

DURING HER PERIOD 01
RIGHT AFTER HER PERIOD HAS ENDED 02
IN THE MIDDLE OF THE CYCLE 03
JUST BEFORE HER PERIOD BEGINS 04
OTHER (SPECIFY) ____ 96
DOESN'T KNOW 98

SECTION 3. CONTRACEPTION

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

CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
THEN PROCEED DOWN COLUMN 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. THEN, FOR EACH METHOD WITH CODE '1' OR '2' CIRCLED IN 301 OR 302, ASK 303.

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

01) PILL. Women can take pill every day to avoid pregnancy.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
02) IUD. Women can have a loop or coil placed inside them by a doctor or a nurse to avoid pregnancy.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
03) INJECTABLES. Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
04) IMPLANTS. Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
05) DIAPHRAGM, FOAM, JELLY. Women can place a sponge, suppository, diaphragm, jelly or cream inside themselves before intercourse.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
06) CONDOM. Men can put a rubber sheath on their penis during sexual intercourse.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
07) FEMALE STERILIZATION. (Tubal ligation). Women can have an operation to avoid having any more children.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
08) MALE STERILIZATION. (Vasectomy). Men can have an operation to avoid having any more children.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3(GO TO NEXT METHOD)
09) RHYTHM, PERIODIC ABSTINENCE. Every month that a woman is sexually active, she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
10) WITHDRAWAL. Men can be careful and pull out before climax ejaculating outside of the vagina.
YES, SPONTANEOUS 1
YES, DESCRIPTION 2
NO 3 (GO TO NEXT METHOD)
11) OTHER METHODS. Couples can use other methods or ways to avoid pregnancy. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
SPECIFY ______
YES, SPONTANEOUS 1
NO 3

303. Have you ever used (METHOD)?

01) PILL. Women can take pill every day to avoid pregnancy.
YES 1
NO 2
02) IUD. Women can have a loop or coil placed inside them by a doctor or a nurse to avoid pregnancy.
YES 1
NO 2
03) INJECTABLES. Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
YES 1
NO 2
04) IMPLANTS. Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
YES 1
NO 2
05) DIAPHRAGM, FOAM, JELLY. Women can place a sponge, suppository, diaphragm, jelly or cream inside themselves before intercourse.
YES 1
NO 2
06) CONDOM. Men can put a rubber sheath on their penis during sexual intercourse.
YES 1
NO 2
07) FEMALE STERILIZATION. (Tubal ligation). Women can have an operation to avoid having any more children. Have you ever had an operation to avoid having any (more) children?
YES 1
NO 2
08) MALE STERILIZATION. (Vasectomy). Men can have an operation to avoid having any more children. Has your spouse/partner ever had an operation to avoid having any (more) children?
YES 1
NO 2
09) RHYTHM, PERIODIC ABSTINENCE. Every month that a woman is sexually active, she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
10) WITHDRAWAL. Men can be careful and pull out before climax ejaculating outside of the vagina.
YES 1
NO 2
11) OTHER METHOD(S) (SPECIFY) ____
YES 1
NO 2

304. CHECK 303:

NOT A SINGLE 'YES' (NEVER USED) (GO TO 305)
AT LEAST ONE 'YES' (EVER USED) (GO TO 309)

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

YES 1
NO 2 (GO TO 331)

307. What have you used or done?
CORRECT 303 AND 304 (AND 302 IF NECESSARY)

309. When you used a method for the first time to avoid getting pregnant, how many living children did you have at that time?
IF NONE, RECORD '00'.

NUMBER OF CHILDREN____

310. When you first used family planning, did you want to have another child but at a later time, or did you not want to have another child at all?

WANTED CHILD LATER 1
DID NOT WANT ANOTHER CHILD 2
OTHER (SPECIFY) ____ 6

311. CHECK 303:

WOMAN NOT STERILIZED (GO TO 312)
WOMAN STERILIZED (GO TO 314A)

312. CHECK 227:

NOT PREGNANT OR UNSURE (GO TO 313)
PREGNANT (GO TO 332)

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

YES 1
NO 2 (GO TO 331)

314. Which method are you using?
314A. CIRCLE CODE '07' FOR FEMALE STERILIZATION

PILL 01
IUD 02 (GO TO 326)
INJECTABLES 03 (GO TO 326)
IMPLANTS 04 (GO TO 326)
DIAPHRAGM, FOAM, JELLY 05 (GO TO 326)
CONDOM 06 (GO TO 326)
FEMALE STERILIZATION 07 (GO TO 318)
MALE STERILIZATION 08 (GO TO 318)
RHYTHM, PERIODIC ABSTINENCE 09 (GO TO 323)
WITHDRAWAL 10 (GO TO 326)
OTHER METHODS (SPECIFY) ____ 96 (GO TO 326)

315. May I see the package of pills you are now using?
RECORD NAME OF BRAND IF PACKAGE IS SEEN

PACKAGE SEEN 1 (GO TO 317)
BRAND NAME_____ (GO TO 317)
PACKAGE NOT SEEN 2

316. Do you know the brand name of the pills you are now using?
RECORD NAME BRAND

BRAND NAME________
DOESN'T KNOW 98

317. How much does one packet of pills cost you last time you bought it?

COST (IN METICAL 1000 [MOZAMBICAN CURRENCY]) ____ (GO TO 326)

FREE 996 (GO TO 326)

DOESN'T KNOW 998 (GO TO326)

318. Where did the operation to stop having children/ sterilization take place?

IF SOURCE IS HOSPITAL OR HEALTH CENTER, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE _____
PUBLIC SECTOR
CENTRAL HOSPITAL 11
PROVINCIAL HOSPITAL 12
RURAL HOSPITAL 13
HEALTH CENTER 14
OTHER (SPECIFY) _____ 16
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 21
PRIVATE DOCTOR 23
PRIVATE NURSE 24
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98

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

YES 1
NO 2 (GO TO 321)

320. Why do you regret the operation?

RESPONDENT WANTS ANOTHER CHILD 01
PARTNER WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
CHILD DIED 04
OTHER (SPECIFY) _____ 96

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

MONTH___ (GO TO 327)
YEAR____ (GO TO 327)

323. How do you determine which days of your monthly cycle not to have sexual relations?

BASED ON CALENDAR 01
BASED ON BODY TEMPERATURE 02
BASED ON CERVICAL MUCUS 03
BASED ON BODY TEMPERATURE AND CERVICAL MUCUS 04
NO SPECIFIC SYSTEM 05
OTHER (SPECIFY) _____ 96

326. For how many months have you been using (METHOD)?
IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS ______
8 YEARS OR LONGER 96

327. CHECK 314:
CIRCLE METHOD CODE:

PILL 01
IUD 02
INJECTABLES 03
IMPLANTS 04
DIAPHRAGM, FOAM, JELLY 05
CONDOM 06
FEMALE STERILIZATION 07 (GO TO 329A)
MALE STERILIZATION 08 (GO TO 329A)
RHYTHM, PERIODIC ABSTINENCE 09 (GO TO 332)
WITHDRAWAL 10 (GO TO 332)
OTHER METHODS 96 (GO TO 332)

328. Where did you obtain (METHOD) the last time?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE______
PUBLIC SECTOR
CENTRAL HOSPITAL 11
PROVINCIAL/GENERAL HOSPITAL 12
RURAL HOSPITAL 13
HEALTH CENTER 14
MOBILE CLINIC 15
OTHER (SPECIFY) _____ 16
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 21
PRIVATE DOCTOR 23
PRIVATE NURSE 24
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
MEDICAL STAFF IN THE NEIGHBORHOOD 35
OTHER (SPECIFY) _____ 36

329. Do you know another place where you could have obtained (METHOD) the last time?

YES 1
NO 2 (GO TO 335)

329A. At the time of the sterilization operation, did you know another place where you could have received the operation?

YES 1
NO 2 (GO TO 335)

330. People select the place where they get family planning services for various reasons. What was the main reason you went to (NAME OF PLACE IN Q. 326 OR Q. 318) instead of some other place you know about?
RECORD RESPONSE AND CIRCLE CODE.

RESPONSE ______
ACCESS-RELATED REASONS
CLOSER TO HOME 11 (GO TO 335)
CLOSER TO MARKET/WORK 12 (GO TO 335)
AVAILABILITY OF TRANSPORT 13 (GO TO 335)
SERVICE-RELATED REASONS
STAFF MORE COMPETENT 21 (GO TO 335)
CLEANER FACILITY 22 (GO TO 335)
OFFERS MORE PRIVACY 23 (GO TO 335)
SHORTER WAITING TIME 24 (GO TO 335)
ATTENTIVE TREATMENT 25 (GO TO 335)
USE OF OTHER FACILITIES 26 (GO TO 335)
LOWER COST/CHEAPER 31 (GO TO 335)
WANTED ANONYMITY 41 (GO TO 335)
OTHER (SPECIFY) _____ 96 (GO TO 335)
DOESN'T KNOW 98 (GO TO 335)

331. What is the main reason you are not using a method of contraception to avoid pregnancy?

NOT MARRIED 11
NOT HAVING SEX 21
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
INFECUND/STERILE 24
POSTPARTUM/BREASTFEEDING 25
WANTS MORE CHILDREN 26
PREGNANT 27
RESPONDENT OPPOSED 31
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
KNOWS NO METHOD 41
KNOWS NO SOURCE 42
HEALTH CONCERNS 51
SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COST TOO MUCH 54
INCONVENIENT TO USE 55
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98

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

YES 1
NO 2 (GO TO 335)

333. Where is that?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE______
PUBLIC SECTOR
CENTRAL HOSPITAL 11
PROVINCIAL/GENERAL HOSPITAL 12
RURAL HOSPITAL 13
HEALTH CENTER 14
MOBILE CLINIC 15
OTHER (SPECIFY) ____ 16
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 21
PRIVATE PHARMACY 22
PRIVATE DOCTOR 23
WORKPLACE 25
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26
OTHER SOURCE
SHOP 31
CHURCH 32
FRIEND/RELATIVE 33
MEDICAL STAFF IN THE NEIGHBORHOOD 35
OTHER (SPECIFY) ______36

335. Have you visited a health facility for any reason in the last 12 months?

YES 1
NO 2 (GO TO 337)

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

YES 1
NO 2

337. Do you think that breastfeeding can affect a woman's chance of becoming pregnant?

YES 1
NO 2 (GO TO 401)
DOESN'T KNOW 8

338. Do you think that if a woman is breastfeeding, is it easier or more difficult to become pregnant?

EASIER 1 (GO TO 401)
MORE DIFFICULT 2
DEPENDS 3
DOESN'T KNOW 8

339. CHECK 210:

ONE OR MORE BIRTHS (GO TO 340)
NO BIRTHS (GO TO 401)

340. Have you ever relied on breastfeeding as a method of avoiding pregnancy?

YES 1
NO 2 (GO TO 401)

341. CHECK 227 AND 311:

NOT PREGNANT OR UNSURE AND NOT STERILIZED (GO TO 342)
EITHER PREGNANT OR STERILIZED (GO TO 401)

342. Are you currently relying on breastfeeding to avoid getting pregnant?

YES 1
NO 2

SECTION 4A. PREGNANCY AND BREASTFEEDING

401. CHECK 225:

ONE OR MORE LIVING BIRTHS SINCE JANUARY 1994 (GO TO 402)
NO LIVING BIRTHS SINCE JANUARY 1994 (GO TO 465)

402. ENTER THE LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1994 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL THESE LIVING BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRES)

Now I would like to ask you some more questions about the health of all your living children born in the past three years. (We will talk about each child separately).

403. LINE NUMBER FROM 212:

LINE NUMBER______

404. FROM 212 AND 216:

NAME _____
ALIVE_____
DEAD_____

405. At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have any more children at all?

THEN 1 (GO TO 407)
LATER 2
NO MORE CHILDREN 3 (GO TO 407)

406. How much longer would you like to have waited?

MONTHS 1 _____
YEARS 2 _____

DOESN'T KNOW 998____

407. When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?
IF YES: Who examined you? Anyone else?
RECORD ALL PERSONS THAT EXAMINED RESPONDENT.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER (SPECIFY) ______X
NO ONE Y (GO TO 410)

408. How many months pregnant were you when you first received antenatal care?

MONTHS_____
DOESN'T KNOW 98

409. How many antenatal appointments did you have during this pregnancy?

NUMBER OF TIMES____
DOESN'T KNOW 98

410. When you were pregnant with (NAME), were you given an injection in the arm?

YES 1
NO 2 (GO TO 412)
DOESN'T REMEMBER 8 (GO TO 412)

410A. What was the injection for?

BABY HAD TETANUS 1
OTHER (SPECIFY) 2 _____ (GO TO 412)
DOESN'T KNOW 8 (GO TO 412)

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

NUMBER OF TIMES____
DOESN'T KNOW 8

412. Where did you give birth to (NAME)?

HOME
YOUR HOME 11
MIDWIFE'S HOME 12
PUBLIC SECTOR
HOSPITAL 21
HEALTH CENTER 22
HEALTH POST 23
OTHER PUBLIC (SPECIFY) _____ 26
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY) _____ 36
OTHER (SPECIFY) _____ 96

413. Who assisted with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
AUXILIARY MIDWIFE C
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT D
FRIENDS/RELATIVES E
OTHER (SPECIFY) _____ X
NO ONE Y

414. Around the time of the birth of (NAME) did you have any of the following problems:

Did your regular contractions last more than 12 hours?
Excessive bleeding that was so much that you feared it was life threatening?
A high fever with bad smelling vaginal discharge?
Convulsions not caused by fever?

CONTRACTIONS FOR MORE THAN 12 HOURS
YES 1
NO 2
EXCESSIVE BLEEDING
YES 1
NO 2
HIGH FEVER AND VAGINAL DISCHARGE
YES 1
NO 2
CONVULSIONS
YES 1
NO 2

415. Was (NAME) delivered by caesarean section?

YES 1
NO 2

416. When (NAME) was born was s/he: very large, large, average, small, or very small?

VERY LARGE 1
LARGE 2
AVERAGE 3
SMALL 4
VERY SMALL 5
DOESN'T KNOW 8

417. Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 419)

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

GRAMS FROM CARD 1____
GRAMS FROM RECALL 2____

DOESN'T KNOW 99998

419.Has you period returned since the birth of (NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2

420. Did your period return between the birth of (NAME) and your next pregnancy?
[DO NOT AST FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 424)

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

MONTHS_____
DOESN'T KNOW 98

422. CHECK 227:
RESPONDENT PREGNANT?
[ASK ONLY FOR MOST RECENT BIRTH]

NOT PREGNANT _____
PREGNANT OR UNSURE _____

423. Have you resumed sexual relations since the birth of (NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 425)

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

MONTHS_____
DOESN'T KNOW 98

425.Did you ever breastfeed (NAME)?

YES 1
NO 2 (GO TO 431)

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

IMMEDIATELY 000

HOURS 1___
DAYS 2___

427. CHECK 404:
CHILD ALIVE?

ALIVE (GO TO 428)
DEAD (GO TO 429)

428. Are you still breastfeeding (NAME)?

YES 1 (GO TO 432)
NO 2

429. For how many months did you breastfeed (NAME)?

MONTHS_____
DOESN'T KNOW 98

430. Why did you stop breastfeeding (NAME)?

MOTHER ILL/WEAK 01
CHILD ILL/WEAK 02
CHILD DIED 03
NIPPLE/BREAST PROBLEM 04
NOT ENOUGH MILK 05
MOTHER WORKING 06
CHILD REFUSED 07
WEANING AGE 08
BECAME PREGNANT 09
STARTED USING CONTRACEPTION 10
OTHER (SPECIFY) _____ 96

431. CHECK 404:
CHILD ALIVE?

ALIVE (GO TO 434)
DEAD (GO BACK TO 405 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 440)

432. How many times did you breastfeed since 6pm yesterday until today at 6 am?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF FEEDINGS____

433. Yesterday, how many times did you breastfeed since 6am until 6 pm?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF FEEDINGS____

434. Did (NAME) drink water or other liquids yesterday or last night?

YES 1
NO 2
DOESN'T KNOW 8

435. At any time yesterday or last night, was (NAME) given any of the following:

Plain water?
Sugar water?
Juice?
Herbal Tea?
Powdered Milk?
Fresh Milk?
Other Liquids?
Any foods made from cereal?
Any foods made from potatoes or yams?
Any peanuts or sesame seeds?
Beans?
Eggs, fish, or other poultry?
Meat?
Any other solid or semi-solid foods?

PLAIN WATER
YES 1
NO 2
DOESN'T KNOW
SUGAR WATER
YES 1
NO 2
DOESN'T KNOW 8
JUICE
YES 1
NO 2
DOESN'T KNOW 8
HERBAL TEA
YES 1
NO 2
DOESN'T KNOW 8
POWDERED MILK
YES 1
NO 2
DOESN'T KNOW 8
FRESH MILK
YES 1
NO 2
DOESN'T KNOW 8
ANY OTHER LIQUIDS
YES 1
NO 2
DOESN'T KNOW 8
ANY FOOD MADE FROM CEREALS
YES 1
NO 2
DOESN'T KNOW 8
ANY FOOD MADE FROM POTATO OR YAM
YES 1
NO 2
DOESN'T KNOW 8
ANY PEANUTS OR SESAME SEEDS
YES 1
NO 2
DOESN'T KNOW 8
BEANS
YES 1
NO 2
DOESN'T KNOW 8
EGGS, FISH OR POULTRY
YES 1
NO 2
DOESN'T KNOW 8
MEAT
YES 1
NO 2
DOESN'T KNOW 8
ANY OTHER SOLID OR SEMI-SOLID FOODS
YES 1
NO 2
DOESN'T KNOW 8

436. CHECK 435:
FOOD OR LIQUID GIVEN YESTERDAY?

'YES' TO ONE OR MORE (GO TO 437)
'NO' OR DOESN'T KNOW FOR ALL (GO TO 438)

437. (Aside from breastfeeding), how many times did (NAME) eat yesterday, including both meals and snacks?
IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES_______
DOESN'T KNOW 8

438. On how many days during last seven days was (NAME) given any of the following:

Plain water?
Any kind of milk (other than breast milk)?
Liquids other than water or milk?
Food made from cereal?
Food made from potatoes or yams?
Peanuts or sesame seeds?
Beans?
Eggs, fish, or poultry?
Meat?
Other solid or semi-solid foods?

IF DOESN'T KNOW, RECORD '8'.

PLAIN WATER
NUMBER OF DAYS___
DOESN'T KNOW 8
ANY KIND OF MILK (OTHER THAN BREAST MILK)
NUMBER OF DAYS___
DOESN'T KNOW 8
LIQUIDS OTHER THAN PLAIN WATER AND MILK
NUMBER OF DAYS___
DOESN'T KNOW 8
FOOD MADE FROM CEREALS
NUMBER OF DAYS___
DOESN'T KNOW 8
ANY FOOD MADE FROM POTATO OR YAM
NUMBER OF DAYS___
DOESN'T KNOW 8
ANY PEANUTS OR SESAME SEEDS
NUMBER OF DAYS___
DOESN'T KNOW 8
BEANS
NUMBER OF DAYS___
DOESN'T KNOW 8
EGGS, FISH OR POULTRY
NUMBER OF DAYS___
DOESN'T KNOW 8
MEAT
NUMBER OF DAYS___
DOESN'T KNOW 8
ANY OTHER SOLID OR SEMI-SOLID FOODS
NUMBER OF DAYS___
DOESN'T KNOW 8

439. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 440.

SECTION 4B. IMMUNIZATION AND HEALTH

440. ENTER LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1994 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE LIVING BIRTHS, BEGINNING WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRES).

441. LINE NUMBER FROM 212:

LINE NUMBER_____

442. FROM QUESTIONS 212 AND 216:

NAME_____
ALIVE (GO TO 443)
DEAD (GO TO 442 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465)

443. Do you have the vaccination card of (NAME)?
IF YES: May I see it please?

YES, CARD SEEN 1 (GO TO 445)
YES, CARD NOT SEEN 2 (GO TO 447)
NO CARD 3

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

YES 1 (GO TO 447)
NO 2 (GO TO 447)

445. (1) COPY VACCINATION DATES 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.

POLIO 0
DAY ____
MONTH ____
YEAR ____
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 ____

446. Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 1-3, AND/OR MEASLES VACCINE(S).

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY IN QUESTION 448. THEN GO TO 448)
NO 2 (GO TO 449)
DOESN'T KNOW 8 (GO TO 449)

447. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

YES 1
NO 2 (GO TO 449)
DOESN'T KNOW 8 (GO TO 449)

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

448A. A BCG vaccination against tuberculosis, that is, an injection in the arm that leaves a scar?

YES 1
NO 2
DOESN'T KNOW 8

448B. POLIO vaccine, that is drops in the mouth?

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

448C. IF ANSWER IS 'YES': How many times?

NUMBER OF TIMES____

448D. When was the first polio vaccines given just after birth or later?

JUST AFTER BIRTH 1
LATER 2

448E. DPT (triplex) vaccination, that is, an injection usually given at the same time as polio drops?

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

448F. IF ANSWER IS 'YES': How many times?

NUMBER OF TIMES____

448G. A MEASLES vaccine, that is, an injection in the arm to prevent measles?

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2 (GO TO 454)
DOESN'T KNOW 8 (GO TO 454)

451. When (NAME) was ill with a cough,

Did s/he breathe more rapidly than usual?
Did s/he breathe with difficulty?
Did s/he have noisy breathing?
Did s/he eat well and had enough liquids?
Was s/he very ill?

MORE RAPID BREATHING
YES 1
NO 2
DOESN'T KNOW 8
DIFFICULTY BREATHING
YES 1
NO 2
DOESN'T KNOW 8
NOISY BREATHING
YES 1
NO 2
DOESN'T KNOW 8
ATE WELL OR ENOUGH LIQUIDS
YES 1
NO 2
DOESN'T KNOW 8
VERY ILL
YES 1
NO 2
DOESN'T KNOW 8

452. Did you seek advice or treatment for the cough?

YES 1
NO 2 (GO TO 454)

453. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.

PUBLIC SECTOR
CENTRAL HOSPITAL A
PROVINCIAL/GENERAL HOSPITAL B
RURAL HOSPITAL C
HEALTH CENTER D
HEALTH POST E
MOBILE CLINIC F
OTHER (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC H
PRIVATE PHARMACY I
PRIVATE DOCTOR J
OTHER PRIVATE MEDICAL (SPECIFY) ____ K
OTHER SOURCE
SHOP L
TRADITIONAL HEALER M
MEDICAL STAFF IN THE NEIGHBORHOOD N
OTHER (SPECIFY) ____ X

454. Has (NAME) has diarrhea in the last two weeks?

YES 1
NO 2 (GO TO 464)
DOESN'T KNOW 8 (GO TO 464)

455. Was there any blood in the stools?

YES 1
NO 2
DOESN'T KNOW 8

456. On the worst day of the diarrhea, how many bowel movements did (NAME) have?

NUMBER OF BOWEL MOVEMENTS____
DOESN'T KNOW 98

457. Was he/she given the same amount to drink as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DOESN'T KNOW 8

458. Was he/she given the same amount of food to eat as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DOESN'T KNOW 8

458A. CHECK 428:
ARE YOU STILL BREASTFEEDING (NAME)?

YES (GO TO 458B)
NO (GO TO 459)

458B. When (NAME) had diarrhea, did you continue breastfeeding him/her?

YES 1
NO 2

459. When (NAME) had diarrhea, was he/she given any of the following to drink:

A fluid called 'Mixture' (salts ORS)?
Thin watery gruel made from rice?
Soup?
Homemade sugar-salt-water solution?
Traditional medicines such as herbal or root teas?
Infant formula?
Tea, juices, coconut water?
Water?
Any other liquids?

ORS MIXTURE
YES 1
NO 2
DOESN'T KNOW 8
RICE GRUEL
YES 1
NO 2
DOESN'T KNOW 8
SOUP
YES 1
NO 2
DOESN'T KNOW 8
SUGAR-SALT WATER
YES 1
NO 2
DOESN'T KNOW 8
TRADITIONAL MEDICINE/HERBAL OR ROOT TEA
YES 1
NO 2
DOESN'T KNOW 8
INFANT FORMULA
YES 1
NO 2
DOESN'T KNOW 8
TEA, JUICE, OR COCONUT WATER
YES 1
NO 2
DOESN'T KNOW 8
WATER
YES 1
NO 2
DOESN'T KNOW 8
OTHER LIQUIDS
YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2 (GO TO 462)
DOESN'T KNOW 8 (GO TO 462)

461. What was given to treat the diarrhea? Anything else?
RECORD ALL MENTIONED.

PILLS OR SYRUP A
INJECTION B
(I.V) INTRAVENOUS C
HOME REMEDIES/HERBAL MEDICINES E
OTHER (SPECIFY) _____ X

462. Did you seek advice to treat the diarrhea?

YES 1
NO 2 (GO TO 464)

463. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.

PUBLIC SECTOR
CENTRAL HOSPITAL A
PROVINCIAL/GENERAL HOSPITAL B
RURAL HOSPITAL C
HEALTH CENTER D
HEALTH POST E
MOBILE CLINIC F
OTHER (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC H
PRIVATE PHARMACY I
PRIVATE DOCTOR J
OTHER PRIVATE MEDICAL (SPECIFY) _____ K
OTHER SOURCE
SHOP L
TRADITIONAL HEALER M
MEDICAL STAFF IN THE NEIGHBORHOOD N
OTHER (SPECIFY) _____ X

464. GO BACK TO 442 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465.

465. When a child has diarrhea, should he/she be given less to drink than usual, about the same amount, or more than usual?

LESS TO DRINK 1
ABOUT THE SAME AMOUNT 2
MORE TO DRINK 3
DOESN'T KNOW 8

466. When a child has diarrhea, should he/she be given less to eat than usual, about the same amount, or more than usual?

LESS TO EAT 1
ABOUT THE SAME AMOUNT 2
MORE TO EAT 3
DOESN'T KNOW 8

467. When a child is sick with diarrhea, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED.

REPEATED WATERY STOOLS A
ANY WATERY STOOLS B
REPEATED VOMITING C
ANY VOMITING D
BLOOD IN STOOLS E
FEVER F
MARKED THIRST G
NOT EATING/NOT DRINKING WELL H
GETTING SICKER/VERY SICK I
AGITATED/ IRRITABLE J
OTHER (SPECIFY) ____ X
DOESN'T KNOW Z

468. When a child is sick with a cough, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED.

RAPID BREATHING A
DIFFICULTY BREATHING B
NOISY BREATHING C
FEVER D
UNABLE TO DRINK/TO NURSE E
NOT EATING/NOT DRINKING WELL F
GETTING SICKER/VERY SICK G
NOT GETTING BETTER H
CONVULSIONS I
NOISY BREATHING J
VERY THIN CHILD K
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z

469. CHECK 459, ALL COLUMNS:

NO CHILD RECEIVED ORS (ORAL REHYDRATION SALTS) (GO TO 470)
ANY CHILD RECEIVED ORS (ORAL REHYDRATION SALTS) (GO TO 501)

470. Have you ever heard of a special product called 'Mixture' (oral rehydration salts) you can get for the treatment of diarrhea?

YES 1
NO 2

SECTION 5. MARRIAGE

501. PRESENCE OF OTHERS AT THIS POINT:

CHILDREN UNDER 10 YEARS OLD
YES 1
NO 2
HUSBAND/PARTNER
YES 1
NO 2
OTHER MALES
YES 1
NO 2
OTHER FEMALES
YES 1
NO 2

502. Are you currently married or living with a man?

YES, CURRENTLY MARRIED 1 (GO TO 507)
YES, LIVING WITH A MAN 2 (GO TO 507)
NO, NOT IN UNION 3

503. Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?

REGULAR SEXUAL PARTNER 1
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3

504. Have you ever been married or lived with a man?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2 (GO TO 511)
NO 3 (GO TO 515)

506. What is your marital status now: are you widowed, divorced, or separated?

WIDOWED 1 (GO TO 511)
DIVORCED 2 (GO TO 511)
SEPARATED 3 (GO TO 511)

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

LIVES WITH HER 1
STAYING ELSEWHERE 2

508. Does your husband/partner have any other wives besides yourself?

YES 1
NO 2 (GO TO 511)

509. How many wives does he have besides yourself?

NUMBER_____
DOESN'T KNOW 98 (GO TO 511)

510. Are you the first, second... wife?

RANK ____

511. Have you been married or lived with a man only once, or more than once?

ONCE 1
MORE THAN ONCE 2

512. CHECK 511:

MARRIED/LIVED WITH A MAN ONLY ONCE: In what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now we will talk about your first husband/partner. In what month and year did you start living with him?

MONTH_____
DOESN'T KNOW MONTH 98
YEAR______ (GO TO 515)
DOESN'T KNOW YEAR 98

513. How old were you when you started living with him?

AGE_____

Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.

515. When was the last time you had sexual intercourse (if ever)?

NEVER 000 (GO TO 608)

DAYS AGO 1 ____
WEEKS AGO 2 ____
MONTHS AGO 3____
YEARS AGO 4____

BEFORE THE LAST BIRTH 996

516. CHECK 301 AND 302:

KNOWS ABOUT CONDOM: The last time you had sex, was a condom used?

DOESN'T KNOW ABOUT CONDOM: Some men use a condom. The last time you had sex, was a condom used?

YES 1
NO 2 (GO TO 517)
DOESN'T KNOW 8 (GO TO 517)

516A. What was the brand of condom used?

BRAND_____
DOESN'T KNOW 98

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

YES 1
NO 2 (GO TO 519)

518. Where is that?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE_____
PUBLIC SECTOR
CENTRAL HOSPITAL A
PROVINCIAL/GENERAL HOSPITAL B
RURAL HOSPITAL C
HEALTH CENTER D
HEALTH POST E
MOBILE CLINIC F
OTHER (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC H
PRIVATE PHARMACY I
PRIVATE DOCTOR J
OTHER PRIVATE MEDICAL (SPECIFY) _____ K
OTHER SOURCE
SHOP L
TRADITIONAL HEALER M
MEDICAL STAFF IN THE NEIGHBORHOOD N
OTHER (SPECIFY) ______ X

519. How old were you when you first had sexual intercourse?

AGE______
FIRST TIME WHEN MARRIED 96

SECTION 6. FERTILITY PREFERENCES

601. CHECK 314:

NEITHER STERILIZED (GO TO 602)
HE OR SHE STERILIZED (GO TO 612)

602. CHECK 227:

NOT PREGNANT OR UNSURE: Now I have some questions about the future. Would you like to have (a/another) child or would you prefer not to have any (more) children?

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

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 606)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 606)
UNDECIDED/DOESN'T KNOW 8 (GO TO 604)

603. CHECK 227:

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

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

MONTHS 1____
YEARS 2____

NOW 993 (GO TO 606)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 606)
AFTER MARRIAGE 995
OTHER (SPECIFY) ______ 996
DOESN'T KNOW 998

604. CHECK 227:

NOT PREGNANT OR UNSURE (GO TO 605)
PREGNANT (GO TO 607)

605. If you became pregnant in the next few weeks, would you be happy, unhappy, or would it not matter to you very much?

HAPPY 1
UNHAPPY 2
WOULD NOT MATTER 3

606. CHECK 313:
USING A METHOD?

NOT ASKED (GO TO 607)
NOT CURRENTLY USING (GO TO 607)
CURRENTLY USING (GO TO 612)

607. Do you think you will use a method to delay or avoid pregnancy within the next 12 months?

YES 1 (GO TO 609)
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2 (GO TO 610)
DOESN'T KNOW 8 (GO TO 610)

609. Which method would you prefer to use?

PILL 01 (GO TO 612)
IUD 02 (GO TO 612)
INJECTABLES 03 (GO TO 612)
IMPLANTS 04 (GO TO 612)
DIAPHRAGM, FOAM, JELLY 05 (GO TO 612)
CONDOM 06 (GO TO 612)
FEMALE STERILIZATION 07 (GO TO 612)
MALE STERILIZATION 08 (GO TO 612)
PERIODIC ABSTINENCE 09 (GO TO 612)
WITHDRAWAL 10 (GO TO 612)
OTHER METHODS (SPECIFY) ______ 96 (GO TO 612)
UNSURE 98 (GO TO 612)

610. What is the main reason that you think you will not use a method?

NOT MARRIED 11
FERTILITY-RELATED REASONS
INFREQUENT SEX 22 (GO TO 612)
MENOPAUSAL/HYSTERECTOMY 23 (GO TO 612)
INFECUND/STERILE 24 (GO TO 612)
WANTS MORE CHILDREN 26 (GO TO 612)
OPPOSITION TO USE
RESPONDENT OPPOSED 31 (GO TO 612)
HUSBAND OPPOSED 32 (GO TO 612)
OTHERS OPPOSED 33 (GO TO 612)
RELIGIOUS PROHIBITION 34 (GO TO 612)
LACK OF KNOWLEDGE
KNOWS NO METHOD 41 (GO TO 612)
KNOWS NO SOURCE 42 (GO TO 612)
METHOD-RELATED RESONS
HEALTH CONCERNS 51 (GO TO 612)
SIDE EFFECTS 52 (GO TO 612)
LACK OF ACCESS/TOO FAR 53 (GO TO 612)
COST TOO MUCH 54 (GO TO 612)
INCONVENIENT TO USE 55 (GO TO 612)
INTERFERES WITH BODY'S NORMAL PROCESSES 56 (GO TO 612)
OTHER (SPECIFY) ______96 (GO TO 612)
DOESN'T KNOW 98 (GO TO 612)

611. Would you ever use a method if you were married?

YES 1
NO 2
DOESN'T KNOW 8

612. 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?

NUMBER____
OTHER (SPECIFY) ______96 (GO TO 614)

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

NUMBER OF BOYS____
OTHER (SPECIFY) ______96
NUMBER OF GIRLS ____
OTHER (SPECIFY) ______96
NUMBER OF EITHER SEX _____
OTHER (SPECIFY) ______96

614. Would you say that you approve or disapprove of couples using a method to avoid getting pregnant?

APPROVE 1
DISAPPROVE 2
NO OPINION 3

615. Is it acceptable or not acceptable to you for information on family planning to be provided:

On the radio?
On the television?

RADIO
ACCEPTABLE 1
NOT ACCEPTABLE 2
DOESN'T KNOW 8
TELEVISION
ACCEPTABLE 1
NOT ACCEPTABLE 2
DOESN'T KNOW 8

616. In the last month have you heard about family planning:

On the radio?
On the television?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTERS
YES 1
NO 2
LEAFLETS OR BROCHURES
YES 1
NO 2

618. In the last few months have you discussed the practice of family planning with your friends, neighbors, or relatives?

YES 1
NO 2 (GO TO 620)

619. With whom?
Anyone else?
RECORD ALL MENTIONED.

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
MOTHER-IN-LAW G
FRIENDS/NEIGHBORS H
OTHER (SPECIFY) ______X

620. CHECK 502:

YES, CURRENTLY MARRIED (GO TO 621)
YES, LIVING WITH A MAN (GO TO 621)
NO, NOT IN UNION/SINGLE (GO TO 701)

Spouses/partners do not always agree on everything. Now I want to ask you about your husband's/partner's views on family planning.

621. Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy?

APPROVES 1
DISAPPROVES 2
DOESN'T KNOW 8

622. How often have you talked to your husband/partner about family planning in the past year?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

623. Do you think your husband/partner wants 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
DOESN'T KNOW 8

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 502 AND 504:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 702)
FORMERLY MARRIED/LIVED WITH A MAN (GO TO 703)
NEVER MARRIED AND NEVER IN UNION/SINGLE (GO TO 709)

702. How old is your husband/partner?

AGE____

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

YES 1
NO 2 (GO TO 706)

704. What was the highest level of school he attended?

PRIMARY 1
SECONDARY 2
HIGH SCHOOL 3
HIGHER/ TEACHER PREP 4
TECHNICAL ELEMENTARY 5
TECHNICAL BASIC 6
TECHNICAL ADVANCED 7
DOESN'T KNOW (GO TO 706)

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

GRADE_____
DOESN'T KNOW 98

706. What is/was your (last) husband/partner's occupation? That is, what kind of work does/did he mainly do?

OCCUPATION______

707. CHECK 706:

WORKS/WORKED IN AGRICULTURE (GO TO 708)
DOES/DID NOT WORK IN AGRICULTURE (GO TO 709)

708. Does/did your husband/partner work mainly on his own land, on family land, or does/did he rent land, or does/did he work on someone else's land?

HIS LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

709. Aside from your housework, are you currently working?

YES 1 (GO TO 712)
NO 2

710. As you know, some women take up jobs for which they are paid in cash or kind. Others sell thing, have a small business or work on the family farm or in the family business. In the past week, have you done any of these things or any other work?

YES 1 (GO TO 712)
NO 2

711. Have you done any work in the last 12 months?

YES 1
NO 2 (GO TO 801)

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

OCCUPATION_______

713. CHECK 712:

WORKS IN AGRICULTURE (GO TO 714)
DOES NOT WORK IN AGRICULTURE (GO TO 715)

714. Do you work mainly on your own land, on family land, or do you rent land, or do you work on someone else's land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

715. Do you do this work for a member of your family, for someone else, or are you self-employed?

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

716. Do you usually work throughout the year, or do you work seasonally, or only once in a while?

THROUGHOUT THE YEAR 1 (GO TO 718)
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3 (GO TO 719)

717. During the last 12 months, how many months did you work?

NUMBER OF MONTHS _____

718. During the last 12 months, how many days a week did you usually work (in the months that you worked)?

NUMBER OF DAYS____ (GO TO 720)

719. During the last month, approximately how many days did you work?

NUMBER OF DAYS____

720. Do you earn cash for your work?
PROBE: Do you make money for working?

YES 1
NO 2 (GO TO 723)

721. How much do you usually earn for this work?
PROBE: Is this by the day, by the week, or by the month?

(REGISTER EM 1.000 METICAIS [MOZAMBICAN CURRENCY])

PER HOUR 1____
PER DAY 2____
PER WEEK 3____
PER MONTH 4____
OTHER (SPECIFY) ______ 999996

722. CHECK 502:

YES, CURRENTLY MARRIED/YES, LIVING WITH A MAN: Who mainly decides how the money you earn will be used: you, your husband/partner, you and your husband/partner jointly, or someone else?

NO, NOT IN UNION/SINGLE: Who mainly decides how the money you earn will be used: you, someone else or you and someone else jointly?

RESPONDENT DECIDES 1
HUSBAND/PARTNER DECIDES 2
JOINTLY WITH HUSBAND/PARTNER 3
SOMEONE ELSE DECIDES 4
JOINTLY WITH SOMEONE ELSE 5

723. Do you usually work at home or away from home?

AT HOME 1
AWAY FROM HOME 2

724. CHECK 217 AND 218:
IS A CHILD LIVING AT HOME WHO IS AGE 5 OR LESS?

YES (GO TO 725)
NO (GO TO 801)

725. Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?

RESPONDENT 01
HUSBAND/PARTNER 02
OLDER FEMALE CHILD 03
OLDER MALE CHILD 04
OTHER RELATIVES 05
NEIGHBORS 06
FRIENDS 07
SERVANTS/HIRED HELP 08
CHILD IS IN SCHOOL 09
INSTITUTIONAL CHILDCARE 10
HAS NOT WORKED SINCE LAST BIRTH 95
OTHER (SPECIFY) ______ 96

TABLE OF LEVEL OF EDUCATION:

CURRENT SYSTEM:

1 PRIMARY 1ST GRADE 1-5
1 PRIMARY 2ND GRADE 6-7
2 SECONDARY 8-10
3 HIGH SCHOOL 11-12
4 HIGHER/ TEACHING PREP 1-7
5 TECHNICAL ELEMENTARY 1-3
6 TECHNICAL BASIC 1-3
7 TECHNICAL ADVANCED 1-3

OLD SYSTEM:

1 PRIMARY 0-4
1 PREPARATORY CYCLE 5-6
2 SECONDARY 7-9
3 HIGH SCHOOL 10-11
4 HIGHER/ TEACHING PREP 1-7
5 TECHNICAL ELEMENTARY 1-3
6 TECHNICAL BASIC 1-3
7 TECHNICAL ADVANCED 1-3

COLONIAL SYSTEM:

1 PRIMARY 0-4
1 PREPARATORY CYCLE 1-2
2 SECONDARY 2ND CYCLE 3-5
3 SECONDARY 3RD CYCLE 6-7
4 HIGHER/ TEACHING PREP 1-7
5 TECHNICAL ELEMENTARY 1-3
6 PREPARATORY SECTION 1-3
7 INSTITUTE/COLLEGE 1-3

SECTION 8. AIDS

801. Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 901)

802. From which sources of information have you learned most about AIDS?
Any other sources?
RECORD ALL MENTIONED,

RADIO A
TELEVISION B
NEWSPAPER OR MAGAZINE C
PAMPHLETS/POSTER D
HEALTH WORKERS E
MOSQUES/CHURCHES F
SCHOOL/TEACHERS G
COMMUNITY MEETINGS/CONFERENCES H
THEATER I
FRIENDS/RELATIVES J
WORK PLACE K
OTHER (SPECIFY) ______ X

803. Do you know how a person can avoid getting AIDS or the virus that cause AIDS?

YES 1
NO 2 (GO TO 807)
DOESN'T KNOW 8 (GO TO 807)

804. What can a person do to avoid the risk of contracting AIDS?
Any other ways?
RECORD ALL MENTIONED.

SAFE SEX A
ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
SEEK PROTECTION FROM TRADITIONAL HEALER K
OTHER (SPECIFY) ______ M
OTHER (SPECIFY) ______ N
DOESN'T KNOW O

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

YES 1
NO 2
DOESN'T KNOW 8

808. Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?

ALMOST NEVER 1
SOMETIMES 2
ALMOST ALWAYS 3
DOESN'T KNOW 8

809. Do you think your chances of getting AIDS are small, moderate, great, or no risk at all?

SMALL 1
MODERATE 2
GREAT 3
NOT RISK AT ALL 4
HAS AIDS 5
DOESN'T KNOW 8

810. Has your knowledge of AIDS influenced or changed your decisions about having sex or your sexual behavior?
IF YES, PROBE: In what way?
RECORD ALL MENTIONED.

DID NOT START SEX A
STOPPED ALL SEX B
STARTED USING CONDOM C
RESTRICTED SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
OTHER (SPECIFY) ______ F
NO CHANGE IN SEXUAL BEHAVIOR G
DOESN'T KNOW H

SECTION 9. MATERNAL DEATH RATE

Now I would like to ask you questions about your brothers and sisters, that is, all of the children born from your mother, including those that live with you or those that not live with you or have died.

901. How many children did you mother have?

NUMBER OF CHILDREN FROM BIOLOGICAL MOTHER ______

902. CHECK 901:

TWO OR MORE BIRTHS (GO TO 903)
ONLY ONE BIRTH (ONLY THE WOMEN [RESPONDENT]) (GO TO 916)

903. Of all of the children, how many were born before you?

NUMBER OF CHILDREN BORN BEFORE HER______

904. What is the name of your older....next sister or brother?

NAME______

905. Is (NAME) male or female?

MALE 1
FEMALE 2

906. Is (NAME) alive?

YES 1
NO 2 (GO TO 906)
DOESN'T KNOW (GO TO NEXT CHILD)

907. How old is (NAME)?

AGE IN YEARS_______ (GO TO NEXT CHILD)

908. In which year did (NAME) die?

YEAR_____ (GO TO 910)
DOESN'T KNOW 98

909. How many years ago did (NAME) die?

YEARS_______

910. How old was (NAME) when s/he died?

AGE___ (IF MALE OR FEMALE THAT DIED BEFORE 12 YEARS OLD GO TO NEXT CHILD)

911. When (NAME) died, was she pregnant?

YES 1 (GO TO 914)
NO 2
DOESN'T KNOW 8

912. Did (NAME) die during labor?

YES 1 (GO TO 915)
NO 2
DOESN'T KNOW 8

913. Did (NAME) die two months after being pregnant or after labor?

YES 1 (GO TO 915)
NO 2
DOESN'T KNOW 8

914. Did she die because of labor or pregnancy complications?

YES 1
NO 2
DOESN'T KNOW 8

915. During her life, how many children did (NAME) have?

NUMBER OF CHILDREN_____ (GO TO NEXT CHILD)

[IF NO MORE SIBLINGS GO TO 916]

916. RECORD THE TIME

HOUR ______
MINUTES______

SECTION 10. HEIGHT AND WEIGHT

1001. CHECK 215:

ONE OR MORE LIVING BIRTHS SINCE JANUARY 1994 (GO TO 1002)
NO LIVING BIRTHS SINCE JANUARY 1994 (END THE INTERVIEW)

IN 1002 (COLUMNS 2 AND 3) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE JANUARY 1994 AND STILL ALIVE. IN 1003 AND 1004 RECORD THE NAME AND BIRTH DATE OF RESPONDENT AND ALL CHILDREN BORN SINCE JANUARY 1994. IN 1006 AND 1008 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN. (NOTE: ALL RESPONDENT WITH ONE OR MORE LIVING BIRTHS SINCE JANUARY 1994, SHOULD BE WEIGHED AND MEASURED EVEN IF ALL OF THE CHILDREN HAVE DIED. IF THERE ARE MORE THAN 2 LIVING CHILDREN BORN SINCE JANUARY 1994, USE ADDITIONAL QUESTIONNAIRES.)

1002. LINE NUMBER FROM QUESTION 212:
[DO NOT ASK FOR RESPONDENT]

LINE NUMBER___

1003. NAME FROM QUESTION 212:

NAME____

1004. DATE OF BIRTH: FROM QUESTION 215 AND ASK FOR DAY OF BIRTH
[DO NOT ASK FOR RESPONDENT]

DAY ____
MONTH____
YEAR____

1005. BCG SCAR ON ARM?
[DO NOT ASK FOR RESPONDENT]

SCAR SEEN 1
NO SCAR 2

1006. HEIGHT (IN CENTIMETERS):

HEIGHT____

1007. WAS LENGTH/HEIGHT OF CHILD MEASURED LYING DOWN OR STANDING UP? [DO NOT ASK FOR RESPONDENT]

LYING DOWN 1
STANDING UP 2

1008. WEIGHT (IN KILOGRAMS):

WEIGHT____

1009. DATE WEIGHED AND MEASURED:

DAY ____
MONTH____
YEAR____

1010. RESULT:

MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) ______ 6

1011. NAME OF MEASURER: _____

NAME OF SUPERVISOR: _____

INTERVIEWER'S OBSERVATIONS

TO BE FILLED OUT AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT ____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS ____

SUPERVISOR'S OBSERVATIONS_____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS_____
NAME _____
DATE _____