IDENTIFICATION

NAME OF HOUSEHOLD HEAD______
PLACE NAME ______
PROVINCE______

URBAN/RURAL

CLUSTER NUMBER ______
HOUSEHOLD NUMBER______

NAME AND LINE NUMBER OF WOMAN______

INTERVIEWER VISITS

FIRST INTERVIEW (REPEAT FOR SECOND AND THIRD INTERVIEWS)
DATE_____
INTERVIEWER'S NAME______

RESULT ______

NEXT VISIT
DATE_____
TIME_____

FINAL VISIT
DAY_____
MONTH_____
YEAR 2003
CODE_____
RESULT______

TOTAL NUMBER OF VISITS______

SUPERVISOR
NAME_____
DATE_____

FIELD EDITOR
NAME_____
DATE_____

OFFICE EDITOR_____

KEYED BY_____
RE-KEYED BY_____

SECTION 1: RESPONDENT'S BACKGROUND

101. RECORD THE TIME:

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

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

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

105. In what month and year were you born?

106. How old are you?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT

107. Have you attended school?

107A. Have you attended a literacy course?

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

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

109A. CHECK 106 IF AGE 24 OR LESS:

109B. Are you currently attending school?

109C. What was the main reason you stopped attending school?

110. CHECK 108 IF SCHOOL LEVEL IS PRIMARY EP1 OR BELOW:

111. Now I would like you to read this sentence to me:

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

114. How many times a week do you read the newspaper?

115. How many times a week do you watch television?

116. How many times a week do you listen to the radio?

118. Do you profess a religion?

118A. What is your religion?

118B. How often do you go to the church/mosque?

119. What language did you grow up speaking?

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 to a boy?
IF ANSWER NO, ASK: Have you ever given birth to a girl?

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

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

204. Do you have any sons or daughters to whom you have given birth who live in another place?

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

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?

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

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

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

210. CHECK 208:

Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.

211. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. PROBE IF SHE HAD/HAS TWINS OR TRIPLETS, CIRCLE 213 FOR REFERENCE

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

213. Were any of these births twins?

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

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

216. Is (NAME) still alive?

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

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

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

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

221. Have you had any other birth between the birth of (NAME) and the preceding birth?

222. Have you had any live births since the birth of (NAME OF LAST BIRTH)?
IF ANSWER IS 'YES', ASK AND RECORD IN THE HISTORY OF BIRTHS SECTION.

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

223A. CHECK:

223B. FOR AGE AT DEATH '12 MONTHS' OR '1 YEAR', RECORD NAME. IF THERE ARE NO DEATHS, GO TO 224.

223C. How many months old was (NAME) when s/he died?
IF DIFFERENT, CORRECT 220 FOR (NAME).

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN JANUARY 1998.
IF NONE, RECORD '0' AND GO TO 226.

225. FOR EACH BIRTH SINCE JANUARY 1998, ENTER 'N' IN THE MONTH OF BIRTH IN COLUMN 1 OF THE CALENDAR. ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'G' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'G's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.) WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'N' CODE.

226. Are you pregnant now?

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

228. 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?

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

230. In what month and year did the last such pregnancy end?

231. CHECK 230:

232. How many months pregnant were you when the last pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS.

232A. ENTER 'T' IN COLUMN 1 OF CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

233. Have you ever had any other pregnancies that did not result in a live birth, after January 1998?

234. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 1998. ENTER 'T' IN COLUMN 1 OF CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

235. Did you have any pregnancies that terminated before 1998 that did not result in a live birth?

236. In what year and month did the last such pregnancy that terminated before 1998 end?

237. When did your last menstrual period start?

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.

301. Which ways or methods have you heard about?
CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you heard of (METHOD)?

THEN CIRCLE CODE '1' FOR EACH KNOWN METHOD OTHERWISE CIRCLE CODE '2' AND CONTINUE WITH NEXT METHOD NOT MENTIONED SPONTANEOUSLY.
FOR EACH RECOGNIZED METHOD, ASK QUESTION 302.

302. Have you ever used (METHOD)?

303. CHECK 302:

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

306. What have you used or done?
CORRECT 302 AND 303 (AND 301 IF NECESSARY).

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

308. CHECK 302(1):

309. CHECK 226:

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

311. Which method are you using?
311A. CIRCLE 'A' FOR FEMALE STERILIZATION
RECORD ALL ANSWERS

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

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

314. CHECK 311:

CODE 'A' CIRCLED OR MARKED FEMALE STERILIZATION: Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

CODE 'B' CIRCLED OR MARKED MALE STERILIZATION: Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?

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

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

316A. For how long have you been using (CURRENT METHOD) now without stopping?

NOTE: THIS DATE MUST BE AFTER LAST BIRTH OR PREGNANCY. IF DATE WAS BEFORE THE LAST BIRTH OR LAST PREGNANCY, CORRECT IF NECESSARY.

317. CHECK 316/316A:

319. CHECK 311/311A:

CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

320. Where did you obtain (CURRENT METHOD) when you started using it?
320A. Where did you learn to use the lactational amenorrhea method?

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

321. In which district or province is the health center located?

321A. CHECK 319:
CIRCLE THE METHOD CODE THAT IS CURRENTLY USED.

322. You obtained (CURRENT METHOD FROM 319) from (SOURCE OF METHOD FROM 313 OR 320): At that time, were you told about side effects or problems you might have with the method?

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

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

325. CHECK 322:

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

CODE '1' NOT CIRCLED: When you obtained the current method, were you told about other methods of family planning that you could use?

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

327. CHECK 311/311A:
CIRCLE METHOD CODE. IF USED VARIOUS METHODS MARK THE ONE CLOSER TO THE TOP.

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

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

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

330. Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.

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

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

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

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

SECTION 4A. PREGNANCY AND BREASTFEEDING

401. CHECK 224:

402. ENTER THE LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1998 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL QUESTIONNAIRES)

Now I would like to ask you some more questions about the health of all your children born in the past five years. (We will talk about one child at a time).

403. LINE NUMBER FROM QUESTION 212:

404. FROM QUESTION 216:

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?

406. How much longer would you like to have waited?
RECORD ANSWER AS GIVEN BY THE INTERVIEWEE.

407. When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
[ASK ONLY FOR MOST RECENT BIRTH]

PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

407A. Where did you have your antenatal care appointment(s)? Anywhere else?
RECORD ALL PLACES MENTIONED.
[ASK ONLY FOR MOST RECENT BIRTH]

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

408. How many months pregnant were you when you first received antenatal care?
RECORD '00' IF LESS THAN A MONTH OF PREGNANCY.
[ASK ONLY FOR MOST RECENT BIRTH]

409. How many antenatal appointments did you have during this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

410. CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE
[ASK ONLY FOR MOST RECENT BIRTH]

411. How many months pregnant were you the last time you received antenatal care?
[ASK ONLY FOR MOST RECENT BIRTH]

412. During this pregnancy (NAME's pregnancy), were any of the following done at least once?
[ASK ONLY FOR MOST RECENT BIRTH]

A. Were you weighed?
B. Was the baby's heartbeat listened to?
C. Was your blood pressure measured?
D. Did you give a urine sample?
E. Did you give a blood sample?
F. Was you belly measured?
G. Was your height measured?

413. Were you told about the signs of pregnancy complications during any of your antenatal appointments?
[ASK ONLY FOR MOST RECENT BIRTH]

414. Were you told where to go if you had these complications?
[ASK ONLY FOR MOST RECENT BIRTH]

414A. During (NAME)'s pregnancy, did you receive information about STD's and HIV/AIDS during any of your antenatal appointments?
[ASK ONLY FOR MOST RECENT BIRTH]

415. When you were pregnant with (NAME) were you given an injection in the arm to prevent the baby from getting tetanus?
[ASK ONLY FOR MOST RECENT BIRTH]

416. During this pregnancy, how many times did you get this injection?
[ASK ONLY FOR MOST RECENT BIRTH]

417. During this pregnancy, were you given or did you buy any iron tablets or iron syrup?
SHOW TABLET/SYRUP.
[ASK ONLY FOR MOST RECENT BIRTH]

418. During the whole pregnancy, for how many days did you take the tablets or syrup?
IF ANSWER IS NOT NUMERIC ASK: How many days or months?
[ASK ONLY FOR MOST RECENT BIRTH]

419. During this pregnancy, did you have:
[ASK ONLY FOR MOST RECENT BIRTH]

A. Swelling of the foot?
B. Cloudy vision?
C. Headaches?
D. Fainting?
E. Vaginal discharge?
F. Painful/burning urination?
G. Bleeding?

420. During this pregnancy, did you have difficulty with your vision during the daylight?
[ASK ONLY FOR MOST RECENT BIRTH]

421. During this pregnancy, did you have difficulty with your vision during night?
[ASK ONLY FOR MOST RECENT BIRTH]

423. When (NAME) was born, was he/she very large, large, average, small or very small?

424. Was (NAME) weighed at birth?

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

425A. Was (NAME) registered in the Office of Vital Records?

425B. Who assisted with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.

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

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

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

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

RECORD ALL PLACES MENTIONED.

428. Was (NAME) delivered by natural birth, natural vacuum-assisted vaginal delivery (VE) or caesarean section?

429. After (NAME) was born, did a health professional or a traditional birth attendant check on your health?

430. How many days or weeks after delivery did the first check take place?
RECORD THE ANSWER IN THE PRECISE GIVEN TIME.
[ASK FOR MOST RECENT BIRTH ONLY]

430A. When you had your post-delivery appointment, did you have any problem related to delivery?
[ASK FOR MOST RECENT BIRTH ONLY]

430B. What type of problem? Any other problem?
RECORD ALL ANSWERS MENTIONED.
[ASK FOR MOST RECENT BIRTH ONLY]

431. Who checked on your health at that time?
[ASK FOR MOST RECENT BIRTH ONLY]

432. Where did the first check take place?
RECORD ALL PLACES MENTIONED.
[ASK FOR MOST RECENT BIRTH ONLY]

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

433. In the first eight weeks after delivery, did you receive a vitamin A does like this?
SHOW CAPSULE.
[ASK FOR MOST RECENT BIRTH ONLY]

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

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

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

437. CHECK 226:
RESPONDENT PREGNANT?
[ASK FOR MOST RECENT BIRTH ONLY]

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

439. For how many months after the birth of (NAME) did you not have sexual relations?
IF LESS THAN A MONTH, RECORD '00'.

440. Did you ever breastfeed (NAME)?

441. 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.

442. In the first three days after delivery, before your milk began flowing regularly, was (NAME) given anything to drink other than breast milk?

443. What was (NAME) given to drink before your milk began flowing regularly?
PROBE: Anything else?
RECORD ALL LIQUIDS MENTIONED.

444. CHECK 404:
IS CHILD LIVING?

445. Are you still breastfeeding (NAME)?

446. For how many months did you breastfeed (NAME)?
IF LESS THAN A MONTH, RECORD '00'.

447. CHECK 404:
IS CHILD LIVING?

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

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

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

451. Was sugar added to any of the foods or liquids that (NAME) ate or drank yesterday?

451A. How many times did (NAME) eat solid, semisolid, or soft foods other than liquids yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD '7'.

452. Now I would like to ask about the liquids (NAME) had during the last seven days including yesterday.

FOR EACH LIQUID, ASK FIRST QUESTION 452A FOR LIQUIDS DRUNK "DURING THE LAST 7 DAYS" AND THEN ASK QUESTION 452B FOR LIQUIDS DRUNK "LAST NIGHT/YESTERDAY".

IF DID NOT HAVE ANY OF THE LIQUIDS MENTIONED BELOW, RECORD '0'. IF HAD A LIQUID 7 OR MORE TIMES, RECORD '7'. IF DOES NOT KNOW, RECORD '8'.

452A: LAST 7 DAYS: How many days during the last seven days did (NAME) drink:
[ASK FOR MOST RECENT BIRTH ONLY]

A. Plain water?
B. Infant formula?
C. Milk (other than breast milk?
D. Fruit juice?
E. Tea (including herbal tea)?
F. Other liquids different from water or milk?

452B: LAST NIGHT/YESTERDAY: How many times in total during yesterday or last night did (NAME) drink:
[ASK FOR MOST RECENT BIRTH ONLY]

A. Plain water?
B. Infant formula?
C. Milk (other than breast milk?
D. Fruit juice?
E. Tea (including herbal tea)?
F. Other liquids different from water or milk?

453. Now I would like to ask about the foods (NAME) had during the last seven days including yesterday.

FOR EACH FOOD ASK FIRST QUESTION 453A FOR FOOD CONSUMED "DURING THE LAST 7 DAYS" AND THEN ASK QUESTION 452B FOR FOOD CONSUMED "LAST NIGHT/YESTERDAY".

IF DID NOT HAVE ANY OF THE FOODS MENTIONED BELOW, RECORD '0'. IF CONSUMED ANY OF THE FOODS 7 OR MORE TIMES, RECORD '7'. IF DOES NOT KNOW, RECORD '8'.

453A. LAST 7 DAYS: How many days during the last seven days did (NAME) eat or consume any of the foods separately or in combination:
[ASK ONLY FOR MOST RECENT BIRTH]

A. Rice, corn, sorghum, spaghetti, cookies, rice or corn cake/bread or any other food made out of any other cereal?
B. Carrots, squash, yams?
C. Food made out of roots or tubers (manioc or potatoes)?
D. Dark leafy greens (lettuce, green beans, collard greens, carrot leaves, etc.)?
E. Ripe mango, ripe papaya, etc.?
F. Other fruits and vegetables (bananas, apples, tomatoes, limes, oranges, tangerine, guava, grapes, cauliflower)?
G. Beef, chicken, fish, eggs, (animal giblets such as liver, kidneys, heart)?
H. Beans (red, black, white, brown, lentils, soy)?
I. Cheese, yogurt, cream?
J. Any food made with oil, lard, margarine, peanut butter or sesame seed butter?

453B. LAST NIGHT/YESTERDAY: How many times in total during yesterday or last night did (NAME) eat or consume any of these foods:
[ASK ONLY FOR MOST RECENT BIRTH]

A. Rice, corn, sorghum, spaghetti, cookies, rice or corn cake/bread or any other food made out of any other cereal?
B. Carrots, squash, yams?
C. Food made out of roots or tubers (manioc or potatoes)?
D. Dark leafy greens (lettuce, green beans, collard greens, carrot leaves, etc.)?
E. Ripe mango, ripe papaya, etc.?
F. Other fruits and vegetables (bananas, apples, tomatoes, limes, oranges, tangerine, guava, grapes, cauliflower)?
G. Beef, chicken, fish, eggs, (animal giblets such as liver, kidneys, heart)?
H. Beans (red, black, white, brown, lentils, soy)?
I. Cheese, yogurt, cream?
J. Any food made with oil, lard, margarine, peanut butter or sesame seed butter?

453C. GO BACK TO Q. 405 IN NEXT COLUMN, OR IF NO MORE BIRTHS, GO TO 454.

SECTION 4B. IMMUNIZATION AND HEALTH

454. ENTER LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1998 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS, BEGINNING WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL QUESTIONNAIRES).

455. LINE NUMBER FROM QUESTION 212:

456. CHECK 216:
LIVING OR DEAD?

457. Did (NAME) receive a vitamin A like this during the last 6 months?
SHOW CAPSULE.

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

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

460. (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.

461. Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0, POLIO 1-3, DPT 1-3 MEASLES AND/OR HEPATITIS B VACCINE(S).

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

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

463A. A BCG vaccination against tuberculosis, that is, an injection in the arm that leaves a scar?

463B. POLIO vaccine, that is, drops in the mouth?

463C. When was the first polio vaccine given, just after birth or later?

463D. How many times?

463E. DPT (triplex) vaccination, that is, an injection usually given at the same time as polio drops?

463F. How many times?

463G. A MEASLES vaccine, that is, an injection in the arm to prevent measles?

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

465A. Does (NAME) have a fever now?

466. Now I would like to know what you did once you noticed that (NAME) had a fever:

466A1. What was the first thing you did?

466A2. What was the second thing you did?

466A3. What was the third thing you did?

466B. CHECK 466A1, 466A2 AND 466A3:
HOME REMEDIES OR DRUGS FROM PHARMACY WITHOUT PRESCRIPTION.

466C1. For the following drugs please tell me if (NAME) took any of them immediately after having fever or how many days after:

A. Chloroquine?
B. Fansidar (sulfadoxine and pyrimethamine)?
C. Quinine?

TYPE OF DRUG:

HOW MANY DAYS AFTER FEVER:

466C2. Any other medicine/drugs?
CIRCLE ALL ANSWERS MENTIONED.

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

467A. CHECK 464:
HAD FEVER?

468. When (NAME) had an illness with a cough, did s/he breathe faster than usual with short, rapid breaths?

470A. Did you seek advice or treatment for the cough?

470B. Did you seek advice or treatment for the fever?

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

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

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

475A. Was there any blood in the stools?

475B. On the worst day of the diarrhea, how many bowel movements did (NAME) have?

476. Was he/she given the same amount to drink as before the diarrhea, or more, or less?
IF GIVEN LESS LIQUID THAN NORMAL, ASK: Was s/he given much less than usual or somewhat less?

477. Was he/she given the same amount of food to eat as before the diarrhea, or more, or less?
IF LESS, PROBE: Was she/he given much less than usual to eat or somewhat less?

477A: CHECK 445:
STILL BREASTFEEDING?

477B. When (NAME) had diarrhea, did you continue breastfeeding him/her?

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

A. A fluid called 'Mixture' (salts ORS)?
B. Homemade sugar-salt-water solution?

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

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

481. Did you seek advice or treatment for the diarrhea?

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

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

483. GO BACK TO 456 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 484.

484. CHECK 215 AND 218:
NUMBER OF CHILDREN BORN SINCE JANUARY 1998 OR LATER LIVING WITH THE RESPONDENT?

485. What is usually done to dispose of your (youngest) child's stools when she/he does not use the latrine?

486. CHECK 478A, ALL COLUMNS:

487. Have you ever heard of a special product called Oral Rehydration Salts or oral mixture you can get for the treatment of diarrhea?

488. CHECK 218:

488A. When (your child/one of your children) is seriously ill, can you decide by yourself whether or not the child should be taken for medical treatment?

IF SAYS NO CHILD EVER SERIOUSLY ILL, ASK: If (your child/one of your children) became seriously ill, could you decide by yourself whether or not the child should be taken for medical treatment?

489. Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?

A. Knowing where to go?
B. Getting permission to go?
C. Getting money needed for treatment?
D. The distance to the health facility?
E. Having to take transport?
F. Not wanting to go alone?
G. Concern that there may not be a female health provider?

490A. When a child is sick with fever, what signs of illness would tell you that he or she should be taken to a health facility or health worker? Any other signs/symptoms?
CIRCLE ALL ANSWERS MENTIONED.

490B. When a child has diarrhea, should he/she be given less to drink than usual, about the same amount, or more than usual?

490C. When a child has diarrhea, should he/she be given less to eat than usual, about the same amount, or more than usual?

490D. 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? Any other signs/symptoms?
RECORD ALL MENTIONED.

490E. 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? Any other signs/symptoms?
RECORD ALL MENTIONED.

491. Do you sleep under a hammock/bed net?

492. How long have you been using the hammock/bed net?
IF LESS THAN 1 MONTH, RECORD '00'. RECORD IN MONTHS IF 3 YEARS OR LESS.

493. Has the hammock/bed net been immersed in mosquito repellent liquid?

494. How long ago was the hammock/bed net immersed in mosquito repellent liquid?
IF LESS THAN 1 MONTH, RECORD '00'. RECORD IN MONTHS IF 3 YEARS OR LESS.

495. Did you sleep under a hammock/bed net last night?

495A. Besides sleeping under a hammock/bed net what other methods do you use to prevent mosquito bites?

496. Do you currently smoke cigarettes or tobacco?
IF YES: What type of tobacco do you smoke?
CIRCLE ALL TYPES MENTIONED

496A. CHECK 496:

496B. In the last 24 hours, how many cigarettes did you smoke?

497. Have you ever consumed an alcoholic beverage?

497A. In the last three months, how many days did you consume alcohol?
IF ANSWER IS 'EVERYDAY', RECORD '90'.

498. Have you ever been drunk?

498A. CHECK 497A:

499. In the last three months, how many times did you get drunk?

SECTION 5. MARRIAGE AND SEXUAL ACTIVITY

500. PRESENCE OF OTHERS AT THIS POINT:
RECORD ALL ANSWERS.

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

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

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

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

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

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

508. How many other wives does he have?

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

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

511. CHECK 510:

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 your husband/partner?

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

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

514. How old were you when you first had sexual intercourse (if ever)?

514A. CHECK 106 IF WOMAN HAS BETWEEN 15-24 YEARS OF AGE:

514B. The first time you had sexual intercourse, was a condom used?

515. When was the last time you had sexual intercourse?
IF ANSWER IS LESS THAN 12 MONTHS, RECORD IN MONTHS. IF 12 OR MORE MONTHS, RECORD IN YEARS. IF SEXUAL INTERCOURSE HAPPENED THAT DAY, RECORD '00'.

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

516A. What was the main reason you or your partner used a condom?

517. What is your relationship to the man with whom you last had sex?
IF MAN IS 'BOYFRIEND' OR 'FIANCÉ', ASK: Was your boyfriend/fiancé living with you when you last had sex?
IF YES, CIRCLE '01', IF NO, CIRCLE '03'

517A. CHECK 106:
WOMAN IS 15-19 YEARS OF AGE?

517B. In your last sexual relation, was the man younger, about the same age, or older than you?
IF OLDER: Do you think he was less or more than 10 years older?

518. For how long have you had sexual relations with this man?
IF ANSWER IS LESS THAN 12 MONTHS, RECORD IN MONTHS/WEEKS OR DAYS. IF 12 OR MORE MONTHS, RECORD IN YEARS. IF SEXUAL INTERCOURSE WITH THAT MAN HAPPENED ONCE, RECORD '01' IN DAYS.

519. Have you had sex with any other man in the last 12 months?

520. The last time you had sexual intercourse with another man, was a condom used?

520A. What was the main reason you or your partner used a condom?

521. What is (was) your relationship to that man with whom you had sex?
IF MAN IS 'BOYFRIEND' OR 'FIANCÉ', ASK: Was your boyfriend/fiancé living with you when you last had sex?

IF YES, CIRCLE '01', IF NO, CIRCLE '03'.

521A. CHECK 517A:
WOMAN IS 15-19 YEARS OF AGE?

521B. In your last sexual relation, was the man younger, about the same age, or older than you?
IF OLDER: Do you think he was less or more than 10 years older?

522. For how long have you had sexual relations with this other man?
IF ANSWER IS LESS THAN 12 MONTHS, RECORD IN MONTHS/WEEKS OR DAYS. IF 12 OR MORE MONTHS, RECORD IN YEARS. IF SEXUAL INTERCOURSE WITH THAT MAN HAPPENED ONCE, RECORD '01' IN DAYS.

522A. Besides these two men, have you had sex with any other man in the last 12 months?

522B. The last time you had sexual intercourse with this other man, was a condom used?

522C. What was the main reason you or your partner used a condom?

522D. What is your relationship to that (third) man with whom you had sex?
IF MAN IS 'BOYFRIEND' OR 'FIANCÉ', ASK: Was your boyfriend/fiancé living with you when you last had sex?

IF YES, CIRCLE '01', IF NO, CIRCLE '03'.

522E. CHECK 517A:
WOMAN IS 15-19 YEARS OF AGE?

522F. In your last sexual relation, was the man younger, about the same age, or older than you?
IF OLDER: Do you think he was less or more than 10 years older?

522G. For how long have you had sexual relations with this man?
IF ANSWER IS LESS THAN 12 MONTHS, RECORD IN MONTHS/WEEKS OR DAYS. IF 12 OR MORE MONTHS, RECORD IN YEARS. IF SEXUAL INTERCOURSE WITH THAT MAN HAPPENED ONCE, RECORD '01' IN DAYS.

523. In the last 12 months, with how many men did you have sexual intercourse?

524. Do you know of a place where you can get condoms (for purchase or for free)?

525. Where is that?
Any other place?
RECORD ALL SOURCES MENTIONED.

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

526. If you wanted to acquire condoms, would it be difficult?

526A. What would the difficulty be? Anything else?
CIRCLE ALL ANSWERS MENTIONED.

SECTION 6. FERTILITY PREFERENCES

601. CHECK 311 AND 311A:
IS RESPONDENT OR SPOUSE/PARTNER STERILIZED?

602. CHECK 226:

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?

603. CHECK 602:

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?

604. CHECK 602:

605. CHECK 310:
USING A METHOD?

606. CHECK 603:

607. CHECK 602:

WANTS TO HAVE A/ANOTHER CHILD (OR RESPONSE TO 602 IS '1') You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy. Can you tell me why? Any other reason?

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

RECORD ALL REASONS MENTIONED.

608. In the next few weeks, if you discovered that you were pregnant, would that be a big problem, a small problem or no problem for you?

609. CHECK 310:
USING A CONTRACEPTIVE METHOD?

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

611. Which method would you prefer to use?

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

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

614. CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE.

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

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

617. Is it acceptable or not acceptable to you that the information on family planning is provided:

A. On the radio?
B. On the television?
C. In a newspaper or magazine?

618. In the last 6 months have you heard about family planning:

A. On the radio?
B. On the television?
C. In a newspaper or magazine?
D. From a poster?
E. From leaflets or brochures?

619. In the last 6 months, have you discussed the practice of family planning with your female friends, neighbors, or relatives?

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

621. CHECK 501:

622. CHECK 311 AND 311A:

623. You have told me that you are currently using contraception. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision or did you both decide together?

Now I want to ask you about your husband's/partner's views on family planning:

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

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

626. CHECK 311/311A:
RESPONDENT AND/OR SPOUSE/PARTNER STERILIZED?

627. 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?

628. Husbands and wives do not always agree on everything. Please tell me if you think a wife is justified in refusing to have sex with her husband when:

A. She has recently given birth?
B. She is tired or not in the mood?
C. She knows her husband has sex with other women?
D. She knows her husband has a sexually transmitted disease?

629. When a wife knows that her husband/partner has a sexually transmitted disease, do you think it is appropriate for her to ask her husband/partner to use a condom?

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

701. CHECK 501 AND 502:

702. How old is your husband/partner?

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

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

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

706. CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN: What is your husband's/partner's occupation? That is, what kind of work does he mainly do?

FORMERLY MARRIED/LIVED WITH A MAN: What was your (last) husband's/partner's occupation? That is, what kind of work did he mainly do?

706A. CHECK 706:

706B. 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?

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

708. 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. During the past seven days, have you done any of these things or any other work?

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

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

711. CHECK 710:

712. 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?

713. Who do you work for?

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

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

715A. During the last 12 months, how many months did you work?

715B. During the last 30 days, how many days did you work?

715C. During the last 12 months, approximately how many days on average did you work each week?

716. Are you paid or do you earn in cash or kind for this work or are you not paid at all?

717. CHECK 701:

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

NEVER MARRIED AND NEVER IN UNION/SINGLE: Usually who mainly decides how the money you earn will be used: you, someone else or you and someone else jointly?

718. On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

719. Who in your family usually has the final say on the following decisions:

A. Your own health care?
B. Making large household purchases?
C. Making household purchases for daily needs?
D. Visits to family or relatives?
E. What food you should cook every day?

720. PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)

721. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

A. If she goes out without telling him?
B. If she neglects the children?
C. If she argues with him?
D. If she refuses to have sex with him?
E. If she burn the food?

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

723. CHECK 710:
HAS (HAD) AN OCCUPATION?

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

SECTION 8. HIV/AIDS

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

801A. From which sources of information have you learned most about HIV/AIDS?
Any other sources?
RECORD ALL MENTIONED.

801B. Do you think that HIV/AIDS has a cure?

801C. How can it be cured?
RECORD ALL ANSWERS MENTIONED.

801D. Do you think that HIV/AIDS is a mortal illness?

801E. Do you think that the risk of you contracting HIV/AIDS is low, moderate, high or no risk at all?

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

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

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

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

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

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

808. Can people avoid the HIV/AIDS virus by abstaining from sex?

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

810. Do you know someone personally who has the virus that causes AIDS or someone who died of HIV/AIDS?

811. Can the virus that causes HIV/AIDS be transmitted from mother to a child?

812. Can the virus that causes HIV/AIDS be transmitted from mother to a child:

A. During pregnancy?
B. During delivery?
C. By breastfeeding?

812A1. Can a mother infected with the HIV/AIDS virus avoid transmitting it to her child by taking appropriate drugs during pregnancy?

813. CHECK 501:

814. Have you ever talked about ways to prevent getting the virus that causes HIV/AIDS with your husband/partner?

814A. In your opinion is it acceptable or not acceptable to provide information on AIDS by means of:

A1. The radio?
A2. The television?
A3. The newspaper?

814B. If you knew that the produce vendor has the HIV/AIDS virus, would you buy his/her products?

815. If a member of your family got infected with the virus that causes HIV/AIDS, would you want it to remain a secret or not?

816. If a relative of yours became sick with the virus that causes HIV/AIDS, would you be willing to care for her or him in your own household?

816A. If a teacher had the virus that causes HIV/AIDS but is not sick, can s/he continue teaching in school?

816B. Should you talk to your children ages 12-14 about the use of condoms to prevent AIDS?

816C. I am not interested in knowing the result, but have you ever had an AIDS test?

816C1. When was the last time you were tested for AIDS?

816C2. The last time you were tested for AIDS, was it voluntarily, was it recommended by someone else, or were you forced to do it?

816C3. I am not interesting in knowing the result, but did you get the results of that test?

816C4. Did you received any advice?

816D. Would you like to be tested for AIDS?

816E. Do you know a place where you can be tested for AIDS?

816F. Where is that?

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

816G. Where did you go to get tested?

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

817. Apart from HIV/AIDS, have you heard about other infections that can be transmitted through sexual contact?

818. If a MAN has a sexually transmitted disease (STD), what symptoms might he have?
Any others?
(DO NOT READ THE ANSWERS) RECORD ALL SYMPTOMS MENTIONED.

818A. If a WOMAN has a sexually transmitted disease (STD), what symptoms might she have? Any others?
(DO NOT READ THE ANSWERS) RECORD ALL SYMPTOMS MENTIONED.

819. CHECK 514:
HAS RESPONDENT HAD SEXUAL RELATIONS?

819A. CHECK 817:
DOES RESPONDENT KNOW ABOUT STD'S?

Now I would like to ask you about your health in the last 12 months:

819B. Have you had any sexually transmitted disease (STD) during the last 12 months?

819C. During the last 12 months, have you had any burning pain in urination or vaginal discharge?

819D. During the last 12 months, have you had any sores, ulcers or warts in the genital or anal area?

819E. CHECK 819B, 819C, AND 819D:

819F. The last time you had those problems (PROBLEMS MENTIONED IN 819B, 819C, AND 819D), did you seek advice or treatment?

820. The last time you had those problems (PROBLEMS MENTIONED IN 819B, 819C, AND 819), did you do any of the following:

A. Did you seek advice or treatment in a hospital, clinic or private clinic?
B. Did you seek advice or treatment/medicine from a traditional healer?
C. Did you seek advice or treatment/medicine from a pharmacy?
D. Did you seek advice or treatment with friends and relatives?

821A. When you had those problems, did you tell your sexual partner(s) about it?

821B.When you had those problems did you do anything to avoid transmitting them to your sexual partner?

822. What did you do to avoid transmitting those problems to your partner?

A. Stopped having sexual relations?
B. Used a condom?
C. Took medicine/drugs?

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, those that do not live with you, or have died.

901. How many children did you mother have?

902. CHECK 901:

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

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

905. Is (NAME) male or female?

906. Is (NAME) alive?

907. How old is (NAME)?

908. In which year did (NAME) die?

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

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

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

912. Did (NAME) died during labor?

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

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

914A. Did (NAME) die at home, in route to the health center, in the health center or somewhere else?

914B. Was (NAME) living in this household?

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

916. DATE AND TIME

PREGNANCY CALENDAR

INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX.

CODES FOR BIRTHS AND PREGNANCIES:

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW.

COMMENTS ABOUT RESPONDENT_____

COMMENTS ON SPECIFIC QUESTIONS_____

ANY OTHER COMMENTS_____

SUPERVISOR'S OBSERVATIONS_____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS_____
NAME _____
DATE _____