IDENTIFICATION

NAME OF HOUSEHOLD HEAD_______

PLACE NAME ________

PROVINCE_______

URBAN/RURAL

NAME AND NUMBER OF ENUMERATION AREA (DHS I.D.)_____

HOUSEHOLD NUMBER_______

NAME AND LINE NUMBER OF WOMAN_______

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE___

INTERVIEWER VISITS

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

RESULT________

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE_________
TIME_________

FINAL VISIT
DAY_________
MONTH_________
YEAR 2011
CODE_________
RESULT_________

TOTAL NUMBER OF VISITS_________

SUPERVISOR
NAME_________
DATE_________

SECTION 1: RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

Good morning/afternoon. My name is _________(SAY YOUR NAME) and I am working with the INE (NATIONAL INSTITUTE OF STATISTICS) and here is my identification (SHOW YOUR ID BADGE). We are conducting a survey about health all over the country. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30 to 45 minutes to complete. All of the answers you give will be kept strictly confidential and will not be shared with anyone other than members of our survey team. We hope that you will participate in this survey since your views are important. If I ask you a question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case that you need more information about the survey, you may contact the province delegate of Statistics.

Do you have any questions? May I begin the interview now?

SIGNATURE OF INTERVIEWER:____________ DATE:________________

101. RECORD THE TIME

102. In what month and year were you born?

103. How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 03 IF INCONSISTENT

104. Have you ever attended school?

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

106. What is the highest grade/year you completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'

107. CHECK 105:

108. 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?

109. CHECK 108:

110. Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

111. Do you listen to the radio at least once a week, less than once a week or not at all?

112. Do you watch television at least once a week, less than once a week or not at all?

113. What is your religion?

113A. How often do you go to the church/mosque?

114. What language did you grow up speaking?

115. In the last 12 months, how many times have you been away from home for one or more nights?

116. In the last 12 months, have you been away from home for one month at a time?

SECTION 2. REPRODUCTION

201. Now I would like to ask about all the births you have had during your life. Have you ever given birth?

202. Do you have any 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:

211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW)

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

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

214. Is (NAME) a twin?

215. In what month and year was (NAME) born?
PROBE: When is his/her birthday?

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 YR', PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN A MONTH; MONTH IF LESS THAN TWO YEARS; OR YEARS.

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME), including any children who died after birth?

222. Have you had any live births since the birth of (NAME OF LAST BIRTH)?
IF 'YES', RECORD BIRTH(S) IN TABLE

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

224. CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2006 OR LATER.

225. FOR EACH BIRTH SINCE JANUARY 2006, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.) WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE.

226. Are you pregnant now?

227. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

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

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

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

231. When did the last such pregnancy end?

232. CHECK 231:

233. How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS

234. Have you ever had any other pregnancies that did not result in a live birth, after January 2006?

235. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2006. ENTER 'T' IN CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236. Did you have any pregnancies (miscarriages, abortions or stillbirths) that terminated before 2006, that did not result in a live birth?

237. In what year and month did the last such pregnancy that terminated before 2006 end?

238. When did your last menstrual period start?

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

240. Is this time just before her period begins, during her period, right after her period has ended or halfway between two periods?

SECTION 3. CONTRACEPTION

301. Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid pregnancy. Which ways or methods have you heard about?
For methods not mentioned spontaneously, ask: Have you heard of (METHOD)?

302. CHECK 226:

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

304. Which method are you using?

CIRCLE ALL MENTIONED.

IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

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

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

307. In what facility did the 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.

308. In what month and year was the sterilization performed?
308A. Since what month and year have you have been using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

309. CHECK 308/308A, 215 AND 231:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A

310. CHECK 308/308A:

311. I will like to ask you some questions about the times you or your partner they have used a method to avoid getting pregnant during the last few years.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2006. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NON USE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:

When was the last time you used a method? Which method was that?
When did you start using that method? How long after the birth of (NAME)?
How long do you use the method then?

IN COLUMN 2, ENTER CODES FOR DISCONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE THE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.

ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.

ILLUSTRATIVE QUESTIONS:
Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?

IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: how many months did it take you to get pregnant after you stop using (METHOD)? AND ENTER '0' IN EACH SUCH MONTH IN COLUMN 1.

312. CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

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

314. CHECK 304:

CIRCLE METHOD CODE:

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

315. Where did you get the (CURRENT METHOD) the first time you used it?
315A. Where did you learn how to use the lactational amenorrhea method?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

316. CHECK 304:

CIRCLE METHOD CODE:

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

317. At that time, were you told about side effects or problems you might have with the method?
317A. When you got sterilized, were you told about side effects or problems you might have with the method?

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

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

320. CHECK 317/317A:

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

CODE '1' NOT CIRCLED: When you obtained (CURRENT METHOD) were you told about other methods of family planning that you could use?

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

322. CHECK 304:

CIRCLE METHOD CODE:

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

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

PROBE TO IDENTIFY THE TYPE OF SOURCE

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

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

325. Where is that? Any other place?

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

RECORD ALL PLACES MENTIONED.

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

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

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

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 224:

402. CHECK 215: ENTER THE LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER IN THE TABLE.
ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OR 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 Q. 212 IN BIRTH HISTORY.

404. FROM 212 AND 216:

405. At the time you became pregnant with (NAME), did you want to get pregnant at that time?

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

407. How much longer did you want to wait?

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

409. Whom did you see? Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

410. Where did you receive antenatal care for this pregnancy? Anywhere else?

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

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

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

413. As part of your antenatal care during this pregnancy, were any of the following done at least once?

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

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

416. During this pregnancy, how many times did you get a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'

417. CHECK 416:

418. At any time before this pregnancy, did you receive any tetanus injections?

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

420. How many years ago did you receive the last tetanus injection before this pregnancy?

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

422. During the whole pregnancy, for how many days did you take the tablets or syrup?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS

423. During this pregnancy, did you take any drug for intestinal worms?

424. During this pregnancy, did you take any drugs to keep you from getting malaria?

425. What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

426. CHECK 425:
DRUGS TAKEN FOR MALARIA PREVENTION

427. How many times did you take (SP/Fansidar) during this pregnancy?

428. CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY.

429. Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility or from another source?

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

431. Was (NAME) weighed at birth?

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

433. Who assisted with the delivery of (NAME)? Anyone else?

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.
IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

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

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

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

436. Before you were discharged after (NAME) was born, did anyone check on your health while you were still in the facility?

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

438. After (NAME) was born, did anyone check on your health?

439. Who checked on your health after delivery?

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

441. CHECK 437:

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

443. How many hours, days or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN A WEEK, RECORD DAYS.

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

445. Where did this first check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

446. In the first two months after delivery, did you receive a vitamin A does like this?
SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS

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

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

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

450. CHECK 226:
IS RESPONDENT PREGNANT?

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

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

453. Did you ever breastfeed (NAME)?

454. CHECK 404:
IS CHILD LIVING?

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

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

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

458. CHECK 404:
IS CHILD LIVING?

459. Are you still breastfeeding (NAME)?

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

461. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501. ENTER LINE NUMBER, NAME AND SURVIVAL STATUS OF EACH BIRTH IN 2006 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS, BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502. LINE NUMBER FROM Q. 212

503. FROM Q. 212 AND Q. 216

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

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

506. (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.

507. CHECK 506:

508. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3 AND/OR MEASLES AND VITAMIN A VACCINE(S).

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

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

510A. A BCG vaccination against tuberculosis, that is an injection in the arm that leaves a scar?

510B. POLIO vaccine, that is drops in the mouth?

510C. Was the first POLIO vaccine received in the first two weeks after birth or later?

510D. How many times was the POLIO vaccine received?

510E. TETRAVALENT/PENTA (DPT/ Hep. B), that is, an injection given at the same time as polio drops?

510F. How many times was TETRAVALENT (DPT/Hep. B) received?

510G. A MEASLES injection or an MMR injection, that is, a shot in the arm to prevent him/her from getting measles?

511. Within the last six months, has (NAME) received a vitamin A dose?
SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

512. In the last seven days, did (NAME) take iron pills, sprinkles with iron, or iron syrup (like this/any of these)?
SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS

513. Has (NAME) taken any drug for intestinal worms in the last six months?

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

515. Was there any blood in the stools?

516. Now I would like to know how (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same amount or more than usual to drink?
IF LESS PROBE: Was she/he given much less than usual to drink or somewhat less?

517. When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat? IF LESS PROBE: Was she/he given much less than usual to eat or somewhat less?

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

519. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL RESPONSES

520. CHECK 519:

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

522. Was he/she given any of the following to drink at any time since he/she started having the diarrhea:

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

524. What (else) was given to treat the diarrhea?
Anything else?
RECORD ALL TREATMENTS GIVEN.

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

526. At any time during the illness, did (NAME) have blood taken from his/her finger or heel for testing?

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

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

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

530. CHECK 525:
HAD FEVER?

531. Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS, PROBE: Was she/he given much less than usual to drink or somewhat less?

532. When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, or more than usual to eat? IF LESS, PROBE: Was she/he given much less than usual to eat or somewhat less?

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

534. Where did you seek advice or treatment?
Anywhere else?
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

RECORD ALL RESPONSES.

535. CHECK 534:

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

537. At any time during the illness, did (NAME) take any drugs for the illness?

538. What drugs did (NAME) take?
Any other drugs?
RECORD ALL MENTIONED

539. CHECK 538:
ANY CODE A-G CIRCLED?

540. CHECK 538:
SP/FANSIDAR ('A') GIVEN

541. How long after the fever started did (NAME) first take (SP/Fansidar)?

542. CHECK 538:
CHLOROQUINE ('B') GIVEN

543. How long after the fever started did (NAME) first take chloroquine?

544. CHECK 538:
AMODIAQUINE ('C') GIVEN

545. How long after the fever started did (NAME) first take amodiaquine?

546. CHECK 538:
QUININE ('D') GIVEN

547. How long after the fever started did (NAME) first take quinine?

548. CHECK 538:
COMBINATION WITH ARTEMISININ ('E') GIVEN

549. How long after the fever started did (NAME) first take (COMBINATION WITH ARTEMISININ)?

549A. CHECK 538:
COARTEM GIVEN?

549B. How long after the fever started did (NAME) first take COARTEM?

550. CHECK 538:
OTHER ANTIMALARIAL ('G') GIVEN?

551. How long after the fever started did (NAME) first take (other antimalarial)?

552. GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2006 OR LATER LIVING WITH THE RESPONDENT

554. The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

555. CHECK 522(a) AND 522(b), ALL COLUMNS:

556. Have you ever heard of a special product called (Oral Rehydration Salts) you can get for the treatment of diarrhea?

557. CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2008 OR LATER LIVING WITH THE RESPONDENT

558. Now I would like to ask you about liquids or foods (NAME FROM 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (NAME FROM 557) (drink/eat):

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

560. Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?

561. How many times did (NAME FROM 557) eat solid, semisolid or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD '7'.

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

601. Are you currently married or living together with a man as if married?

602. Have you ever been married or lived together with a man as if married?

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

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

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

606. Does your husband/partner have any other wives or does he live with other women as if married?

607. Including yourself, in total, how many other wives or live-in partners does he have?

608. Are you the first, second? wife?

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

610. CHECK 609:

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: In what month and year did you start living with your first husband/partner?

611. How old were you when you first started living with him?

612. CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

613. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. How old were you when you had sexual intercourse for the very first time?

614. Now I would like to ask some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone.

615. When was the last time you had sexual intercourse?
IF ANSWER IS IN LESS THAN 12 MONTHS, RECORD IN DAYS, WEEKS OR MONTHS. IF IS 12 OR MORE MONTHS RECORD IN YEARS. IF SAME DAY OR LAST NIGHT, RECORD '00' IN "DAYS AGO".

616. When was the last time you had sexual intercourse with this person?

617. The last time you had sexual intercourse (with this second/third person), was a condom used?

618. Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

619. What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married?
IF YES, CIRCLE '2'. IF NO, CIRCLE '3'

620. CHECK 609:

621. CHECK 613:

622. How long ago did your first have sexual intercourse with this (second/third) person?

623. How many times during the last 12 months did you have sexual intercourse with this person?
IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'

623A. Do you expect to have sexual intercourse with this person again?

624. How old is this person?

625. Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

625A. How many partners do you currently have?

626. In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'

627. In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'

628. BEFORE CONTINUING CHECK FOR THE PRESENCE OF OTHERS DURING THE SECTION

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

630. Where is that? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

631. If you wanted to, could you yourself get a condom?

SECTION 7. FERTILITY PREFERENCES

701. CHECK 304:

702. CHECK 226:

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

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

705. CHECK 226:

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

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

706. CHECK 226:

707. CHECK 303:

708. CHECK 705:

709. CHECK 703 AND 704:

WANTS TO HAVE A/ANOTHER CHILD: 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 you are not using a method? Any other reason?

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

RECORD ALL REASONS MENTIONED.

710. CHECK 303:
USING A CONTRACEPTIVE METHOD?

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

712. CHECK 216:

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

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

PROBE FOR A NUMERIC RESPONSE

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

714. In the last few months have you:

716. CHECK 601:

717. CHECK 303:

718. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision, or did you both decide together?

719. CHECK 304:

720. Does your husband/partner want the same number of children that you want, or does he want more or fewer than you want?

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801. CHECK 601 AND 602:

802. How old was your husband/partner on his last birthday?

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

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

805. What was the highest grade he completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'

806. CHECK 801:

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

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

807. Aside from your own housework, have you done any work in the last seven days?

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

809. Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave or any other such reason?

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

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

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

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

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

815. CHECK 601:

816. CHECK 814:

817. Who usually decides how the money you earn will be used: mainly you, mainly your husband/partner, or you and your husband/partner jointly?

818. Would you say that the money you earn is more than what your husband/partner earns, less than what he earns or about the same?

819. Who usually decides how your husband/partner's earnings will be used: you, your husband/partner, or you and your husband/partner jointly?

820. Who usually makes decisions about health care for yourself: you, your husband/partner, you and your husband/partner jointly, or someone else?

821. Who usually makes decisions about making major household purchases?

822. Who usually makes decisions about visits to your family or relatives?

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

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

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

826. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

SECTION 9. HIV/AIDS

901. Now I would like to talk about something else. Have you ever heard of an illness called AIDS?

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

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

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

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

906. Can people avoid the AIDS virus because of witchcraft or other supernatural means?

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

908. Can the virus that causes AIDS be transmitted from mother to a child:

909. CHECK 908:

910. Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?

911. CHECK 208 AND 215:

912. CHECK 408 FOR LAST BIRTH:

913. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

914. During any of the antenatal visits for your last birth, were you given any information about:

915. Were you offered a test for the AIDS virus as part of your antenatal care?

916. I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

917. Where was the test done?

918. I don't want to know the results, but did you get the results of the test?

919. All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

920. CHECK 434 FOR LAST BIRTH:

921. Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

922. I don't want to know the results, but were you tested for the AIDS virus at that time?

923. I don't want to know the results, but did you get the results of the test?

924. Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

925. How many months ago was your most recent HIV test?

926. I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

927. How many months ago was your most recent HIV test?

928. I don't want to know the results, but did you get the results of the test?

929. Where was the test done?

930. Do you know of a place where people can go get tested for the AIDS virus?

931. Where is that?

932. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

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

934. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

935. In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

936. Should children age 12-14 be taught about using a condom to avoid getting AIDS?

937. CHECK 901:

HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

NOT HEARD ABOUT AIDS: Have you heard about other infections that can be transmitted through sexual contact?

938. CHECK 613:

939. CHECK 937:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

940. Now I would like to ask you about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

941. Sometimes women experience a bad smelling abnormal genital discharge. During the last 12 months, have you had a bad smelling abnormal genital discharge?

942. Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

943. CHECK 940, 941 AND 942:

944. The last time you had (PROBLEMS FROM IN 940/941/942), did you seek any kind of advice or treatment?

945. Where did you seek advice or treatment?

946. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

947. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

948. CHECK 601:

949. Can you say no to your husband/partner if you do not want to have sexual intercourse?

950. Could you ask your husband/partner to use a condom if you wanted him to?

SECTION 10. OTHER HEALTH ISSUES

1001. Now I would like to ask you some questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1002. Among these injections, how many were administered by a health worker (a doctor, a nurse,..)?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1003. The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

1004. Do you currently smoke cigarettes?

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

1006. Do you currently smoke or use any other type of tobacco?

1007. What (other) type of tobacco do you currently smoke or use?
RECORD ALL ANSWERS MENTIONED.

1008. 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?

1009. Are you covered by any health insurance?

SECTION 11. MATERNAL MORTALITY

1101. 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 who are living with you, those living elsewhere and those who have died. How many boys did your mother give birth to, including you?

1102. CHECK 1101:

1103. How many of these births did your mother have before you were born?

1104. What was the name given to your oldest (next oldest) sister or brother?

1105. Is (NAME) male or female?

1106. Is (NAME) alive?

1107. How old is (NAME)?

1108. In what year did (NAME) die?

1109. How many years ago did (NAME) die?

1110. How old was (NAME) when s/he died?

1111. Was (NAME) pregnant when she died?

1112. Did (NAME) died during labor?

1113. Did (NAME) die two months after being pregnant or after labor?

1114. Did she die due to pregnancy complications, miscarriage, or labor?

1114A. Did (NAME) die at home, on the way to the hospital, in the hospital or in another place?

1114B. Did (NAME) live in this household?

1115. How many live-born children did (NAME) give birth to during her lifetime?

1116. ANY OTHER DEAD BROTHER/SISTER:

SECTION 12. DOMESTIC VIOLENCE MODULE

1200. CHECK HOUSEHOLD QUESTIONNAIRE:

1201. CHECK FOR PRESENCE OF OTHERS:

DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

1202. CHECK 601 AND 602:

1203. First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?

1204. Now if you will permit me, I would like to ask some more questions about your relationship with your (last) husband/partner. If we come to a question that you do not want to answer, tell me and we will go to the next question.

A. (Does/did) your (last) husband/partner ever:

B. How often did this happen during the last 12 months: often, only sometimes, rarely, or not at all?

1205. A. (Does/did) your (last) husband/partner ever:

B. How often did this happen during the last 12 months: often, sometimes, rarely, or not at all?

1206. CHECK:

1207. How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?
IF LESS THAN 1 YEAR, RECORD '00'.

1208. Did the following ever happen as a result of what your husband/partner did to you:

1209. Have you ever hit, slapped, kicked or done anything else to physically hurt your husband/partner at times when he was not already beating or physically hurting you?

1210. How often did this happen during the last 12 months: often, only sometimes, rarely or not at all?

1211. Does (did) your husband/partner drink beer, wine, or any other alcoholic beverage?

1212. During the course of a month how often does (did) he get drink alcohol: often, only sometimes, rarely or not at all?

1212A. Some men can be violent when they drink alcohol and become drunk. Has your husband/partner, during the last 12 months, become violent after drinking alcoholic beverages?

1212B. In the last 12 months how many times did your husband/partner become violent after drinking alcoholic beverages: often, only sometimes, rarely or not at all?

1213. CHECK 601 AND 602:

EVER MARRIED/LIVED WITH A MAN: From the time you were 15 years old, has anyone other than your (current/last) husband/partner hit, slapped, kicked or done anything else to hurt you physically?

NEVER MARRIED/NEVER LIVED WITH A MAN: From the time you were 15 years old, has anyone hit, slapped, kicked or done anything else to hurt you physically?

1214. Who has hurt you in this way? Anyone else?
RECORD ALL MENTIONED.

1215. In the past 12 months, how often were you hit, slapped, kicked or hurt physically by this (these) person(s): often, only sometimes, rarely or not at all?

1216. CHECK 201 AND 226:

1217. Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

1218. Who has done any of these things to physically hurt you while you were pregnant? Anyone else?
RECORD ALL MENTIONED.

1219. CHECK 613:

1220. The first time you had sexual intercourse, would you say that you had it because you wanted to, or because you were forced to have it against your will?

1221. CHECK 601 AND 602:

EVER MARRIED/LIVED WITH A MAN: In the last 12 months, has anyone other than your (current/last) husband/partner forced you to have sexual intercourse against your will?

NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months, has anyone forced you to have sexual intercourse against your will?

1222. CHECK 1220 AND 1221:

1223. CHECK '1205(h)' AND 1205(i):

1224. At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts?

1225. How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

1226. Who was the person who was forcing you at that time?

1226A. Were you forced to have sexual intercourse or perform any other sexual acts often, only sometimes, rarely or not at all?

1226B. Did you seek medical help after (the last time) you were forced to have sexual intercourse or perform any other sexual acts?

1226C. How long after you were forced to have sexual intercourse did you seek medical help?

1227. CHECK 1205A, 1213, 1217, 1221 AND 1224:

1228. Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?

1229. From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.

1229A. What was the reason you did not seek any help?
RECORD ALL MENTIONED.

1230. Have you ever told anyone else about this?

1231. As far as you know, did your father ever beat your mother?

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1232. DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

1233. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE____________________________________________

1234. RECORD TIME

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENT ABOUT THE RESPONDENT: __________

COMMENTS ON SPECIFIC QUESTIONS __________

ANY OTHER COMMENTS________

SUPERVISOR'S OBSERVATIONS________________

Name of Supervisor:__________________
Date:________

EDITOR'S OBSERVATIONS________________________________________

Name of Editor:__________________
Date:________

CALENDAR

INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX. ALL MONTHS SHOULD BE FILLED IN.

INFORMATION TO BE CODED FOR EACH COLUMN

COLUMN 1: BIRTHS AND PREGNANCIES, CONTRACEPTIVE USE

COLUMN 2: NOT USING CONTRACEPTIVE METHODS