Data Cart

Your data extract

0 variables
0 samples
View Cart


REPUBLIC OF NIGER 2006
DEMOGRAPHIC AND HEALTH SURVEYS - MEN'S QUESTIONNAIRE

NATIONAL INSTITUTE OF STATISTICS
DEMOGRAPHIC AND HEALTH AND MULTIPLE INDICATORS SURVEY (EDSN-MICIII, 2006)

IDENTIFICATION

PLACE NAME __________
CLUSTER NUMBER __________
COMPOUND NUMBER __________
HOUSEHOLD NUMBER _______
REGION __________

FIRST AND LAST NAME OF HEAD OF HOUSEHOLD _____

URBAN/RURAL:

URBAN 1
RURAL 2

NIAMEY/OTHER REGION CAPITAL/OTHER CITY/RURAL:

NIAMEY 1
OTHER REGION CAPITAL 2
OTHER CITY 3
RURAL 4

LINE NUMBER OF THE HEAD OF HOUSEHOLD ___

INTERVIEWER VISITS

INTERVIEWER 1
DATE _____
DAY _____
MONTH _____
YEAR 2006
INTERVIEWER NAME __________
RESULT * __________

INTERVIEWER 2
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________

INTERVIEWER 3
DATE _____
DAY _____
MONTH _____
YEAR 1998
INTERVIEWER NAME __________
RESULT * __________

*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER OR COMPETENT RESPONDENT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
7 OTHER (SPECIFY) __________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE _____
TIME _____

TOTAL NUMBER OF VISITS ___

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN ___

LANGUAGE OF QUESTIONNAIRE __________

LANGUAGE OF INTERVIEW

1 FRENCH
2 HAOUSSA
3 ZARMA
4 TAMASHEQ
5 FULFULDE
6 OTHERS __________

INTERPRETER

YES 1
NO 2

SUPERVISOR
NAME __________
DATE _____

FIELD EDITOR
NAME __________
DATE _____

OFFICE EDITOR __________
KEYED BY __________

SECTION 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS

INTRODUCTION AND CONSENT STATEMENT:

Hello. My name is _____ and I work for the National Institute of Statistics. We are conducting a national survey that asks about the health of men, women and children. We would very much appreciate your participation in this survey. I would like to ask you questions about your health (and that of your children). This information will be useful to the government for planning health services. The interview usually takes between 1hour and 1hour and 30 minutes. The information that you give us will be strictly confidential.

Participation in this survey is voluntary and you can refuse to respond to particular questions or to all of the questions. We hope, however, that you will accept to participate in this survey because your opinion is important to the country.

Do you have questions about the survey?
Can I begin the interview now?

THE RESPONDENT ACCEPTS 1 (CONTINUE)
THE RESPONDENT REFUSES 2 (END)

SIGNATURE OF INTERVIEWER __________ DATE _____

101. RECORD THE TIME

HOUR ___
MINUTES ___

102. To begin, I would like to ask you questions about yourself and your household. Until the age of 12 years, did you live the majority of the time in Niamey, in another capital, in a city or in a rural area? IF A CITY OR CAPITAL, ASK THE NAME OF THE CITY

NIAMEY 1

CAPITAL OTHER COUNTRY 2 __________
OTHER CITIES 3 __________
RURAL AREA 4

103. How long have you been living continuously in (NAME OF CURRENT CITY/VILLAGE OF RESIDENCE)? IF LESS THAN A YEAR, WRITE '00'.

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

104. Just before you moved here, did you live in Niamey, another capital, a city, or village?
IF A CITY, ASK THE NAME OF THE CITY

NIAMEY 1

CAPITAL OTHER COUNTRY 2 __________
OTHER CITIES 3 __________
RURAL AREA 4

105. During the past 12 months, how many times did you travel outside of your locality and slept somewhere besides your home?

NUMBER OF TRIPS ___
DID NOT TRAVEL 00 (GO TO 107)

106. In the past 12 months, have you been outside of your locality for more than a month continuously?

YES 1
NO 2

107. In which month and in which year were you born?

MONTH _____
DON'T KNOW MONTH 98
YEAR 19___
DON'T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS ___

109. Did you go to school?

YES 1
NO 2 (GO TO 111)

110. What is the highest level of school you attended: primary (first cycle), primary (second cycle), secondary (high school or technical) or superior?

PRIMARY 1
SECONDARY (FIRST CYCLE) 2
SECONDARY (SECOND CYCLE) 3
SUPERIOR 4

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

CLASS __________

112. CHECK 110:

PRIMARY 1 (GO TO 113)
SECONDARY OR MORE (GO TO 116)

113. Now I would like you to read this sentence out loud. Read as much as you can.

SHOW THE CARD TO THE RESPONDENT.

IF THE RESPONDENT CANNOT READ THE WHOLE PHRASE, INSIST: Can you read certain parts of the phrase to me?

CANNOT READ AT ALL 1
CAN READ SOME PARTS 2
CAN READ THE WHOLE PHRASE 3
NO CARD IN THE RIGHT LANGUAGE (SPECIFY LANGUAGE) __________ 4
NO/LOW VISION 5

114. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

YES 1
NO 2

115. CHECK 113:

CODE '2', '3' OR '4' CIRCLED (GO TO 116)
CODE '1' OR '5' CIRCLED (GO TO 117)

116. Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

117. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

118. Do you watch television almost every day, at least once a week, less than once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

119. Do you currently have a job for which you earn money?

YES 1 (GO TO 122)
NO 2

120. In the past 12 months did you have any sort of job for which you earned money?

YES 1 (GO TO 122)
NO 2

121. What did you do for most of the time during the past 12 months?

GO TO SCHOOL 1 (GO TO 129)
LOOK FOR WORK 2 (GO TO 129)
INACTIVE 3 (GO TO 129)
COULD NOT WORK/HANDICAPPED 4 (GO TO 129)
DOMESTIC WORK/CARE OF CHILDREN 5 (GO TO 129)
OTHER (SPECIFY) __________ 6

122. What is (was) your occupation, that is to say, what kind of work do (did) you mainly do?

__________

123. CHECK 122:

WORKS IN AGRICULTURE (GO TO 124)
DOES NOT WORK IN AGRICULTURE (GO TO 125)

124. Do you work on your own land, or your family's land, or land that you rent, or someone else's land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
OTHER 6

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

NUMBER OF MONTHS ___

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

CASH ONLY 1
MONEY AND KIND 2
IN KIND ONLY 3 (GO TO 129)
NOT PAID 4 (GO TO 129)

127. Who decides how the money you earn will be used?

THE RESPONDENT HIMSELF 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER TOGETHER 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE TOGETHER 5

128. On average, how much of your household 's expenses are paid by what you earn: almost nothing, less than half, about half, more than half, or all?

ALMOST NONE 1
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, ALL EARNINGS ARE KEPT 6

129. What is your religion?

MUSLIM 1
CHRISTIAN 2
ANIMIST 3
NO RELIGION 4
OTHER (SPECIFY) __________ 6

131. What is your ethnicity?
ETHNICITY CODE

ARABE 01
DJERMA/SONGHAI 02
GOURMANTCHE 03
HAOUSSA 04
KANOURI 05
PEUL 06
TOUAREG 07
TOUBOU 08
OTHER (SPECIFY) __________ 96

132. What language do you mostly speak at home?

ARABE 01
DJERMA/SONGHAI 02
GOURMANTCHE 03
HAOUSSA 04
KANOURI 05
PEUL 06
TOUAREG 07
TOUBOU 08
OTHER (SPECIFY) __________ 96

SECTION 2. REPRODUCTION

201. Now I would like to ask you questions about your children. I am only interested in the children of whom you are the biological father. Do you have or have you had any children?

YES 1
NO 2 (GO TO 206)

202. Do you have any sons or daughters of whom you are the father and who are now living with you?

YES 1
NO 2 (GO TO 204)

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

SONS AT HOME ___
DAUGHTERS AT HOME ___

204. Do you have any sons or daughters to whom you have given birth and who are alive but do not live with you?

YES 1
NO 2 (GO TO 206)

205. How many sons are alive but do not live with you?
How many daughters are alive but do not live with you?

IF NONE, RECORD '00'.

SONS ELSEWHERE ___
DAUGHTERS ELSEWHERE ___

206. Did you have a son or daughter who was born alive but later died?
IF NO, PROBE: Did you have any who cried and showed signs of life at birth but only survived a few hours or days?

YES 1
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)

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

SONS DEAD ___
DAUGHTERS DEAD ___

208. (Besides the children that you just mentioned) did you have:

A) Other sons or daughters that are still alive, of whom you are the biological father, but whom you would not recognize or who do not carry your name?

B) Other sons or daughters who were born alive and who died later, of whom you are the biological father, but whom you would not recognize or who do not carry your name?

NO IN BOTH CASES (GO TO 209)
YES IN AT LEAST ONE OF THE CASES (PROBE AND CORRECT 201 TO 207)

209. SUM ANSWERS TO QUESTION 203, 205, AND 207, AND RECORD THE TOTAL.
IF NONE, RECORD '00'.

TOTAL ___

210. CHECK 209:

HAD MORE THAN ONE CHILD (GO TO 211)
ONLY HAD ONE CHILD (GO TO 213)
DID NOT HAVE ANY CHILDREN (GO TO 301)

211. Do all of the children of whom you are the biological father have the same biological mother?

YES 1 (GO TO 213)
NO 2

212. In all, with how many women have you had children?

NUMBER OF WOMEN ___

213. How old were you when your first child was born?

AGE IN YEARS ___

SECTION 3. CONTRACEPTION

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

CIRCLE EACH METHOD (CODE 1) WITH WHICH THE RESPONDENT IS FAMILIAR. ONLY CIRCLE METHODS ANSWERED SPONTANEOUSLY. CONTINUE DOWN COLUMN 302 READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 FOR METHODS WITH WHICH THE RESPONDENT IS FAMILIAR. CIRCLE CODE 3 FOR METHODS WITH WHICH THE RESPONDENT IS UNFAMILIAR.

301. Which methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have ever heard about (METHOD)?

01. FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO NEXT METHOD)
02. MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO NEXT METHOD)
03. PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
04. IUD: Women can have a loop or a coil placed inside them by a doctor or a nurse to avoid becoming pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
05. INJECTIONS: Women can have an injection by a health provider to avoid becoming pregnant during one or more months.
YES 1
NO 2 (GO TO NEXT METHOD)
06. IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2 (GO TO NEXT METHOD)
07. CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
08. FEMALE CONDOM: Women can place a sheath in their vagina before intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
09. DIAPHRAGM: Women can place a diaphragm in their vagina before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
10. COMPRESS, FOAM OR JELLY: Women can insert a compress, jelly or lotion in their vagina before intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
11. LACTATIONAL AMENORRHEA METHOD (LAM): Up to 6 months after a birth and before her period returns, a woman can use a method consisting of nursing her baby each time that he/she wants, day and night, without ever giving him/her any other food.
YES 1
NO 2 (GO TO NEXT METHOD)
12. RHYTHM METHOD: Every month that a woman is sexually active she can avoid pregnancy by Not having intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
13. WITHDRAWAL: Men can be careful to pull out before climax.
YES 1
NO 2 (GO TO NEXT METHOD)
14. DAY AFTER PILL: Women can take pills days following intercourse until the third day after to avoid getting pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
15. Have you heard of other ways or methods that women or men can use to avoid pregnancy?
YES (SPECIFY) __________ 1
NO 2

302. Have ever used this method?

02. MALE STERILIZATION: Men can have an operation to avoid having any more children. Has your husband or partner ever had an operation to avoid having (other) children?
YES 1
NO 2
07. CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
12. RHYTHM METHOD: Every month that a woman is sexually active she can avoid pregnancy by Not having intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
13. WITHDRAWAL: Men can be careful to pull out before climax.
YES 1
NO 2

303. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual intercourse?

YES 1
NO 2 (GO TO 305)
DON'T KNOW 8 (GO TO 305)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
JUST AFTER THE END OF HER PERIOD 3
HALFWAY BETWEEN 2 PERIODS 4
OTHER (SPECIFY) __________ 6
DON'T KNOW 8

306. Now I would like to read you some declarations about contraception.
Could you tell me if you agree or disagree with each one of these declarations?

Contraception is a woman's issue in which a man should not be interested.
AGREES 1
DISAGREES 2
DON'T KNOW 8
A woman who uses contraception can be considered a woman of loose morals.
AGREES 1
DISAGREES 2
DON'T KNOW 8
The woman is the one who can become pregnant, so it is she who is the one who should use contraception.
AGREES 1
DISAGREES 2
DON'T KNOW 8

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401. Are you currently married or do you currently live with a woman?

YES, CURRENTLY MARRIED 1
YES, LIVES WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3 (GO TO 406)

402. How many wives do you currently have?
IF ONLY ONE, RECORD '01'.

NUMBER OF WIVES ___

403. Are there other women with whom you live as if you are married?

YES 1
NO 2 (GO TO 405)

404. With how many women do you live as if married?
IF ONLY ONE WIFE/PARTNER, RECORD '01'.

NUMBER OF OTHER WIVES/PARTNERS WITH WHOM HE LIVES ___

405. Besides your wife/wives/partner(s) that you declared, do you currently have other women (another woman) with whom you have sexual intercourse regularly or occasionally?

REGULAR PARTNER(S) ONLY 1 (GO TO 409)
OCCASIONAL PARTNER(S) ONLY 2 (GO TO 409)
REGULAR AND OCCASIONAL PARTNERS 3 (GO TO 409)
NO OTHER SEXUAL PARTNERS 4 (GO TO 409)

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

REGULAR PARTNER(S) ONLY 1
OCCASIONAL PARTNER(S) ONLY 2
REGULAR AND OCCASIONAL PARTNERS 3
NO OTHER SEXUAL PARTNERS 4

407. Have you ever been married or lived with a woman?

YES, HAS BEEN MARRIED 1
YES, HAS ONLY LIVED WITH A WOMAN 2 (GO TO 411)
YES, BOTH
NO 4 (GO TO 416)

408. What is your current marital situation: are you widowed, divorced or separated?

WIDOWED 1 (GO TO 411)
DIVORCED 2 (GO TO 411)
SEPARATED (GO TO 411)

409. LOOKING AT THE HOUSEHOLD QUESTIONNAIRE WRITE THE NAME AND LINE NUMBER OF EACH WIFE/PARTNER DECLARED IN QUESTIONS 402 AND 404 ONLY. IF A WIFE/PARTNER DOES NOT LIVE IN THE HOUSEHOLD, RECORD '00' IN THE BOXES CORRESPONDING TO THIS WIFE/PARTNER. THE NUMBER OF FILLED IN BOXES MUST BE EQUAL TO THE NUMBER OF WIVES AND PARTNERS.

410. CHECK 402 AND 404:

THE SUM OF 402 AND 404 EQUALS 1: Please, tell me the name of your wives.

THE SUM OF 402 AND 404 EQUALS 2 OR MORE: Please, tell me the name of your wives and partners with whom you live and then indicate whether their relationship to you. Begin with the first one with whom you lived.

NAME OF WIFE (WIVES)/PARTNER(S) ____
LINE NO. OF WIFE (WIVES)/PARTNER(S) _____
WIFE 1
PARTNER 2

410A. How old was your wife/partner at her last birthday?

AGE OF WIFE (WIVES)/PARTNER(S)___

410B. CHECK 410:

ONLY ONE WIFE/PARTNER (GO TO 411)
2 OR MORE WIVES/PARTNERS (GO TO 414)

411. Have you been married or lived with a woman only once or more than once?

ONLY ONCE 1
MORE THAN ONCE 2

414. CHECK 410 AND 411:

MARRIED/LIVED WITH ONE WOMAN ONLY ONCE AND 411=1: I would like to talk about when, for the first time, you were married/began to live with a woman as if married.

OTHER: In which month and in which year were you married/did you begin to live with a woman for the first time?

MONTH _____
DON'T KNOW THE MONTH 98
YEAR _____ (GO TO 416)
DON'T KNOW THE YEAR 9998

415. How old were you when you began to live with her?

AGE ___

Now I would like to ask you some questions about your sexual activity in order to better understand certain problems in family life.

416. If you have already had sexual intercourse: How old were you when you had sexual intercourse for the first time?

NEVER 00
AGE IN YEARS ___ (GO TO 416B)
FIRST TIME WHEN I FIRST BEGAN LIVING WITH MY FIRST WIFE/PARTNER 95 (GO TO 416B)

416A. If you have not already had sexual intercourse: Do you intend to wait to be married, or do you intend to begin having sexual intercourse?

WAIT TILL MARRIAGE 1 (GO TO 439)
BEGIN 2 (GO TO 439)
UNSURE 8 (GO TO 439)

416B. CHECK 108:

AGE 15-24 YEARS (GO TO 416C)
AGE 25-59 YEARS (GO TO 417)

416cC.The last time you had sexual intercourse was a condom used?

YES 1
NO 2

416D. How old was the person with whom you had sexual intercourse for the first time?

PARTNER'S AGE ___ (GO TO 417)
DON'T KNOW 98

416E. Was this person older, younger or about the same age as you?

OLDER 1
YOUNGER 2 (GO TO 417)
SAME AGE 3 (GO TO 417)
DON'T KNOW/REMEMBER 8 (GO TO 417)

417. When did you last have sex?
IF IT WAS 12 MONTHS AGO OR MORE, THE RESPONSE MUST BE CONVERTED AND RECORDED IN YEARS.

1 ___ DAYS AGO
2 ___ WEEKS AGO
3 ___ MONTHS AGO
4 ___ YEARS AGO (GO TO 436A)

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

YES 1
NO 2 (GO TO 421)

419. What was the main reason why you used a condom at this time?

RESPONDENT WANTS TO AVOID MST/AIDS 1
RESPONDENT WANTS TO AVOID PREGNANCY 2
RESPONDENT WANTS TO AVOID BOTH MST/AIDS AND PREGNANCY 3
DID NOT TRUST PARTNER/SUSPECTED PARTNER TO HAVE OTHER PARTNERS 4
PARTNER INSISTED 5
OTHER (SPECIFY) __________ 6
DON'T KNOW 8

420. Have you used a condom each time you had sex with this person during the past 12 months?

YES 1
NO 2

421. CHECK 302:

RESPONDENT NOT STERILIZED (GO TO 422)
RESPONDENT STERILIZED (GO TO 426)

422. CHECK 419:

CONDOM USED TO AVOID PREGNANCY ('2' OR '3' CIRCLED): The last time you had sexual intercourse with this woman, did you or your partner use another method besides a condom to avoid pregnancy?

OTHER ('1,' '4,' '5,' '6,' OR '8' CIRCLE OR NOT ASKED): The last time you had sexual intercourse with this woman, did you or your partner do something or use a method to avoid pregnancy?

YES 1
NO 2 (GO TO 424)
DON'T KNOW 8 (GO TO 426)

423. Which method was used?
(IF MORE THAN ONE METHOD WAS USED, CIRCLE THE CODE OF THE METHOD THAT COMES FIRST IN THE LIST)

FEMALE STERILIZATION 01
PILL 03
IUD 04
INJECTIONS 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMENORRHEA METHOD (LAM) 11
RHYTHM METHOD 12
WITHDRAWAL 13
OTHER METHOD 96
DON'T KNOW 98

423A. GO TO 426.

424. CHECK 419:

CONDOM USED TO AVOID PREGNANCY (IF CODE 2 OR 3 CIRCLED, GO TO 426)

OTHER (GO TO 425)

425. What is the main reason why you did not use a method of contraception to avoid pregnancy?

OCCASIONAL SEXUAL PARTNER/NOT HIS RESPONSIBILITY 11
CONTRACEPTION IS A WOMAN'S ISSUE 12
NO NEED, A CONDOM WAS USED TO AVOID MST/AIDS 13
REASONS LINKED TO FERTILITY
WIFE/PARTNER MENOPAUSE/HYSTERECTOMY 23
COUPLE UNDER FERTILE/STERILE 24
WIFE/PARTNER PREGNANT 25
WIFE/PARTNER POSTPARTUM AMENORRHEA 26
WIFE/PARTNER BREASTFED 27
WANTED (OTHER) CHILDREN 28
OPPOSITION TO USE
RESPONDENT OPPOSED 31
WIFE/PARTNER OPPOSED 32
OTHER PEOPLE OPPOSED 33
RELIGIOUS INTERDICTION 34
LACK OF KNOWLEDGE
KNOWS NO METHOD 41
KNOWS NO SOURCE 42
REASONS LINKED TO METHODS
HEALTH PROBLEMS 51
HEAR OF SECONDARY EFFECTS 52
NO ACCESSIBLE/TOO FAR 53
TOO EXPENSIVE 54
NOT PRACTICAL TO USE 55
INTERFERES WITH BODY'S NATURAL PROCESSES 56
OTHER (SPECIFY) __________ 96
DON'T KNOW 98

426. The last time you had sexual intercourse with this (second, third) person, did you or this person drink alcohol?

YES 1
NO 2 (GO TO 428)

427. Were you or this person drunk at that time?
IF YES, who was drunk?

ONLY RESPONDENT 1
ONLY PARTNER 2
RESPONDENT AND PARTNER 3
NEITHER 4

428. What was your relationship with the person with whom you had sexual intercourse?

Wife 01 (GO TO 434)
PARTNER (OR GIRLFRIEND) LIVING WITH RESPONDENT 02 (GO TO 434)
GIRLFRIEND NOT LIVING WITH RESPONDENT 03
OCCASIONAL ENCOUNTER 04
SEX PROFESSIONAL 05
OTHER (SPECIFY) __________ 96

429. For how long have you been having sex with this person?
IF THE RESPONDENT ONLY HAD SEX ONCE, RECORD '01' DAY

DAYS 1
MONTHS 2
YEARS 3

434. Besides (this/these two people) have you had sexual intercourse with someone else during the past 12 months?

YES (RETURN TO 418)
NO (GO TO 436)

435. During the last 12 months with how many people have you had sexual intercourse?

IN THE CASE OF A NON-NUMERIC RESPONSE, PROBE TO GET AN ESTIMATE. IF THE NUMBER IS MORE THAN '95', RECORD '95'

NUMBER OF PARTNERS ___
DON'T KNOW 98

436. CHECK 428 ALL THE COLUMNS:

NO PARTNER IS A SEX PROFESSIONAL (NUMBER '05' IS CIRCLED) (GO TO 436A)

AT LEAST ONE PARTNER IS A SEX PROFESSIONAL (AT LEAST ONE '05' IS CIRCLED) (GO TO 438)

436A. During the last 12 months, did you pay someone in exchange for sex?

YES 1
NO 2 (GO TO 438)

436B. The last time you paid someone in exchange for sex, was a condom used?

YES 1
NO 2 (GO TO 438)

436C. During the last 12 months, did you use a condom during sexual intercourse, each time you paid someone in exchange for sex?

YES 1
NO 2
DON'T KNOW/NOT SURE 8

438. In all, with how many different people have you had sexual intercourse in your whole life?

IN THE CASE OF A NON-NUMERICAL RESPONSE, PROBE FOR AN ESTIMATE. IF THE NUMBER IS MORE THAN '95', RECORD '95'

NUMBER OF PARTNERS ___
DON'T KNOW 98

438B. CHECK THE PRESENCE OF OTHER PEOPLE.
DO NOT CONTINUE UNTIL YOU ARE COMPLETELY IN PRIVATE WITH THE RESPONDENT

PRIVACY OBTAINED 1
PRIVACY IMPOSSIBLE 2 (GO TO 439)

438C. The first time you had sexual intercourse, would you say that you wanted to have sexual intercourse or would you say that you were forced against your will?

WANTED 1
WAS FORCED 2
REFUSED TO RESPOND/NO RESPONSE 3

438D. During the last 12 months, has someone made you have sexual intercourse against your will?

YES 1
NO 2

439. Do you know a place where one could get condoms?

YES 1
NO 2 (GO TO 501)

440. Where is this?
Is there another place?

IF THE PLACE IS A HOSPITAL, A HEALTH CENTER OR A CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO DETERMINE THE SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE __________
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH HUT C
COMMUNITY HEALTH CARE WORKER D
OTHER PUBLIC (SPECIFY) __________ E
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC F
PRIVATE DOCTOR G
PHARMACY H
DOCTOR'S OFFICE I
WALKING SALESMAN J
OTHER PRIVATE MEDICAL (SPECIFY) __________ K
OTHER SOURCE
SHOP L
BAR/NIGHTCLUB M
KIOSK N
AMBULANT SALESPERSON O
FRIEND/ACQUAINTANCE/RELATIVE P
HOTEL/MOTEL Q
OTHER (SPECIFY) __________ X

441. If you wanted to, could you procure a condom?

YES 1
NO 2
DON'T KNOW/UNSURE 8

442. CHECK 418 ALL COLUMNS:

AT LEAST ONE 'YES' (GO TO 443)
OTHER (GO TO 501)

443. Where did you get condoms the last time?

IF THE PLACE IS A HOSPITAL, A HEALTH CENTER OR A CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO DETERMINE THE SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE __________
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH HUT C
COMMUNITY HEALTH CARE WORKER D
OTHER PUBLIC (SPECIFY) __________ E
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC F
PRIVATE DOCTOR G
PHARMACY H
DOCTOR'S OFFICE I
WALKING SALESMAN J
OTHER PRIVATE MEDICAL (SPECIFY) __________ K
OTHER SOURCE
SHOP L
BAR/NIGHTCLUB M
KIOSK N
AMBULANT SALESPERSON O
FRIEND/ACQUAINTANCE/RELATIVE P
HOTEL/MOTEL Q
OTHER (SPECIFY) __________ X

444. Do you know the brand name of the condoms that you used last time?

VISA 1
ROMED 2
DUMPER 3
CAREX 4
SULTAN 5
OTHER (SPECIFY) __________ 6
DON'T KNOW 8

445. The last time you bought condoms, how many did you buy?

NUMBER OF CONDOMS ___
DON'T KNOW 98
NEVER BOUGHT CONDOMS 97 (GO TO 501)

446. How much did you pay?

COST _____
DON'T KNOW 9998

SECTION 5. FERTILITY PREFERENCES

501. CHECK 410

HAS ONE WIFE/PARTNER (GO TO 502)
HAS 2 WIVES/PARTNERS OR MORE (GO TO 502)
NOT ASKED (GO TO 505)

502. Is your wife/partner (one of your wives/partners) currently pregnant?

YES 1
NO 2
NOT SURE 8

503. CHECK 502:

NO, NO PREGNANT WIFE/PARTNER/NOT SURE: Now I have some questions about the future. Would you like to have a (another) child, or would you prefer to have no (more) children at all?

YES, WIFE/PARTNER PREGNANT: Now I have some questions about the future. After the child that your wife/partner is expecting, would you like to has a (another) child, or do you prefer to have no (more) children at all?

HAVE A (ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 505)
WIFE/PART. CANNOT GET PREGNANT/IS STERILIZED 3 (GO TO 505)
UNDECIDED/DON'T KNOW 8 (GO TO 505)

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

MONTHS 1 ___
YEARS 2 ___
SOON/NOW 993
AFTER MARRIAGE 995
OTHER (SPECIFY) ___ 996
DON'T KNOW 998

505. CHECK 203 AND 205:

HAS LIVING CHILDREN: If you could return to the time when you did not have children and choose the number of children that you will have in your life, how many would you have?

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

PROBE TO GET A NUMERIC RESPONSE.

NO CHILDREN 00 (GO TO 507)
NUMBER ___
OTHER (SPECIFY) __________ 96 (GO TO 507)

506. Among these children how many boys do you want, how many girls, and for how many is the gender not important?

NUMBER OF BOYS ___
NUMBER OF GIRLS ___
NOT IMPORTANT ___
OTHER (SPECIFY) __________ 96

507. Do you approve or disapprove of couples who use a method to avoid pregnancies?

APPROVE 1
DISAPPROVE 2
DON'T KNOW/NOT SURE 8

508. During the last few months, have you heard about family planning:

On the radio?
YES 1
NO 2
On the television?
YES 1
NO 2
In newspapers or magazines?
YES 1
NO 2

510. During the past few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?

YES 1
NO 2 (GO TO 512)

511. With whom did you discuss this? Anyone else?
RECORD EVERYTHING MENTIONED.

WIFE/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER(S) F
SON(S) G
STEP MOTHER(S)/MOTHER(S) IN LAW H
FRIEND(S)/NEIGHBOR(S) I
OTHER (SPECIFY) __________ X

512. During these past months, did you discuss the practice of family planning with a health worker or health professional?

YES 1
NO 2

SECTION 6. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

601. Now I would like to talk to you about something else. Have you ever heard of a disease called AIDS?

YES 1
NO 2 (GO TO 635)

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

YES 1
NO 2
DON'T KNOW 8

603. Can people get AIDS from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

604. Can people reduce their risk of getting AIDS by using a condom every time they have sex?

YES 1
NO 2
DON'T KNOW 8

605. Can people get AIDS by sharing food with someone who has AIDS?

YES 1
NO 2
DON'T KNOW 8

606. Can people reduce their chance of getting AIDS by not having sexual intercourse at all?

YES 1
NO 2
DON'T KNOW 8

607. Can people get AIDS by witchcraft of other supernatural means?

YES 1
NO 2
DON'T KNOW 8

608. Is there something (else) that a person can do to avoid or reduce their risks of contracting the virus that causes AIDS?

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

609. What can a person do?
Anything else?
RECORD ALL MENTIONED.

ABSTAIN FROM SEX A
USE CONDOMS B
LIMIT TO ONE PARTNER/STAY LOYAL TO ONE PARTNER C
LIMIT THE NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WITH MULTIPLE PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH THOSE WHO MIGHT INJECT THEMSELVES WITH DRUGS H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING THE SAME BLADES/RAZORS K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM A TRADITIONAL HEALER N
OTHER (SPECIFY) __________ W
OTHER (SPECIFY) __________ X
DON'T KNOW Z

610. Is it possible that a person who appears to be healthy, in fact, has the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

611. Can the virus that causes AIDS be transmitted from mother to her baby?

During the pregnancy?
YES 1
NO 2
DON'T KNOW 8
During birth?
YES 1
NO 2
DON'T KNOW 8
During breastfeeding?
YES 1
NO 2
DON'T KNOW 8

612. CHECK 611:

AT LEAST ONE 'YES' (GO TO 613)
OTHER (GO TO 614)

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

YES 1
NO 2
DON'T KNOW 8

614. Are there any special drugs that a doctor or nurse can give people infected with the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 620)

616. When did you last get tested for the AIDS virus?

LESS THAN 12 MONTHS AGO 1
BETWEEN 12 AND 23 MONTHS AGO 2
2 OR MORE YEARS AGO 3

617. The last time you had the test, did you yourself ask for the test, was it offered and you accepted, or was it required?

ASKED FOR TEST 1
TEST OFFERED AND ACCEPTED 2
REQUIRED 3

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

YES 1
NO 2

619. Where was the test done?

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

PLACE NAME __________
PUBLIC SECTOR
HOSPITAL 11 (GO TO 622)
CEDAV (ANONYMOUS AND VOLUNTARY TESTING CENTER) 12 (GO TO 622)
OTHER PUBLIC (SPECIFY) __________ 16 (GO TO 622)
PRIVATE MEDICAL SECTOR
HOSPITAL/CLINIC 21 (GO TO 622)
PRIVATE LAB 22 (GO TO 622)
OTHER PRIVATE MEDICAL (SPECIFY) __________ 26 (GO TO 622)
OTHER (SPECIFY) __________ 96 (GO TO 622)

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

YES 1
NO 2 (GO TO 622)

621. Where is this?
Is there another place?

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

PLACE NAME __________
PUBLIC SECTOR
HOSPITAL A
CEDAV (ANONYMOUS AND VOLUNTARY TESTING CENTER) B
OTHER PUBLIC (SPECIFY) __________ 16 G
PRIVATE MEDIAL SECTOR
HOSPITAL/CLINIC H
PRIVATE LAB 22 I
OTHER PRIVATE MEDICAL (SPECIFY) __________ J
OTHER (SPECIFY) __________ X

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

YES 1
NO 2
DON'T KNOW 8

623. If a member of your family had the AIDS virus would you like it to remain a secret or not?

YES, REMAIN SECRET 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

624. If a member of your family becomes sick with the AIDS virus would you be willing to take care of him/her in your own household?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

625. If a teacher has the AIDS virus but is not sick, should s/he be able to continue teaching in the school?

SHOULD BE ALLOWED 1
SHOULD NOT BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8

626. Do you personally know someone who has been denied health service in the last 12 months because he or she is suspected to have the AIDS virus?

YES 1
NO 2
DON'T KNOW ANYONE WITH AIDS 8 (GO TO 631)

627. Do you personally know someone who has been denied involvement in social events, religious services or community events in the last 12 months because he or she is suspected to have the AIDS virus?

YES 1
NO 2

628. Do you personally know someone who has been insulted or teased in the last 12 months because he or she is suspected to have the AIDS virus?

YES 1
NO 2

629. CHECK 626, 627 AND 628:

NO 'YES' (GO TO 630)
AT LEAST ONE 'YES' (GO TO 631)

630. Do you know someone who is suspected to have or has the AIDS virus?

YES 1
NO 2

631. Do you agree or disagree with the following statement: People with the AIDS virus should be ashamed of themselves.

AGREE 1
DISAGREE 2
DON'T KNOW/NO OPINION 8

632. Do you agree or disagree with the following statement: People with the AIDS virus should be blamed for bringing the disease into the community.

AGREE 1
DISAGREE 2
DON'T KNOW/NO OPINION 8

633. Should children ages 12-14 be taught about using a condom to avoid getting the AIDS virus?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

634. Should children ages 12-14 be taught to wait until they get married to have sex or to avoid getting AIDS?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

635. Do you think that young men should wait until marriage to have sexual intercourse?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

636. Do you think that young women should wait until marriage to have sexual intercourse?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

637. Do you think that married men should only have sexual intercourse with their wives?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

638. Do you think that most of the men you know only have sexual intercourse with their wives?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

639. Do you think that married women should only have sexual intercourse with their husband?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

640. Do you think that most of the women that you know only have sexual intercourse with their husband?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

641. CHECK 601:

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

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

YES 1
NO 2 (GO TO 644)

642. When a man has a sexually transmitted infection, which symptom could he have?
Are there other symptoms? RECORD ALL MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL-SMELLING DISCHARGE C
BURNING URINATION D
GENITAL REDNESS/INFLAMMATION E
GENITAL SWELLING F
GENITAL SORE/ULCER G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
WEIGHT LOSS K
IMPOTENCE L
OTHER (SPECIFY) __________ W
OTHER (SPECIFY) __________ X
NO SYMPTOMS Y
DON'T KNOW Z

643. When a woman has a sexually transmitted infection, which symptom could she have?
Are there other symptoms? RECORD ALL MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL-SMELLING DISCHARGE C
BURNING URINATION D
GENITAL REDNESS/INFLAMMATION E
GENITAL SWELLING F
GENITAL SORE/ULCER G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINATION J
WEIGHT LOSS K
DIFFICULTY GETTING PREGNANT L
OTHER (SPECIFY) __________ W
OTHER (SPECIFY) __________ X
NO SYMPTOMS Y
DON'T KNOW Z

644. CHECK 416:

HAS HAD SEXUAL INTERCOURSE (GO TO 645)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 654)

645. CHECK 641:

HAS HEARD ABOUT SEXUALLY TRANSMITTED DISEASES (GO TO 646)
HAS NOT HEARD ABOUT SEXUALLY TRANSMITTED DISEASES (GO TO 647)

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

646. During the last 12 months have you had a disease which you got from sexual contact?

YES 1
NO 2
DON'T KNOW 8

647. Sometimes a man has a bad smelling penile discharge. During the last 12 months have you had a bad smelling penile discharge?

YES 1
NO 2
DON'T KNOW 8

648. Sometimes men have a genital sore or ulcer. During the past 12 months have you had a sore or ulcer in area of the penis?

YES 1
NO 2
DON'T KNOW 8

649. CHECK 646, 647 AND 648:

HAS HAD AN INFECTION (AT LEAST ONE 'YES') (GO TO 650)
HAS NOT HAD AN INFECTION OR DON'T KNOW (GO TO 654)

650. The last time you had (PROBLEM IS MENTIONED IN 646, 647, AND/OR 648) did you seek any kind of advice or treatment?

YES 1
NO 2

651. Where did you go?
Was there another place?
RECORD ALL MENTIONED.

PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
CTV CENTER C
HEALTH HUT D
COMMUNITY HEALTH CARE WORKER E
OTHER PUBLIC (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
Private hospital/clinic H
DOCTOR I
CTV CENTER J
PHARMACY K
HEALTH CARE WORKER L
OTHER PRIVATE MEDICAL (SPECIFY) _____ M
OTHER SOURCE
TRADITIONAL HEALER N
SHOP O
OTHER (SPECIFY) __________ X
DON'T KNOW Z

652. The last time you had (PROBLEM IS MENTIONED IN 646, 647, AND/OR 648) did your partner seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 654)
DON'T KNOW 8 (GO TO 654)

653. Where did she go? Was there another place?
RECORD ALL MENTIONED.

PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
CTV CENTER C
HEALTH HUT D
COMMUNITY HEALTH CARE CENTER E
OTHER PUBLIC (SPECIFY) __________ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC H
DOCTOR I
CTV CENTER J
PHARMACY K
HEALTH CARE WORKER L
OTHER PRIVATE MEDICAL (SPECIFY) __________ M
OTHER SOURCE
TRADITIONAL HEALER N
SHOP O
OTHER (SPECIFY) __________ X
DON'T KNOW Z

654. As you know, some men are circumcised. Did you also undergo this ordeal?

YES 1
NO 2

SECTION 7. FEMALE CIRCUMCISION

701. Have you ever heard of female circumcision?

YES 1 (GO TO 703)
NO 2

702. In certain countries there is a practice that involves cutting a part of the external genitals of girls. Have you heard of this practice?

YES 1
NO 2 (GO TO 711)

703. What are the advantages to circumcising a girl?
What are the other advantages? RECORD ALL MENTIONED.

BETTER HYGIENE A
SOCIAL RECOGNITION B
BETTER CHANGE FOR MARRIAGE C
PRESERVATION OF VIRGINITY/PREVENT SEXUAL INTERCOURSE BEFORE MARRIAGE D
MORE SEXUAL PLEASURE FOR THE MAN E
RELIGIOUS NECESSITY F
OTHER (SPECIFY) _____ X
NO ADVANTAGE Y

704 What are the advantages of girls not being circumcised?
Anything else? RECORD ALL MENTIONED.

FEWER HEALTH PROBLEMS A
AVOIDING THE SUFFERING B
MORE SEXUAL PLEASURE FOR HER C
MORE PLEASURE FOR THE MAN D
IN ACCORDANCE WITH RELIGION E
OTHER (SPECIFY) __________ X
NO ADVANTAGE Y

705. CHECK 703:

CODE 'D' NOT CIRCLED IN 703 (GO TO 706)
CODE 'D' CIRCLED IN 703 (GO TO 707)

706. Do you think this practice is a way for preventing girls from having sexual intercourse before marriage or do you think, on the contrary, that this has no effect?

PREVENTS SEX 1
NO EFFECT 2
DON'T KNOW 8

707. CHECK 703 AND 704

CODE 'F' NOT CIRCLED IN 703 AND 704 (GO TO 708)
CODE 'F' CIRCLED IN 703 AND 704 (GO TO 709)

708. Do you think that this practice is required by your religion?

YES 1
NO 2
DON'T KNOW 8

709. Do you think that this practice should be maintained or that it should disappear?

MAINTAINED 1
DISAPPEAR 2
DEPENDS 3
DON'T KNOW 8

710. Do you think that women want this practice to be preserved or do you think they are favorable to abandoning it?

PRESERVED 1
ABANDONED 2
IT DEPENDS 3
DON'T KNOW 8

711. RECORD THE TIME:

HOURS ___
MINUTES ___

INTERVIEWER'S OBSERVATIONS

FILL OUT AFTER HAVING ENDED THE INTERVIEW

COMMENTS ABOUT THE RESPONDENT: _____

COMMENTS ON PARTICULAR QUESTIONS: _____

OTHER COMMENTS: _____

SUPERVISOR'S OBSERVATIONS _____
SUPERVISOR'S NAME _______
DATE _____

FIELD EDITOR'S OBSERVATIONS _____
FIELD EDITOR'S NAME ______
DATE _____