IDENTIFICATION

NAME AND THE CODE OR REGION __________

PLACE (LOCALITY) NAME __________

CLUSTER NAME _____

HOUSEHOLD NUMBER _____

NAME AND LINE NUMBER OF WOMAN __________

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

WOMAN SELECTED FOR SECTION 12?

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME __________

RESULT* __________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)

DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. NUMBER _____
RESULT _____

TOTAL NUMBER OF VISITS ___

LANGUAGE OF QUESTIONNAIRE _____

LANGUAGE OF INTERVIEW _____

LANGUAGE OF RESPONDENT _____

TRANSLATOR USED

SUPERVISOR
NAME __________
DATE __________

FIELD EDITOR
NAME __________
DATE __________

OFFICE EDITOR _____
KEYED BY _____

SECTION 1. RESPONDENT'S BACKGROUND

INFORMED CONSENT

101A) COLLECT ANY RELEVANT DOCUMENTS THAT MAY HAVE INFORMATION ON THE RESPONDENT AND HER CHILDREN'S AGE AND IMMUNIZATIONS.

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 103 IF INCONSISTENT.

104) Have you ever attended school?

105) What is the highest level of school you attended: primary, secondary, or higher?

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?

108A) Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

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?

114) What is the main language spoken in your home?

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 more than one month at a time?

SECTION 2. REPRODUCTION

201A) CHECK COVER PAGE:

201B) CHECK 103:

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 not 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 are alive but do not live with you?

205) How many sons are alive but do not live with you? And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

206) Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of live but did not survive?

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 a 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/ TRIPLETS/ MULTIPLES ON SEPARATE ROWS.

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?
RECORD NAME, BIRTH HISTORY NUMBER

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

214) Were any of these births multiples?

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 THAT 1 MONTH; MONTHS 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 NAME OF BIRTHS IN 2008 OR LATER

225) FOR EACH BIRTH SINCE JANUARY 2008, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE. FOR EACH BIRTH, 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.)

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) Since January 2008, have you had any other pregnancies that did not result in a live birth?

235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2008.

ENTER 'T' IN THE CALDENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2008?

237) When did the last such pregnancy that terminated before 2008 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 a pregnancy.

Have you ever 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?
PROVE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

308) In what month and year was the sterilization performed?

308A) Since what month and year have you been using (CURRENT METHOD) without stopping? PROBE: For how long have you been using (CURRENT METHOD) not without stopping?

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

YES:
GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).

NO (GO TO 310)

310) CHECK 308/308A:

YEAR IS 2008 OR LATER:
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND IN EACH MOTH BACK TO THE DATE STARTED USING.

YEAR IS 2007 OR EARLIER:
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK TO JANUARY 2008. THEN GO TO 322

311) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OR USE AND NONUSE, STARTING WITH MOIST RECENT USE, BACK TO JANUARY 2008.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

IN COLUMN 1, ENTER METHOD USE CODE OR '0' FOR NONUSE 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 did 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 SAME AS NUMBER OF INTERRUPTIONS OR 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 stopped 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) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?

315A) Where did you learn how to use the rhythm/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 METHOD 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:

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

CODE '1' NOT CIRLCED:
When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

321) Were you ever told by a 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?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OF PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

326) In the last 12 months, were you visited by a fieldworker/community health worker/health promoter who talked to you about family planner?

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?

SECTOR 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215:
ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2008 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

Now I would like to ask some questions about your children about your children born in the last five years. (We will talk about each separately.)

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

404) FROM 212 AND 216:

405) When you got pregnant with (NAME), did you want to get pregnant at the time?

406) Did you want to have a baby later on, or did you 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 recieve antenatal care for this pregnancy? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

410A) Did your husband/partner attend (any of) your antenatal care visit(s) for this pregnancy?

411) How many months pregnant were you when you first recieved antenatal care for this pregnancy?

412) How many times did you recieve antenatal care 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 things to look out for that might suggest problems with the pregnancy?

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?

417) CHECK 416:

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

419) Before this pregnancy, how many times did you recieve a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'.

420) How many years ago did you recieve the last tetanus injection before this pregnancy?

421) During this pregnancy, were you given or did you buy any iron tables? SHOW TABLETS.

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

423) During this pregnancy, did you take any drugs intestional 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 DRUGS IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIA DRUGS TO RESPONDENT.

426) CHECK 425:
SP/FANSIDAR 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 health facility or from another source?

430) When (NAME) was born, was he/she very large, larger than average, average, smaller than average, 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.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

434A) How long after (NAME) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

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

436) I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. 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?

437A) Why didn't you deliver in a health facility?
PROBE: Any other reasons?
RECORD ALL MENTIONED.

438) I would like to talk to you about checks on your health after deliver, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?

439) Who checked on your health at that time?
PROVE FOR MOST QUALIFED PERSON.

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.

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 ONE WEEK, RECORD DAYS.

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

445) Where did this frist check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRLCE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVEATE SECTOR, WRITE THE NAME OF THE PLACE.

446) In the first two months after delivery, did you recieve a vitamin A dose like this? SHOW CAPSULE.

447) Has your menstrual 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 had sexual intercourse since the birth of (NAME)?

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

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? 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 IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2008 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) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

503) FROM 212 AND 216

504) Do you have a card where (NAME)'s vaccinations are written down? IF YES: May I see it please?

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

506)
(1) COPY DATES FROM THE CARD
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

507) CHECK 506:

508) Has (NAME) had any vaccinations that are not recorded on this card, including vaccinations given in a national immunization day campaign?
RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN/

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

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

510A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

510B) Polio vaccine, that is, drops in the mouth?

510C) Was the first polio vaccine given in the first two weeks after birth or later?

510D) How many times was the polio vaccine given?

510E) A DPT/Pentavalent vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

510F) How many times was the DPT/Pentavalent vaccination given?

510G) A measles injection or an MMR injection - that is, a shot in the arm at the age of 9 months or older - to prevent him/her from getting measles?

511) Within the last six months, was (NAME) given a vitam A does like this?
SHOW CAPSULE.

513) Was (NAME) given any medication for intestinal worms in the last six months?

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

515) Was there any blood in the stools?

516) Now I would like to know how much (NAME) was given to drink during the diarrhoea (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 he/she given much less than usual to drink or somewhat less?

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

518) Did you seek advice or treatment for the diarrhoea from any source?

519) Where did you seek advice or treatment? Anywhere else?PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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 diarrhoea:

523) Was anything (else) given to treat the diarrhoea?

524) What (else) was given to treat the diarrhoea? 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 for malaria?

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 he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

529) Was the fast or difficult breathing due to 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 he/she given much less than usual to drink or somehwat less?

532) When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual or nothing to eat?
IF LESS, PROBE: Was he/she 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?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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 medication for the illness?

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

539) CHECK 538:
ANY CODE A-C CIRLCED?

546) CHECK 538:
QUINNE ('A') GIVEN

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

548) CHECK 538:
ARTEMETHER LUMFANTRINE ('B') GIVEN

549) How long after the fever started did (NAME) first take Artemether Lumefantrine (AL)?

550) CHECK 538:
OTHER ANTIMALARIAL ('C') 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 2008 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 522a, ALL COLUMNS:

556) Have you ever heard of a special product called ORS you can get for the treatment of diarrhea?

557) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2011 OR LATER LIVING WITH THE RESPONDENT

558) Now I would like to ask you about liquids or foods that (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 "u"):

560) Did (NAME) eat any solid, semi-solid, or soft foods yesterday during the day or at night?
IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

561) How many times did (NAME FROM 557) eat solid, semi-solid, 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 somewhere else?

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 you (husband/partner) have other wives or does he live with other women as if married?

607) Including yourself, in total, how many 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?:
Now I would like to ask about your first (husband/partner). In what month and year did you start living with him?

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 would like to ask 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 you 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. If we should come to any questions that you don't want to answer, just let me know and we will go to the next question.

615) When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

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) Was a condom used 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 you 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 NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

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?

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

628) PRESENCE OF OTHERS DURING THIS SECTION:

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

630) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
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?

632) Do you know of a place where a person can get female condoms?

633) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE HTE NAME OF THE PLACE.

634) If you wanted to, could you yourself get a female condom?

SECTION 7. FERTILITY PREFERENCES

701A) CHECK COVER PAGE:

701B) CHECK 103:

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:
USING A CONTRACEPTIVE METHOD?

708) CHECK 705:

709) CHECK 704:
RECORD ALL REASONS MENTIONED.

WANTS TO HAVE A/ANOTHER CHILD:
You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy? Any other reason?

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

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:
PROBE FOR A NUMERIC RESPONSE.

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?

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 it matter if it's a boy or girl?

714) In the last few months have you:

716) CHECK 601:

717) CHECK 303:
USING A CONTRACEPTIVE METHOD?

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: primary, secondary, or higher?

805) What was the highest (grade/year) 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's/partner's) occupation? This 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?

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 or any other work?

809) Although you did not work in the last seven days, do you have any job or business form 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 in at all?

815) CHECK 601:

816) CHECK 814:

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

818) Would you say that the money that 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's/ 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 visit 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 HIV/AIDS?

902) Can people reduce their chance of getting HIV by having just one uninfected sex partner who has no other sex partners?

903) Can people get HIV from mosquito bites?

904) Can people reduce their chance of getting HIV by using a condom every time they have sex?

905) Can people get HIV by sharing food with a person who has AIDS?

906) Can people get HIV because of witchcraft or other supernatural means?

907) Is it possible for a healthy-looking person to have HIV?

908) Can HIV be transmitted from a mother to her baby:

909) CHECK 908:

910) Are there any special medications that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby?

911) CHECK 208 AND 925:

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 HIV as part of your antenatal care?

916) Were you tested for HIV as part of your antenatal care?

917) Were was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

918) Did you get the results of the test?

918A) Will you be willing to share the results with me?

918B) What was your HIV rest result?

918C) All women are supposed to receive counselling before and after being tested. Before and after you were tested, did you receive counselling?

918D) Have you disclosed your result to your partner?

919A) Was your partner tested for HIV during any of the ANC visits for your last birth?

919B) CHECK 916 TESTED DURING ANC:

919C) CHECK 918, 918A, AND 918B FOR HIV TEST RESULTS:

920) CHECK 434 FOR LAST BIRTH:

921) Between the time you went for delivery but before (NAME) was born, were you offered a test for HIV?

922) Were you tested for HIV at the time?

923) Did you get the results of the test?

923A) Will you be willing to share the results with me?

923B) What was your HIV test result?

923C) Have you disclosed your result to your partner?

923D) Was (NAME) tested for HIV during the first 18 weeks of his/her life?

923E) Was (NAME) tested for HIV during the first 18 months of his/her life?

923F) Was (NAME) tested for HIV more than once during the first 18 months of his/her life?

923G) Did you get the results of the (last) HIV test for (NAME)?

923H) Will you be willing to share the results with me?

923I) What was (NAME)'s HIV test result?

923J) CHECK 216 LAST ROW:
IS CHILD LIVING?

923L) Is (NAME) currently taking ARV's daily?

923M) CHECK 926 AND 922:
WOMAN TESTED FOR HIV

924) Have you been tested for HIV since that time you were tested during your pregnancy?

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

926) Have you ever been tested to see if your have HIV?

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

927A) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

928) Did you get the results of the test?

928A) Will you be willing to share the results with me?

928B) What was your HIV test result?

928C) All women are supposed to receive counseling before and after being tested. Before and after you were tested, did you receive counseling?

928D) Have you disclosed your result to your partner?

928E) Did you receive HIV counseling and testing individually or as a couple?

928F) Would you consider HIV counseling and testing as a couple in the future?

928G) What is the main reason you would not consider HIV counseling and testing as a couple in the future?

928H) CHECK 918B, 923B, AND 928B:
HIV TEST RESULT

928I) Are you currently taking ARV'S daily?

928J) What is the main reason for not taking ARV's daily?

930) Do you know of a place where people can go to get tested for HIV?

931) Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

932) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had HIV?

933) If a member of your family got infected with HIV, would you want 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 HIV but is not sick, should she be allowed to continue teaching in the school?

936) Should children 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 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 some questions 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 )PROBLEM FROM 940/941/942), did you seek any kind of advice or treatment?

945) Where did you go? Any other place? PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

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 to have sex with her husband when she knows he 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

1000A) Have you ever heard of an illness called tuberculosis or TB?

1000B) How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORDE ALL MENTIONED.

1000C) What symptoms will a person with tuberculosis or TB have? Anything else?
RECORD ALL MENTIONED.

1000D) Can tuberculosis be cured?

1000E) If a member of your family got tuberculosis, would you want it to remain a secret or not?

1001) Now I would like to ask you some other 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 90 OR MORE, 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 doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS 90 OR MORE, 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 view 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 MENTIONED.

1007A) Do you use or smoke tobacco products daily?

1007B) How old were you when you first started using any tobacco products daily?

1007C) Have you ever consumed an alcoholic drink, such a beer, wine, spirits, or other home-brewed liquor?

1007F) Have you consumed an alcoholic drink during the past two weeks?

1007G) During the past two weeks, on how many days did you have at least one alcoholic drink?

1007H) During the past two weeks, when you consumed alcohol, on average, how many bottles/glasses/tots of alcohol did you have per day?

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?

1010) What type of health insurance are you covered by? RECORD ALL MENTIONED.

1010A) Now I am going to ask you some questions about physical activity. Are you involved in exercise that causes an increase in your heart rate for at least 10 minutes continuously?

IF YES, ASK: At work?
During other physical activities?

1010B) In the last 7 days, on how many days did you do exercise that lasted for at least 10 minutes each time?
IF 'NONE' RECORD '0'

1010E) Now I would like to ask you about liquids and foods that you consume.
How many glasses of water do you drink in one day on average?
IF 'NONE' RECORD '00'

1010F) In a typical week, on how many days do you eat fruits, such as apples, pears, oranges, bananas, mangoes, etc.?
IF 'NONE' RECORD '0'

1010G) On a day when you eat fruits, how many times do you eat on average?
IF 'NONE' RECORD '00'

1010H) In a typical week, on how many days do you eat vegetables, such as tomatoes, carrots, cabbage, dark green leafy vegetables (e.g. spinach) pumpkin, squash, etc?

1010I) On a day when you eat vegetables, how many times do you eat on average? IF 'NONE' RECORD '00'

1010M) In the past 30 days, when you were seated in a vehicle either as a driver or passenger, have you used a seatbelt always, sometimes or never?

1010N) Now I would like to ask about women's health. Have you ever heard of cervical cancer?

1010O) Have you ever had a test or exam to see if you have cervical cancer?

1010P) What type of exam did you have to see if you have cervical cancer?

1010Q) Have you ever exampled your breasts to detect or check for breast cancer?

1010R) Has a doctor or other health professional examined your breasts to detect or check for breast cancer?

1010S) Now I would like to ask some questions about mental health. Are there times when you see or hear things that are actually not there?

1010T) In the past 12 months, have you ever felt seriously worthless, hopeless, or wished you were dead?

1010U) In the past two weeks, have you felt that you had little interest or pleasure in doing things?
IF YES, ASK: How many days did you feel this way?

1010V) In the past two weeks, have you felt very low in energy, been in a bad mood, or been sad all the time? IF YES, ASK: How many days did you feel this way?

1010W) CHECK 1010S, 1010T, 1010U, AND 1010V:

1010X) Did you seek any medical care?

SECTION 11. MATERNAL MORTALITY

1101A) CHECK COVER PAGE:

1101B) CHECK 103:

1101) Now I would like to ask you some questions about your brothers and sister, that is, all of the children born to your natural mother, including those who are living with you, those living elsewhere, and those who have died.

How many children did your mother give birth to, including you?

1102) CHECK 1101:

1103) How many births did your mother have before you were born?

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

1105) Is (NAME) male or female?

1106) Is (NAME) still alive?

1107) How old is (NAME)?

1108) How many years ago did (NAME) die?

1109) How old was (NAME) when he/she died?

IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO NEXT OLDEST

1110) Was (NAME) pregnant when she died?

1111) Did (NAME) die during childbirth?

1112) Did (NAME) die within two months after the end of a pregnancy or childbirth?

1113) How many live born children did (NAME) give birth to during her lifetime?

IF NO MORE BROTHERS OR SISTER, GO TO 1201A

SECTION 12. DOMESTIC VIOLENCE

1201A) CHECK COVER PAGE:

1201B) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

READ TO RESPONDENT:
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Namibia. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.

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 I need to ask you some questions about your relationship with your (last) (husband/partner) ever:

A) Did your (last) (husband/partner) ever:

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

1205) A) Did your (last) (husband/partner) ever do any of the following things to you:

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

1206) CHECK 1205A (a-j):

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

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

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

1210) In the last 12 months, how often have you done this to your (last) (husband/partner): often, only sometimes, or not at all?

1211) Does (did) your (last) (husband/partner) drink alcohol?

1212) How often does (did) he get drunk: often, only sometimes, or never?

1213) Are (Were) you afraid of your (last) (husband/partner): most of the time, sometimes, or never?

1214) CHECK 609:

1215) A) So far we have been talking about the behavior of your (current/last)(husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

B) How long ago did this last happen?

1216) CHECK 601 AND 602:

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

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

1217) Who has hurt you in this way? Anyone else? RECORD ALL MENTIONED.

1218) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

1219) CHECK 201, 226, AND 230:

1220) Has anyone ever hit, slapped, or kicked, or done anything else to hurt you physically while you were pregnant?

1221) Who has done any of these things to physically hurt you while you were pregnant? Anyone else? RECORD ALL MENTIONED

1222) CHECK 601 AND 602:

1222A) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).

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 when you did not want to?

1222B) 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 when you did not want to?

1223) Who was the person who was forcing you the first time this happened?

1224) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN:
In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

NEVER MARRIED/NEVER LIVED WITH A MAN:
In the last 12 months has anyone physically forced you to have sexual intercourse when you did not want to?

1224A) CHECK 1205A (h-j) and 1215A (b)

1225) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN:
How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts by anyone, including (your/any) husband/partner.

NEVER MARRIED/EVER LIVED WITH A MAN:
How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

1226) CHECK 1205A (a-j), 1215A (a,b), 1216, 1220, 1222A, AND 1222B:

1227) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

1228) From whom have you sought help? Anyone else? RECORD ALL MENTIONED.

1229) Have you ever told anyone about this?

1230) 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 WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

PROVIDE LIST OF REFERRAL PLACES TO RESPONDENT.

1231) 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?

1232) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

1233) RECORD THE TIME

CALENDAR
INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX.
COLUMN 1 REQUIRES A CODE IN EVERY MONTH.

INFORMATION TO BE CODED FOR EACH COLUMN.

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE

COLUMN 2: DISCONTUINATION OF CONTRACEPTIVE USE

2013

2012

2011

2010

2009

2008

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: __________

COMMENTS ON SPECIFIC QUESTIONS: __________

ANY OTHER COMMENTS: __________

SUPERVISOR OBSERVATIONS: __________

NAME OF SUPERVISOR: __________
DATE: __________

EDITOR OBSERVATIONS: __________

NAME OF EDITOR: __________
DATE: __________