IDENTIFICATION

NAME AND CODE OF REGION __________
PLACE (LOCALITY) NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____

MAN SELECTED FOR SECTION 9?

NAME AND LINE NUMBER OF MAN __________

INTERVIEWER VISITS

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

RESULT __________

NEXT VISIT (REPEAT FOR SECOND AND THIRD VISIT)
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR 2013
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

INTRODUCTION AND CONSENT
INFORMED CONSENT
Hello. My name is __________. I am working with the Ministry of Health and Social Services. We are conducting a survey about health all over Namibia. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any questions you don't want to answer, just let me know and I will go on to the next questions or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.
Do you have any questions? May I begin the interview now?
SIGNATURE OF INTERVIEWER __________
DATE _____

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

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 involved learning to read or write (not including primary school)?

109) CHECK 108:
CODE '2', '3', OR '4' CIRCLED (GO TO 110)
CODE '1', OR '5' CIRCLED (GO TO 111)

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 103:
MAN AGE 15-49 (GO TO 201)
MAN AGE 50-64 (GO TO 401)

201) Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name.

Have you ever fathered any children with any woman?

202) Do you have any sons or daughters that you have fathered 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 that you have fathered 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 fathered a son or daughter 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:

210) Did all of the children you have fathered have the same biological mother?

211) In all, how many women have you fathered children with?

212) How old were you when your (first) child was born?

213) CHECK 203 AND 205:

214) How old is your (youngest) child?

215) CHECK 214:

216) What is the name of your (youngest) child? WRITE NAME OF (YOUNGEST) CHILD.

217) When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?

218) Were you ever present during any of those antenatal check-ups?

218A) Were you tested for HIV in any of the antenatal check-ups you attended when our wife was pregnant with (NAME)?

219) Was (NAME) born in a hospital or health facility?

219A) What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?

220) When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual, or nothing to drink at all?

SECTION 3. CONTRACEPTION

301) Now I would like to talk about family planning- the various ways or methods that a couple can use or delay or avoid a pregnancy. Have you ever heard of (METHOD)?

302) In the last few months have you:

303) In the last few months, have you discussed family planning with a health worker or health professional?

304) Now I would like to ask you about a woman's risk of pregnancy.

From on menstrual period to the next, are there certain days when a woman is more likely to become pregnant when she has sexual relations?

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

306) I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.

307) CHECK 301 (08):
KNOWS MALE CONDOM

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

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

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

311) CHECK 301 (09):
KNOWS FEMALE CONDOM

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

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

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

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401) Are you currently married or living together with a women as if married?

402) Have you ever been married or live together with a woman as if married?

403) What is your marital status now: are you widowed, divorced, or separated?

404) Is your (wife/partner) living with you now or is she staying elsewhere?

405) Do you have other wives or do you live with other women as if married?

406) Altogether, how many wives or live-in partners do you have?

407) CHECK 405:
RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER.
IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

ONE WIFE/PARTNER:
Please tell me the name of (your wife/the woman you are living with as if married).

MORE THAN ONE WIFE/PARTNER:
Please tell me the name of each of your wives or each woman you are living with as if married.

408) How old was (NAME) on her last birthday? ASK 408 FOR EACH PERSON

409) CHECK 407:

410) Have you been married or lived with a woman only once or more than once?

411) In what month and year did you start living with your (wife/partner)

411A) Now I would like to ask about your first (wife/partner). In what month and year did you start living with her?

412) How old were you when you first started living with her?

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

414) Now I would like to ask some questions about sexual activities 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?

415) 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 question that you don't want to answer, just let me know and we will go to the next question.

416) 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.

417) When was the last time you had sexual intercourse with this person?

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

419) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

420) What was your relationship to this person with whom you had sexual intercourse?
IF YES, CIRCLE '2'
If NO, CIRLCE '3'

IF GIRLFRIEND: Were you living together as if married?

421) CHECK 410:

422) CHECK 414:

423) How long ago did you first have sexual intercourse with this (second/third) person?

424) 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'

425) How old is this person?

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

427) 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"

428) CHECK 420 (ALL COLUMNS):

429) CHECK 420 AND 418 (ALL COLUMNS):

430) In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

431) Have you ever paid anyone in exchange for having sexual intercourse?

432) The last time you paid anyone in exchange for having sexual intercourse, was a condom used?

433) Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse the last 12 months?

434) In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMBERIC ANSWER, PROBE TO GET ESTIMATE.
IF NUMBER OF PARTNERS IS 95 OR MORE, WRITE '95'.

435) CHECK 418, MOST RECENT PARTNER (FIRST COLUMN):

436) You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?
IF BRAND IS NOT KNOWN, ASK TO SEE THE PACKAGE.

437) From where did you obtain the condom the last time?
PROBE TO IDENTIFY TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

438) The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

439) What method did you or your partner use?
PROBE: Did you or your partner use any other method to prevent pregnancy?
RECORD ALL MENTIONED.

SECTION 5. FERTILITY PREFERENCES

501A) CHECK 103:
MAN AGE 15-49 (GO TO 501)
MAN AGE 50-64 (GO TO 601)

501) CHECK 401:
CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 502)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 509)

502) CHECK 439:
MAN NO STERILIZED (GO TO 503)
MAN STERILIZED (GO TO 509)

503) (Is your (wife/partner)/Are any of your (wives/partners)) currently pregnant?

504) Now I have some questions about the future. After the (child/children) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not to have any more children?

505) 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?

506) CHECK 407:

507) CHECK 503:

WIFE/PARTNER NOT PREGNANT OR DON'T KNOW: How long would you like to wait from now before the birth of (a/another) child?

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

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

509) CHECK 203 AND 205:

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?

510) How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or girl?

SECTION 6. EMPLOYMENT AND GENDER ROLES

601) Have you done any work in the last seven days?

602) 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, or any other such reason?

603) Have you done any work in the last 12 months?

604) What is your occupation, that is, what kind of work do you mainly do?

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

606) Are you paid in cash or kind for this work or are you not paid at all?

607) CHECK 401:

608) CHECK 606:

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

610) Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly or someone else?

611) Who usually makes decisions about making major household purchases?

612) Do you own this or any other house either alone or jointly with someone else?

613) Do you own any land either alone or jointly with someone else?

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

SECTION 7. HIV/AIDS

701) Now I would like to talk about something else. Have you ever heard of HIV/AIDS?

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

703) Can people get HIV from mosquito bites?

704) Can people reduce their chance of getting HIV by using a condom everything they have sex?

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

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

707) Is it possible for a health-looking person to have HIV?

708) Can HIV be transmitted from her mother to her baby?

709) CHECK 708:

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

711) CHECK FOR PRESENCE OF OTHERS BEFORE CONTINUING, MAKE EFFORT TO ENSURE PRIVACY.

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

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

714) Did you get the results of the test?

714A) Will you be willing to share the results with me?

714B) What was your HIV test result?

714C) All men are supposed to receive counseling before and after being tested. Before and after you were tested, did you receive counseling?

714D) Have you disclosed your result to your partner?

715) 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.

715A) Did you receive HIV counseling and testing individually or as a couple?

715B) Would you consider HIV counseling and testing as a couple in the future?

715C) What is the main reason you would not consider HIV counseling as a couple in the future?

715D) CHECK 714B: HIV TEST RESULT

715E) Are you currently taking ARV's daily?

715F) What is the main reason for not taking ARV's daily?

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

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

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

719) If a member of your family got infected with HIV, would you want it to remain a secret or not?

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

721) In your opinion, if a female teacher has HIV but is not sick, should she be allowed to continue teaching in the school?

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

723) CHECK 701:

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?

724) CHECK 414:

725) CHECK 723: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTION?

726) 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?

727) Sometimes men experience an abnormal discharge from their penis? During the last 12 months, have you had an abnormal discharge from your penis?

728) Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?

729) CHECK 726, 727, AND 728:

730) The last time you had (PROBLEM FROM 726/727/728), did you seek any kind of advice or treatment?

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

732) 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?

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

SECTION 8. HEALTH ISSUES

801) Now I would like to ask you some other questions relating to health matters. Some men are circumcised, that is, the foreskin is completely removed from your penis. Are you circumcised?

802) How old were you when you got circumcised?

803) Who did the circumcision?

804) Where was it done?

804A) If you had a baby boy, would you have him circumcised?

804B) Are there any benefits to male circumcision?

804C) What are the benefits of male circumcision? RECORD ALL MENTIONED.

804D) Have you ever heard of an illness called tuberculosis or TB?

804E) How does tuberculosis spread from one person to another? PROBE: Any other ways? RECORD ALL MENTIONED.

804F) What symptoms will a person with tuberculosis or TB have? Anything else?
RECORD ALL MENTIONED.

804G) Can tuberculosis be cured?

804H) If a member of your family got tuberculosis, would you want it to remain a secret or not?

805) 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.

806) 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.

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

808) Do you currently smoke cigarettes?

809) In the last 24 hours, how many cigarettes did you smoke?

810) Do you currently smoke or use (other) type of tobacco?

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

811A) Do you use or smoke tobacco products daily?

811B) How old were you when first started using any tobacco products daily?

811C) Have you ever consumed an alcoholic drink, such as beer, wine, spirits, or other home-brewed liquor?

811F) Have you consumed an alcoholic drink during the past two weeks?

811G) During the past two weeks, on how many days did you have at least one alcoholic drink?

811H) During the past two weeks, when you consumed alcohol, on average, how many bottles/glasses/tots or alcohol did you have per day?

812) Are you covered by any health insurance?

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

813A) 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?

813B) 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'

813E) 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'.

813F) In a typical week, on how many days do you eat fruits, such as apples, pears, oranges, bananas, mangoes, etc? IF 'NONE' RECORD '0'

813G) On a day when you eat fruits, how many times do you eat on average? IF 'NONE' RECORD '0'

813H) 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?

813N) CHECK 103:

813O) Have you ever heard of prostate cancer?

813P) Have you ever had a test or exam to see if you have prostate cancer?

813Q) Now I would like to ask some questiosn about mental health. Are there times when you see or hear things that are actually not there?

813R) In the past 12 months, have you ever felt seriously worthless, hopeless, or wished you were dead?

813S) 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?

813T) 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?

813U) CHECK 813Q, 813R, 813S, AND 813T:

813V) Did you seek any medical care?

SECTION 9. DOMESTIC VIOLENCE

901A) CHECK HOUSEHOLD QUESTIONNAIRE.

901B) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

READ TO THE RESPONDENT:
Now I would like to ask you questions about some other important aspects of a man's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition or men 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.

902) CHECK 401 AND 402:

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

904) Now I need to ask you some more questions about your relationship with your (last) (wife/partner):

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

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

905) A) Did your (last) (wife/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?

906) CHECK 905A (a-j):

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

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

a) You had cuts, bruises, or aches?

b) You had eye injuries, sprains, dislocations, or burns?

c) You had deep wounds, broken bones, broken teeth, or any other serious injury?

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

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

911) Does (did) your (last) (wife/partner) drink alcohol?

912) How often does (did) she get drunk: often, only sometimes, or never?

913) Are (were) you afraid of your (last) (wife/partner): most of the time, sometimes, or never?

914) CHECK 410:

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

B) How long ago did this last happen?

916) CHECK 401 AND 402:

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

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

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

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

922) CHECK 401 AND 402:

922A) Now I want to ask you about things that may have been done to you by someone other than (your/any) (wife/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?

922B) 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?

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

924) CHECK 401 AND 402:

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

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

924A) CHECK 905A (h-j) and 915(b)

925) CHECK 401 AND 402:

EVER MARRIED/ EVER LIVED WITH A WOMAN
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) wife/partner?

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

926) CHECK 905A (a-j), 915A (a,b), AND 922B:

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

928) From whom have you sough help? Anyone else?
RECORD ALL MENTIONED.

929) Have you ever told anyone about this?

930) As far as you know, did your father ever beat your mother?

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

PROVIDE LIST OF REFERRAL PLACES TO RESPONDENT.

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

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

933) RECORD THE TIME

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: __________
COMMENTS ON SPECIFIC QUESTIONS: __________
ANY OTHER COMMENTS: __________

SUPERVISOR'S OBSERVATIONS __________

NAME OF SUPERVISOR: __________
DATE: __________

EDITOR'S OBSERVATIONS: __________

NAME OF EDITOR: __________
DATE: __________