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NEPAL FAMILY HEALTH SURVEY INDIVIDUAL QUESTIONNAIRE (ENGLISH)

IDENTIFICATION

DISTRICT NAME AND NUMBER

VILLAGE/MUNICIPALITY NAME AND NUMBER

WARD NUMBER

CLUSTER NUMBER

HOUSEHOLD NUMBER

CITY/TOWN/COUNTRYSIDE

City 1
Town 2
Countryside 3

NAME OF HOUSEHOLD HEAD

NAME AND LINE NUMBER OF WOMAN

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
NAME
RESULT

TOTAL NO. OF VISITS

*RESULT CODES:

COMPLETED 1
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 _____________
(SPECIFY)

LANGUAGE OF QUESTIONNAIRE**

NATIVE LANGUAGE OF RESPONDENT**

LANGUAGE OF INTERVIEW**

TRANSLATOR USED

YES 1
NO 2

**LANGUAGE CODES
NEPALI 1
BHOJPURI 2
MAITHILI 3
THARU 4
OTHER (SPECIFY) 5 _____________

SUPERVISOR
NAME _________
DATE ____________

FIELD EDITOR
NAME _______________
DATE _______________

OFFICE EDITOR ____________

KEYED BY _____________

SECTION 1. RESPONDENT'S BACKGROUND

100. RECORD THE TIME.

HOUR__
MINUTES__

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

102. First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a city, in a town, or in the countryside?

CITY 1
TOWN 2
COUNTRYSIDE 3

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

YEARS _________________
ALWAYS (SINCE BIRTH) 95 (SKIP TO 105)
VISITOR 96 (SKIP TO 105)

104. Just before you moved here, did you live in a city, in a town, or in the countryside?

CITY 1
TOWN 2
COUNTRYSIDE 3

105. In what month and year were you born?

MONTH ______________
DON'T KNOW MONTH 98
YEAR ________________
DON'T KNOW YEAR 98

106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT

AGE IN COMPLETED YEARS ______________________

107. Have you ever attended school?

YES 1
NO 2 (SKIP TO 113)

108. What is the highest grade you completed?

GRADE ________________

109. CHECK 106:

AGE 24 OR BELOW
AGE 25 OR ABOVE (SKIP TO 112)

110. Are you currently attending school?

YES 1 (SKIP TO 112)
NO 2

111. What was the main reason you stopped attending school?

GOT PREGNANT 01
GOT MARRIED 02
TO CARE FOR YOUNGER CHILDREN 03
FAMILY NEEDED HELP ON FARMOR IN BUSINESS 04
COULD NOT PAY SCHOOL FEES 05
NEEDED TO EARN MONEY 06
GRADUATED/HAD ENOUGH SCHOOLING 07
FAILED SLC/DID NOT PASS
ENTRANCE EXAMS 08
DID NOT LIKE SCHOOL 09
SCHOOL NOT ACCESSIBLE/
TOO FAR 10
OTHER (SPECIFY)__________________________96
DON'T KNOW 98

112. CHECK 108:

GRADE 5 AND BELOW
GRADE 6 AND ABOVE (SKIP TO 115)

113. Can you read and understand a letter or newspaper?

YES 1
NO 2 (SKIP TO 116)

114. Can you read this sentence? (SHOW SENTENCE TO BE READ)

READS EASILY 1
READS WITH DIFFICULTY 2
IS NOT ABLE TO READ 3 (SKIP TO 116)

115. Do you usually read a newspaper or magazine at least once a week?

YES 1
NO 2

116. Do you usually listen to a radio every day?

YES 1
NO 2

117. Do you usually watch television at least once a week?

YES 1
NO 2

118. What is your religion?

HINDU 01
BUDDHIST 02
MUSLIM 03
CHRISTIAN 04
OTHER (SPECIFY)________________ 96

119. What is your caste?
WRITE CASTE IN SPACE PROVIDED. CODE WILL BE ENTERED BY FIELD EDITOR.

___________________________
(CASTE)

120. What is your current marital status?

CURRENTLY MARRIED 1
WIDOWED 2 (SKIP TO 125)
DIVORCED 3 (SKIP TO 125)
SEPARATED 4 (SKIP TO 125)

121. Is your husband living with you now or is he staying elsewhere?

LIVING WITH HER 1
STAYING ELSEWHERE 2

122. Does your husband have any other wives besides yourself?

YES 1
NO 2 (SKIP TO 125)

123. How many other wives does he have?

NUMBER _____________
DON'T KNOW 98 (SKIP TO 125)

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

RANK ____________

125. Have you been married only once, or more than once?

ONCE 1
MORE THAN ONCE 2

126. How old were you when you (first) got married?

AGE ________

127. CHECK 125:
MARRIED ONLY ONCE
In what month and year did you first start living with your husband?
PROMPT: At gauna?
MARRIED MORE THAN ONCE
Now we will talk about your first husband. In what month and year did you first start living with him?

MONTH ___________
DON'T KNOW WHAT MONTH 98
YEAR ____ (SKIP TO 129)
DON'T KNOW YEAR 98
HAS NOT STARTED LIVING WITH HUSBAND 95 (SKIP TO END)

128. How old were you when you first started living with him?
PROMPT: At gauna?

AGE ______

129. CHECK COLUMN 6 OF THE INTERVIEWER'S ASSIGNMENT SHEET.

THE WOMAN INTERVIEWED IS NOT A USUAL RESIDENT
THE WOMAN INTERVIEWED IS A USUAL RESIDENT (SKIP TO 201)

130. Now I would like to ask about the place in which you usually live. What is the name of the place in which you usually live?
Is that a city, town, or countryside?

(NAME OF PLACE) ___________
CITY 1
TOWN 2
COUNTRYSIDE 3

131. In which district is that located?
(NAME OF DISTRICT)

DISTRICT _____________

132. Now I would like to ask about the household in which you usually live. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO RESIDENCE/YARD/PLOT 11 (SKIP TO 134)
PUBLIC TAP 12
WELL WATER
WELL IN RESIDENCE/YARD/PLOT 21 (SKIP TO 134)
PUBLIC WELL 22
HAND PUMP
RESIDENCE/YARD/PLOT 31 (SKIP TO 134)
PUBLIC 32
SURFACE WATER
SPRING/KUWA 41
RIVER/STREAM 42
POND/LAKE 43
STONE TAP (OHARA) 44
OTHER (SPECIFY)_____________________________96

133. How long does it take to get there, get water, and come back?

MINUTES ______________
ON PREMISES 996

134. What kind of toilet facility does your husband have?

FLUSH TOILET 11
PIT TOILET/LATRINE
TRADITIONAL PIT TOILET 21
VENTILATED IMPROVED PIT 22
PAN 31
NO FACILITY/BUSH/FIELD 41
OTHER________________________________96

135. Does your household have:
Electricity?
A radio?
A television?
A telephone?
A bicycle?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
TELEPHONE
YES 1
NO 2
BICYCLE
YES 1
NO 2

136. Could you describe the main material of the floor of your home?

NATURAL FLOOR
MUD/DUNG 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
POLISHED WOOD 31
CEMENT 32
LINOLEUM 33
MARBLE CHIPS 34
CARPET 35
OTHER (SPECIFY)_____________________96

SECTION 2. REPRODUCTION

Now I would like to talk to you about all the pregnancies that you have had in your lifetime. By this I mean all the children born to you, whether they were born alive or dead, whether still living or not, whether living with you or elsewhere, and all the pregnancies that you have had that did not result in a live birth. I understand that it is not easy to talk about children who have died, or pregnancies that have terminated before full term, but it is extremely important that you tell us about all of them, so that we can develop programs that would help the Government of Nepal improve children's health in the future.

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

YES 1
NO 2 (SKIP TO 206)

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

YES 1
NO 2 (SKIP TO 204)

203. How many sons live with you?
And 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 who are alive but do not live with you?

YES 1
NO 2 (SKIP TO 206)

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'.

SONS ELSEWHERE _____________
DAUGHTERS ELSEWHERE ________

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 life but survived only a few hours or days?

YES 1
NO 2 (SKIP TO 208)

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

BOYS DEAD ____________
GIRLS DEAD ___________

208. Women sometimes have pregnancies that do not result in a live born child. That is, a pregnancy can end very early, in a miscarriage, or the child can be born dead. Have you had any such pregnancy that did not result in a live birth?

YES 1
NO 2 (SKIP TO 210)

209. In all, how many such pregnancies have there been?

PREGNANCY LOSSES ______________

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

TOTAL ____________

211. Just to make sure that I have this right: you have had
________ children who are still living (CHECK 203 and 205)
________ children who have died (CHECK 207), and
________ pregnancies which did not result in a live birth (CHECK 209).
Is that correct?

YES
NO (PROBE AND CORRECT 201-210 AS NECESSARY).

212. CHECK 210:

ONE OR MORE PREGNANCIES
NO PREGNANCIES (SKIP TO 234)

213. Now I would like to ask you about all of your pregnancies, whether born alive, born dead, or lost before full term, starting with the first one you had.
RECORD ALL THE PREGNANCIES. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

214. Think back to the time of your (first/next) pregnancy

215. Was that a single or multiple pregnancy?

SINGLE 1
MULTIPLE 2

216. Was the baby born alive, born dead, or lost before full term?

BORN ALIVE 1 (SKIP TO 218)
BORN DEAD 2
LOST BEFORE FULL TERM 3 (SKIP TO 225)

217. Did that baby cry, move, or breathe when it was born?

YES 1
NO 2 (SKIP TO 225)

218. What was the name given to that child?

NAME _____________

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

BOY 1
GIRL 2

220. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
OR: In what season was he/she born?

MONTH _________
YEAR ____________

221. Is (NAME) still alive?

YES 1
NO 2 (SKIP TO 224)

222. IF BORN ALIVE AND STILL LIVING: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

AGE IN YEARS ______________

223. IF BORN ALIVE AND STILL LIVING: Is (NAME) living with you?

YES 1
NO 2
(1ST: SKIP TO NEXT PREGNANCY, 2ND AND ON: GO TO 228)

IF BORN ALIVE BUT NOW DEAD:
224. How old was (NAME) when he/she died?
IF '1 YR', PROBE: How many months old was (NAME)? RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

DAYS 1
MONTHS 2
YEARS _________
(1ST: SKIP TO NEXT PREG., 2ND AND ON: SKIP TO 228)

225. IF BORN DEAD OR LOST BEFORE FULL TERM: In what year and month did this pregnancy end?

MONTH ________
YEAR _________

226. IF BORN DEAD OR LOST BEFORE FULL TERM: How many months did the pregnancy last?
RECORD COMPLETED MONTHS.

MONTHS ________

LOST BEFORE FULL TERM:
227. Did you or a doctor or someone else do anything to end this pregnancy?

YES 1
NO 2

228. FROM YEAR OF THIS PREGNANCY SUBTRACT YEAR OF PREVIOUS PREGNANCY. IS THE DIFFERENCE 4 OR MORE YEARS?

YES 1
NO 2 (SKIP TO NEXT PREG.)

229. Were there any other pregnancies between the previous pregnancy mentioned and this pregnancy?

YES 1
NO 2

230. FROM YEAR OF INTERVIEW SUBTRACT YEAR OF LAST PREGNANCY.
IS THE DIFFERENCE 4 YEARS OR MORE?

YES 1
NO 2 (SKIP TO 232)

231. Have you had any pregnancies since the last pregnancy mentioned?

YES 1
NO 2

232. COMPARE 210 WITH NUMBER OF PREGNANCIES IN HISTORY ABOVE AND MARK:

NUMBERS ARE THE SAME
CHECK:
FOR EACH PRENANCY: YEAR IS RECORDED IN 220 AND 225.
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED IN 222.
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED IN 224.
FOR EACH PREGNANCY LOSS: DURATION IS RECORDED IN 226.
FOR AGE AT DEATH 12 MONTHS OR 1 YR.: PROBE TO DETERMINE EXACT NUMBER OF MONTHS.
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

233. CHECK 220 AND ENTER THE NUMBER OF BIRTHS SINCE BAISAKH 2049.

BIRTHS SINCE BAISAKH___

234. CHECK 120:

CURRENTLY MARRIED
WIDOWED, DIVORCED, SEPARATED (SKIP TO 301)

235. Are you pregnant?

YES 1
NO 2 (SKIP TO 238)
UNSURE (SKIP TO 238)

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

MONTHS ___________

237. At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to become pregnant at all?

THEN 1
LATER 2
NOT AT ALL 3

238. When did your last menstrual period start?
(DATE, IF GIVEN)

DAYS AGO 1 _______
WEEKS AGO 2 ______
MONTHS AGO 3 ______
YEARS AGO 4 _______
IF MENOPAUSE 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

SECTION 3. CONTRACEPTION

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

CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 302, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 301 OR 302, ASK 303.

301. Which ways or methods have you heard about?

01 PILL Women can take a pill every day.
YES/SPONT 1
NO (GO TO 302 01)
02. IUD Women can have a loop or coil placed inside them by a doctor or a nurse.
YES/SPONT 1
NO (GO TO 302 02)
03 INJECTIONS Women can have an injection by a doctor, nurse or pharmacist, which stops them from becoming pregnant for several months.
YES/SPONT 1
NO (GO TO 302 03)
04 NORPLANT Women can have several small rods placed in their upper arms by a doctor or nurse which can prevent pregnancy for several years.
YES/SPONT 1
NO (GO TO 302 04)
05 DIAPHRAGM, FOAM, JELLY Women can place a sponged, suppository, diaphragm, jelly, or cream inside themselves before intercourse.
YES/SPONT 1
NO (GO TO 302 05)
06 CONDOM Men can put a rubber sheath on their penis during sexual intercourse.
YES/SPONT 1
NO (GO TO 302 06)
07 FEMALE STERILIZATION Women can have an operation to avoid having any more children.
YES/SPONT 1
NO (GO TO 302 07)
08 MALE STERILIZATION Men can have an operation to avoid having any more children.
YES/SPONT 1
NO (GO TO 302 08)
09 RHYTHEM, PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES/SPONT 1
NO (GO TO 302 09)
10 WITHDRAWAL Men can be careful and pull out before climax.
YES/SPONT 1
NO (GO TO 302 10)
11 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES/SPONT 1
(SPECIFY)

302. Have you ever heard of (METHOD)?

01 PILL Women can take a pill every day.
YES/PROBED 2
NO 3
02. IUD Women can have a loop or coil placed inside them by a doctor or a nurse.
YES/PROBED 2
NO 3
03 INJECTIONS Women can have an injection by a doctor, nurse or pharmacist, which stops them from becoming pregnant for several months.
YES/PROBED 2
NO 3
04 NORPLANT Women can have several small rods placed in their upper arms by a doctor or nurse which can prevent pregnancy for several years.
YES/PROBED 2
NO 3
05 DIAPHRAGM, FOAM, JELLY Women can place a sponged, suppository, diaphragm, jelly, or cream inside themselves before intercourse.
YES/PROBED 2
NO 3
06 CONDOM Men can put a rubber sheath on their penis during sexual intercourse.
YES/PROBED 2
NO 3
07 FEMALE STERILIZATION Women can have an operation to avoid having any more children.
YES/PROBED 2
NO 3
08 MALE STERILIZATION Men can have an operation to avoid having any more children.
YES/PROBED 2
NO 3
09 RHYTHM, PERIODIC ABSTINENCE. Every month that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES/PROBED 2
NO 3
10 WITHDRAWAL Men can be careful and pull out before climax.
YES/PROBED 2
NO 3
11 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
NO 3

303. Have you ever used (METHOD)?

01 PILL Women can take a pill every day.
YES 1
NO 2
02. IUD Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
03 INJECTIONS Women can have an injection by a doctor, nurse or pharmacist, which stops them from becoming pregnant for several months.
YES 1
NO 2
04 NORPLANT Women can have several small rods placed in their upper arms by a doctor or nurse which can prevent pregnancy for several years.
YES 1
NO 2
05 DIAPHRAGM, FOAM, JELLY Women can place a sponged, suppository, diaphragm, jelly, or cream inside themselves before intercourse.
YES 1
NO 2
06 CONDOM Men can put a rubber sheath on their penis during sexual intercourse.
YES 1
NO 2
07 FEMALE STERILIZATION Women can have an operation to avoid having any more children.
Have you ever had an operation to avoid having any more children?
YES 1
NO 2
08 MALE STERILIZATION Men can have an operation to avoid having any more children.
Has your husband ever had an operation to avoid having children?
YES 1
NO 2
09 RHYTHM, PERIODIC ABSTINENCE. Every month that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
10 WITHDRAWAL Men can be careful and pull out before climax.
YES 1
NO 2
11 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1
NO 2

304. CHECK 303:

NOT A SINGLE "YES" (NEVER USED)
AT LEAST ONE "YES" (EVER USED) (SKIP TO 307A)

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

YES 1
NO 2 (SKIP TO 326)

306. What have you used or done?
CORRECT 303 AND 304 (AND 302 IF NECESSARY).

307A. Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.
What was the first method you ever used?

PILL 01
IUD 02
INJECTIONS 03
NORPLANT 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
OTHER (SPECIFY)________________________96

307B. What is the main reason you chose to use this method?

EASY TO OBTAIN 01
CONVENIENT TO USE 02
INEXPENSIVE METHOD 03
DON'T LIKE STERILIZATION 04
PERMANENT METHOD 05
TEMPORARY METHOD 06
EFFECTIVE METHOD 07
RECOMMENDED BY HEALTH WORKER 08
HEALTH REASONS 09
NO/LITTLE SIDE EFFECTS 10
OTHER (SPECIFY)____________________________96

308. How many living sons did you have at the time you first used contraception (family planning), if any?
How many living daughters did you have at that time, if any?
IF NONE, RECORD '00'.

NUMBER OF SONS ________
NUMBER OF DAUGHTERS ___________

309. When you first used family planning, did you want to have another child but at a later time, or did you not want to have another child at all?

WANTED CHILD LATER 1
DID NOT WANT ANOTHER CHILD 2
OTHER (SPECIFY)_____________________________6

310. CHECK 120:

CURRENTLY MARRIED
WIDOWED, DIVORCED, SEPARATED (SKIP TO 401)

311. CHECK 303:

WOMAN NOT STERILIZED
WOMAN STERILIZED (SKIP TO 314A)

312. CHECK 235

NOT PREGNANT OR UNSURE
PREGNANT (SKIP TO 327)

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

YES 1
NO 2 (SKIP TO 326)

314. Which method are you using? (NOTE: probably # tag these 2 together)
314A. CIRCLE '07' FOR FEMALE STERILIZATION

PILL 01
IUD 02 (SKIP TO 321)
INJECTIONS 03 (SKIP TO 321)
NORPLANT 04 (SKIP TO 321)
DIAPHRAGM/FOAM/JELLY 05 (SKIP TO 321)
CONDOM 06 (SKIP TO 321)
FEMALE STERILIZATION 07 (SKIP TO 316)
MALE STERILIZATION 08 (SKIP TO 316)
PERIODIC ABSTINENCE 09 (SKIP TO 320)
WITHDRAWAL 10 (SKIP TO 321)
OTHER (SPECIFY)________________________96 (SKIP TO 321)

315A. At the time you first started using the pill, did you consult a doctor or a nurse or a health worker or not?

YES 1
NO 2

315B. At the time you last got the pills, did you consult a doctor or a nurse or a health worker or not?

YES 1 (SKIP TO 321)
NO 2 (SKIP TO 321)

316. Where did the sterilization take place?
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) ______________
PUBLIC SECTOR
HOSPITAL/DISTRICT CLINIC 11
PRIMARY/HEALTH CENTRE 12
MOBILE CAMP 13
OTHER PUBLIC (SPECIFY)_____________________16
PRIVATE SECTOR
HOSPITAL 21
CLINIC/NURSING HOME 22
FPAN 23
OTHER PRIVATE (SPECIFY)____________________26
OTHER (SPECIFY)__________________________________96
DON'T KNOW 98

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

YES 1
NO 2 (SKIP TO 319)

318. Why do you regret the operation?

RESPONDENT WANTS ANOTHER CHILD 01
SPOUSE WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
CHILD DIED 04
OTHER (SPECIFY)__________________________________96

319. In what month and year was the sterilization performed?
IF DON'T KNOW YEAR
PROBE: How many years ago?

MONTH ________
DON'T KNOW MONTH 98
YEAR _____ (SKIP TO 322)
DON'T KNOW YEAR 98

319A. How old were you at the time of sterilization?

AGE IN COMPLETED YEARS _____ (SKIP TO 322)

320. How do you determine which days of your monthly cycle not to have sexual relations?

BASED ON CALENDAR 01
BASED ON BODY TEMPERATURE 02
BASED ON CERVICAL MUCUS (BILLINGS METHOD) 03
BASED ON BODY TEMPERATURE AND CERVICAL MUCUS 04
NO SPECIFIC SYSTEM 05
OTHER (SPECIFY)___________________________________96

321. For how many months have you been using (METHOD) continuously?
IF LESS THAN 1 MONTH, RECORD '00'.

MONTHS ________
8 YEARS OR LONGER 96

322. CHECK 314:
CIRCLE METHOD CODE:

PILL 01
IUD 02
INJECTIONS 03
NORPLANT 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07 (SKIP TO 324A)
MALE STERILIZATION 08 (SKIP TO 324A)
PERIODIC ABSTINENCE 09 (SKIP TO 327)
WITHDRAWAL 10 (SKIP TO 327)
OTHER (SPECIFY)____________________________96 (SKIP TO 327)

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

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

(NAME OF PLACE) _____________

PUBLIC SECTOR
HOSPITAL/DISTRICT CLINIC 11
PRIMARY/HEALTH CENTRE 12
FAMILY PLANNING CLINIC 13
HEALTH POST 14
SUB-HEALTH POST 15
MOBILE CLINIC 17
OTHER PUBLIC (SPECIFY)___________________16
PRIVATE SECTOR
HOSPITAL 21
CLINIC/NURSING HOME 22
PHARMACY 23
CHW 24
FPAN 25
OTHER PRIVATE (SPECIFY)___________________26
OTHER SOURCE
FCHV 31
SHOP 32
FRIEND/RELATIVE 33
OTHER (SPECIFY)____________________________36

323A. How long does it usually take to travel from your home to this place?

MINUTES ______________
DON'T KNOW 998

323B. Is it easy or difficult to get there?

EASY 1
DIFFICULT 2
DON'T KNOW 8

324. Do you know another place where you could have obtained (METHOD) the last time?

YES 1
NO 2 (SKIP TO 329)

324A. At the time of the sterilization operation, did you know another place where you could have received the operation?

YES 1
NO 2 (SKIP TO 329)

325. People select the place where they get family planning services for various reasons.

What was the main reason you went to (NAME OF PLACE IN Q.323 OR Q.316) instead of the other place you know about?

RECORD RESPONSE AND CIRCLE CODE. _______________

ACCESS-RELATED REASONS
CLOSER TO HOME 11
CLOSER TO MARKET/WORK 12
AVAILABILITY OF TRANSPORT 13
SERVICE-RELATED REASONS
STAFF MORE COMPETENT/FRIENDLY 21
CLEANER FACILITY 22
OFFERS MORE PRIVACY 23
SHORTER WAITING TIME 24
LONGER HRS OF SERVICE 25
USE OTHER SERVICES AT THE FACILITY 26
LOWER COST/CHEAPER 31
WANTED ANONYMITY 41
OTHER (SPECIFY)___________________________________96
DON'T KNOW 98

326. What is the main reason you are not using a method of contraception to avoid pregnancy?

FERTILITY-RELATED REASONS
NOT HAVING SEX 21
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
POSTPARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
OPPOSITION TO USE
RESPONDENT OPPOSED 31
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
LACK OF KNOWLEDGE
KNOWS NO METHOD 41
KNOWS NO SOURCE 42 (SKIP TO 329)
METHOD-RELATED REASONS
HEALTH CONCERNS 51
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COST TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NATURAL PROCESS 56
OTHER_______________________________________96
DON'T KNOW 98

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

YES 1
NO 2 (SKIP TO 329)

328. Where is that?
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) ________________
PUBLIC SECTOR
HOSPITAL/DISTRICT CLINIC 11
PRIMARY/HEALTH CENTRE 12
FAMILY PLANNING CLINIC 13
HEALTH POST 14
SUB-HEALTH POST 15
MOBILE CLINIC 17
OTHER PUBLIC_____________________16
PRIVATE SECTOR
HOSPITAL 21
CLINIC/NURSING HOME 22
PHARMACY 23
CHW 24
FPAN 25
OTHER PRIVATE____________________26
OTHER SOURCE
FCHV 31
SHOP 32
FRIEND/RELATIVE 33
OTHER (SPECIFY)_____________________________36

329. Were you visited by a family planning programme worker or health worker in the last 12 months?

YES 1
NO 2

330. Have you visited a health facility for any reason in the last 12 months?

YES 1
NO 2 (SKIP TO 332)

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

YES 1
NO 2

332. Do you think that breastfeeding can affect a woman's chance of becoming pregnant?

YES 1
NO 2 (SKIP TO 401)
DON'T KNOW 8 (SKIP TO 401)

333. Do you think a woman's chance of becoming pregnant is increased or decreased by breastfeeding?

INCREASED 1 (SKIP TO 401)
DECREASED 2
DEPENDS 3
DON'T KNOW 8

334. CHECK 202, 204, AND 206:

ONE OR MORE BIRTHS
NO BIRTHS (SKIP TO 401)

335. Have you ever relied on breastfeeding as a method of avoiding pregnancy?

YES 1
NO 2 (SKIP TO 401)

336. CHECK 235 AND 314:

NOT PREGNANT OR UNSURE AND NOT STERILIZED
EITHER PREGNANT OR STERILIZED (SKIP TO 401)

337. Are you currently relying on breastfeeding to avoid getting pregnant?

YES 1
NO 2

SECTION 4A. PREGNANCY AND BREASTFEEDING

401. CHECK 233:

ONE OR MORE BIRTHS SINCE BAISAKH 2049
NO BIRTHS SINCE BAISKH 2049 (SKIP TO 465)

402. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE BAISAKH 2049 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNARES).

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

403. LINE NUMBER FROM Q221

LAST BIRTH LINE NUMBER__
NEXT-TO-LAST LINE NUMBER__

404. NAME FROM Q218 AND SURVIVAL STATUS FROM Q221

NAME_________________

ALIVE
DEAD

405. At the time you became pregnant with (NAME), did you want to become pregnant then did you want to wait until later or did you want no (more) children at all?

THEN 1 (SKIP TO 407)
LATER 2
NO MORE 3 (SKIP TO 407)

406. At the time you became pregnant with (NAME) how much longer would you like to have waited?

MONTHS 1 _________
YEARS 2 ___________
DON'T KNOW 998

407. When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/ANM B
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT C
MATERNAL AND CHILD HEALTH WORKER D
OTHER_____________________________X
NO ONE Y (SKIP TO 410)

407A. How long did it take to get from your home to the nearest place where you saw a person?

MINUTES _____________
SEEN AT HOME 990

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

MONTHS ____________
DON'T KNOW 98

409. How many times did you receive antenatal care during this pregnancy?

NO. OF TIMES ___________
DON'T KNOW 98

410. When you were pregnant with (NAME) were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

YES 1
NO 2 (SKIP TO 412A)
DON'T KNOW 8

411. During this pregnancy, how many times did you get this injection?

NO. OF TIMES ________
DON'T KNOW 8

412. When you were pregnant with (NAME) did you receive any iron tablets?
SHOW IRON TABLETS.

YES 1
NO 2
DON'T KNOW 8

412B. When you were pregnant with (NAME) did you receive a combined iron and folic acid tablets?
SHOW COMBINED IRON AND FOLIC ACID TABLETS.

YES 1
NO 2
DON'T KNOW 8

412C. When you were pregnant with (NAME) did you suffer from [local term for night blindness]?
IF 'NO' OR 'DON'T KNOW' PROBE: Did you have any difficulty seeing at dusk, at night, or in a room with poor light?

YES 1
RESPONDENT BLIND 2
NO 3
DON'T KNOW 8

413. Where did you go to give birth to (NAME)?

HOME
YOUR HOME 11 (GO TO 413B)
OTHER HOME 12 (GO TO 413B)
PUBLIC SECTOR
HOSPITAL 21
PRY./ HEALTH CENTRE 22
HEALTH POST 23
OTHER PUBLIC (SPECIFY)____________________26
PRIVATE SECTOR
HOSPITAL 31
CLINIC/NURSING HOME 32
OTHER PRIVATE (SPECIFY)___________________36
OTHER_________________________________96

413A. GO TO Q414

413B. Was a special safe delivery kit used?
SHOW SAFE DELIVERY KIT THAT IS MARKETED BY CRS.

YES 1
NO 2
DON'T KNOW 8

414. Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSONS AND RECORD ALL PERSONS ASSISSTING.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/ANM B
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT C
MATERNAL AND CHILD HEALTH WORKER D
RELATIVE/FRIEND E
OTHER (SPECIFY)____________________________X
NO ONE Y

414A. Did you receive a check-up (postpartum care) from anyone within 24 hours following the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSONS AND RECORD ALL PERSONS ASSISTING.

HEALTH PROFESSIONAL
DOCTOR A
NURSE/ANM B
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT C
MATERNAL AND CHILD HEALTH WORKER D
RELATIVE/FRIEND E
OTHER (SPECIFY)_____________________________X
NO ONE Y

415. Around the time of the birth of (NAME), did you have any of the following problems:
Long labour, that is, did your regular contractions last more than 12 hours?
Excessive bleeding that was so much that you feared it was life threatening?
A high fever with bad smelling vaginal discharge?
Convulsions?

LABOUR MORE THAN 12 HOURS
YES 1
NO 2
EXCESSIVE BLEEDING
YES 1
NO 2
FEVER/BAD SMELLING VAG. DISCHARGE
YES 1
NO 2
CONVULSIONS
YES 1
NO 2

416. Was (NAME) delivered by caesarian section?

YES 1
NO 2

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

VERY LARGE 1
LARGE 2
AVERAGE 3
SMALL 4
VERY SMALL 5
DON'T KNOW 8

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

YES 1 (SKIP TO 420)
NO 2 (SKIP TO 421)

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

YES 1
NO 2 (SKIP TO 423)

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

MONTHS ____________
DON'T KNOW 98

421. CHECK 235:
RESPONDENT PREGNANT?

NOT PREGNANT
PREGNANT OR UNSURE (SKIP TO 423)

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

YES 1
NO 2 (SKIP TO 424)

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

MONTHS ______________
DON'T KNOW 98

424. Did you ever breastfeed (NAME)?

YES 1
NO 2 (SKIP TO 430)

425. 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.

IMMEDIATELY 000
HOURS 1 __________
DAYS 2 ___________

425A. Did you squeeze out the milk from the breast before you first put (NAME) to the breast?

YES 1
NO 2

426. CHECK 404: CHILD ALIVE?

ALIVE
DEAD (SKIP TO 428)

427. Are you still breastfeeding (NAME)?

YES 1 (SKIP TO 431)
NO 2

428. For how many months did you breastfeed (NAME)?

MONTHS __________________
DON'T KNOW 98

429. Why did you stop breastfeeding (NAME)?

MOTHER ILL/WEAK 01
CHILD ILL/WEAK 02
CHILD DEAD 03
NIPPLE/BREAST PROBLEM 04
NOT ENOUGH MILK 05
MOTHER WORKING 06
CHILD REFUSED 07
WEANING AGE/AGE TO STOP 08
BECAME PREGNANT 09
STARTED USING CONTRACEPTION 10
OTHER (SPECIFY)_____________________________96

430. CHECK 404: CHILD ALIVE?

ALIVE (SKIP TO 433)
DEAD (GO BACK TO 405 IN NEXT COL. OR, IF NO MORE BIRTHS, GO TO 439)

431. How many times did you breastfeed (NAME) last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC PROBE FOR APPROXIMATE NUMBER.

NUMBER OF NIGHTTIME FEEDINGS ________________

432. How many times did you breastfeed (NAME) yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC PROBE FOR APPROXIMATE NUMBER.

NUMBER OF DAYLIGHT FEEDINGS ______________

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

YES 1
NO 2
DON'T KNOW 8

434. At any time yesterday or last night, was (NAME) given any of the following:
Plain water?
Sugar water?
Juice?
Tea?
Baby formula?
Tinned or powdered milk?

Fresh milk?
Any other liquid?
Any food made from wheat, maize, rice, or other grain, such as porridge, bread, or noodles?

Any food made from potatoes, yams, or local tuber?
Eggs, fish or poultry?
Meat?
Any other solid or semi-solid foods?

PLAIN WATER
YES 1
NO 2
DK 8
SUGAR WATER
YES 1
NO 2
DK 8
JUICE
YES 1
NO 2
DK 8
TEA
YES 1
NO 2
DK 8
BABY FORMULA
YES 1
NO 2
DK 8
TINNED/POWDERED MILK
YES 1
NO 2
DK 8
FRESH MILK
YES 1
NO 2
DK 8
OTHER LIQUIDS
YES 1
NO 2
DK 8
FOOD MADE FROM GRAIN
YES 1
NO 2
DK 8
FOOD MADE FROM TUBER
YES 1
NO 2
DK 8
EGGS/FISH/POULTRY
YES 1
NO 2
DK 8
MEAT
YES 1
NO 2
DK 8
OTHER SOLID/SEMI-SOLID FOODS
YES 1
NO 2
DK 8

435. CHECK 434:
FOOD OR LIQUID GIVEN YESTERDAY?

"YES" TO ONE OR MORE
"NO/DK" TO ALL (SKIP TO 437)

436. (Aside from breastfeeding,) how many times did (NAME) eat yesterday, including both meals and snacks?
IF 7 OR MORE TIMES, RECORD "7"

NUMBER OF TIMES ______________
DON'T KNOW 8

437. On how many days during the last seven days was (NAME) given any of the following:
Plain water?
Any kind of milk (other than breast milk)?
Liquids other than plain water or milk?
Food made from wheat, maize, rice, or other grain?
Food made from potatoes, yams, or tuber?
Eggs, fish, or poultry?
Meat?
Any other solid or semi-solid foods?

IF DON'T KNOW, RECORD '8'.

RECORD THE NUMBER OF DAYS.

PLAIN WATER _________
MILK __________
OTHER LIQUIDS ___________
FOOD MADE FROM GRAIN ___________
FOOD MADE FROM TUBER ______________
EGGS/FISH/POULTRY __________
MEAT ______________
OTHER SOLIDS/SEMI-SOLID FOODS ___________

438. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 439.

SECTION 4B. IMMUNIZATION AND HEALTH

439. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE BAISAKH 2049 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRES).

440. LINE NUMBER FROM Q214

LINE NUMBER ___________

441. NAME FROM Q218
AND SURVIVAL STATUS FROM Q221

NAME________________________
ALIVE
DEAD (GO TO 441 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465.)

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

YES, SEEN 1 (SKIP TO 444)
YES, NOT SEEN 2 (SKIP TO 446)
NO CARD 3

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

YES 1 (SKIP TO 446)
NO 2

444.
(1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.
BCG
DPT 1
DPT 2
DPT 3
Polio 1
Polio 2
Polio 3
Measles

BCG
DAY ___________
MONTH ___________
YEAR _________
D1
DAY ______________
MONTH ____________
YEAR ___________
D2
DAY ____________
MONTH _________________
YEAR __________
D3
DAY _____________
MONTH __________
YEAR ____________
P1
DAY _____________
MONTH ____________
YEAR _______________
P2
DAY ______________
MONTH _____________
YEAR ______________
P3
DAY _________________
MONTH _______________
YEAR _____________
MEA
DAY ____________
MONTH _______________
YEAR _____________

NAME FROM Q218

NAME_________________

445. Has (NAME) received any vaccinations that are not recorded on this card?

RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 1-3, DPT 1-3, AND/OR MEASLES VACCINE(S).

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 444) (SKIP TO 448A)
NO 2 (SKIP TO 448A)
DON'T KNOW 8 (SKIP TO 448A)

446. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

YES 1
NO 2 (SKIP TO 448A)
DON'T KNOW 8 (SKIP TO 448A)

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

447A. A BCG vaccination against tuberculosis, that is, an injection in the arm that caused a scar?

YES 1
NO 2
DON'T KNOW 8

447B. Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (SKIP TO 447D)
DON'T KNOW 8 (SKIP TO 447D)

447C. How many times?

NUMBER OF TIMES ______________

447D. DPT vaccination, that is, an injection usually given at the same time as polio drops?

YES 1
NO 2 (SKIP TO 447F)
DON'T KNOW 8 (SKIP TO 447F)

447E. How many times?

NUMBER OF TIMES __________________

447F. An injection to prevent measles?

YES 1
NO 2
DON'T KNOW 8

448A. Did (NAME) receive Vitamin A during the last 6 months?
SHOW VITAMIN A CAPSULE.

YES 1
NO 2
DON'T KNOW 8

448B. Did (NAME) receive iodine capsules during the last 6 months?
SHOW IODINE CAPSULES.
IF YES: How many times?

YES 1
NO 2
NUMBER OF TIMES _____________________

448C. Does (NAME) suffer from (local term for night blindness)?

IF NO OR DON'T KNOW PROBE: Does (NAME) have any difficulty (more difficulty than usual) seeing at dusk, at night, or in a room with poor light?

YES 1
CHILD BLIND 2
NO 3
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 454)
DON'T KNOW 8 (SKIP TO 454)

451. When (NAME) was ill with a cough, did he/she breathe faster than usual with short, fast breaths?

YES 1
NO 2
DON'T KNOW 8

452. Did you seek advice or treatment for the cough or difficult breathing?

YES 1
NO 2 (SKIP TO 454)

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

PUBLIC SECTOR
HOSP./DISTRICT CLINIC A
PRY./HEALTH CENTRE B
HEALTH/SUB-HEALTH POST C
MOBILE CLINIC D
FIELD WORKER E
OTHER PUBLIC (SPECIFY)_________________________F
PRIVATE SECTOR
HOSPITAL G
CLINIC/NURSING HOME H
PHARMACY I
MOBILE CLINIC J
COMM. HEALTH WORKER K
OTHER PRIVATE (SPECIFY)________________________L
OTHER SOURCE
SHOP N
TRAD. PRACTITIONER O
OTHER (SPECIFY)_________________________________X

454. Has (NAME) had diarrhea, that is, loose or watery stool in the last 2 weeks?

YES 1
NO 2 (SKIP TO 464)
DON'T KNOW 8 (SKIP TO 464)

455. Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

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

NUMBER OF BOWEL MOVEMENTS ________________________
DON'T KNOW 98

457. Was he/she given the same amount to drink as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

458. Was he/she given the same amount of food to eat as before the diarrhea, or more, or less?

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

459. Was (NAME) given a fluid made from a special packet such as Jeevan Jal to drink?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 464)
DON'T KNOW 8 (SKIP TO 464)

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

RECOMMENDED HOME FLUID A
PILL OR SYRUP B
INJECTION C
(I.V.) INTRAVENOUS D
HOME REMEDIES/HERBAL MEDICINES E
OTHER (SPECIFY)____________________________X

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

YES 1
NO 2 (SKIP TO 464)

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

PUBLIC SECTOR
HOSP./DISTRICT CLINIC A
PRY./HEALTH CENTRE B
HEALTH/SUB-HEALTH POST C
MOBILE CLINIC D
FIELD WORKER E
OTHER PUBLIC (SPECIFY)_________________________F
PRIVATE SECTOR
HOSPITAL G
CLINIC/NURSING HOME H
PHARMACY I
MOBILE CLINIC J
COMM. HEALTH WORKER K
OTHER PRIVATE (SPECIFY)________________________L
OTHER SOURCE
SHOP N
TRAD. PRACTITIONER O
OTHER (SPECIFY)_________________________________X

464. GO BACK TO 441 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465.

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

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

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

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

467. When a child is sick with diarrhea, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED.

REPEATED WATERY STOOLS A
ANY WATERY STOOLS B
REPEATED VOMITING C
ANY VOMITING D
BLOOD IN STOOLS E
FEVER F
MARKED THIRST G
NOT EATING/NOT DRINKING WELL H
GETTING SICKER/VERY SICK I
NOT GETTING BETTER J
OTHER (SPECIFY)___________________________________X
DON'T KNOW Z

468. When a child is sick with a cough, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED.

FAST BREATHING A
DIFFICULT BREATHING B
NOISY BREATHING C
FEVER D
CHEST IN DRAWING E
UNABLE TO DRINK F
NOT EATING/NOT DRINKING WELL G
GETTING SICKER/VERY SICK H
NOT GETTING BETTER I
OTHER (SPECIFY)___________________________________X
DON'T KNOW Z

469. CHECK 459, ALL COLUMNS:

NO CHILD RECEIVED ORS OR QUESTION NOT ASKED
ANY CHILD RECEIVED ORS (SKIP TO 470B)

470. Have you ever heard of a special product called ORS such as Jeevan Jal you can get for treatment for diarrhea?

YES 1 (SKIP TO 470B)
NO 2

470A. Have you ever seen (a) packet(s) like this?
SHOW PACKET OF JEEVAN JAL OR OTHER ORS PACKETS LIKELY TO BE USED IN THE LOCALITY OF THE INTERVIEW.

YES 1
NO 2 (SKIP TO 501)

470B. Have you ever prepared the contents of a packet of Jeevan Jal or a packet of any other ORS with water, either for yourself or for someone else?

YES, JEEVAN JAL 1
YES, OTHER ORS 2 (SKIP TO 472A)
NO 3 (SKIP TO 472A)

471A. Did you prepare the whole packet at once or only part of the packet?

WHOLE PACKET AT ONCE
ONLY PART OF PACKET 2 (SKIP TO 472A)

471B. How much water did you mix with a packet of Jeevan Jal?

LITRE 1
MANA 2
TEA GLASS 3
OTHER (SPECIFY)_________________4
DON'T KNOW 998

472A. Where can you buy or obtain a packet of ORS like Jeevan Jal?
PROBE: Where else?
RECORD ALL MENTIONED.

PUBLIC SECTOR
HOSP./DISTRICT CLINIC A
PRY./HEALTH CENTRE B
HEALTH/SUB-HEALTH POST C
MOBILE CLINIC D
FIELD WORKER E
OTHER PUBLIC (SPECIFY)_________________________F
PRIVATE SECTOR
HOSPITAL G
CLINIC/NURSING HOME H
PHARMACY I
MOBILE CLINIC J
COMM. HEALTH WORKER K
OTHER PRIVATE (SPECIFY)________________________L
OTHER SOURCE
SHOP N
TRAD. PRACTITIONER O
OTHER (SPECIFY)_________________________________X

472B. How long does it take to get from your home to the nearest source of ORS?

MINUTES ______________________

SECTION 5. FERTILITY PREFERENCES

501. CHECK 120:

CURRENTLY MARRIED
WIDOWED, DIVORCED, SEPARATED (SKIP TO 512)

502. CHECK 314:

NEITHER STERILIZED
HE OR SHE STERILIZED (SKIP TO 512)

503. CHECK 235:

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

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

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (SKIP TO 507)
SAYS SHE CAN'T GET PREGNANT (SKIP TO 507)
UNDECIDED/DON'T KNOW 8 (SKIP TO 505)

504. CHECK 235:
NOT PREGNANT OR UNSURE
How long would you like to wait from now before the birth of (a/another) child?

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

MONTHS 1 ____________
YEARS 2 ____________
SOON/NOW 993 (SKIP TO 507)
SAYS SHE CAN'T GET PREGNANT 994 (SKIP TO 507)
OTHER (SPECIFY) ___________________________________996
DON'T KNOW 998

505. CHECK 235:

NOT PREGNANT
PREGNANT (SKIP TO 508)

506. If you became pregnant in the next few weeks, would you be happy, unhappy, or would it not matter very much?

HAPPY 1
UNHAPPY 2
WOULD NOT MATTER 3

507. CHECK 313: USING A METHOD.

NOT ASKED
NOT CURRENTLY USING
CURRENTLY USING (SKIP TO 512)

508. Do you think you will use a method to delay or avoid pregnancy within the next 12 months?

YES 1 (SKIP TO 510)
NO 2
DON'T KNOW 8

509. Do you think you will use a method of family planning at any time in the future?

YES 1
NO 2 (SKIP TO 511)
DON'T KNOW 8 (SKIP TO 511)

510. Which method would you prefer to use?
(ALL ANSWERS SKIP TO 512)

PILL 01
IUD 02
INJECTION 03
NORPLANT 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
OTHER (SPECIFY)____________________________96
UNSURE 98

511. What is the main reason that you think you will never use a method?

FERTILITY-RELATED REASONS
INFREQUENT SEX 11
MENOPAUSAL/HYSTERECTOMY 12
SUBFECUND/INFECUND 13
WANTS MORE CHILDREN 14
OPPOSITION TO USE
RESPONDENT OPPOSED 21
HUSBAND OPPOSED 22
OTHERS OPPOSED 23
RELIGIOUS PROHIBITION 24
LACK OF KNOWLEDGE
KNOWS NO METHOD 31
KNOWS NO SOURCE 32
METHOD-RELATED REASONS
HEALTH CONCERNS 41
FEAR OF SIDE EFFECTS 42
LACK OF ACCESS/TOO FAR 43
COST TOO MUCH 44
INCONVENIENT TO USE 45
INTERFERES WITH BODY'S NORMAL PROCESSES 46
OTHER (SPECIFY)____________________________________96
DON'T KNOW 98

512. CHECK 221:
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 how many would that be?
PROBE FOR A NUMERIC RESPONSE.

NUMBER ____________
OTHER (SPECIFY)_______________________96 (SKIP TO 514)

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

NUMBER (BOYS)
OTHER (SPECIFY)______________________96

NUMBER (GIRLS)
OTHER (SPECIFY)______________________96

NUMBER (EITHER)
OTHER (SPECIFY)______________________96

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

APPROVE 1
DISAPPROVE 2
NO OPINION 3

515. Is it acceptable or not acceptable to you for information on family planning to be provided:
On the radio?
On the television?

RADIO
ACCEPTABLE 1
NOT ACCEPTABLE 2
DON'T KNOW 8
TELEVISION
ACCEPTABLE 1
NOT ACCEPTABLE 2
DON'T KNOW 8

516. In the last few months have you heard about family planning:
On the radio?
On the television?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2
POSTER
YES 1
NO 2
LEAFLETS OR BROCHURES
YES 1
NO 2

516A. In the last few months have you heard the following programs on the radio:
Jana Swastha Karyakram?
Ghanti Heri Had Nilaun, the drama?
Ghanti Heri Had Nilaun, the song?
Shriman Shrimatile Pariwarbare Kurakani Gareko Chhoto Radio
Natak?

JANA SWASTHA
YES 1
NO 2
GHANTI HERI DRAMA
YES 1
NO 2
GHANTI HERI SONG
YES 1
NO 2
SHRIMAN SHRIMATILE
YES 1
NO 2

517. In the last few months have you discussed the practice of family planning with your friends, neighbours, or relatives?

YES 1
NO 2 (SKIP TO 519)

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

HUSBAND A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
MOTHER-IN-LAW G
FRIENDS/NEIGHBOURS H
OTHER (SPECIFY)_______________________X

519. CHECK 120:

CURRENTLY MARRIED
WIDOWED, DIVORCED, SEPARATED (SKIP TO 601)

520. Spouses do not always agree on everything. Now I want to ask you about your husband's views on family planning.
Do you think that your husband approves or disapproves of couples using a method to avoid pregnancy?

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

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

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

522. Do you think your husband wants the same number of children that you want, or does he want more or fewer than you want?

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8

SECTION 6. HUSBAND'S BACKGROUND AND WOMAN'S WORK

601. CHECK 120:

CURRENTLY MARRIED
WIDOWED, DIVORCED, SEPARATED (SKIP TO 603)

602. How old was your husband on his last birthday?

AGE _____________

603. Did your (last) husband ever attend school?

YES 1
NO 2 (SKIP TO 605)

604. What was the highest grade he completed?

GRADE ____________________
DON'T KNOW 98

605. What (is/was) your (last) husband's occupation?
That is, what kind of work (does/did) he mainly do?

________________________________________

________________________________________

606. CHECK 605:

WORKS (WORKED IN AGRICULTURE
DOES (DID) NOT WORK IN AGRICULTURE (SKIP TO 608)

607. (Does/did) your husband work mainly on his own land or on family land, or (does/did) he rent land or does he work on someone else's land?

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

608. Aside from your own housework, are you currently working?

YES 1 (SKIP TO 611)
NO 2

609. 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. Are you currently doing any of these things or any other work?

YES 1 (SKIP TO 611)
NO 2

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

YES 1
NO 2 (SKIP TO 701)

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

_______________________________________

_______________________________________

612. CHECK 611:

WORKS IN AGRICULTURE
DOES NOT WORK IN AGRICULTURE (SKIP TO 614)

613. Do you work mainly on your own land or on family land, or do you rent land or work on someone else's land?

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

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

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

615. Do you usually work throughout the year, or do you work seasonally/part of the year, or only once in a while?

THROUGHOUT THE YEAR 1 (SKIP TO 617)
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3 (SKIP TO 618)

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

NUMBER OF MONTHS _____________________

617. During the last 12 months (in the months you worked,) how many days a week did you usually work?

NUMBER OF DAYS _____________ (SKIP TO 619)

618. During the last 12 months, approximately how many days did you work?

NUMBER OF DAYS _________________

619. Do you earn cash for your work?
PROBE: Do you make money for working?

YES 1
NO 2 (SKIP TO 622)

620. How much do you usually earn for this work?
PROBE: Is this by the day, by the week, or by the month?

PER HOUR 1
PER DAY 2
PER WEEK 3
PER MONTH 4
PER YEAR 5
OTHER (SPECIFY)__________________999996

621. CHECK 120:
CURRENTLY MARRIED: Who mainly decides how the money you earn will be used: you, your husband, you and your husband jointly, or someone else?

WIDOWED, DIVORCED, SEPARATED: Who mainly decides how the money you earn will be used: you, someone else, or you and someone else jointly?

RESPONDENT DECIDES 1
HUSBAND DECIDES 2
JOINTLY WITH HUSBAND 3
SOMEONE ELSE DECIDES 4
JOINTLY WITH SOMEONE ELSE 5

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

HOME 1
AWAY 2

623. CHECK 222 AND 223: HAS A CHILD LIVING AT HOME WHO IS AGE 5 OR LESS?

YES
NO (SKIP TO 701)

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

RESPONDENT 01
HUSBAND 02
OLDER FEMALE CHILD 03
OLDER MALE CHILD 04
OTHER RELATIVES 05
NEIGHBOURS 06
FRIENDS 07
SERVANTS/HIRED HELP 08
CHILD IS IN SCHOOL 09
INSTITUTIONAL CHILD CARE 10
HAS NOT WORKED SINCE LAST BIRTH 95
OTHER (SPECIFY)________________________________96

SECTION 7. AIDS

701. Have you ever heard of an illness called AIDS?

YES 1
NO 2 (SKIP TO 711)

702. From which sources of information have you learned most about AIDS?
Any other sources? RECORD ALL MENTIONED.

RADIO A
TELEVISION B
NEWSPAPERS/MAGAZINES C
PAMPHLETS/POSTERS D
HEALTH WORKERS E
TEMPLES/MOSQUES F
SCHOOLS/TEACHERS G
COMMUNITY MEETINGS H
FRIENDS/RELATIVES I
WORK PLACE J
OTHER (SPECIFY) ___ X

703. Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

YES 1
NO 2 (SKIP TO 707)
DON'T KNOW 8

704. What can a person do? Any other ways? RECORD ALL MENTIONED.

SAFE SEX A
ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
SEEK PROTECTION FROM TRADITIONAL HEALER K
OTHER (SPECIFY)_________________________________W
OTHER (SPECIFY)_________________________________X
DON'T KNOW Z

705. CHECK 704:

MENTIONED SAFE SEX
DID NOT MENTION SAFE SEX (SKIP TO 707)

706. What does "safe sex" mean to you?

ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
OTHER (SPECIFY)_______________________________X
DON'T KNOW Z

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

YES 1
NO 2
DON'T KNOW 8

708. Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?

ALMOST NEVER 1
SOMETIMES 2
ALMOST ALWAYS 3
DON'T KNOW 8

709. Do you think your chances of getting AIDS are small, moderate, great, or that you have no risk at all?

SMALL 1
MODERATE 2
GREAT 3
NO RISK AT ALL 4
HAS AIDS 5
DON'T KNOW 8

710. Has your knowledge of AIDS influenced or changed your decisions about having sex or your sexual behavior?

IF YES, PROBE: In what way?
RECORD ALL MENTIONED.

STOPPED ALL SEX B
STARTED USING CONDOMS C
RESTRICTED SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
OTHER (SPECIFY)_________________________________X
NO CHANGE IN SEXUAL BEHAVIOR Y
DON'T KNOW Z

711. CHECK 120:

CURRENTLY MARRIED
WIDOWED, DIVORCED, SEPARATED (SKIP TO 801)

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

When was the last time you had sexual intercourse?

NEVER 000 (SKIP TO 801)
DAYS AGO 1 ___________
WEEKS AGO 2 __________
MONTHS AGO 3 __________
YEARS AGO 4 ____________
BEFORE LAST BIRTH 996

713. CHECK 301 AND 302:
KNOWS CONDOM: The last time you had sex, was a condom used?

DOES NOT KNOW CONDOM: Some men us a condom which means that they put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 716)

715. Where is that?

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

(NAME OF PLACE) ______________________

PUBLIC SECTOR
HOSPITAL/DISTRICT CLINIC 11
PRIMARY HEALTH CENTRE 12
FAMILY PLANNING CLINIC 13
HEALTH POST 14
SUB-HEALTH POST 15
MOBILE CLINIC 17
OTHER PUBLIC (SPECIFY)___________________16
PRIVATE SECTOR
HOSPITAL 21
CLINIC/NURSING HOME 22
PHARMACY 23
CHW 24
FPAN 25
OTHER PRIVATE (SPECIFY)__________________26
OTHER SOURCE
FCHV 31
SHOP 32
FRIEND/RELATIVE 33
OTHER (SPECIFY)___________________________36

716. How old were you when you first had sexual intercourse?

AGE ______________
FIRST TIME WHEN MARRIED 95
FIRST TIME AT GAUNA 96

717. PRESENCE OF OTHERS AT THIS POINT.

CHILDREN UNDER 10
YES 1
NO 2
HUSBAND
YES 1
NO 2
OTHER MALES
YES 1
NO 2
OTHER FEMALES
YES 1
NO 2

804. What was the name given to your next oldest brother?

805. Is (NAME) male or female?

MALE 1
FEMALE 2

806. Is (NAME) still alive?

YES 1
NO 2 (GO TO 808)
DK 8 (GO TO [8])

807. How old is (NAME)?

____________ (GO TO NEXT)

808. In what year did (NAME) die?

___ (GO TO 810)
DK 58

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

________________

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

__________ (IF MALE OR DIED BEFORE 12 YEARS OF AGE GO TO NEXT)

811. Was (NAME) pregnant when she died?

YES 1 (GO TO 814)
NO 2

812. Did (NAME) die during childbirth?

YES 1 (GO TO 815)
NO 2

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

YES 1
NO 2 (GO TO 815)

814. Was her death due to complications of pregnancy or childbirth?

YES 1
NO 2

815. How many children did (NAME) give birth to during her lifetime?

_________________ (GO TO NEXT)

IF NO MORE BROTHERS OR SISTERS, GO TO 816

816. RECORD THE TIME.

HOUR ______________
MINUTES ______________

SECTION 9. HEIGHT AND WEIGHT

901. CHECK 233:

ONE OR MORE BIRTHS SINCE BAISAKH 2049
NO BIRTHS SINCE BAISAKH 2049 (SKIP TO END)

IN 902 (COLUMNS 2 AND 3) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE BAISAKH 2049 AND STILL ALIVE. IN 903 AND 904 RECORD THE NAME (ALL COLUMNS) AND BIRTH DATE (COLUMNS 2 AND 3) FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE BAISAKH 2049. IN 906 AND 908 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN. (NOTE: ALL RESPONDENTS WITH ONE OR MORE BIRTHS SINCE BAISAKH 2049 SHOULD BE WEIGHED AND MEASURED EVEN IF ALL OF THE CHILDREN HAVE DIED. IF THERE ARE MORE THAN 2 LIVING CHILDREN SINCE BAISAKH 2049, USE ADDITIONAL QUESTIONNAIRES).

902. LINE NO. FROM Q214

903. NAME FROM Q218 FOR CHILDREN

NAME ______________

904. DATE OF BIRTH FROM Q220, AND ASK FOR DAY OF BIRTH

DAY ___________
MONTH _____________
YEAR _____________

905. BCG SCAR ON TOP OF SHOULDER

SCAR SEEN 1
NO SCAR 2

906. HEIGHT (in centimeters)

____________________

907. WAS LENGTH/HEIGHT OF CHILD MEASURED LYING DOWN OR STANDING UP?

LYING 1
STANDING 2

908. WEIGHT (in kilograms)

____________________

909. DATE WEIGHED AND MEASURED

DAY ______________
MONTH _____________
YEAR ________________

910. RESULT

RESPONDENT
MEASURED 1
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) 6
YOUNGEST LIVING CHILD
MEASURED 1
CHILD SICK 2
CHILD NOT
PRESENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY) _________________6
NEXT-TO-YOUNGEST CHILD
MEASURED 1
CHILD SICK 2
CHILD NOT
PRESENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY) _________________6

911.

NAME OF MEASURER:
NAME OF ASSISTANT: ________________

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 _____________________