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NEPAL DEMOGRAPHIC AND HEALTH SURVERY 2001
WOMAN???S QUESTIONNAIRE

IDENTIFICATION

NAME AND CODE OF DISTRICT ________________
NAME AND CODE OF VILLAGE/MUNICIPALITY __________

WARD NUMBER ____________
CLUSTER NUMBER __________

HOUSEHOLD NUMBER ______________

CITY 1
TOWN 2
COUNTRYSIDE 3

NAME OF HOUSEHOLD HEAD_____

NAME AND LINE NUMBER OF WOMAN ____________

INTERVIEWER VISITS

DATE

DAY __
MONTH __
YEAR ____

INTERVIEWER???S NAME ___________
INT. CODE ________

RESULT* ___

*RESULT CODES
1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ___________________

NEXT VISIT

DATE ________
TIME ________

LANGUAGE

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE OF INTERVIEW*** ___________________
HOME LANGUAGE OF RESPONDENT *** ___________________

WAS A TRANSLATOR USED

YES 1
NO 2
***LANGUAGE CODES

1 NEPALI
2 BHOJPURI
3 MAITHILI
4 THARU
5 OTHER

SUPERVISOR

NAME ____________
DATE _____________

FIELD EDITOR

NAME _________________
DATE __________________

OFFICE EDITOR ___

KEYED BY ____

SECTION 1. RESPONDENT???S BACKGROUND

INFORMED CONSENT
Hello. My name is _______________ and I am working with the Ministry of Health. We are conducting a national survey about the health of women and children. We would very much appreciate your participation in this survey. I would like to ask you about your health (and the health of your children). This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey? May I begin the interview now?

Signature of interview: __________________ Date:_____________

RESPONDENT AGREES TO BE INTERVIEWED 1 (101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101. RECORD THE TIME

HOURS______
MINUTES_____

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

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)?

IF LESS THAN ONE YEAR, RECORD ???00??? YEARS

YEARS_______
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO 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 9998

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 (GO TO 110)

108. What is the highest grade you completed?

GRADE__________

109. CHECK 108:

GRADE 5 OR BELOW (GO TO 110)
GRADE 6 AND ABOVE (GO TO 113)

110. Now I would like you to read out loud as much of this sentence as you can.

SHOW CARD TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) ____________ 4

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

YES 1
NO 2

112. CHECK 110:

CODE ???2???, ???3??? OR ???4??? CIRCLED (GO TO 113)
CODE ???1??? CIRCLED (GO TO 114)

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

YES 1
NO 2

114. Do you usually listen to the radio every day?

YES 1
NO 2

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

YES 1
NO 2

116. What is your religion?

HINDU 1
BUDDHIST 2
MUSLIM 3
CHRISTIAN 4
OTHER (SPECIFY) ______ 6

117. What is your caste?
WRITE IN SPACE PROVIDED. DO NOT FILL BOX. CODE WILL BE ENTERED BY FIELD EDITOR.

CASTE _______________

118. Are you currently married or are you widowed, divorced, or separated?

CURRENTLY MARRIED 1
WIDOWED 2 (GO TO 124)
DIVORCED 3 (GO TO 124)
SEPARATED 4 (GO TO 124)

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

LIVING WITH HER 1 (GO TO 121)
STAYING ELSEWHERE 2

120. How long has he been away without coming back?
IF LESS THAN 1 MONTH, WRITE ???OO???.

MONTHS________
MORE THAN 2 YEARS 95
DOES NOT KNOW 98

121. RECORD THE HUSBAND???S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD ???00???.

NAME_______________
LINE NO. ____________

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

YES 1
NO 2 (GO TO 124)

123. How many other wives does he have?

NUMBER __________
DON???T KNOW 98 (GO TO 124)

123A. Are you the first, second, ....wife?

RANK________

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

ONCE 1
MORE THAN ONCE 2

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

AGE_________

126. CHECK 124:

MARRIED ONLY ONCE
In what month and year did you start living with your husband?
MARRIED MORE THAN ONCE
Now we will talk about your first husband. In what month and year did you start living with him?
MONTH_________
DON???T KNOW MONTH 98
YEAR _________________ (GO TO 201)
DON???T KNOW YEAR 9998
HAS NOT STARTED LIVING WITH HIM 9996 (END)

127. How old were you when you started living with him?

PROMPT: At Gauna?

AGE______________

SECTION 2: REPRODUCTION

Now I would like to ask about all the pregnancies you have had during your life. By this I mean all the children born to you, whether they were born alive or dead, whether they are still living or not, whether they live with you or somewhere else, and all the pregnancies which 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 ended before full term, but it is important that you tell us about all of them, so that we can develop programs to improve children???s health.

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

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO 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 (GO 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?

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 (GO 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 early, in a miscarriage or the child can be born dead. Have you ever had a pregnancy that did not end in a live birth?

YES 1
NO 2 (GO TO 210)

209. How many pregnancies have you had that did not end in a live birth?

PREGNANCY LOSSES_______

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

TOTAL__________

211. CHECK 210:
Just to make sure that I have this right: you have had in TOTAL _____ pregnancies during your life. Is that correct?

YES (GO TO 212)
NO (PROBE AND CORRECT 201-210 AS NECESSARY)

212. CHECK 210:

ONE OR MORE PREGNANCIES (GO TO 213)
NO PREGNANCIES (GO TO 233)

213. Now I would like to record all your pregnancies, whether born alive, born dead, or lost before birth. Start with the first pregnancy you had. RECORD ALL THE PREGNANCIES. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

214. ___

215. Think back to time of your first pregnancy. Was that a single of multiple pregnancy.

SING 1
MULT 2

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

BORN ALIVE 1 (GO TO 218)
BORN DEAD 2
LOST BEFORE BIRTH 3 (GO TO 226)

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

YES 1
NO 2 (GO TO 226)

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 any year was (NAME) born?
PROBE: What is his/her birthday?

MONTH __
YEAR ____

221. Is (NAME) still alive?

YES 1
NO 2 (GO TO 225)

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

AGE IN YEARS __

223. Is (NAME) living with you?

YES 1
NO 2

224. RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD ???00??? IF CHILD NOT LISTED IN HOUSEHOLD)

LINE NUMBER ___ (GO TO NEXT PREGNANCY)

225. IF BORN ALIVE BUT NOW DEAD: 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 2 YEARS; OR YEARS.

DAYS 1 __
MONTHS 2 __
YEARS 3 __
(GO TO NEXT PREGNANCY)

226. IF BORN DEAD OR LOST BEFORE BIRTH: In what month and year did this pregnancy end?

MONTH __
YEAR ____

227. How many months did the pregnancy last?
RECORD IN COMPLETED MONTHS.

MONTHS __

228. Did you or someone else do anything to end this pregnancy?

YES 1
NO 2

229. Were there any other pregnancies between the previous pregnancy and this pregnancy?
(ASK FOR ALL EXCEPT FIRST PREGNANCY)

YES 1
NO 2

230. Have you had any pregnancy since the last pregnancy mentioned?

YES 1
NO 2

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

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

232. CHECK 220 AND ENTER THE NUMBER OF LIVE BIRTHS SINCE BAISAKH 1, 2052.
IF NONE, RECORD ???0???.

233. CHECK 118:

CURRENTLY MARRIED (GO TO 234)
WIDOWED, DIVORCED, SEPARATED (GO TO 237)

234. Are you pregnant now?

YES 1
NO 2 (GO TO 237)
UNSURE 8 (GO TO 237)

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

MONTHS _____

236. 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 have any (more) children at all?

WANTED THEN 1
WANTED TO WAIT LATER 2
DID NOT WANT AT ALL 3

237. When did your last menstrual period start?

DATE, IF GIVEN ______________

DAYS AGO 1 __
WEEKS AGO 2 __
MONTHS AGO 3 __
YEARS AGO 4 __
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

238. From one menstrual period to the next, is there a time when a woman is more likely to become pregnant if she has sexual relations?

YES 1
NO 2 (GO TO 301)
DON???T KNOW 8 (GO TO 301)

239. Is this time before her period begins, during her period, right after her period has ended, or half way between two periods?

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN PERIODS 4
OTHER (SPECIFY) ________ 6
DON???T KNOW 8

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 3O1 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.

301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOULY, ASK: Have you ever heard of (MEHOD)?

01 FEMALE STERILIZATION Women can have an operation to avoid having any more children (also known as tubal ligation).
YES 1
NO 2
02 MALE STERILIZATION Men can have an operation to avoid having any more children (also known as a vasectomy).
YES 1
NO 2
03 PILL Women can take a pill every day to avoid becoming pregnant (ex. Nilocon).
YES 1
NO 2
04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse (ex. Copper-T, Loop).
YES 1
NO 2
05 INJECTABLES Women can have an injection by a health provider which stops them from becoming pregnant for one or more months (ex. Sangini/Depo Provera).
YES 1
NO 2
06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can help prevent pregnancy for one or more years (also known as NORPLANT).
YES 1
NO 2
07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse (ex. Daal).
YES 1
NO 2
08 FOAM OR JELLY Women can place a suppository, foaming tablets, jelly, or cream in their vagina before intercourse (ex. Kamal).
YES 1
NO 2
09 RHYTHM OR PERIODIC ABSTINENCE Every month that a woman is sexually active, she can avoid pregnancy by not 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
SPECIFY ______________
SPECIFY_______________
NO 2

302. Have you ever used (METHOD)?

01 FEMALE STERILIZATION Women can have an operation to avoid having any more children (also known as tubal ligation).
Have you ever had an operation to avoid having any more children?
YES 1
NO 2
02 MALE STERILIZATION Men can have an operation to avoid having any more children (also known as a vasectomy).
Have you ever had a partner who had an operation to avoid having any more children?
YES 1
NO 2
03 PILL Women can take a pill every day to avoid becoming pregnant (ex. Nilocon).
YES 1
NO 2
04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse (ex. Copper-T, Loop).
YES 1
NO 2
05 INJECTABLES Women can have an injection by a health provider which stops them from becoming pregnant for one or more months (ex. Sangini/Depo Provera).
YES 1
NO 2
06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can help prevent pregnancy for one or more years (also known as NORPLANT).
YES 1
NO 2
07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse (ex. Daal).
YES 1
NO 2
08 FOAM OR JELLY Women can place a suppository, foaming tablets, jelly, or cream in their vagina before intercourse (ex. Kamal).
YES 1
NO 2
09 RHYTHM OR PERIODIC ABSTINENCE Every month that a woman is sexually active, she can avoid pregnancy by not 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?
SPECIFIED METHOD
YES 1
NO 2

SPECIFIED METHOD
YES 1
NO 2

303. CHECK 302:

NOT A SINGLE "YES" (NEVER USED) (GO TO 304)
AT LEAST ONE "YES" (EVER USED) (GO TO 306)

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

YES 1
NO 2 (GO TO 329)

305. What have you used or done?

CORRECT 302 AND 303 (AND 301 IF NECESSARY).

306. Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant. How many living children did you have at that time, if any?
IF NONE, RECORD ???00???.

NUMBER OF CHILDREN __

307. CHECK 118:

CURRENTLY MARRIED (GO TO 308)
WIDOWED, DIVORCED, SEPARATED (GO TO 401)

308. CHECK 302 (01):

WOMAN NOT STERILIZED (GO TO 309)
WOMAN STERILIZED (GO TO 311A)

309. CHECK 234:

NOT PREGNANT OR UNSURE (GO TO 310)
PREGNANT (GO TO 329)

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

YES 1
NO 2 (GO TO 329)

311. Which method are you using?
311A. CIRCLE ???A??? FOR FEMALE STERILIZATION.
IF MORE THAN ONCE METHOD MENTIONED, CIRCLE ALL METHODS MENTIONED. IF MORE THAN ONCE METHOD MENTIONED, FOLLOW SKIP INSTURCTIONS FOR HIGHESTMETHOD ON LIST.

FEMALE STERILIZATION A
MALE STERILIZATION B
PILL C (GO TO 316A)
IUD D (GO TO 316A)
INJECTABLES E (GO TO 316A)
IMPLANTS F (GO TO 316A)
CONDOM G (GO TO 316A)
FOAM/JELLY H (GO TO 316A)
PERIODIC ABSTINENCE I (GO TO 316A)
WITHDRAWAL J (GO TO 316A)
OTHER (SPECIFY) ____________ X (GO TO 316A)

312. Where did the sterilization take place?

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

NAME OF PLACE ___________

IF BOTH CODE ???A??? AND CODE ???B??? ARE CIRCLED IN 311, ASK 312-317 ABOUT FEMALE STERILIZATION ONLY.

GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC 11
PRIMARY HEALTH CARE CENTER/HEALTH CENTER 12
MOBILE CAMP 19
OTHER GOVT. (SPECIFY) _______ 16
NON-GOVT. (NGO) SECTOR
FP ASSN. OF NEPAL 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
OTHER NGO (SPECIFY) ________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
OTHER PRIVATE (SPECIFY) ________ 36

OTHER (SPECIFY) ___________ 96
DON???T KNOW 98

313. CHECK 311:

CODE ???A??? CIRCLED
Before your sterilization operation, were you told that you would not be able to have any more children because of the operation?
CODE ???A??? NOT CIRCLED
Before the sterilization operation, was your husband told that he would not be able to have any more children because of the operation?
YES 1
NO 2
DON???T KNOW 8

314. Do you regret that you/your husband had the operation?

YES 1
NO 2 (GO TO 316)

315. Why do you regret the operation?

RESPONDENT WANTS ANOTHER CHILD 01
HUSBAND WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
MARITAL STATUS HAS CHANGED 04
OPERATION FAILED 05
CHILD DIED 06
OTHER (SPECIFY) ____________ 96

316. In what month and year was the sterilization performed?
316A. For how long have you been using (CURRENT METHOD) now without stopping?
PROBE: In what month and year did you start using (CURRENT METHOD) continuously?

MONTH __
YEAR ____

317. CHECK 316/316A:

CIRCLE METHOD CODE:

IF MORE THAN ONCE METHOD CODE CIRCLED IN 311/311A, CIRLCE CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01 (GO TO 321)
MALE STERILIZATION 02 (GO TO 332)
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FOAM/JELLY 08 (GO TO 332)
PERIODIC ABSTINENCE 09 (GO TO 332)
WITHDRAWAL 10 (GO TO 332)
OTHER METHOD 96

319. Where did you obtain (CURRENT METHOD) when you started using it?

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

NAME OF PLACE _______________
GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC 11
PRIMARY HEALTH CARE CENTER/HEALTH CENTER 12
HEALTH POST 13
SUB-HEALTH POST 14
PHC OUTREACH CLINIC 15
FCHV 17
CONDOM BOX 18
OTHER GOVT. (SPECIFY) ____________ 16
NON-GOVT. (NGO) SECTOR
FP ASSN. OF NEPAL 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
OTHER NGO (SPECIFY) ___________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
PHARMACY 32
OTHER PRIVATE (SPECIFY) _______ 36
OTHER SOURCE
SHOP 41
FRIEND/RELATIVE 42

OTHER (SPECIFY) ______________ 96

320. CHECK 311/311A: CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRLCE CODE FOR HIGHEST METHOD IN LIST.

PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07 (GO TO 326)
FOAM/JELLY 08 (GO TO 326)

321. You obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM 312 OR 319).
At any time, were you told about side effects or problems you might have with the method?

YES 1 (GO TO 323)
NO 2

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

YES 1
NO 2 (GO TO 324)

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

YES 1
NO 2

324. CHECK 321:

CODE ???1??? CIRCLED
At any time, were you told about other methods of family planning which you could use?
CODE ???1??? NOT CIRCLED
When you obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM 312 OR 319), were you told about other methods of family planning which you could use?
YES 1 (GO TO 326)
NO 2

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

YES 1
NO 2

326. CHECK 311/311A:
CIRCLE METHOD CODE

FEMALE STERILIZATION 01 (GO TO 332)
MALE STERILIZATION 02 (GO TO 332)
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FOAM/JELLY 08
PERIODIC ABSTINENCE 09 (GO TO 332)
WITHDRAWAL 10 (GO TO 332)
OTHER 96 (GO TO 332)

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

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

NAME OF PLACE _______________
GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC 11
PRIMARY HEALTH CARE CENTER/HEALTH CENTER 12
HEALTH POST 13
SUB-HEALTH POST 14
PHC OUTREACH CLINIC 15
FCHV 17
CONDOM BOX 18
OTHER GOVT. (SPECIFY) ____________ 16
NON-GOVT. (NGO) SECTOR
FP ASSN. OF NEPAL 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
OTHER NGO (SPECIFY) ___________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
PHARMACY 32
OTHER PRIVATE (SPECIFY) _______ 36
OTHER SOURCE
SHOP 41
FRIEND/RELATIVE 42

OTHER (SPECIFY) ______________ 96

328. How long does it take you to travel from your house to this place?

MINUTES 1 __ (GO TO 332)
HOURS 2 __ (GO TO 332)
DOES NOT KNOW 998 (GO TO 332)

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

YES 1
NO 2 (GO TO 332)

330. Where is that?

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

NAME OF PLACE _______________

Any other place?
RECORD ALL PLACES MENTIONED.

GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC A
PRIMARY HEALTH CARE CENTER/HEALTH CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH CLINIC E
FCHV F
CONDOM BOX G
OTHER GOVT. (SPECIFY) ____________ H
NON-GOVT. (NGO) SECTOR
FP ASSN. OF NEPAL I
MARIE STOPES J
ADRA K
NEPAL RED CROSS L
OTHER NGO (SPECIFY) ___________ M
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME N
PHARMACY O
OTHER PRIVATE (SPECIFY) _______ P
OTHER SOURCE
SHOP Q
FRIEND/RELATIVE R

OTHER (SPECIFY) ______________ X

331. How long does it take you to travel from your house to the nearest place?

MINUTES 1 __
HOURS 2 __
DOES NOT KNOW 998

332. In the last 12 months, were you visited by a health worker who talked to you about family planning?

YES 1
NO 2

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

YES 1
NO 2

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

YES 1
NO 2

SECTION 4A. PREGNANCY, POSTNATAL CARE AND BREASTFEEDING

401. CHECK 232:

ONE OR MORE BIRTHS SINCE BAISAKH 1, 2052 (GO TO 402)
NO BIRTHS SINCE BAISAKH 1, 2052 (GO TO 484)

402. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE BAISAKH 1, 2052 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 2 BIRTHS, USE THE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

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

403. LINE NUMBER FROM 214

LINE NUMBER __

404. FROM 218 AND 221

NAME ________
ALIVE __
DEAD __

405. At any time you became pregnant with (NAME), did you want to become pregnant then, did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

THEN 1 (GO TO 407)
LATER 2
NOT AT ALL 3 (GO TO 407)

406. How much longer would you like to have waited?

MONTHS 1 __
YEARS 2 __
DON???T KNOW 998

407. 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/AUX.N.MIDWIFE B
HEALTH ASST/AUX.HEALTH WORKER C
MCH WORKER D
VILLAGE HEALTH WORKER E
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT F

OTHER (SPECIFY) ____________ X
NO ONE Y (GO TO 415)

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

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. CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE

ONCE __ (GO TO 412)
MORE THAN ONCE OR DON???T KNOW (GO TO 411)

411. How many months pregnant were you the last time you received antenatal care?

MONTHS __
DON???T KNOW 98

412. During this pregnancy, were any of the following done at least once?

Were you weighed?
YES 1
NO 2
Was your height measured?
YES 1
NO 2
Was your blood pressure measured?
YES 1
NO 2
Did you give a urine sample?
YES 1
NO 2
Did you give a blood sample?
YES 1
NO 2

413. Were you told about the signs of pregnancy complications?

YES 1
NO 2 (GO TO 415)
DON???T KNOW 8 (GO TO 415)

414. Were you told where to go if you had these complications?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 417)
DON???T KNOW 8 (GO TO 417)

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

TIMES __
DON???T KNOW 8

417. During this pregnancy, were you given or did you buy any iron/folic acid tablets?
SHOW IRON FOLATE TABLETS.

YES 1
NO 2 (GO TO 419)
DON???T KNOW 8 (GO TO 419)

418. During the whole pregnancy, for how many days did you take the tablets?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

NUMBER OF DAYS ___
DON???T KNOW 998

419. During this pregnancy, did you have difficulty with your vision during the daylight?

YES 1
NO 2
DON???T KNOW 8

420. During this pregnancy, did you suffer from night blindness [USE LOCAL TERM]?

YES 1
NO 2
DON???T KNOW 8

421. During this pregnancy, did you eat less than usual, about the same, or more than you ate before you got pregnant?

LESS THAN USUAL 1
ABOUT THE SAME 2
MORE THAN USUAL 3
DON???T KNOW 8

422. When (NAME) was born, was he/she: very large, larger than average, average, smaller than average, or very small?

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON???T KNOW 8

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

HEALTH PROFESSIONAL
DOCTOR A
NURSE/AUX.N.MIDWIFE B
HEALTH ASST/AUX.HEALTH WORKER C
MCH WORKER D
VILLAGE HEALTH WORKER E
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT F
RELATIVES/FRIENDS G

OTHER (SPECIFY) ____________ X
NO ONE Y

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

HOME
YOUR HOME 11 (GO TO 426)
OTHER HOME 12 (GO TO 426)
GOVERNMENT SECTOR
GOVT. HOSPITAL 21
PRIMARY HEALTH CARE CENTER 22
HEALTH OR SUB0HLTH POST 23
OTHER GOVT. (SPECIFY) _________ 26
NON-GOVT. (NGO) SECTOR
UMN/RED CROSS HOSPITAL 31
OTHER NGO (SPECIFY) _______ 36
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/NURSING HOME 41
OTHER PRIVATE (SPECIFY) _______ 46

OTHER (SPECIFY) ____ 96 (GO TO 426)

425. Was (NAME) delivered by caesarian section?

YES 1 (GO TO 431)
NO 2 (GO TO 431)

426. Was a special safe delivery kit used?
SHOW SAFE DELIVERY KIT MARKETED BY CRS.

YES 1
NO 2
DOES NOT KNOW 8

427. After (NAME) was born, did a health professional or a traditional birth attendant check on your health?

YES 1
NO 2 (GO TO 431)

428. How many days or weeks after the delivery did the first check take place?
RECORD ???00??? DAYS IF SAME DAY.

DAYS AFTER DELIVERY 1 __
WEEKS AFTER DELIVERY 2 __
DON???T KNOW 998

429. Who checked your health at that time?
PROBE FOR MOST QUALIFIED PERSON.

HEALTH PROFESSIONAL
DOCTOR 11
NURSE/AUX.N.MIDWIFE 12
HEALTH ASST/AUX.HEALTH WORKER 13
MCH WORKER 14
VILLAGE HEALTH WORKER 15
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT 21

OTHER (SPECIFY) ____________ 96

430. Where did this first check take place?

HOME
YOUR HOME 11
OTHER HOME 12
GOVERNMENT SECTOR
GOVT. HOSPITAL 21
PRIMARY HEALTH CARE CENTER 22
HEALTH OR SUB-HLTH POST 23
OTHER GOVT. (SPECIFY) ______ 26
NON-GOVT. (NGO) SECTOR
UMN/RED CROSS HOSPITAL 31
OTHER NGO (SPECIFY) _______ 36
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/NURSING HOME 41
OTHER PRIVATE (SPECIFY) ________ 46

OTHER (SPECIFY) ________ 96

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

YES 1
NO 2

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

YES 1 (GO TO 434)
NO 2 (GO TO 435)

433. Did your period return between the birth of (NAME) and your next pregnancy?
ASK FOR ALL EXCEPT FIRST PREGNANCY.

YES 1
NO 2 (GO TO 437)

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

MONTHS __
DON???T KNOW 98

435. CHECK 234: RESPONDENT PREGNANT?

NOT PREGNANT (GO TO 436)
PREGNANT OR UNSURE (GO TO 437)

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

YES 1
NO 2 (GO TO 438)

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

MONTHS __
DON???T KNOW 98

438. Did you ever breastfeed (NAME)?

YES 1
NO 2 (GO TO 446)

439. 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 00
HOURS 1 __
DAYS 2 __

440. Did you give (NAME) the yellow milk from the breast or did you squeeze it out and throw it away before you first put (NAME) to the breast?

GAVE YELLOW MILK 1
SQUEEZED AND DISCARDED 2

441. In the first three days after delivery, before your milk began flowing regularly, was (NAME) given anything to drink other than breast milk?

YES 1
NO 2 (GO TO 443)

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

MILK OTHER THAN BREASTMILK A
PLAIN WATER B
SUGAR OR HONEY WATER C
GHEE D
OTHER (SPECIFY) ______ X

443. CHECK 404: CHILD ALIVE?

ALIVE __
DEAD __ (GO TO 445)

444. Are you still breastfeeding (NAME)?

YES 1 (GO TO 447)
NO 2

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

MONTHS __
DON???T KNOW 98

446. CHECK 404: CHILD ALIVE?

ALIVE (GO TO 449)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 452)

447. How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF NIGHTTIME FEEDINGS __

448. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.

NUMBER OF DAYLIGHT FEEDING __

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

YES 1
NO 2
DON???T KNOW 8

449A. Was sugar added to any of the foods or liquids (NAME) ate yesterday?

YES 1
NO 2
DON???T KNOW 8

450. How many times did (NAME) eat solid, semi-solid or soft foods other than liquids yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD 7.

NUMBER OF TIMES __
DON???T KNOW 8

451. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 452.

SECTION 4B. IMMUNIZATION AND HEALTH

452. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS IF EACH BIRTH SINCE BAISAKH 1, 2052 OR LATER, ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES).

453. LINE NUMBER FROM 214.

LINE NUMBER __

454. FROM 218 AND 221

NAME _______
ALIVE (GO TO 455)
DEAD (GO TO 454 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 481)

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

YES, SEEN 1 (GO TO 457)
YES, NOT SEEN 2 (GO TO 459)
NO CARD 3

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

YES 1 (GO TO 459)
NO 2 (GO TO 459)

457. (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
DAY __
MONTH __
YEAR __
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY __
MONTH __
YEAR _____
POLIO 1
DAY __
MONTH __
YEAR ____
POLIO 2
DAY __
MONTH __
YEAR ____
POLIO 3
DAY __
MONTH __
YEAR ____
DPT 1
DAY __
MONTH __
YEAR ____
DPT 2
DAY __
MONTH __
YEAR ____
DPT 3
DAY __
MONTH __
YEAR ____
MEASLES
DAY __
MONTH __
YEAR ____

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

YES 1 (PROBE FOR VACCINATIONS AND WRITE ???66??? IN THE CORRESPONDENT DAY COLUMN IN 457) (GO TO 461)
NO 2 (GO TO 461)
DON???T KNOW 8 (GO TO 461)

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

YES 1
NO 2 (GO TO 463)
DON???T KNOW 8 (GO TO 463)

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

460A. A BCG vaccination against tuberculosis, that is, an injection in the upper arm that usually causes a scar?

YES 1
NO 2
DON???T KNOW 8

460B. Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (GO TO 460E)
DON???T KNOW 8 (GO TO 460E)

460C. When was the first polio vaccine received, just after birth or later?

JUST AFTER BIRTH 1
LATER 2

460D. How many times was the polio vaccine received?

NUMBER OF TIMES __

460E. DPT vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 460G)
DON???T KNOW 8 (GO TO 460G)

460F. How many times?

NUMBER OF TIMES __

460G. An injection to prevent measles?

YES 1
NO 2
DON???T KNOW 8

461. Were any of the vaccinations (NAME) received during the last two years given as a part of a national immunization day campaign?

YES 1
NO 2 (GO TO 463)
DON???T KNOW 8 (GO TO 463)

462. At which national immunization day campaigns did (NAME) receive vaccination?
RECORD ALL MENTIONED.

MAGH 2057 A
MANGSIRE 2057 B
POUSH 2056 C
MANGSIR 2056 D

463. Do you remember the recent vitamin A capsule distribution?
IF NO, ASK: Does anyone in the household remember the event?
SPEAK TO THAT PERSON.

YES 1
NO 2 (GO TO 466)
DON???T KNOW 8 (GO TO 466)

464. Did (NAME) receive a vitamin A capsule during the event in (Kartik/Baisakh)?
IF INTERVIEW IS BEFORE THE BAISAKH, ASK ABOUT KARTIK. IF INTERVIEW AFTER BAISAKH, ASK ABOUT BAISAKH.

YES 1
NO 2 (GO TO 466)
DON???T KNOW 8 (GO TO 466)

465. Please tell me what happened when you took (NAME) for vitamin A?
SHOW CAPSULE. IF MENTIONS SPONTANEOUSLY, CIRCLE CODE ???1???. FOR ALL NOT MENTIONED, PROBE, AND CIRCLE ???2??? IF YES AND ???8??? IF NO OR DON???T KNOW.

RED CAPSULE
YES, SPONTANEOUSLY 1
YES, PROBE 2
NO/DON???T KNOW 8
CAPSULE WAS CUT
YES, SPONTANEOUSLY 1
YES, PROBE 2
NO/DON???T KNOW 8
CHILD???S NAME WRITTEN
YES, SPONTANEOUSLY 1
YES, PROBE 2
NO/DON???T KNOW 8
CENTRAL SITE
YES, SPONTANEOUSLY 1
YES, PROBE 2
NO/DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 469)
DON???T KNOW 8 (GO TO 469)

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

YES 1
NO 2
DON???T KNOW 8

469. CHECK 466 AND 467:
FEVER OR COUGH?

"YES" IN 466 OR 467 (GO TO 470)
OTHER (GO TO 472)

470. Did you seek advice or treatment for the fever/cough?

YES 1
NO 2 (GO TO 472)

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

GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC A
PRIM. HEALTH CARE CENTER B
HEALTH POST/SUB-H. POST C
PHCC OUTREACH CLINIC D
FCHV E
OTHER GOVT. (SPECIFY) ______ F
NON-GOVT. (NGO) SECTOR
UMN/RED CROSS G
OTHER NGO (SPECIFY) ____________ H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL I
CLINIC/NURSING HOME J
PHARMACY K
OTHER PRIVATE (SPECIFY) _____ L
OTHER SOURCE
SHOP M
TRAD. PRACTITIONER N

OTHER (SPECIFY) ________ X

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

YES 1
NO 2 (GO TO 480)
DON???T KNOW 8 (GO TO 480)

473. Now I would like to know how much (NAME) was offered to drink during the diarrhea. Was he/she offered less than usual to drink, about the same amount, or more than usual to drink?

LESS THAN USUAL 1
ABOUT THE SAME 2
MORE THAN USUAL 3
NOTHING TO DRINK 4
DON???T KNOW 8

474. When (NAME) had diarrhea, was he/she offered less than usual to eat, about the same amount, more than usual, or nothing to eat?

LESS THAN USUAL 1
ABOUT THE SAME 2
MORE THAN USUAL 3
STOPPED FOOD 4
NEVER GAVE FOOD 5
DON???T KNOW 8

475. Was he/she given a fluid made from a special packet such as Jeevan Jal to drink?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (GO TO 478)
DON???T KNOW (GO TO 478)

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

PILL OR SYRUP A
INJECTION B
(I.V.) INTRAVENOUS C
HOME REMEDIES/HERBAL MEDICINES D
OTHER (SPECIFY) _______ X

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

YES 1
NO 2 (GO TO 480)

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

GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC A
PRIM. HEALTH CARE CENTER B
HEALTH POST/SUB-H. POST C
PHCC OUTREACH CLINIC D
FCHV E
OTHER GOVT. (SPECIFY) _________ F
NON-GOVT. (NGO) SECTOR
UMN/RED CROSS G
OTHER NGO (SPECIFY) _______ H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL I
CLINIC/NURSING HOME J
PHARMACY K
OTHER PRIVAT (SPECIFY) ___ L
OTHER SOURCE
SHOP M
TRAD. PRACTITIONER N

OTHER (SPECIFY) ______ X

480. GO BACK TO 454 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 481.

481. CHECK 220 AND 223:
NUMBER IF CHILDREN BORN SINCE BAISAKH 1, 2052 AND LIVING WITH HER

ONE OR MORE (GO TO 482)
NONE (GO TO 484)

482. What usually happens with your (youngest) child???s stools when he/she does not use any toilet facility?

ALWAYS USE TIOLET/LATRINE 01
THROWN IN TOILET/LATRINE 02
THROW OUTSIDE DWELLING 03
THROW OUTSIDE THE YARD 04
BURY IN THE YARD 05
RINSE AWAY 06
USE DIAPERS 07
NOT DISPOSED OF 08
OTHER (SPECIFY) _____ 96

483. CHECK 475, ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR Q. 475 NOT ASKED (GO TO 484)
ANY CHILD RECEIVED FLUID FROM ORS PACKET (GO TO 486)

484. Have you ever heard of a special product called Jeevan Jal or NavaJeevan you can get for the treatment of diarrhea?

YES 1 (GO TO 486)
NO 2

485. Have you ever seen a packet like these?
SHOW PACKET OF JEEVAL JAL, OTHER TYPES OF ORS.

YES 1
NO 2

486. CHECK 223:

HAS ONE OR MORE CHILDREN LIVING WITH HER (GO TO 487)
HAS NO CHILDREN LIVING WITH HER (GO TO 488)

487. When (your child/one of your children) is seriously ill, can you decide by yourself whether the child should be taken for medical treatment?
IF SAYS NO CHILD EVER ILL, ASK: If (your child/one of your children) became seriously ill, could you decide by yourself whether the child should be taken for medical treatment?

YES 1
NO 2
DEPENDS 3

488. Now I would like to ask you some questions about medical care for you yourself.

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, a small problem, or not a problem for you:

Knowing where to go.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3
Getting permission to go.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3
Getting money needed for treatment.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3
The distance to the health facility.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3
Having to take transport.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3
Not wanting to go alone.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3
Concern that there may not be a female health provider.
BIG PROBLEM 1
SMALL PROBLEM 2
NOT A PROBLEM 3

489. CHECK 220 AND 223:

HAS AT LEAST 1 CHILD BORN SINCE BAISAKH 1, 2054 AND LIVING WITH HER

RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 490
NAME _______________

DOES NOT HAVE ANY CHILD BORN SINCE BAISAKH 1, 2054 LIVING WITH HER (GO TO 493)

490. Now I would like to ask you about liquids [NAME FROM Q. 489] drank over the last seven days, including yesterday.

How many days during the last seven days did [NAME] drink each of the following?

FOR EACH ITEM GIVEN AT LEAST ONCE IN LAST SEVEN DAYS, ASK: In total, how many times yesterday during the day or at night did [NAME] drink [ITEM]?

a. Plain water?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
b. Any milk, other than breastmilk, such as cow milk, mohi, tinned or powdered milk or infant formula?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
c. Any other liquids such as ghee, honey, tea, soup, rice water?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __

IF 7 OR MORE TIMES, RECORD ???7???. IF DON???T KNOW, RECORD ???8???.

491. Now I would like to ask you about the types of foods [NAME FROM Q. 489] ate over the last seven days, including yesterday.

How many days during the last seven days did [NAME] eat each of the following foods, either separately or combined with other food?

FOR EACH ITEM GIVEN AT LEAST ONCE IN LAST SEVEN DAYS, BEFORE PROCEEDING TO THE NEXT ITEM, ASK:
In total, how many times yesterday during the day or at night did [NAME] eat [ITEM]?

a. Any food made from grains, like rice, millet, sorghum, maize, wheat, or porridge?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
b. Pumpkin, carrots, papaya, or mango?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
c. Food made from roots or tubers, like potatoes, yams, tapioca?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
d. Any green leafy vegetables?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
e. Any other fruits and vegetables, like bananas, apples, guava, green beans, amala, orange, tomatoes?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
f. Meat, poultry, fish, liver, or eggs?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
g. Any food make from legumes, like daal, peanuts, beans?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
h. Cheese or yogurt?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __
i. Any food make from ghee, oil, fat, or butter?
NUMBER OF DAYS OF LAST 7 DAYS __
NUMBER OF TIMES YESTERDAY/LAST NIGHT __

IF 7 OR MORE TIMES, RECORD ???7???. IF DON???T KNOW, RECORD ???8???.

492. The last time you fed your child(ren), did you wash your hands immediately before feeding (him/her/them)?

YES 1
NO 2
NEVER FED CHILD(REN) 3

493. Do you smoke cigarettes or bidis or tobacco?

YES, CIGARETTES/BIDIS A
YES, PIPE B
YES, OTHER TOBACCO C
NO Y

494. CHECK 493:

CODE ???A??? CIRCLED (GO TO 495)
CODE ???A??? NOT CIRCLED (GO TO 501)

495. In the last 24 hours, how many cigarettes/bidis did you smoke?

CIGARETTES/BIDIS __

SECTION 5. FERTILITY PREFERENCES

501. CHECK 118:

CURRENTLY MARRIED (GO TO 502)
WIDOWED, DIVORCED, SEPARATED (GO TO 514)

502. CHECK 311/311A:

NEITHER STERILIZED (GO TO 503)
HE OR SHE STERILIZED (GO TO 514)

503. CHECK 234:

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 (GO TO 505)
SAYS SHE CAN???T GET PREGNANT 3 (GO TO 514)
UNDECIDED/DON???T KNOW AND PREGNANT 4 (GO TO 511)
UNDECIDED/DON???T KNOW AND NOT PREGNANT OR UNSURE 5 (GO TO 509)

504. CHECK 234:

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?
MONTHS 1 __
YEARS 2 __
SOON/NOW 993 (GO TO 510)
SAYS SHE CAN???T GET PREGNANT 994 (GO TO 514)
OTHER (SPECIFY) _______ 996 (GO TO 510)
DON???T KNOW 998 (GO TO 510)

505. CHECK 234:

NOT PREGNANT OR UNSURE (GO TO 506)
PREGNANT (GO TO 511)

506. CHECK 310: USING A METHOD?

NOT ASKED (GO TO 507)
NOT CURRENTLY USING (GO TO 507)
CURRENTLY USING (GO TO 509)

507. CHECK 504:

NOT ASKED (GO TO 508)
24 MONTHS OR MORE OR 02 OR MORE YEARS (GO TO 508)
23 MONTHS OR LESS OR LESS THAN 02 YEARS (GO TO 511)

508. CHECK 503:

WANTS A/ANOTHER CHILD
You have said that you do not want (a/another) child soon, but you are not using any method to avoid pregnancy. Can you tell me why?
WANTS NO (MORE) CHILDREN
You have said that you do not want any (more) children, but you are not using any method to avoid pregnancy?
Can you tell me why?

PROBE: Any other reason?
RECORD ALL MENTIONED.

FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SUBFECUND/INFECUND E
POSTPARTUM AMENORRHEIC F
BREASTFEEDING G
FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS O
FEAR OF SIDE EFFECTS P
LACK OF ACCESS/TOO FAR Q
COST TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY???S NATURAL PROCESSES T
OTHER (SPECIFY) ____________X
DON???T KNOW Z

509. In the next few weeks, if you discovered that you were pregnant, would that be a big problem, a small problem, or no problem for you?

BIG PROBLEM 1
SMALL PROBLEM 2
NO PROBLEM 3
SAYS SHE CAN???T GET PREGNANT 4

510. CHECK 310: USING A METHOD?

NOT ASKED (GO TO 511)
NOT CURRENTLY USING (GO TO 511)
CURRENTLY USING (GO TO 514)

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

YES 1
NO 2 (GO TO 513)
DON???T KNOW 8 (GO TO 513)

512. Which method would you prefer to use?

FEMALE STERILIZATION 01 (GO TO 514)
MALE STERILIZATION 02 (GO TO 514)
PILL 03 (GO TO 514)
IUD 04 (GO TO 514)
INJECTABLES 05 (GO TO 514)
IMPLANTS 06 (GO TO 514)
CONDOM 07 (GO TO 514)
FOAM/JELLY 08 (GO TO 514)
PERIODIC ABSTINENCE 09 (GO TO 514)
WITHDRAWAL 10 (GO TO 514)
OTHER (SPECIFY) ____ 96 (GO TO 514)
UNSURE 98 (GO TO 514)

513. What is the main reason that you think you will not use a method at any time in the future?

FERTILITY-RELATED REASONS
INFREQUENT SEX/NO SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
WANTS AS MANY CHILDREN AS POSSIBLE 26
OPPOSITION TO USE
RESPONDENT OPPOSED 31
HUSBAND OPPOSED 32
OTHER OPPOSED 33
RELIGIOUS PROHIBITION 34
LACK OF KNOWLEDGE
KNOWS NO METHOD 41
KNOWS NO SOURCE 42
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 NORMAL PROCESSES 56

OTHER (SPECIFY) ____ 96
DON???T KNOW 98

514. 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 in your whole life, how many would that be?

PROBE FOR A NUMERIC RESPONSE.

NUMBER __
OTHER (SPECIFY) _______ 96 (GO TO 516)

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

NUMBER
BOYS __
GIRLS __
EITHER __
OTHER (SPECIFY) ______ 96

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

APPROVE 1
DISAPPROVE 2
DON???T KNOW/UNSURE 3

517. In the last few months, have you heard about family planning:

On the radio?
YES 1
NO 2
On the television?
YES 1
NO 2
In a newspaper or magazine?
YES 1
NO 2
In street drama?
YES 1
NO 2

518. In the last few months, have you heard the following programs on the radio:

Jana Swastha Karyakram?
YES 1
NO 2
Ghanti Heri Had Niluan, the drama?
YES 1
NO 2
Ghanti Heri Had Niluan, the song?
YES 1
NO 2
Shriman Shrimatile Pariwarbare Kuradani Gareko Chhoto Radio Natak?
YES 1
NO 2

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

YES 1
NO 2 (GO TO 521)

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

HUSBAND A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
SON G
MOTHER-IN-LAW H
FRIENDS/NEIGHBORS I
OTHER (SPECIFY) ________ X

521. CHECK 118:

CURRENTLY MARRIED (GO TO 522)
WIDOWED, DIVORCED, SEPARATED (GO TO 528)

522. CHECK 311/311A:

ANY CODE CIRCLED (GO TO 523)
NO CODE CIRCLED (GO TO 524)

523. You have told me that you are currently using contraception. Would you say that using contraception is mainly your decision, mainly your husband???s decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND 2
JOINT DECISION 3
OTHER (SPECIFY) ______ 6

524. 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

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

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

526. CHECK 311/311A:

NEITHER STERILIZED (GO TO 527)
HE OR SHE STERILIZED (GO TO 528)

527. Do you think your husband/partner 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

528. Husbands and wives do not always agree on everything. Please tell me if you think a wife is justified in refusing to have sex with her husband when:

She is tired or not in the mood?
YES 1
NO 2
DON???T KNOW 8
She has recently given birth?
YES 1
NO 2
DON???T KNOW 8
She knows her husband has sex with other women?
YES 1
NO 2
DON???T KNOW 8
She knows her husband has a sexually transmitted disease?
YES 1
NO 2
DON???T KNOW 8

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

601. CHECK 118:

CURRENTLY MARRIED (GO TO 602)
WIDOWED, DIVORCED, SEPARATED (GO TO 603)

602. How was your husband on his last birthday?

AGE IN COMPLETED YEARS __

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

YES 1
NO 2 (GO TO 605)

604. What was the highest grade he completed?

GRADE __
DON???T KNOW 98

605. CHECK 601:

CURRENTLY MARRIED
What is your husband???s occupation? That is, what kind of work does he mainly do?
FORMERLY MARRIED
What was your (last) husband???s occupation? That is, what kind of work did he mainly do?

______________________________________________

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

YES 1 (GO TO 609)
NO 2

607. 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 (GO TO 609)
NO 2

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

YES 1
NO 2 (GO TO 618)

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

___________________________________________

610. CHECK 609:

WORKS IN AGRICULTURE (GO TO 611)
DOES NOT WORK IN AGRICULTURE (GO TO 612)

611. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else???s land?

OWN LAND/FAMILY LAND 1
RENTED LAND/TENANCY 2
SOMEONE ELSE???S LAND 3

612. Are you self-employed, employed by someone else, or do you do this work for a member of your family?

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

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

HOME 1
AWAY FROM HOME 2

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

THROUGHOUT THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

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

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3 (GO TO 618)
NOT PAID 4 (GO TO 618)

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

RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5

617. On average, how much of your household???s expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

ALMOST NONE 1
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, HER INCOME IS ALL SAVED 6

618. Do you own any land, either by yourself or jointly with someone else?

YES, OWNS ALONE 1
YES, OWNS JOINTLY 2 (GO TO 620)
NO 3 (GO TO 620)

619. If you ever needed to, could you sell the land without anyone else???s permission?

YES 1
NO 2
NOT SURE/DOES NOT KNOW 8

620. Do you own any livestock, such as goats or cows, either by yourself or jointly with someone else?

YES, OWNS ALONE 1
YES, OWNS JOINTLY 2 (GO TO 622)
NO 3 (GO TO 622)

621. If you ever needed to, could you sell the animals without anyone else???s permission?

YES 1
NO 2
NOT SURE/DOES NOT KNOW 8

622. Have you yourself ever taken a loan to start or expand a business?

YES 1
NO 2 (GO TO 624)

623. How did you pay back the loan?

NOT YET PAID BACK 1
SOMEONE ELSE PAID FOR HER 2
PROFITS FROM BUSINESS 3
SOLD ASSETS TO PAY LOAN 4
OTHER (SPECIFY) ___________ 6

624. Who in your family usually has the final say on the following decisions:

Your own health care?
RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
Making large household purchases?
RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
Making household purchases for daily needs?
RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
Visits to family, friends, or relatives?
RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
What food should be cooked each day?
RESPONDENT 1
HUSBAND 2
RESPONDENT AND HUSBAND JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6

625. Sometimes a husband is annoyed or angered by things which his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
YES 1
NO 2
DON???T KNOW 8
If she neglects the children?
YES 1
NO 2
DON???T KNOW 8
If she argues with him?
YES 1
NO 2
DON???T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON???T KNOW 8
If she burns the food?
YES 1
NO 2
DON???T KNOW 8

SECTION 7: AIDS AND SEXUAL BEHAVIOR

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

YES 1
NO 2 (GO TO 708)

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

YES 1
NO 2 (GO TO 706)
DON???T KNOW 8 (GO TO 706)

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

ABSTAIN FROM SEX A
USE CONDOMS B
LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C
LIMIT NUMBER OF SEX PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID KISSING K
AVOID MOSQUITO BITES L
SEEK PROTECTION FROM TRADITIONAL HEALER M
AVOID SHARING RAZORS/BLADES N
WHO HAS AIDS O
OTHER (SPECIFY) _________ X
OTHER (SPECIFY) _________ Y
DON???T KNOW Z

704. Can people protect themselves from getting the AIDS virus by having just one sex partner who has no other partners?

YES 1
NO 2
DON???T KNOW 8

705. Can people protect themselves from getting the AIDS virus by using a condom every time they have sex?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

707. Can the virus that causes AIDS be transmitted from a mother to a child?

YES 1
NO 2
DON???T KNOW 8

708. CHECK 118 AND 701:

CURRENTLY MARRIED AND KNOWS AIDS (GO TO 709)
CURRENTLY MARRIED AND DOES NOT KNOW AIDS (GO TO 710)
WIDOWED, DIVORCED, SEPARATED (GO TO 716)

709. Have you ever talked about ways to prevent getting the virus that causes AIDS with your husband?

YES 1
NO 2

710. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues.
How old were you when you first had sexual intercourse?

NEVER 00 (GO TO 713)
AGE IN YEARS __
FIRST TIME WHEN STARTED LIVING WITH FIRST HUSBAND 96

711. When was the last time you had sexual intercourse?
RECORD ???YEARS AGO??? ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO.

DAYS AGO 1 __
WEEKS AGO 2 __
MONTHS AGO 3 __
YEARS AGO 4 __ (GO TO 713)

712. The last time you had sexual intercourse, was a condom used?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 716)

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

NAME OF PLACE _______________

Any other place?
RECORD ALL MENTIONED.

GOVERNMENT SECTOR
GOVT. HOSPITAL/CLINIC A
PRIMARY HEALTH CARE CENTER/HEALTH CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH CLINIC E
FCHV F
CONDOM BOX G
OTHER GOV???T (SPECIFY) _______ H
NON-GOV???T (NGO) SECTOR
FP ASSN. OF NEPAL I
MARIE STOPES J
ADRA K
NEPAL RED CROSS L
OTHER NGO (SPECIFY) ________ M
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME N
PHARMACY O
OTHER PRIVATE (SPECIFY) ___________ P
OTHER SOURCE
SHOP Q
FRIEND/RELATIVE R
OTHER (SPECIFY) _______ X

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

YES 1
NO 2
DON???T KNOW/UNSURE 8

716. RECORD THE TIME.

HOUR __
MINUTES __

INTERVIEWER???S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: __________________________________________

COMMENTS ABOUT SPECIFIC QUESTIONS: ______________________________________

ANY OTHER COMMENTS: ____________________________________

EDITOR???S OBSERVATIONS: ____________________

NAME OF EDITOR: ________________
DATE: ___________

SUPERVISOR???S OBSERVATIONS: _________________________________

NAME OF SUPERVISOR: ______________________
DATE: _________________

SENTENCES FOR LITERACY TEST

1. Parents love their children.
2. Farming is hard work.
3. The child is reading a book.
4. Children should go to school.
5. Boys and girls are equal.