IDENTIFICATION

NAME AND CODE OF DISTRICT

NAME AND CODE OF VILLAGE/MUNICIPALITY

WARD NUMBER

CLUSTER NUMBER

HOUSEHOLD NUMBER

CITY/TOWN/RURAL

NAME AND LINE NUMBER OF WOMAN

NAME OF HOUSEHOLD HEAD

WOMAN ELIGIBLE FOR VERBAL AUTOPSY QUESTIONNAIRE

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER NAME
RESULT

NEXT VISIT:
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE: ENGLISH 5

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

SUPERVISOR

NAME ____
DATE ____

FIELD EDITOR

NAME ____
DATE ____

OFFICE EDITOR

___

KEYED BY

___

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________ and I am working with the MINISTRY OF HEALTH AND POPULATION. We are conducting a national survey that asks women (and men) about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes about 1 hour 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 if we should come to any question you don't want to answer, just let me know and
I will go on to the next question; or you can stop the interview at any time. 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 INTERVIEWER:____________________________ DATE:______________

101. RECORD TIME

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

102. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

103. Just before you moved here, did you live in a city, in a town, or in the country side?

104. Have you travelled away from your home community at any time in the last 12 months? IF LESS THAN 1 MONTH RECORD '00'.

105. How many months in total have you been away in the last 12 months? IF LESS THAN 1 MONTH RECORD '00'.

106. Where have you travelled in the last 12 months?
PROBE: Anywhere else? RECORD ALL PLACES MENTIONED. IF INDIA, WRITE NAME OF STATE/CITY. IF OTHER THAN INDIA AND NEPAL, WRITE NAME OF THE COUNTRY.

107. In what month and year were you born?

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

109. Have you ever attended school?

110.What is the highest grade you completed?

111. CHECK 110:

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

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

114. CHECK 112

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

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

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

118. What is your religion?

119. What is your caste/ethnicity? WRITE CASTE/ETHNICITY ON LINE PROVIDED. LEAVE BOX BLANK. CODE WILL BE FILLE DBY FIELD EDITOR.

SECTION 2. REPRODUCTION

201. Now I would like to ask you about all the pregnancies that 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 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 ended before full term, but it is important that you tell us about all of them, so that the government can develop programs to improve children's health.

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

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

204. How many sons live with you? And how many daughters live with you? IF NONE, RECORD '00'.

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

206. 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'.

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

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

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

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

211. SUM ANSWERS TO 204, 206, 208, AND 210 AND ENTER TOTAL. IF NONE, RECORD '00'.

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

213. CHECK 211:

214. Now I would like to record all your pregnancies, whether born alive, born dead, or lost before full term, starting with the first one you had. RECORD ALL THE PREGNANCIES IN 216. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. (IF THERE ARE MORE THAN 10 PREGNANCIES, USE AN ADDITIONAL QUESTIONNAIRE STARTING WITH THE SECOND ROW).

215.

216. Think back to your first pregnancy. Was that a single or multiple pregnancy?

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

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

219. What name was given to the child?

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

221. In what month and year was name born?

222. Is (NAME) still alive?

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

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

225. IF BORN ALIVE AND STILL LIVING: RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD'00' IF CHILD NOT LISTED IN HOUSEHOLD.)

226. 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 TWO YEARS; OR YEARS.

226A. IF BORN ALIVE BUT NOW DEAD: IF AGE AT DEATH IS REPORTED AS 5 YEARS OR LESS PROBE FOR EXACT NUMBER OF MONTHS AT DEATH. FOR AGE AT DEATH MORE THAN 5 YEARS, FOLLOW SKIP AS SHOWN.

227. IF BORN ALIVE BUT NOW DEAD: In what month and year did (NAME) die?

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

229. IF BORN DEAD OR LOST BEFORE BIRTH: How many months did this pregnancy last? RECORD IN COMPLETED MONTHS.

230. IF BORN DEAD OR LOST BEFORE BIRTH: Did you or someone else do something to end this pregnancy?

231. IF BORN DEAD OR LOST BEFORE BIRTH: Were there any other pregnancies between the previous pregnancy and this pregnancy?

232. Have you had any pregnancy since the last pregnancy mentioned? IF YES, RECORD PREGNANCY(S) IN TABLE.

233. COMPARE 211 WITH NUMBER OF PREGNANCIES IN HISTORY ABOVE AND MARK:

CHECK:

223A. CHECK 228 AND 229 AND ENTER THE NUMBER OF STILL BIRTH SIN 2057 OR LATER AND THE PREGNANCY LASTED FOR 7 MONTHS OR MORE. IF NONE, RECORD '0'

223B. CHECK 226, 226A AND 227 AND ENTER THE NUMBER OF DEATHS AT AGE 0-59 MONTHS IN 2057 OR LATER. IF NONE, RECORD '0'.

233C. CHECK 223A AND 233B. IF ONE OR MORE READ THE FOLLOWING STATEMENT: We would like to get more information on the circumstances around the deaths of young children so that the government can provide services to help reduce these deaths. We would like to come back and talk with you about your child(ren's) death. Is this okay?

234. CHECK 221. AND ENTER THE NUMBER OF BIRTHS IN 2057 OR LATER. IF NONE, RECORD'0'.

235. FOR EACH BIRTH SINCE BAISAKH 2057, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE RIGHT OF THE 'B' CODE. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.) CHECK 228 FOR EACH PREGNANCY THAT DID NOT END IN A LIFE BIRTH. CHECK 230.
IF YES (CODE '1' CIRCLED), ENTER 'A' FOR ABORTION OR 'T' (IF CODE '2' CIRCLED) FOR MISCARRIAGE OR STILLBIRTH, IN CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS OF PREGNANCY.

236. Are you pregnant now?

237. How many months pregnant are you? RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P'S IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

238. 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?

238A. CHECK 228

238B. Did you suffer any complications from your last miscarriage/abortion?

238C. Did you have your uterus cleaned at a health facility?

239. When did your last menstrual period start?

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

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

241A. Is abortion legal in Nepal?

241B. Do you know of a place where a woman can go to get an abortion?

241C. Where is that? Any other place? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE. NAME OF THE PLACE(S) ____

SECTION 3A. MARRIAGE AND COHABITATION

301. What is your current marital status?

302. Are you living with your husband now or is he staying elsewhere?

303. For how long have you and your husband not been living together? IF LESS THAN 1 YEAR, RECORD MONTHS, OTHERWISE RECORD IN COMPLETED YEARS.

304. RECORD THE HUSBAND'S NAME AND LIEN NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD'00'.

305. Besides yourself, does your husband have other wives?

306. How many other wives does your husband have?

307. Have you been married only once or more than once?

308. In what month and year did you get married?

308A. Now I would like to ask about when you married your first husband. In what month and year was that?

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

310. CHECK 307:
MARRIED ONLY ONCE: In what month and year did you start living with your husband?
MARRIED MORE THAN ONCE: Now I would like to ask about when you started living with your first husband. In what month and year was that?

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

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

313. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues. How old were you when you had sexual intercourse for the very first time?

313A. Do you intend to wait until you get married or until gauna has taken place to have sexual intercourse for the first time?

SECTION 3B. CONTRACEPTION

313. 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.
Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?
CIRCLE CODE 1 IN 314 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 314, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED.
PERFORM THE CHECK IN 315. IF '00' IS NOT CIRCLED IN 313,
THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 314, ASK 316.

315. CHECK 313:

316. Have you/your partner ever had an operation to avoid having any more children?

317. CHECK 316:

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

319. ENTER '0; IN THE CALENDAR IN EACH BLANK MONTH. (GO TO 345)

320. What have you used or done? CORRECT 316 AND 317 (AND 314 IF NECESSARY)

321. 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'.

322. CHECK 316 (01):

323. CHECK 236:

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

325. Which method are you using? CIRCLE ALL MENTIONED. IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD ON LIST. CIRCLE 'A' FOR FEMALE STERILIZATION.

326. The last time you obtained (HIGHEST METHOD ON LIST IN 325), how much did you pay in total, including the cost of the method and any consultation you may have had?

326A. CHECK 325/325A:

327. In what facility did the sterilization take place? PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE
THE NAME OF THE PLACE.

328. CHECK 325/325A:

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/partner told that he would not be able to have any(more) children because of the operation?

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

330. Why do you regret the operation?

331. In what month and year was the sterilization performed?

331A. Since what month and year have you been using (CURRENT METHOD) without stopping? PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

332. CHECK 331/331A, 221 AND 228: ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 331/331A. GO BACK TO 331/331A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINOUS CHECK OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).

333. CHECK 331/331A:

334. I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO BAISAKH 2057.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.
ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.
ILLUSTRATIVE QUESTIONS:
When was the last time you used a method?
Which method was that?
When did you start using that method?
How long after the birth of (NAME)?
How long did you use the method then?

335. CHECK 325/325A: CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 325/325A, CIRCLE CODE FOR HIGHES TMETHOD IN LIST.

336. Where did you obtain (CURRENT METHOD) when you started using it? Where did you learn to use the rhythm method? IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

337. CHECK 325/325A: CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 325/325A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

338. You obtained (CURRENT METHOD FROM 335) from (SOURCE OF METHOD FROM 327 OR 336) in (DATE FROM 331/331A). At that time, were you told about side effects or problems you might have with the method?

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

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

341. CHECK 338:

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

343. CHECK 325/325A: CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 325/325A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

344. Where did you obtain (CURRENT METHOD) the last time? PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

344A. How long did it take you to travel from your house to this place?

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

346. Where is that? Any other place? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

347. In the last 12 months, were you visited by a fieldworker who talked to you about family planning?

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

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

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 234:

402. CHECK 221: ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2057 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).
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 215

404. FROM 219 AND 222

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 not want to have any (more) children at all?

406. How much longer would you have liked to wait?

407. Did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see?
Anyone else? PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

407A. CHECK 407

407B. Did you discuss your pregnancy with an FCHV?

408. Where did you receive antenatal care for this pregnancy?
Anywhere else?
PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

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

411. As part of your antenatal care during this pregnancy, were any of the following done at least once?
Were you weighed?
Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?

412. During (any of) your antenatal care visit(s). were you advised to use a skilled birth attendant?

412A. During (any of) your antenatal care visit(s), were you told about the signs of pregnancy complications?

413. Were you told where to go if you had any of these complications?

413A. Did you discuss your pregnancy with an FCHV?

413B. What kind of preparation did you make beforehand for the delivery of (NAME)? Anything else? CIRCLED ALL MENTIONED.

414. During this pregnancy, were you given an injection in the arm to prevent you and the baby from getting tetanus?

415. During this pregnancy, how many times did you get this tetanus injection? IF MORE THAN 7, WRITE '7'.

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

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

418. During this pregnancy, did you take any drug for intestinal worms?

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

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

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

422. Was (NAME) weighted at birth?

423. How much did (NAME) weigh? RECORD WEIGHT IN KILGRAMS FROM HEALTH CARD, IF AVAILABLE.

424. Who assisted with the delivery of (NAME)?
Anyone else? PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED. IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

425. Where did you give birth to (NAME)? PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

425A. Did you receive a blood transfusion at this facility when (NAME) was born?

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

427. Was (NAME) delivered by caesarean section?

428. Before you were discharged after (NAME) was born, did any health care provider check on your health?

429. How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK RECORD DAYS.

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

431. After you were discharged, did any health care provider or traditional birth attendant check on your health?

431A. As part of your postnatal care, were you examined for pelvic discharge or normal involution of uterus or abnormality of the lochia or bleeding?

432.Why didn't you deliver in a health facility? PROBE: Any other reason? RECORD ALL MENTIONED.

432A. Was a special safe delivery kit used? SHOW SAFE DELIVERY KIT MARKETED BY CRS.

432B. When (NAME) was born, what instrument was used to cut the umbilical cord?

432C. Was anything placed on the slump after the umbilical cord was cut?

432D. Was (NAME) wrapped in cloth before the placenta was delivered?

432F. How long after delivery was (NAME) bathed for the first time? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

433. After (NAME) was born, did any health care provider of a traditional birth attendant check on your health?

434. How long after delivery did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK RECORD DAYS.

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

436. Where did this first check take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE NAME OF THE PLACE.

436A. As part of your postnatal care, were you examined for pelvic discharge or normal involution of the uterus or abnormality of the lochia or bleeding?

437. CHECK 431:

438. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?

439. How many hours, days or weeks after the birth of (NAME) did the first check take place? IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

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

441. Where did this first check of (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE NAME OF THE PLACE.

442. In the first two months after delivery, did you receive a vitamin A dose (like this/any of these)? SHOW COMMON TYPES OF AMPULES/CAPSULES/SYRUPS.

442A. After delivery were you given or did you buy any iron/folic acid tablets? SHOW TABLETS.

442B. After delivery, for how many days did you take the tablets? IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBERS OF DAYS.

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

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

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

446. CHECK 236: IS RESPONDENT PREGNANT?

447. Have you begun to have sexual intercourse again since the birth of (NAME)?

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

449. Did you ever breastfeed (NAME)?

450. 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

451. In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

452. What was (NAME) given to drink? Anything else? RECORD ALL LIQUIDS MENTIONED.

453. CHECK 404: IS CHILD LIVING?

454. Are you still breastfeeding (NAME)?

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

456. CHECK 404: IS CHILD LIVING?

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

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

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

460. GO BACK TO 405 IN NEXT COLUMN OR IF NO MORE BIRTHS, GO TO 501.

SECTION 5. CHILD IMMUNIZATION AND HEALTH AND CHILD'S AND WOMAN'S NUTRITION

501. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2057 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

502. LINE NUMBER FROM 215

503. FROM 219 AND 222

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

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

506. 1. COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. 2. WRITE '44' IN 'DAY' COLUMN IF CARD WHOS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED. 3. IF HEP. B IS GIVEN IN COMBINATION WITH DPT. RECORD SEPARATELY FOR BOTH DPT AND HEP. B.

507. 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, HEP. B 1-3 AND/OR MEASLES VACCINES.

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

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

509A. A BCG vaccination against tuberculosis, that is, an injection in the right arm that usually causes a scar?

509B. Polio vaccine, that is, drops in the mouth?

509C. How many times was the polio vaccine received?

509D. A DPT vaccination, that is, an injection given in the left thigh, sometimes given at the same time as polio drops?

509E. How many times was a DPT vaccination received?

509F. A HEP. B vaccination, that is, an injection given in the right thigh, sometimes given at the same time as DPT?

509G. How many times was a HEP. B vaccination received?

509H. A measles injection, that is, a shot in the arm at the age of 9 months or older, to prevent him/her from getting measles?

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

511. At which national immunization day campaigns did (NAME) receive the polio vaccinations? RECORD ALL CAMPAIGNS MENTIONED.

511A. At which national immunization day campaigns did (NAME) receive the measles injections? RECORD ALL CAMPAIGNS MENTIONED.

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

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

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

515. Has (NAME) taken any drug for intestinal worms in the last six months (including any deworming tablet given during the vitamin A distribution?)

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

517. Was there any blood in the stools?

518. Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

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

520. Did you seek advice or treatment for the diarrhea from any source?

521. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

521A. CHECK 521:

521B. Did you seek advice or treatment from an FCHV?

521C. CHECK 521:

521D. At the pharmacy:

522. CHECK 521:

523. Where did you first seek advice or treatment? USE LETTER CODE FROM 521.

524. How many days after the diarrhea began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD '00'.

524A. Did you seek advice or treatment from an FCHV?

525. Does (NAME) still have diarrhea?

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

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

528. What (else) was given to treat the diarrhea? Anything else? RECORD ALL TREATMENTS GIVEN.

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

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

531. When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

532. Was the fast or difficult breathing due to a problem in the chest or to a blocked or running nose?

533. CHECK 529: HAD FEVER?

534. Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). Was he/she given less than usual to drink, about the same amount, or more than usual to drink? IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

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

536. Did you seek advice or treatment for the illness from any source?

537. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

537A. CHECK 537:

537B. Did you seek advice or treatment from an FCHV?

537C. CHECK 537:

537D. At the pharmacy:

538. CHECK 537:

539. Where did you first seek advice or treatment? USE LETTER CODE FROM 537.

540. How many days after the illness began did you first seek advice or treatment for (NAME)? IF THE SAME DAY, RECORD '00'.

541. Is (NAME) still sick with a (fever/cough)?

542. At any time during the illness, did (NAME) take any drugs for the illness?

543. What drugs did (NAME) take? Any other drugs? RECORD ALL MENTIONED.

544. GO BACK TO 503 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 545)

545. CHECK 221 AND 224, ALL ROWS: NUMBER OF CHILDREN BORN IN 2057 OR LATER LIVING WITH THE RESPONDENT.

546. The last time (NAME OF YOUNGEST CHILD) passed stools, what was done to dispose of the stools?

547. CHECK 525, ALL COLUMNS:

NO CHILD RECEIVED JEEVAN JAL OR NAVAJEEVAN OR OTHER ORS OR NOT ASKED (CONTINUE)
ANY CHILD RECEIVED JEEVAN JAL OR NAVAJEEVAN OR OTHER ORS (GO TO 549)

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

548A. Have you ever seen a packet like this? SHOW PACKET OF JEEVAN JAL OR NAVAJEEVAN OR OTHER TYPES OF ORS.

549. CHECK 221 AND 224, ALL ROWS:
HAS AT LEAST ONE CHILD BORN IN 2059 OR LATER AND LIVING WITH HER: RECORD NAME OF YOUNGEST CHILD LIVING WITH HER (AND CONTINUE WITH 550)
DOES NOT HAVE ANY CHILDREN BORN IN 2059 OR LATER AND LIVING WITH HER (GO TO 601)

550. Now I would like to ask you about liquids or foods (NAME FROM 549) had yesterday during the day or at night. Did (NAME FROM 549) (drink/eat):

551. Now I would like to ask you about (other) liquids or foods that (NAME FROM 549)/you may have had yesterday during the day or at night. I am interested in whether your child/you had the item even if it was combined with other foods.
Did (NAME FROM 549)/you drink (eat):

a. Milk such as tinned, powdered, or fresh animal milk?

b. Tea or coffee?

c. Any other liquids?

d. Any food such as roti or porridge, made from grains, like rice, millet, wheat, maize, buckwheat or barley?

e. Pumpkin, carrots, squash or sweet potatoes (shakharkhanda) that are yellow or orange inside?

f. White potatoes, white yams, colocasia, or any other foods made from roots?

g. Any dark green, leafy vegetables such as colocasia leaves, spinach, amaranth leaves, mustard leaves, swiss chard?

h. Ripe mangoes, papayas, apricot, persimmon?

i. Any other fruits or vegetables such as banana, apple, guava, amala, orange, tomatoes?

j. Liver, kidney, heart or other organ meats?

k. Chicken, goat, lamb, buffalo, pork, duck or any other meat?

l. Eggs?

m. Fresh or dried fish or shellfish?

n. Any foods made from beans, peas, lentils (daal) or nuts?

o. Cheese, yogurt or other milk products?

p. Any ghee, oil, fats, or butter, or foods made with any of these?

q. Any sugary foods such as chocolates, sweets, candies, pastries, cakes, or biscuits?

r. Any other solid or semi-solid food?

552. CHECK 550 (LAST 2 CATEGORIES: BABY CEREALS OR OTHER PORRIDGE/GRUEL) AND 551 (CATEGORIES d THROUGH r FOR CHILD):

553. How many times did (NAME FROM 549) eat solid, semisolid, or soft foods yesterday during the day or at night? IF 7 OR MORE TIMES, RECORD '7'.

SECTION 6. SEXUAL LIFE

601. CHECK 313:

READ TO RESPONDENTS: Now I need to ask you some more questions about relationships and sexual life. Once again, let me assure you that your answers are completely confidential. If we should come to any question that you don't want to answer, just let me know and I will skip to the next question.

602. CHECK 108:

603. How old was the person you first had sexual intercourse with?

604. Would you say this person was ten or more years older than you?

604A. What was this person's relationship to you?

605. The first time you had sexual intercourse, was a condom used?

606. When was the last time you had sexual intercourse? IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS AGO.

607. When was the last time you had sexual intercourse with this other person?

608. The last time you had sexual intercourse (with this other person), was a condom used?

609. Did you use a condom every time you had sexual intercourse with person in the last 12 months?

610. What was this person's relationship to you?

611. For how long (have you had/did you have) a sexual relationship with this person? IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

612. CHECK 108:

613. How old is this person?

614. Would you say this person is ten or more years older than you?

615. Apart from this person, have you had sexual intercourse with any other person in the last 12 months?

616. In total, with how many different people have you had sexual intercourse in the last 12 months? IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

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

618. Where is that? Any other place? IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL SECTOR, WRITE THE NAME OF THE PLACE(S).

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

SECTION 7. FERTILITY PREFERENCES

701. CHECK 301:

702. CHECK 325/325A:

703. CHECK 236:
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?

704. CHECK 236:
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?

705. CHECK 236:

706. CHECK 324: USING A CONTRACEPTIVE METHOD?

707. CHECK 704:

708. CHECK 703:
WANTS TO HAVE 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 you are not using a method? Any other reason?
WANTS NO MORE/NONE: You have said you do not want any (more) children, but you are not using any method to avoid pregnancy. Can you tell me why you are not using a method? Any other reason?

709. CHECK 324: USING A CONTRACEPTIVE METHOD?

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

711. Which contraceptive method would you prefer to use?

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

713. CHECK 222:
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?

714. 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?

715. In the last few months have you heard or seen any message about family planning: On radio, on television, in a newspaper, magazine or brochure, on a poster, hoarding board or billboard, street dramas?

716. CHECK 301:

717. CHECK 325/325A:

718. Does your husband know you are using a method of family planning?

719. Would you say that using contraception is mainly your decision, mainly your husband's decision, or did you both decide together?

719A. Now I want to ask you about your husband's views on family planning. Do you think your husband approves or disapproves of couples using a method to avoid pregnancy?

719B. How often have you talked to your husband about family planning in the past year?

720. CHECK 325/325A:

721. Does your husband want the same number of children that you want, or does he want more or fewer than you want?

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801. CHECK 301:

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

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

804. What was the highest grade he completed?

805. CHECK 801:
CURRENTLY MARRIED: What is your husband's occupation? That is, what kind of work does he mainly do?
OTHER: What was your (last) husband's occupation? That is, what kind of work did he mainly do?

806. Aside from your own housework, have you done any work in the last seven days?

807. As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?

808. Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave or any other such reason?

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

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

811. CHECK 810:

812. 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?

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

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

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

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

817. CHECK 301:

818. CHECK 816:

819. Who usually decides how the money that you earn will be used: you, your husband, or you and your husband jointly?

820. Would you say that the money that you earn is more than what your husband earns, less than what he earns, or about the same?

821. Who usually decides how your husband's earnings will be used: you, your husband, or you and your husband jointly?

822. Who usually makes decisions about health care for yourself?

823. Who usually makes decisions about making major household purchases?

824. Who usually makes decisions about making purchases for daily household needs?

825. Who usually makes decisions about visits to your family or relatives?

826. PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)

827. Sometimes a husband is annoyed or angered by things that 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?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

SECTION 9. HIV/AIDS

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

902. Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has sexual intercourse with no other partners?

903. Can people get the AIDS virus from mosquito bites?

904. Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

905. Can people get the AIDS virus by sharing food with a person who has AIDS?

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

907. Can people get the AIDS virus by touching someone who has AIDS?

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

908A. Have you ever been tested to see if you have the AIDS virus?

908B. Did you test positive for the AIDS virus?

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

910. Where is that? Any other place? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

912. If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?

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

914. In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

915. CHECK 901:
HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?

916. CHECK 313:

917. CHECK 915: HEARD ABOUT OTHE RSEXUALLY TRANSMITTED INFECTIONS?

918. Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

919. Sometimes women experience a bad smelling abnormal genital discharge. During the last 12 months, have you had a bad smelling abnormal genital discharge?

920. Sometimes women have a genital sore or ulcer. During the last 12 months have you had a genital sore or ulcer?

921. CHECK 918, 919, AND 92:

922. The last time you had (PROBLEM FROM 918/919/920). Did you seek any kind of advice or treatment?

923. Where did you go?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

924. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

925. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

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

SECTION 10. OTHER HEALTH ISSUES

1001. Have you ever heard of an illness called tuberculosis or TB?

1002. How does tuberculosis spread from one person to another?
PROBE: Any other ways? RECORD ALL MENTIONED

1003. Can tuberculosis be cured?

1004. If a member of your family got tuberculosis, would you want it to remain a secret or not?

1005A. Do you have a tetanus injection card (s)? IF YES: May I see it please?

1005B.
(1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD(S).
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.

1005C. CHECK 414:

1005D. Have you ever received a tetanus injection?

1005E. How many tetanus injections have you received in your life time?

1005F. CHECK 213:

1005G. Have you ever experienced signs of uterine prolapse (Patheghar Khasne/Ang Khasne)?

1006. Do you currently smoke cigarettes?

1007. In the last 24 hours, how many cigarettes did you smoke?

1008. Do you currently smoke or use any other type of tobacco?

1009. What (other) type of tobacco do you currently smoke or use? RECORD ALL MENTIONED.

1010. Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not?
Getting permission to go?
Getting money needed for treatment?
The distance to the health facility?
Having to take transport?
Not wanting to go alone?
Concern about security?
Concern that there may not be a female health provider?
Concern that there may not be any health provider?
Concern that there may be no drugs available?

1010A. In the last few months have you heard or seen the following programs on the radio and/or television:
Jana Swastha Radio Karyakram? Sewa Nai Dharma Ho?
Gyan Nai Shakti Ho?
Hamro Swastha Radio Karyakram?
Jeevan Chakra?
Teli-Swastha Karyakram?
Ek Apaas Ka Kura?
Sathi Sanga Manka Kura?
Desh Pardesh?

1011. Did you use a soap for any purpose yesterday?

1012. For what purpose did you use soap? Any other purpose? RECORD ALL MENTIONED.

1013. CHECK 1012:

1014. How many times did you wash your hands with soap yesterday? IF MORE THAN 7 TIMES, RECORD '7'.

SECTION 11. MATERNAL MORTALITY

1101. Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother, including those who are living with you, those living elsewhere and those who have died. How many children did your mother give birth to, including you?

1102. CHECK 1101:

1103. How many of these births did your mother have before you were born?

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

1105. Is (NAME) male or female?

1106. Is (NAME) still alive?

1107. How old is (NAME)?

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

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

1110. Was (NAME) pregnant when she died?

1111. Did (NAME) die during childbirth?

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

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

IF NO MORE BROTHERS OR SISTERS, GO TO 1114

1114. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT ___________

COMMENTS ON SPECIFIC QUESTIONS: __________

ANY OTHER COMMENTS: _________

SUPERVISOR'S OBSERVATION _____________

NAME OF SUPERVISOR: ________

DATE: ____________

EDITOR'S OBSERVATIONS ___________

NAME OF EDITOR: __________

DATE: _________