IDENTIFICATION

PLACE NAME_______________
NAME OF HOUSEHOLD____________
PROVINCE ____

URBAN/RURAL

MAJOR CITY/DIVISION/DISTRICT ____
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___

MAJOR CITY/SMALL CITY, TOWN/VILLAGE

NAME AND LINE NUMBER OF WOMEN______________
NAME AND LINE NUMBER OF HUSBAND (IF ELIGIBLE)

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

INTERVIEWER'S NAME: ______
DATE: ______
RESULT _____

NEXT VISIT:
DATE _____
TIME ______

FINAL VISIT:
DAY ____
MONTH ___
YEAR ____
NAME ____
RESULT ____

TOTAL NUMBER OF VISITS ______

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE OF INTERVIEW:

NATIVE LANGUAGE OF RESPONDENT:

TRANSLATOR USED

FIELD EDITED BY
NAME _____
DATE _____

OFFICE EDITED BY
NAME _____
DATE _____

KEYED BY
NAME _____
DATE _____

KEYED BY ____

QUESTIONS AND FILTERS

101. RECORD THE CURRENT TIME

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 or a village?

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

104. Just before you moved here, did you live in a city or in a village?

105. In what month and year were you born?

106. How old are you in completed years?

107. Are you now married, widowed, divorced, or separated?

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

109. CHECK 107 AND 108:

110. Have you ever attended school?

111. What is the highest level of school you attended?

112. What is the highest class you completed at that level?

113. CHECK 111:

114. Can you read and understand a letter or newspaper easily, with difficulty, or not at all?

115. Can you write a simple letter?

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

117. Do you usually listen to a radio at least once a week?

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

119. CHECK HOUSEHOLD QUESTIONNAIRE, COLUMN (4):

120. Now let's talk about the household where you usually live. What is the source of water your household uses for handwashing and dishwashing?

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

122. Does your household get drinking water from this same source?

123. What is the source of drinking water for members of your household?

124. What kind of toilet facility does your household have?

125. Does your household have:

126. Does any member of your household own:

127. How many rooms in your household are used for sleeping?

128. What material are the outer walls of your house made of?

129. What material is the roof of your house made of?

130. What province do you usually live in?

131. Is the place that you usually live a city or a village?

SECTION 2: REPRODUCTION

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

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

203. How many sons live with uou? And how many daughters live with you? (IF NONE, RECORD '00')

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

205. How many sons are alive but do not live with you? And how many daughters are alive but do not live with you?

206. 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 any sign of life but only survived a few hours or days?

207. In all, how many boys have died? And how many girls have died? (IF NONE, RECORD '00').

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

209. CHECK 208: Just to make sure that I have this right: you have had in TOTAL_______ live births during your life. Is that correct?

210. CHECK 208:

211. Now I would like to talk to you about all of your births, whether still alive or not, starting with the first one you had. (RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES).

212. What name was given to your (first, next) baby?

213. RECORD SINGLE OR MULTIPLE BIRTH STATUS

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

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

216. Is (NAME) still alive?

217. IF ALIVE: How old is (NAME) in completed years?

218. IF ALIVE: Is (NAME) living with you?

219. IF LESS THAN 15 YRS. OF AGE: With whom does he/she live? (IF AGE 15+: GO TO NEXT BIRTH)

220. IF DEAD: How old was he/she 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)

221. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

222. CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1986, IF NONE ENTER '0'.

223. CHECK 107:

224. Are you pregnant now?

225. How many months pregnant are you?

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

227. When did your last menstrual period start?

228. Between the first day of a woman's period and the first of her next period, are there certain times when she has a greater chance of becoming pregnant than other times?

229. During which times of the month does a woman have the greatest chance of becoming pregnant?

SECTION 3: CONTRACEPTION

301. Now I would like to talk about family planning- the various ways or methods that a couple can use to delay or avoid a pregnancy. Which ways or methods have you heard about?
CIRCLE CODE 1 IN 302 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
THEN PROCEED DOWN THE COLUMN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY.
CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED.
THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 302, ASK 303-304 BEFORE PROCEEDING TO THE NEXT METHOD.

302. Have you ever heard of (METHOD)?
READ DESCRIPTION OF EACH METHOD

303. Have you ever used (METHOD)?

304. Do you know where a person could go to get (METHOD)?

305. CHECK 303:

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

307. What have you used or done?
CORRECT 303-305 (AND 302 IF NECESSARY).

308. Now I would like to ask you about the time when you first did something or used a method to avoid getting pregnant. What method did you use at that time?

309. How many living children did you have at that time if any?

310. CHECK 303(01):
EVER USED PILL?

311. At the time you first started using the pill, did you consult a doctor, a nurse, or a family planning worker?

312. When you met with that person, did you already have a preference for a particular method of family planning?

313. Which method was that?

314. Did the provider talk to you about any methods other than the pill?

315. Which method or methods?

316. Were you satisfied with the information you got from the provider on the method(s) you discussed or not?

317. CHECK 224:

318. CHECK 107:

319. CHECK 303 (06):

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

321. What is the main reason you are not using a method to delay or avoid getting pregnant?

322. Which method are you using?
322A. CIRCLE '06' FOR FEMALE STERILIZATION

323. At the time you last got pills, did you consult a doctor, a nurse, or a family planning worker?

324. May I see the package of pills you are using now? (RECORD NAME OF BRAND.)

325. Do you know the brand name of the pills you are now using? (RECORD NAME OF BRAND.)

326. How much does one packet of pills cost you?

327. May I see the package of condoms you are using now? (RECORD NAME OF BRAND.)

328. Do you know the brand name of the condoms you are now using? (RECORD NAME OF BRAND.)

329. How much does on condom cost you?

330. How much did it cost for the IUD insertion/sterilization operation/last injection?

331. CHECK 322:

SHE/HE STERILIZED: Where did the sterilization take place?
USING ANOTHER METHOD: Where did you obtain (METHOD) the last time?

332. How long does it take to travel from your home to this place?
IF LESS THAN 60 MINUTES, RECORD MINUTES. OTHERWISE, RECORD HOURS.

333. Is it easy or difficult to get there?

334. CHECK 322:

335. In what month and year was the sterilization operation performed?

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

337. Do you intend to use a method to delay or avoid pregnancy at any time in the future?

338. What is the main reason you do not intend to use a method?

339. If the decision were entirely up to you, would you want to use a method to delay or avoid a pregnancy at any time in the future?

340. Do you intend to use a method within the next 12 months?

341. When you use a method, which method would you prefer to use?

342. Where can you get (METHOD MENTIONED IN 341)?

343. Do you know of a source where you can obtain a method of family planning?

344. What source is that?

345. How long does it take to travel from your home to this place?
IF LESS THAN 60 MINUTES, RECORD MINUTES. OTHERWISE, RECORD HOURS.

346. Is it easy or difficult to get there?

347. In the last month, have you heard a message about family planning on:

348. CHECK 347:

349. Do you think that the message you heard was effective or not effective in persuading couples to use family planning?

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

SECTION 4A. PREGNANCY AND BREASTFEEDING

401. CHECK 222:

402. ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1986 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).

Now I would like to ask you some more questions about the health of children you had in the past five years. (We will talk about one child at a time.)

FROM Q. 212 AND Q. 216

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

404. How much longer would you like to have waited?
(RECORD MONTHS OR YEARS)

405. When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy? IF YES: Whom did you see? Anyone else?
CIRCLE ALL PERSONS SEEN ON ANY VISIT.

406. Were you given an antenatal card for this pregnancy?

407. How many months pregnant were you when you first saw someone for an antenatal check on that pregnancy?

408. How many antenatal visits did you have during that pregnancy?

409. Did anyone advise you to eat more food than usual during that pregnancy?

410. Were you weighed at any time during that pregnancy?

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

412. How many times did you get this injection?

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

414. Who delivered (NAME) or assisted with the delivery? Anyone else? (CIRCLE ALL PERSONS ASSISTING)

415. How long were you in labor?

416. Was (NAME) born on time or prematurely?

417. Was (NAME) delivered by caesarian section?

418. Was (NAME) weighed at birth?

419. How much did (NAME) weigh?

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

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

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

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

424. CHECK 224:
RESPONDENT PREGNANT?

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

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

427. Did you ever breastfeed (NAME)?

428. Who suggested that you should not breastfeed (NAME)?

429. Why did you not breastfeed (NAME)?

430. 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.

431. What was (NAME) fed before you put (him/her) to the breast?
(CIRCLE ALL MENTIONED)

432. CHECK 216:
CHILD ALIVE?

433. Are you still breastfeeding (NAME)?

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

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

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

437. What is the main reason that you stopped breastfeeding?

438. CHECK 216:
CHILD ALIVE?

439. At any time yesterday or last night was (NAME) given any of the following? IF YES: How many times?

440. CHECK 439:
FOOD OR LIQUID GIVEN YESTERDAY?

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

442. Was (NAME) ever given anything to drink from a bottle with a nipple?

443. How many months old was (NAME) when he/she started drinking from a bottle with a nipple on a regular basis?

444. CHECK 439:
FOOD OR LIQUID GIVEN YESTERDAY?

445. Was (NAME) ever given any water, or something else to drink or eat (other than breastmilk)?

446. How many months old was (NAME) when you started giving the following on a regular basis? IF LESS THAN 1 MONTH, RECORD '00'.

447. CHECK 446:
AGE IN MONTHS GIVEN FOR SOLID OR FOOD?

448. How many months old was (NAME) when you started giving him/her solid or mushy foods every day?

449. GO BACK TO 403 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 450

SECTION 4B. IMMUNIZATION AND HEALTH.

450. ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1986 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS)

FROM Q. 212 AND Q. 216

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

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

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

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

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

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

457. CHECK 216: CHILD ALIVE?

458. Did a doctor or a health worker tell you about the cause of death of (NAME)?

459. What did they say was the cause of death?

460. What do you believe was the cause of death of (NAME)?

461. GO BACK TO 451 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 490

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

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

464. Has (NAME) been ill with a cough in the last 24 hours?

465. For how many days (has the cough lasted/did the cough last)?

466. When (NAME) had the illness with a cough, did he/she breathe faster than usual with short, rapid breaths?

467. CHECK 462 AND 463:
FEVER OR COUGH?

468. What was given to treat the fever/cough if anything?

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

470. From whom did you seek advice or treatment?

471. Has (NAME) had diarrhea in the last two weeks?

472. GO BACK TO 451 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 490

473. Has (NAME) had diarrhea in the last 24 hours?

474. For how many days (has the diarrhea lasted/did the diarrhea last)?

475. Was there any blood in the stools?

476. CHECK 427/433: LAST CHILD STILL BREASTFEED?

477. During (NAME)'s diarrhea, did you change the frequency of breastfeeding?

478. Did you increase the frequency of breastfeeding or reduce the frequency or did you stop completely?

479. (Aside from breastmilk) Was (NAME) given the same amount to drink as before the diarrhea, or more, or less?

480. Was (NAME) given the same amount of food as before the diarrhea, or more, or less?

481. Was (NAME) given a fluid made from a special packet?

482. Was (NAME) given any of the following during the diarrhea?

483. CHECK 481 AND 482: CHILD GIVEN FLUID PACKET (481) AND/OR ANY HOME MADE FLUID (482)?

484. For how many days was (NAME) given this fluid?

485. Was anything given for the diarrhea (other than this fluid)?

486. What was given to treat the diarrhea?

487. Did you seek any advice or treatment for the diarrhea?

488. From whom did you seek advice or treatment?

489. GO BACK TO 451 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 490

490. CHECK 481:

491. Have you ever heard of a special product called ORS or Nimkol (or LOCAL NAME) you can get for the treatment of diarrhea?

492. Have you ever seen a packet like this before?

493. Have you ever prepared a solution with one of these packets to treat diarrhea in yourself or someone else?

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

495. How much water did you use to prepare (LOCAL NAME)?

496. Where can you get the (LOCAL NAME) packet?

497. CHECK 482:

498. Who taught you to prepare the home-made fluid made from sugar, salt and water?

SECTION 5. MARRIAGE

501. CHECK 107:

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

503. In the last four weeks, were you and your husband always living together or were you apart some of the time or all of the time?

504. During the last four weeks, were you and your husband apart all of the time or did you stay together any of the time?

505. For how long have you and your husband been living apart?

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

507. How many other wives does he have?

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

509. (Is/was) there a blood relationship between you and your husband?

510. What type of relationship (is/was) it?

511. How old were you when you started living with your (first) husband?

512. In what month and year did you start living with him?
COMPARE 511 AND 512 WITH 105 AND 106. MAKE CORRECTIONS IF INCONSISTENT.

513. PRESENCE OF OTHERS AT THIS POINT.

SECTION 6. FERTILITY PREFERENCES

601. CHECK 322:

602. CHECK 107:

603. CHECK 224:

NOT PREGANT 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, would you like to have another child or would you prefer not to have any more children?

604. Would you prefer your next child to be a boy or a girl or doesn't it matter?

605. CHECK 224:

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

PREGNANT: How long would you like to wait after the birth of the child you are expecting before the birth of another child?

606. CHECK 216 AND 224:
HAS LIVING CHILDREN OR PREGNANT?

607. CHECK 224:

NOT PREGNANT OR UNSURE: How old would you like your youngest child to be when your next child is born?

PREGNANT: How old would you like the child you are expecting to be when your next child is born?

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

609. Why do you regret it?

610. Given your present circumstances, if you had to do it over again, do you think you would make the same decision to have a sterilization?

611. Do you think that your husband approves or disapproves of couples using a method to avoid pregnancy?

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

613. Have you and your husband ever discussed the number of children you would like to have?

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

615. How long should a husband and wife wait before starting sexual intercourse after the birth of a baby?

616. Should a mother wait until she has completely stopped breastfeeding before starting to have sexual relations again, or doesn't it matter?

617. In general, do you approve or disapprove of couples using a method to avoid pregnancy?

618. CHECK 216:

NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?

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?

619. How many of these children would you like to be boys and how many would you like to be girls?

620. We would like to know how much schooling you would like your children to have. (IF NOT STERILIZED: Consider the children you already have and also any children that you might have in the future). First, let's talk about sons. What is the highest level of school that you would like any of your sons to attend?

621. And how about daughters? What is the highest level of schooling that you would like any of your daughters to attend?

622. What do you think is the ideal age at marriage for boys?

623. And what is the ideal age at marriage for girls?

624. If you needed to go to a health clinic or a hospital, could you go by yourself or would you need to be accompanied by someone?

701. CHECK 107:

702. How old is you husband in completed years?

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

704. What was the highest level of school he attended: primary, middle, secondary, or higher?

705. What was the highest class he completed at that level?

706. What kind of work (did) your (last) husband mainly do?

707. CHECK 706:

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

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

710. 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?

711. If you could find a suitable job, would you like to work?

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

713. In your current work, do you work for a member of your family, for someone else, or are you self-employed?

714. Do you earn cash for this work?
PROBE: Do you make money for working?

715. Do you do this work at home or away from home?

716. CHECK 215/216/218: HAS CHILD BORN SINCE JAN. 1986 AND LIVING AT HOME?

717. While you are working, do you usually have (NAME OF YOUNGEST CHILD AT HOME) with you, sometimes have him/her with you, or never have him/her with you?

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

719. Did you work at any time before you (first) got married?

720. Did you work just after you (first) got married?

721. CHECK 709/710/719/720:

722. How old were you when you first started working?

723. Why did you start working initially?

724. RECORD THE CURRENT TIME

SECTION 8. HEIGHT AND WEIGHT

801. CHECK 215, 216:

INTERVIEWER: IN 802-804, RECORD THE LINE NUMBERS, NAMES AND BIRTH DATES OF ALL LIVING CHILDREN BORN SINCE JANUARY 1, 1986 STARTING WITH THE YOUNGEST CHILD. THEN RECORD 805-811 FOR EACH CHILD.

802. LINE NO. FROM Q. 212

803. NAME FROM Q. 212

804. DATE OF BIRTH FROM Q. 215

805. HEIGHT (in cm.)

806. HEIGHT: LYING OR STANDING

807. WEIGHT (in kg.)

808. ARM CIRCUMFERENCE (in cm.)

809. BCG SCAR ON ARM

810. DATE CHILD WEIGHED AND MEASURED

811. RESULTS:

812. NAME OF MEASURER: __________
NAME OF ASSISTANT: ___________