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DEMOGRAPHIC AND HEALTH SURVEY-RWANDA 1992-INDIVIDUAL (WOMAN'S) QUESTIONNAIRE

IDENTIFICATION

PREFECTURE (ADMINISTRATIVE CENTER) __________

TOWN OR MUNICIPALITY__________

SECTOR____

SUB-SECTOR___

HOUSEHOLD NUMBER____

URBAN/RURAL

URBAN 1
RURAL 2

KIGALI, OTHER CITY, OR RURAL?

KIGALI 1
OTHER CITY 2
RURAL 3

NAME AND LINE NUMBER OF HUSBAND

LINE NUMBER OF ALL ELIGIBLE WOMEN

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER NAME__________
RESULT___

RESULT__________

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 OTHER (SPECIFY)_____

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE_____
TIME____

FINAL VISIT
DAY__________
MONTH__________
YEAR_____
NAME__________
RESULT__________

TOTAL NUMBER OF VISITS___

FIELD EDITOR
NAME__________
DATE_____

OFFICE EDITOR
NAME__________
DATE_____

KEYED BY
NAME__________
DATE_____

SECTION 1. RESPONDENT'S BACKGROUND

101) RECORD TIME

HOUR___
MINUTES___

102) To begin, I'd like to ask you some questions about yourself. During the first 12 years of your life, did you mostly live in the city of Kigali, another city, or a rural village?

CITY OF KIGALI 1
ANOTHER CITY 2
RURAL VILLAGE 3

103) For how long have you been living continuously in (KIGALI, OTHER CITY, RURAL VILLAGE)?

NUMBER OF YEARS___

ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 104B)

104A) Just before moving here, did you live in the city of Kigali, another city, or a rural village?

CITY OF KIGALI 1 (GO TO 105)
ANOTHER CITY 2 (GO TO 105)
RURAL VILLAGE 3 (GO TO 105)

104B) Do you live in a prefecture (administrative center), town or municipality, sector, or sub-sector?
WRITE NAME OF PLACE

PREFECTURE (ADMINISTRATIVE CENTER) __________
TOWN OR MUNICIPALITY__________
SECTOR__________
SUB-SECTOR__________

105) In what month and year were you born?

MONTH__________
DON'T KNOW MONTH 98
YEAR_____
DON'T KNOW YEAR 98

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

AGE IN COMPLETED YEARS___

107) Have you ever attended school?

YES 1
NO 2 (GO TO 111)

108) What is the highest level of education that you attended: primary, post-primary, secondary, or higher?

PRIMARY 1
POST-PRIMARY 2
SECONDARY 3
HIGHER 4

109) What is the highest (CLASS, YEAR) you successfully completed at that level?

CLASS___

109A) Did you finish that level (primary, post-primary, secondary, or higher)?

YES 1
NO 2

110) CHECK 108:

PRIMARY (GO TO 111)
SECONDARY OR HIGHER (GO TO 123)

111) Do you know how to read and understand a letter or newspaper easily, with difficulty, or not at all?

EASILY 1
WITH DIFFICULTY 2
NOT AT ALL 3

123) What is your religion?

CATHOLIC 1
PROTESTANT 2
SEVENTH DAY ADVENTIST 3
MUSLIM 4
TRADITIONAL 5
NO RELIGION 6
OTHER 7

124) What is your ethnicity?

HUTU 1
TUTSI 2
TWA 3
OTHER 4

SECTION 2. REPRODUCTION

201) Now I'd like to ask you some questions about all the children you have given birth to in 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, ENTER '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?
IF NONE, ENTER '00'.

NUMBER OF SONS ELSEWHERE___
NUMBER OF DAUGHTERS ELSEWHERE___

206) Have you ever given birth to a boy or girl who was born alive but later died?

YES 1
NO 2 (GO TO 207B)

207A) How many sons have died? And how many daughters have died?
IF NONE, WRITE '00'.

BOYS DEAD___
GIRLS DEAD___

207B) Any child who cried or showed signs of life but survived only a few hours or days who you did not mention in the previous question?

YES 1
NO 2 (GO TO 208)

207C) How many sons have died that you have forgotten? And how many daughters have died that you have forgotten?
IF NONE, RECORD '00'.

BOYS DEAD___
GIRLS DEAD___

208) ADD THE RESPONSES FROM 203, 205, 207A, AND 207C, AND RECORD THE TOTAL.
IF NONE, RECORD '00'.

TOTAL____

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

YES (GO TO 210)
NO (PROBE AND CORRECT 201-209 AS NECESSARY)

210) CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 223)

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

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

NAME__________

213) RECORD THE TYPE OF BIRTH: SINGLE OR MULTIPLE

SINGLE 1
MULTIPLE 2

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

BOY 1
GIRL 2

215) In what month and year was (NAME) born?
PROBE: What is his/her birthday? OR: In what season was (NAME) born?
WRITE THE SEASON GIVEN BY THE WOMAN IF THE BIRTH MONTH IS UNKNOWN

MONTH__________
YEAR_____
SEASON___

216) Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

217) IF ALIVE: How old was (NAME) at his/her last birthday?
PROBE: HOW MANY COMPLETED YEARS?

AGE IN YEARS___

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

YES 1 (GO TO NEXT BIRTH)
NO 2

219) IF LESS THAN 15 YEARS OLD: With whom does he/she live?
IF 15 YEARS OR OLDER: GO TO NEXT BIRTH

FATHER 1 (GO TO NEXT BIRTH)
OTHER RELATIVE 2 (GO TO NEXT BIRTH)
SOMEONE ELSE 3 (GO TO NEXT BIRTH)

220) IF DEAD: How old was he/she when he/she died?
IF "1 YEAR", PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN ONE MONTH, MONTHS IF LESS THAN TWO YEARS, OR YEARS.

DAYS 1 ___
MONTHS 2 ___
YEARS 3 ___

221) COMPARE 208 WITH THE NUMBER OF BIRTHS RECORDED IN THE ABOVE TABLE AND MARK:

NUMBERS ARE THE SAME
CHECK:
FOR EACH LIVE BIRTH: YEAR OF BIRTH IS RECORDED__
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED__
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED__
FOR AGE AT DEATH 12 MONTHS: CHECK TO DETERMINE THE EXACT NUMBER OF MONTHS__
NUMBERS ARE DIFFERENT (PROBE AND CORRECT)

222) CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1987.
IF NONE, RECORD '0'.

223) Are you pregnant now?

YES 1
NO 2 (GO TO 226)
UNSURE 8 (GO TO 226)

224) How many months pregnant are you?
(IF THE WOMAN HESITATED BETWEEN TWO MONTHS, TAKE THE SMALLER NUMBER)

MONTHS___

225) At the time you became pregnant, did you want to become pregnant then, later, or did you not want to become pregnant at all?

THEN 1
LATER 2
NOT AT ALL 3

226) When did your last menstrual period start?

DAYS 1____
WEEKS 2_____
MONTHS 3_____
YEARS 4_____

BEFORE LAST BIRTH 994
NEVER MENSTRUATED 995
IN MENOPAUSE 996

227) Between the first day of a woman's period and the first day of her next period, when do you think she has the greatest chance of becoming pregnant?
PROBE: During which days of the menstrual cycle must a woman pay attention in order to not become pregnant?

DURING HER PERIOD 1
RIGHT AFTER HER PERIOD HAS ENDED 2
IN THE MIDDLE OF THE CYCLE 3
JUST BEFORE HER PERIOD BEGINS 4
ANYTIME 5
OTHER (SPECIFY)____ 6
DON'T KNOW 8

SECTION 3. CONTRACEPTION

301) Now I would like to talk to you about family planning -- the different 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 THE 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.

01) PILL: Women can take a pill every day.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
02) IUD: Some women have an IUD or intrauterine device placed in their uterus by a doctor or nurse.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
03) INJECTABLES: Some women have an injection by a doctor or nurse to avoid becoming pregnant for several months.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
04) DIAPHRAGM/FOAM/JELLY: Some women put a diaphragm, effervescent pills, or jelly inside them before intercourse.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
05) CONDOM: Some men wear a condom during sexual intercourse.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
06) FEMALE STERILIZATION: Some women have an operation to avoid having any more children.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
07) MALE STERILIZATION: Some men have an operation to avoid having any more children.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
08) NORPLANT: Some women have 6 little sticks inserted into their arm, under the skin, which prevents them from becoming pregnant for several years.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
09) PERIODIC ABSTINENCE: Some couples avoid having sexual intercourse on certain days of the month when the woman is more likely to become pregnant.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
10) WITHDRAWAL: Some men are careful and pull out before ejaculation.
YES/SPONTANEOUSLY 1
YES/PROBED 2
NO 3
11) OTHER METHODS: Have you heard of other ways or methods that women or men can use to avoid pregnancy? (LIST UP TO THREE METHODS)
(SPECIFY)____
YES/SPONTANEOUSLY 1
NO 3

303) Have you ever used (METHOD)?

01) PILL: Women can take a pill every day.
YES 1
NO 2
02) IUD: Some women have an IUD or intrauterine device placed in their uterus by a doctor or nurse.
YES 1
NO 2
03) INJECTABLES: Some women have an injection by a doctor or nurse to avoid becoming pregnant for several months.
YES 1
NO 2
04) DIAPHRAGM/FOAM/JELLY: Some women put a diaphragm, effervescent pills, or jelly inside them before intercourse.
YES 1
NO 2
05) CONDOM: Some men wear a condom during sexual intercourse.
YES 1
NO 2
06) FEMALE STERILIZATION: Some women have an operation to avoid having any more children: Have you had an operation to avoid having any more children?
YES 1
NO 2
07) MALE STERILIZATION: Some men have an operation to avoid having any more children.
YES 1
NO 2
08) NORPLANT: Some women have 6 little sticks inserted into their arm, under the skin, which prevents them from becoming pregnant for several years.
YES 1
NO 2
09) PERIODIC ABSTINENCE: Some couples avoid having sexual intercourse on certain days of the month when the woman is more likely to become pregnant.
YES 1
NO 2
10) WITHDRAWAL: Some men are careful and pull out before ejaculation.
YES 1
NO 2
11) OTHER METHOD(S): (SPECIFY)_____
YES 1
NO 2

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

01) PILL: Women can take a pill every day.
YES 1
NO 2
02) IUD: Some women have an IUD or intrauterine device placed in their uterus by a doctor or nurse.
YES 1
NO 2
03) INJECTABLES: Some women have an injection by a doctor or nurse to avoid becoming pregnant for several months.
YES 1
NO 2
04) DIAPHRAGM/FOAM/JELLY: Some women put a diaphragm, effervescent pills, or jelly inside them before intercourse.
YES 1
NO 2
05) CONDOM: Some men wear a condom during sexual intercourse.
YES 1
NO 2
06) FEMALE STERILIZATION: Some women have an operation to avoid having any more children.
YES 1
NO 2
07) MALE STERILIZATION: Some men have an operation to avoid having any more children.
YES 1
NO 2
08) NORPLANT: Some women have 6 little sticks inserted into their arm, under the skin, which prevents them from becoming pregnant for several years.
YES 1
NO 2
09) PERIODIC ABSTINENCE: Some couples avoid having sexual intercourse on certain days of the month when the woman is more likely to become pregnant: Do you know where a person can obtain advice about how to use periodic abstinence?
YES 1
NO 2

305) CHECK 303:

NOT A SINGLE 'YES' (NEVER USED) (GO TO 306)
AT LEAST ONE 'YES' (EVER USED) (GO TO 308)

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

YES 1
NO 2 (GO TO 324)

307) What have you done or used?
CORRECT 303, 304, 305 (AND 302 IF NECESSARY)

METHOD__________

308) Now I would like to talk about the time you first did something or used a method to avoid getting pregnant. How many children did you have at that time?
IF NONE, RECORD '00'.

NUMBER OF CHILDREN___

309) CHECK 223:

NOT PREGNANT OR UNSURE (GO TO 310)
PREGNANT (GO TO 324)

310) CHECK 303:

WOMAN NOT STERILIZED (GO TO 311)
WOMAN STERILIZED (GO TO 312A)

311) Are you currently doing something or using a method to avoid pregnancy?

YES 1
NO 2 (GO TO 324)

312) What method are you using?
312A) CIRCLE '06' FOR FEMALE STERILIZATION

PILL 01
IUD 02 (GO TO 318)
INJECTABLES 03 (GO TO 318)
DIAPHRAGM/FOAM/JELLY 04 (GO TO 318)
CONDOM 05 (GO TO 318)
FEMALE STERILIZATION 06 (GO TO 318A)
MALE STERILIZATION 07(GO TO 318A)
NORPLANT 08 (GO TO 318)
PERIODIC ABSTINENCE 09 (GO TO 323)
WITHDRAWAL 10 (GO TO 323)
OTHER (SPECIFY)____ 11 (GO TO 323)

313) When you first started using the pill, did you consult a doctor or a nurse?

YES 1
NO 2
DON'T KNOW 8

314) The last time you obtained the pill, did you consult a doctor or nurse?

YES 1
NO 2

315) May I see the package of pills you are currently using?
RECORD NAME OF BRAND.

PACKAGE SEEN 1 (GO TO 317)
BRAND NAME __________ (GO TO 317)
PACKAGE NOT SEEN 2

316) Do you know the brand name of the pills that you are currently using?
RECORD NAME OF BRAND.

BRAND NAME__________
DON'T KNOW 98

317) How much does one packet (cycle) of pills cost you?

COST _____

FREE 996
DON'T KNOW 998

318) Where did you get (METHOD) the last time?
318A) Where did the sterilization take place?

NAME OF PLACE__________
HOSPITAL 01
HEALTH CENTER 02
FAMILY PLANNING CLINIC 03
ABAKANGURAMBAGA 04 (GO TO 321)
PRIVATE DOCTOR OR CLINIC 05
PHARMACY 06
SHOP OR KIOSK 07
FRIENDS/RELATIVES 09 (GO TO 321)
OTHER (SPECIFY)____ 10 (GO TO 321)
DON'T KNOW 98 (GO TO 321)

319) How long does it take to travel from your home to this place?

MINUTES ___ 1
HOURS___ 2

DON'T KNOW 998

320) Is it easy or difficult to get there?

EASY 1
DIFFICULT 2

321) CHECK 312:

SHE/HE STERILIZED (GO TO 322)
USING ANOTHER METHOD (GO TO 323)

322) In what month and year (were you/was he) sterilized?

MONTH__________ (GO TO 333)
YEAR_____ (GO TO 333)

323) For how many months have you been using (CURRENT METHOD) continuously?
IF SINCE THE LAST PREGNANCY OR IF LESS THAN ONE MONTH, RECORD '00'.

MONTHS ___ (GO TO 333)
5 YEARS OR MORE 96 (GO TO 333)

324) Do you intend to use a method to avoid getting pregnant in the future?

YES 1 (GO TO 326)
NO 2
DON'T KNOW 8 (GO TO 329)

325) What is the main reason you do not intend to use a method?

WANTS CHILDREN 01 (GO TO 329)
LACK OF INFORMATION 02 (GO TO 329)
PARTNER DISAPPROVES 03 (GO TO 329)
COSTS TOO MUCH 04 (GO TO 329)
SIDE EFFECTS 05 (GO TO 329)
HEALTH PROBLEMS 06 (GO TO 329)
DIFFICULT TO OBTAIN 07 (GO TO 329)
RELIGION 08 (GO TO 329)
OPPOSED TO FAMILY PLANNING 09 (GO TO 329)
FATALISTIC 10 (GO TO 329)
OTHER PEOPLE OPPOSED 11 (GO TO 329)
INFREQUENT SEX 12 (GO TO 329)
DIFFICULT TO GET PREGNANT 13 (GO TO 329)
MENOPAUSAL/STERILIZED 14 (GO TO 329)
INCONVENIENT 15 (GO TO 329)
NOT MARRIED 16 (GO TO 329)
OTHER (SPECIFY)____ 17 (GO TO 329)
DON'T KNOW 98 (GO TO 329)

326) Do you intend to use a method within the next 12 months?

YES 1
NO 2
DON'T KNOW 8

327) When you will use a method, which method would you prefer to use?

PILL 01
IUD 02
INJECTABLES 03
SPERMICIDES 04
CONDOM 05
FEMALE STERILIZATION 06
MALE STERILIZATION 07
NORPLANT 08
PERIODIC ABSTINENCE 09 (GO TO 328A)
WITHDRAWAL 10 (GO TO 329)
OTHER (SPECIFY)____ 11 (GO TO 329)
UNSURE 98 (GO TO 329)

328) Where can you get (METHOD FROM 327)?
(IF MULTIPLE PLACES MENTIONED, INDICATE WHICH THE WOMAN PREFERS)
328A) Where can you obtain information on how to use the periodic abstinence method?

NAME OF PLACE__________
PUBLIC HOSPITAL 01 (GO TO 331)
PUBLIC HEALTH CENTER 02 (GO TO 331)
FAMILY PLANNING CLINIC 03 (GO TO 331)
ABAKANGURAMBAGA 04 (GO TO 333)
PRIVATE DOCTOR OR CLINIC 05 (GO TO 331)
PHARMACY 06 (GO TO 331)
SHOP OR KIOSK 07 (GO TO 331)
CHURCH 08 (GO TO 333)
FRIENDS/RELATIVES 09 (GO TO 333)
OTHER (SPECIFY)__________ 10 (GO TO 333)
NOWHERE 11
DON'T KNOW 98

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

YES 1
NO 2 (GO TO 333)

330) Where is that?
(IF MULTIPLE PLACES MENTIONED, INDICATE WHICH THE WOMAN PREFERS)

NAME OF PLACE__________
PUBLIC HOSPITAL 01
PUBLIC HEALTH CENTER 02
FAMILY PLANNING CLINIC 03
ABAKAGURAMBAGA 04 (GO TO 333)
PRIVATE DOCTOR OR CLINIC 05
PHARMACY 06
SHOP OR KIOSK 07
CHURCH 08
FRIENDS/RELATIVES 09 (GO TO 333)
OTHER (SPECIFY)____ 10 (GO TO 333)

331) How long does it take to travel from your home to this place?

MINUTES___ 1
HOURS___ 2

DON'T KNOW 998

332) Is it easy or difficult to get there?

EASY 1
DIFFICULT 2

333) In the last month, have you heard announcements on the radio or read in newspapers about family planning?

On the radio?
YES 1
NO 2
In newspapers?
YES 1
NO 2

334) Do you think it is acceptable or not acceptable that information about family planning is provided on the radio and in newspapers?

ACCEPTABLE 1
NOT ACCEPTABLE 2
DON'T KNOW 8

335) In the last month, have you heard about family planning anywhere besides the radio or newspapers?

YES 1
NO 2 (GO TO 401)

336) From whom did you hear it?

ABAKANGURAMBAGA 1
HEALTH PROFESSIONAL 2
OTHER (SPECIFY)____ 3

SECTION 4. HEALTH AND BREASTFEEDING

401) CHECK 222:

ONE OR MORE BIRTHS SINCE JANUARY 1987 (GO TO 402)
NO LIVE BIRTHS SINCE JANUARY 1987 (GO TO 501)

402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS FOR EACH BIRTH SINCE JANUARY 1987 IN THE TABLE. ASK THE QUESTIONS FOR ALL THE BIRTHS, BEGINNING WITH THE LAST BIRTH.

Now I would like to ask you some questions about the health of all of the children you have had in the last 5 years. (We will talk about one child at a time.)

LINE NUMBER FROM Q. 212

LINE NO.___

FROM Q. 212 AND Q. 216

NAME__________
ALIVE___
DEAD___

403) At the time you became pregnant with (NAME), did you want to become pregnant then, later, or did you not want any (more) children?

THEN 1 (GO TO 405)
LATER 2
NO MORE 3 (GO TO 405)

404) How much longer would you have liked to wait?

MONTHS___ 1
YEARS___ 2

DON'T KNOW 998

405) When you were pregnant with (NAME), did you see anyone for a consultation about this pregnancy? IF YES: Whom did you see? Anyone else?

PROBE ABOUT THE KIND OF PERSON AND RECORD ALL PERSONS SEEN.

DOCTOR 1
NURSE/MEDICAL ASSISTANT 1
TRAINED TRADITIONAL MIDWIFE 1
UNTRAINED TRADITIONAL MIDWIFE 1
OTHER (SPECIFY)____ 1
NO ONE 1 (GO TO 409)

406) Were you given an antenatal card or booklet for this pregnancy?

YES 1
NO 2
DON'T KNOW 8

407) How many months pregnant were you when you first saw someone for a consultation concerning this pregnancy?

MONTHS___
DON'T KNOW 98

408) How many antenatal visits did you have during this pregnancy?

NUMBER___

409) When you were pregnant with (NAME) were you given an antenatal injection to prevent tetanus?

YES 1
NO 2 (GO TO 411)
DON'T KNOW 8 (GO TO 411)

410) How many times did you get this injection?

NUMBER___
DON'T KNOW 8

411) Where did you give birth to (NAME)?

YOUR HOME 1
OTHER HOME 2
HEALTH CENTER/DISPENSARY 3
CLINIC 4
HOSPITAL 6
OTHER (SPECIFY)____7

412) Who assisted you with the delivery of (NAME)? Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL MENTIONED.

DOCTOR 1
NURSE/MEDICAL ASSISTANT 1
TRAINED TRADITIONAL MIDWIFE 1
UNTRAINED TRADITIONAL MIDWIFE 1
MOTHER-IN-LAW 1
HUSBAND 1
OTHER (SPECIFY)__________ 1
NO ONE 1

413) Was (NAME) born on time or prematurely?

ON TIME 1
PREMATURELY 2
DON'T KNOW 8

414) Was (NAME) delivered by caesarian section?

YES 1
NO 2

415) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 417)

416) How much did he/she weigh?

GRAMS___
DON'T KNOW 9998

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

LARGE 1
AVERAGE 2
SMALL 3
DON'T KNOW 8

418) Has your period returned since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 420)

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

MONTHS___
DON'T KNOW 98

420) Have you resumed sexual relations since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

YES (OR PREGNANT) 1
NO 2 (GO TO 422)

420A) How many days after the birth of (NAME) did you have sexual relations for the first time?

DAYS___

MORE THAN 3 MONTHS 96
DON'T KNOW 98

421) How long after the birth of (NAME) did you resume sexual relations regularly?

MONTHS___
DON'T KNOW 98

422) Did you breastfeed (NAME)?

YES 1 (GO TO 424 FOR LAST BIRTH; GO TO 430 FOR ALL OTHER BIRTHS)
NO 2

423) Why did you not breastfeed (NAME)?

MOTHER ILL/WEAK 1 (GO TO 432)
CHILD ILL/WEAK 2 (GO TO 432)
CHILD DIED 3 (GO TO 432)
BREAST PROBLEM 4 (GO TO 432)
NO MILK 5 (GO TO 432)
MOTHER WORKING 6 (GO TO 432)
CHILD REFUSED 7 (GO TO 432)
OTHER (SPECIFY)____ 8 (GO TO 432)

424) How long after delivery did you first put (NAME) to the breast?
RECORD IN DAYS IF MORE THAN 24 HOURS.
[FOR LAST BIRTH ONLY]

IMMEDIATELY 000

HOURS ___ 1
DAYS ___ 2

425) IF STILL ALIVE: Are you still breastfeeding (NAME)?
IF DEAD, CIRCLE '2'
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 430)

426) How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.
[FOR LAST BIRTH ONLY]

NUMBER OF NIGHTTIME FEEDINGS___

427) How many times did you breastfeed yesterday, during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.
[FOR LAST BIRTH ONLY]

NUMBER OF DAYLIGHT FEEDINGS___

428) At any time yesterday or last night, did you give (NAME) one of the following things?
[FOR LAST BIRTH ONLY]

Plain water?
YES 1
NO 2
Sugar water?
YES 1
NO 2
Juice?
YES 1
NO 2
Powdered milk?
YES 1
NO 2
Fresh milk?
YES 1
NO 2
Other milk?
YES 1
NO 2
Other liquids?
YES 1
NO 2
Solid or semi-solid food?
YES 1
NO 2

429) CHECK 428:
FOOD OR LIQUID GIVEN YESTERDAY?

YES TO ONE OR MORE (GO TO 434)
NO TO ALL (GO TO 433)

430) For how many months did you breastfeed (NAME)?

MONTHS___
UNTIL DEATH (GO TO 433)

431) Why did you stop breastfeeding (NAME)?

MOTHER ILL/WEAK 01
CHILD ILL/WEAK 02
CHILD DIED 03
BREAST PROBLEM 04
NO MILK 05
MOTHER WORKING 06
CHILD REFUSED 07
WEANING AGE 08
BECAME PREGNANT 09
OTHER (SPECIFY)__________ 10

432) CHECK 216:
CHILD ALIVE?

ALIVE (GO TO 434)
DEAD (GO TO 433)

433) Have you ever given (NAME) water or anything else to drink or eat other than breast milk?

YES 1
NO 2 (GO TO 437)

434) How many months old was (NAME) when you started giving him/her the following things regularly?

Canned milk or milk other than breast milk?
AGE IN MONTHS___
NOT GIVEN 96
Water or other liquids?
AGE IN MONTHS___
NOT GIVEN 96
Solid or semi-solid food?
AGE IN MONTHS___
NOT GIVEN 96

435) CHECK 216:
CHILD ALIVE?

ALIVE 1 (GO TO 436)
DEAD 2 (GO TO 437)

436) Did (NAME) drink anything from a bottle with a nipple yesterday or last night?
[FOR LAST BIRTH ONLY]

YES 1
NO 2
DON'T KNOW 8

437) GO BACK TO 403 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 438.

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

YES, SEEN 1 (GO TO 440)
YES, NOT SEEN 2 (GO TO 442)
NO CARD 3

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

YES 1 (GO TO 442)
NO 2 (GO TO 442)

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

BCG
DAY____
MONTH____
YEAR_____
POLIO 0
DAY____
MONTH____
YEAR_____
POLIO 1
DAY____
MONTH____
YEAR_____
POLIO 2
DAY____
MONTH____
YEAR_____
POLIO 3
DAY____
MONTH____
YEAR_____
LAST DOSE
DAY____
MONTH____
YEAR_____
DPT 1
DAY____
MONTH____
YEAR_____
DPT 2
DAY____
MONTH____
YEAR_____
DPT 3
DAY____
MONTH____
YEAR_____
LAST DOSE
DAY____
MONTH____
YEAR_____
MEASLES
DAY____
MONTH____
YEAR_____

441) Has (NAME) received a vaccination that is not recorded on this card?

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 440)
NO 2 (GO TO 444)
DON'T KNOW 8 (GO TO 444)

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

YES 1
NO 2 (GO TO 444)
DON'T KNOW 8 (GO TO 444)

443) Please tell me if (NAME) has received one of the following vaccinations:

A BCG vaccination, that is, an injection in the arm or shoulder that leaves a scar?
YES 1
NO 2
DON'T KNOW 8
Polio vaccine, that is, drops in the mouth?
IF YES: How many times?
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES___
An injection against measles?
YES 1
NO 2
DON'T KNOW 8

444) CHECK 216:
CHILD ALIVE?

ALIVE (GO TO 446)
DEAD (GO TO 445)

445) GO BACK TO 438 FOR THE NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 472.

446) Has (NAME) had a fever at any time during the last two weeks?

YES 1
NO 2
DON'T KNOW 8

447) Has (NAME) been ill with a cough at any time during the last 2 weeks?

YES 1
NO 2 (GO TO 450)
DON'T KNOW 8 (GO TO 450)

448) How long did the cough last? (For how long has the cough lasted?)
IF LESS THAN ONE DAY, RECORD '00'

DAYS___

449 When (NAME) was sick with a cough, did he/she breathe faster than usual (with short, rapid breaths)?

YES 1
NO 2
DON'T KNOW 8

450) CHECK 446 AND 447:
FEVER OR COUGH?

'YES' IN 446 OR 447 (GO TO 451)
OTHER (GO TO 454)

451) Was anything given to (NAME) to treat the fever/cough?

YES 1
NO 2 (GO TO 452)
DON'T KNOW 8 (GO TO 452)

451A) What was given to treat the fever/cough? Anything else?
(CIRCLED ALL MENTIONED)

NO TREATMENT 1
INJECTION 1
ANTIBIOTIC (PILL OR SYRUP) 1
ANTIMALARIAL (PILL OR SYRUP) 1
COUGH SYRUP 1
OTHER PILL OR SYRUP 1
UNKNOWN PILL OR SYRUP 1
HOME REMEDY/HERBAL MEDICINE 1
OTHER (SPECIFY)___ 1

452) Did you seek advice or treatment for the fever/cough?

YES 1
NO 2 (GO TO 454)

453) From whom did you seek advice or treatment for the fever/cough? Anyone else?
CIRCLE ALL MENTIONED

COMMUNITY HEALTH WORKER 1
HEALTH POST 1
CLINIC 1
HOSPITAL 1
PRIVATE DOCTOR 1
TRADITIONAL HEALER 1
PHARMACY 1
OTHER (SPECIFY)____ 1

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

YES 1 (GO TO 456)
NO 2
DON'T KNOW 8

455) GO BACK TO 438 FOR THE NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 472

456) Has (NAME) had diarrhea in the past 24 hours?

YES 1
NO 2
DON'T KNOW 8

457) How long did the diarrhea last? (For how long has the diarrhea lasted?)
IF LESS THAN ONE DAY, RECORD '00'

DAYS___

458) Was there any blood in the stool?

YES 1 (GO TO 462 FOR ALL BIRTHS OTHER THAN LAST BIRTH)
NO 2 (GO TO 462 FOR ALL BIRTHS OTHER THAN LAST BIRTH)
DON'T KNOW 8 (GO TO 462 FOR ALL BIRTHS OTHER THAN LAST BIRTH)

459) CHECK 425:
LAST CHILD STILL BREASTFEEDING?

YES (GO TO 460)
NO (GO TO 462)

460) When (NAME) had diarrhea, did you change the number of breastfeedings?
[FOR LAST BIRTH ONLY]

YES 1
NO 2 (GO TO 462)

461) During the diarrhea, did you increase the number of breastfeedings, reduce them, or did you stop them completely?
[FOR LAST BIRTH ONLY]

INCREASED 1
REDUCED 2
STOPPED COMPLETELY 3
DID NOT EAT 4

462) Aside from breastmilk, did you give him/her the same amount to drink as before the diarrhea, more to drink, or less?

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

463) During the diarrhea, did (NAME) receive a fluid made from a special packet?

YES 1
NO 2
DON'T KNOW 8

464) Was (NAME) given a home-made fluid recommended by a health worker (with sugar, salt, and water)?

YES 1
NO 2
DON'T KNOW 8

465) CHECK 463 AND 464:
CHILD RECEIVED FLUID FROM A PACKET (463) AND/OR RECOMMENDED HOME-MADE FLUID (464)?

YES, RECEIVED LIQUID (PACKET/HOME-MADE FLUID) (GO TO 466)
NO LIQUID (GO TO 467)

466) For how many days did (NAME) receive this liquid?
IF LESS THAN 1 DAY, ENTER '00'

DAYS___
DON'T KNOW 98

467) Did he/she receive anything else to treat the diarrhea (aside from this liquid)?

YES 1
NO 2 (GO TO 469)
DON'T KNOW 8 (GO TO 469)

468) What was given or made to treat the diarrhea? Anything else?
CIRCLE ALL MENTIONED

ANTIBIOTIC PILL OR SYRUP 1
OTHER PILL OR SYRUP 1
INJECTION 1
(I.V.) INTRAVENOUS 1
HOME REMEDY/HERBAL MEDICINE 1
OTHER (SPECIFY)____ 1

469) Did you seek advice or treatment for the diarrhea?

YES 1
NO 2 (GO TO 471)

470) From whom did you seek advice or treatment? Anyone else?
CIRCLE ALL MENTIONED

COMMUNITY HEALTH WORKER 1
HEALTH POST 1
HEALTH CENTER 1
HOSPITAL 1
PRIVATE DOCTOR 1
TRADITIONAL HEALER 1
PHARMACY 1
OTHER (SPECIFY)____ 1

471) GO BACK TO 438 FOR THE NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 472

472) CHECK 463:

ORS SOLUTION MENTIONED FOR A CHILD IN QUESTION 463 (GO TO 475)
ORS SOLUTION NOT MENTIONED OR 463 NOT ASKED (GO TO 473)

473) Have you ever heard of a special product in a packet?

YES 1
NO 2

474) Have you ever seen a packet like this before?
SHOW THE PACKET.

YES 1
NO 2 (GO TO 478)

475) Have you ever prepared a solution with one of these packets to treat diarrhea for yourself or someone else?
SHOW THE PACKET.

YES 1
NO 2 (GO TO 477)

476) How much water did you use to prepare the liquid from the special packet for diarrhea?

½ LITER 1
1 LITER 2
1 ½ LITERS 3
2 LITERS 4
ACCORDING TO PACKAGE INSTRUCTIONS 5
CONTENTS OF PRIMUS BOTTLE 6
OTHER (SPECIFY)____ 7
DON'T KNOW 8

477) Where can you get this packet?
PROBE: Anywhere else?
RECORD ALL PLACES MENTIONED.

ABAKANGURAMBAGA 1
DISPENSARY 1
HEALTH CENTER 1
HOSPITAL 1
PRIVATE DOCTOR 1
TRADITIONAL HEALER 1
PHARMACY 1
SHOP 1
OTHER (SPECIFY)____ 1
DON'T KNOW 1

478) CHECK 464:

HOME-MADE FLUID MENTIONED (YES IN 464) (GO TO 479)
HOME-MADE FLUID NOT MENTIONED OR 464 NOT ASKED (GO TO 501)

479) Who taught you how to prepare the home-made solution made with sugar, salt, and water, which you gave to (NAME)?

ABAKANGURAMBAGA 01
DISPENSARY 02
HEALTH CENTER 03
HOSPITAL 04
PRIVATE DOCTOR 05
TRADITIONAL HEALER 06
PHARMACY 07
FRIEND/RELATIVE 08
OTHER (SPECIFY)____ 09
DON'T KNOW 98

SECTION 5. MARRIAGE

501) Have you ever been married or lived with a man?

YES 1
NO 2 (GO TO 510)

502) Are you currently married or living in a union with a man, or are you widowed, divorced, or separated?

MARRIED 1
UNION 2
WIDOWED 3 (GO TO 507)
DIVORCED/SEPARATED 4 (GO TO 507)

503) Does your husband/partner live with you, or is he staying elsewhere?

LIVING WITH HER 1
STAYING ELSEWHERE 2

504) Does your husband/partner have other wives besides you?

YES 1
NO 2 (GO TO 507)

505) How many other wives does he have?

NUMBER___
DON'T KNOW 98 (GO TO 507)

506) Are you the first, second, third… spouse?

RANK_____

507) Have you been married only once, or more than once?

ONCE 1
MORE THAN ONCE 2

508) How old were you when you started living with your (first) husband/partner?

AGE___

509) In what month and year did you start living with him?
COMPARE AND CORRECT 508 AND/OR 509 IF INCONSISTENT.

MONTH__________ (GO TO 511)
DON'T KNOW MONTH 98 (GO TO 511)
YEAR_____ (GO TO 511)
DON'T KNOW YEAR 98 (GO TO 511)

510) IF NEVER IN UNION: Have you ever had sexual intercourse?

YES 1
NO 2 (GO TO 515)
NO RESPONSE OR REFUSED 3 (GO TO 515)

511) Now we need some information about your sexual activity in order to get a better understanding of contraception and fertility. How many times have you had sexual intercourse in the last four weeks?

NUMBER OF TIMES___

512) How many times per week do you usually have sexual intercourse?

NUMBER OF TIMES___

513) When was the last time you had sexual intercourse?

DAYS ___ 1
WEEKS___ 2
MONTHS___ 3
YEARS___ 4

BEFORE LAST BIRTH 996

514) How old were you when you first had sexual intercourse?

AGE___
FIRST TIME WHEN MARRIED 96

515) PRESENCE OF OTHERS AT THIS POINT

CHILDREN UNDER 10 YEARS OLD
YES 1
NO 2
HUSBAND
YES 1
NO 2
OTHER MEN
YES 1
NO 2
OTHER WOMEN
YES 1
NO 2

SECTION 6. FERTILITY PREFERENCES

601) CHECK 312:

NOT STERILIZED (GO TO 602)
HE OR SHE STERILIZED (GO TO 606)

602) CHECK 501 AND 502:

CURRENTLY IN UNION (GO TO 603)
NOT CURRENTLY IN UNION (GO TO 613)

603) Now I have some questions about the future.
CHECK 223 AND MARK THE APPROPRIATE BOX:

NOT PREGNANT OR UNSURE: Would you like to have a/another child or would you prefer to not have any (more) children?

PREGNANT: After the child you're expecting, would you like to have another child or would you prefer to not have any more children?

HAVE A/ANOTHER CHILD 1
NO MORE/NONE 2 (GO TO 609)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 609)
UNDECIDED OR DON'T KNOW 8 (GO TO 609)

604) CHECK 223 AND MARK THE APPROPRIATE BOX:

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?

MONTHS___ 1 (GO TO 609)
YEARS___ 2 (GO TO 609)

SOON/NOW 994 (GO TO 609)
SAYS SHE CAN'T GET PREGNANT 995 (GO TO 609)
OTHER (SPECIFY)____ 996
DON'T KNOW 998

605) CHECK 216:
How old would you like your youngest child to be before having another child?
IF NO LIVING CHILDREN, CIRCLE '96'

AGE OF YOUNGEST CHILD IN YEARS___ (GO TO 609)
NO LIVING CHILDREN 96 (GO TO 609)
DON'T KNOW 98 (GO TO 609)

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

YES 1
NO 2 (GO TO 608)

607) Why do you regret it?

RESPONDENT WANTS ANOTHER CHILD 1 (GO TO 616)
PARTNER WANTS ANOTHER CHILD 2 (GO TO 616)
SIDE EFFECTS 3 (GO TO 616)
OTHER REASON (SPECIFY)___4 (GO TO 616)

608) In your current situation, if you had to do it again, do you think to you would make the same decision to get sterilized?

YES 1 (GO TO 616)
NO 2 (GO TO 616)

609) Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy?

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

610) How often have you talked to your husband/partner about this subject in the last 12 months?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

611) Have you talked to your husband/partner about the number of children you would like to have?

YES 1
NO 2

612) Do you think your husband/partner wants the same number of children that you want, more, or less than you want?

SAME 1
MORE 2
LESS 3
DON'T KNOW 8

613) After childbirth, how long should couples wait before starting to have sexual relations again?

DAYS___ 1
MONTHS___ 2
YEARS___ 3

OTHER (SPECIFY)____996

614) Should a mother wait until she has completely stopped breastfeeding before starting to have sexual relations again, or does it not matter?

WAIT 1
DOESN'T MATTER 2

615) In general, do you approve or disapprove of couples using a method to avoid getting pregnant?

APPROVE 1
DISAPPROVE 2
UNDECIDED 3

616) CHECK 216 AND MARK THE APPROPRIATE BOX:

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?

RECORD SINGLE NUMBER OR OTHER ANSWER

NUMBER ___
OTHER ANSWER (SPECIFY)__________

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701) CHECK 501:

EVER MARRIED OR LIVED IN UNION (ASK QUESTIONS ABOUT CURRENT OR MOST RECENT HUSBAND/PARTNER) (GO TO 702)
NEVER MARRIED/NEVER LIVED IN UNION (GO TO 708)

702) Did your husband/partner ever attend school?

YES 1
NO 2 (GO TO 705)

703) What is the highest level of school that he attended: primary, post-primary, secondary, or higher?

PRIMARY 1
POST-PRIMARY 2
SECONDARY 3
HIGHER 4
DON'T KNOW 8 (GO TO 705)

704) What was the last (CLASS, YEAR) that he completed at that level?

CLASS___
DON'T KNOW 98

704A) Did he finished that level (primary, post-primary, secondary, or higher)?

YES 1
NO 2
DON'T KNOW 8

705) What kind of work does (did) your (last) husband mainly do?

OCCUPATION___

706) CHECK 705:

WORKS (WORKED) IN AGRICULTURE (GO TO 707)
DOES (DID) NOT WORK IN AGRICULTURE (GO TO 708)

707) (Does/did) your husband/partner work mainly on his own land or family land, or someone else's land?

HIS/FAMILY LAND 1
OTHER LAND 2

708) Aside from their own housework, many women take jobs for which they are paid in cash or in 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 aside from your own housework?

YES 1
NO 2 (GO TO 716)

709) What is your main occupation, that is, what kind of work do you do?

OCCUPATION___

710) In your work, are you an employee, are you self-employed or do you work for your family, or are you an employer?

EMPLOYEE 1
SELF-EMPLOYED OR IN FAMILY BUSINESS 2
EMPLOYER 3

711) Do you earn money for this work?

YES 1 (GO TO 711A)
NO 2

711A) Do you receive a regular salary?

YES 1
NO 2

712) Do you do this work at home or away from home?

HOME 1
AWAY 2

713) CHECK 215/216/218:
CHILD BORN SINCE JANUARY 1987 AND LIVING AT HOME?

YES (GO TO 714)
NO (GO TO 716)

714) While you are working, do you usually have (NAME OF YOUNGEST CHILD AT HOME) with you, sometimes with you, or never with you?

USUALLY 1 (GO TO 716)
SOMETIMES 2
NEVER 3

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

HUSBAND 01
OLDER CHILD(REN) 02
OTHER RELATIVES 03
NEIGHBORS 04
FRIENDS 05
SERVANTS/HIRED HELP 06
CHILD IS IN SCHOOL 07
KINDERGARTEN/PRESCHOOL 08
OTHER (SPECIFY)____09

716) RECORD THE TIME

HOUR___
MINUTES___

SECTION 8. WEIGHT AND HEIGHT

801) CHECK 222:

ONE OR MORE BIRTHS SINCE JANUARY 1987 AND STILL LIVING (GO TO 802)
NO BIRTHS SINCE JANUARY 1987 AND STILL ALIVE (END INTERVIEW)

IN 801-803, RECORD THE LINE NUMBER, THE NAME, AND DATE OF BIRTH OF EACH LIVING CHILD BORN SINCE JANUARY 1, 1987, BEGINNING WITH THE YOUNGEST CHILD. RECORD THE WEIGHT AND HEIGHT IN 805 AND 806.

802) LINE NUMBER FROM Q. 212

LINE NO.____

803) NAME FROM Q. 212

NAME___

804) BIRTH DATE FROM Q. 215 AND ASK THE DAY

DAY__________
MONTH__________
YEAR_____

805) WEIGHT (IN KILOGRAMS)

WEIGHT___

806) HEIGHT (IN CENTIMETERS)

HEIGHT___

807) BCG SCAR ON ARM OR SHOULDER

SCAR SEEN 1
NO SCAR 2

808) DATE WEIGHED AND MEASURED

DAY__________
MONTH__________
YEAR_____

809) RESULT (WEIGHT AND HEIGHT)

MEASURED 1
CHILD SICK 2
CHILD ABSENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY)____ 6

810 NAME OF MEASURER__________

NAME OF ASSISTANT__________

INTERVIEWER'S OBSERVATIONS

(TO BE FILLED IN AFTER COMPLETING INTERVIEW)

COMMENTS ABOUT RESPONDENT_____

COMMENTS ON SPECIFIC QUESTIONS____

ANY OTHER COMMENTS____

NAME OF INTERVIEWER__________
DATE___

SUPERVISOR'S OBSERVATIONS

OBSERVATIONS____

NAME OF SUPERVISOR__________
DATE_____

FIELD EDITOR'S OBSERVATIONS

OBSERVATIONS___

NAME OF FIELD EDITOR__________
DATE_____

CHECKER'S OBSERVATIONS

OBSERVATIONS___

NAME OF CHECKER__________
DATE_____