NATIONAL INSTITUTE OF STATISTICS OF RWANDA
REPUBLIC OF RWANDA

IDENTIFICATION

LOCALITY NAME __________

NAME OF HOUSEHOLD HEAD ____________

PROVINCE _____________

DISTRICT _______________

CLUSTER NUMBER _____________

STRUCTURE NUMBER ______________

HOUSEHOLD NUMBER ______________

URBAN/RURAL

CITY/LARGE TOWN/SMALL TOWN/VILLAGE

NAME AND LINE NUMBER OF MAN ____________

FIRST VISIT
DATE _________
INTERVIEWER'S NAME ____________
RESULT* _____________

NEXT VISIT:
DATE _________
TIME _________

SECOND VISIT
DATE ____________
INTERVIEWER'S NAME _________
RESULT*

NEXT VISIT:
DATE _________
TIME________

THIRD VISIT
DATE _________
INTERVIEWER'S NAME __________
RESULT* ____________

FINAL VISIT
DAY ______
MONTH _______
YEAR 200______
NAME________
RESULT________

TOTAL NO. OF VISITS ________

*RESULT CODES:

LANGUAGE OF INTERVIEW

WAS A TRANSLATOR USED?

SUPERVISOR
NAME __________
DATE ___________

FIELD EDITOR
NAME ____________
DATE ____________

OFFICE EDITOR _________

KEYED BY __________

SECTION 1. RESPONDENT'S BACKGROUND

INFORMED CONSENT

Hello. My name is _____________ and I am working with the National Institute of Statistics. We are conducting a national survey about the health of women, men, and children. We would very much appreciate your participation in this survey. I would like to ask you some questions about yourself and your family. This information will help the government to plan health services. The survey usually takes between 10 and 15 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.

Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.

At this time, do you want to ask me anything about the survey? May I begin the interview now?

Signature of interviewer: ____________________
Date: ________________

100) RECORD THE TIME.

101) In what month and year were you born?

MONTH ________
DOES NOT KNOW MONTH 98
YEAR ____________
DON'T KNOW YEAR 9998

102) How old were you at your last birthday? COMPARE AND CORRECT 101 AND/OR 102 IF INCONSISTENT.

AGE IN COMPLETED YEARS ________

103) How you ever attended school?

104) What is the highest level of school you attended: primary, middle/JSS, seconday/SSS, or higher?

105) What is the highest grade you completed at that level?

106) What is your religion?

107) Are you currently married or living with a woman?

108) Have you ever been married or lived with a woman?

109) What is your marital status now: are you widowed, divorced, or separated?

110) Is your wife/partner living with you or elsewhere?

111) Are there any other women with whom you live as if married?

112) In total, how many women are you living with as if you were married?

SECTION 2. REPRODUCTION

201) Now I would like to ask about any children you have had. I am interested only in the children that are biologically yours. Have you ever fathered any children with any woman?

202) Do you have any sons or daughters that you have fathered who are now living with you?

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

204) Do you have any sons or daughters you have fathered 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? IF NONE, WRITE '00.'

206) Have you ever fathered a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

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

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

209) CHECK 208:

210) Do the children that you have fathered all have the same biological mother?

211) In all how many women have you fathered children with?

SECTION 3. CONTRACEPTION

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

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

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

302) Have you ever used (METHOD)?

303) CHECK 301(07), KNOWLEDGE OF MALE CONDOM

304) Do you know of a place where a person can get male condoms?

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

Any other place? RECORD ALL SOURCES MENTIONED.

401) Some men are circumcised. Are you circumcised?

402) How old were you when you were circumcised?

403) Who performed your circumcision?

404) What is the main reason for you circumcision?

405) Would you like to be circumcised?

406) What is the main reason that you would like to be circumcised?

407) What is the main reason you would not like to be circumcised?

408) RECORD THE TIME

HOURS ______
MINUTES _________

INTERVIEWER'S OBSERVATIONS: TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: _____________

COMMENTS ON SPECIFIC QUESTIONS: ____________

ANY OTHER COMMENTS: __________

SUPERVISOR'S OBSERVATIONS _______________
NAME OF THE SUPERVISOR: ________________
DATE: _____________

EDITOR'S OBSERVATIONS ______________
NAME OF EDITOR: ________________
DATE: _____________