Data Cart

Your data extract

0 variables
0 samples
View Cart


Republic of Chad
Ministry of Planning and of International Cooperation
Ministry of Public Health, Social Action, and National Solidarity
National Institute of Statistics, Economic and Demographic Studies (INSEED)
Demographic and Health Survey with Multiple Indicators 2014
Woman's Questionnaire

IDENTIFICATION

REGION NAME

REGION __ __

LOCALITY NAME (NEIGHBORHOOD/VILLAGE)__________

NAME OF HEAD OF HOUSEHOLD____________

CLUSTER NUMBER

CLUSTER __ __

HOUSEHOLD NUMBER (URBAN=01 TO 25; RURAL=01 TO 30)

HOUSEHOLD URBAN RURAL __ __

HOUSEHOLD NUMBER (SEQUENTIAL IN THE CLUSTER)

HOUSEHOLD CLUSTER __ __

URBAN/RURAL (URBAN=1, RURAL=2)

MILIEU __ __

N'DJAMENA-MOUNDOU/SARH/ABECHE-OTHER CITY-RURAL (N'DJAMENA=1, MOUNDOU/SARH/ABECHE=2, OTHER CITY=3, RURAL=4)

RESIDENCE __ __

WOMAN'S NAME AND LINE NUMBER_________________

Check cover of household questionnaire: Household was selected for the men's survey and the HIV test?

YES 1
NO 2

HOUSEHOLD SELECTED FOR MEN'S SURVEY

IF YES (=1) CHECK Q. 403 OF HOUSEHOLD QUESTIONNAIRE: WOMAN SELECTED FOR THE "DOMESTIC VIOLENCE" MODULE? (YES=1, NO=2). IF THE HOUSEHOLD IS NOT SELECTED FOR THE MEN'S SURVEY, LEAVE THE SPACE BLANK.
WOMAN SELECTED FOR THE "DOMESTIC VIOLENCE" SURVEY

INTERVIEWER VISITS
1 2 3
DATE_____

INTERVIEWER'S NAME
RESULT*

FINAL VISIT

DAY__ __
MONTH __ __
YEAR 201__
INT. NUMBER__ __ __
CODE RESULT __

NEXT VISIT

DATE_______
TIME________

TOTAL NO. OF VISITS

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

LANGUAGE OF INTERVIEW**
INTERPRETER

YES 1
NO 2

**LANGUAGE CODES
01 FRENCH
02 CHADIAN ARABIC
03 SARA
04 GORANE
05 KANEMBOU
06 MABA (OUADDAIEN)
07 MOUDANG
08 MOUSSEYE
09 PEUL/FOULF/BODORE
10 LELE/MARBA
11 TOUPOURI
12 BOULALA
13 ZAGHAWA/BERI.BIDEYAT
96 OTHER CHADIAN LANGUAGES (SPECIFY)

SUPERVISOR
NAME___________
DATE____

FIELD EDITOR
NAME___________
DATE____

OFFICE EDITOR

__ __

KEYED BY

__ __

SECTION 1. RESPONDENT'S BACKGROUND

Introduction and consent
Informed Consent

Hello. My name is ___. I am working with the National Institute of Statistics, Economic and Demographic Study (INSEED). We are conducting a survey about health all over Chad. The information we collect will help the government to improve health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you 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.

In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household.

Do you have any questions?
May I begin the interview?

Signature of interviewer____________
Date____

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2-END

101) Record time

HOURS____
MINUTES_____

102) In what month and year were you born?

MONTH __ __
DON'T KNOW MONTH 98
YEAR __ __ __ __
DON'T KNOW YEAR 9998

103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

AGE IN COMPLETED YEARS ___

104) Have you ever attended school?

YES 1
NO 2 (SKIP TO 108)

105) What is the highest level of education you attended: primary, secondary, technical secondary, professional secondary, higher, or professional higher?

PRIMARY 1
SECONDARY 2
TECHNICAL SECONDARY 3
PROFESSIONAL SECONDARY 4
HIGHER 5
PROFESSIONAL HIGHER 6

106) What is the highest (grade/form/year) you completed at this level?*
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

GRADE/FORM/YEAR____

107) CHECK 105:

PRIMARY
SECONDARY OR TECHNICAL SECONDARY OR PROFESSIONAL SECONDARY OR HIGHER OR PROFESSIONAL HIGHER?-SKIP TO 110

Code for q. 106

Level

1 Primary
2 Secondary
3 Secondary technical
4 Secondary professional
5 Higher
6 Higher professional
8 Don't know

00 less than one year completed

Grade

01 CP1
02 CP2
03 CE1
04 CE2
05 CM1
06 CM2
98 Don't know

01 6th
02 5th
03 4th
04 3rd
05 Second
06 First
07 Final
98 Don't know

01 1st year
02 2nd year
03 3rd year
04 4th year
05 5th year
06 6th year
07 7th year or higher
98 Don't know

01 6th or 1st year
02 5th or 2nd year
03 4th or 3rd year
04 3rd or 4th year
05 Second or 5th year
06 1st or 6th year
07 Final or 7th year
98 Don't know

01 1st year
02 2nd year
03 3rd year
04 4th year
05 5th year
06 6th year
07 7th year or higher
98 Don't know

01 1st year
02 2nd year
03 3rd year
04 4th year
05 5th year
06 6th year or higher
98 Don't know

08) Now I would like 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?

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) 4
BLIND/VISUALLY IMPAIRED 5

109) CHECK 108:

CODE '2', '3', OR '4' CIRCLED
CODE '1' OR '5' CIRCLED - SKIP TO 111

110) Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

111) Do you listen to the radio at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

112) Do you watch television almost at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

113) What is your religion?

CATHOLIC 1
PROTESTANT 2
ISLAM 3
ANIMIST 4
NO RELIGION 5
OTHER 6

114) What is your ethnicity?
IF YOU CANNOT CLASSIFY THE ETHNICITY DECLARED BY THE RESPONDENT AMONG THE CATEGORIES LISTED, RECORD IT IN THE SPACE PROVIDED.
(ETHNICITY DECLARED BY THE RESPONDENT)

GORANE 01
ARAB 02
BAGUIRMI/BARMA 03
KANEMBOU/BORNOU/BOUDOUMA 04
BOULALA/MEDEGO/KOUKA 05
OUADDAI/MABA/MASSALIT/MIMI 06
ZAGHAWA/BIDEYAT/KOBE 07
DADJO/KIBET/MOURO 08
BIDIO/MIGAMI/KENGA/DANGLEAT 09
MOUNDANG 10
MASSA/MOUSSEYE/MOUSGOU,E 11
TOUPOURI/KERA 12
SARA (NGAMBAYE/SARA MADJIN-GAYE/MBAYE) 13
PEUL/FOULBE/BODORE 14
TAMA/ASSONGORI/MARARIT 15
GABRI/KABALAYE/NANGTCHERE/SOUMRAYE 16
MARBA/LELE/MESME 17
MESMEDJE/MASSALAT/KADJASKE 18
KARO/ZIME/PEVE 19
AOTHER CHADIAN ETHNICITIES (ACHIT/BADA/KIM) 20
OTHER FOREIGN ETHNICITIES (BAMBARA/HAOUSSA/TOWER) 21
OTHER NATIONALITIES 22

115) In the last 12 months, how many times have you been away from for one or more nights?

NUMBER OF TIMES ________
NONE 00 (SKIP TO 201)

116) In the last 12 months, have you been away from home for more than one month at a time?

YES 1
NO 2

SECTION 2. REPRODUCTION

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

YES 1
NO 2 (SKIP 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 (SKIP TO 204)

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

SONS AT HOME__ __
DAUGHTERS AT HOME__ __

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

YES 1
NO 2 (SKIP 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, RECODE '00'

SONS ELSEWHERE__ __
DAUGHTERS ELSEWHERE__ __

206) Have you ever given birth to a boy or girl who was born alive but later died?
If no, probe: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2 (SKIP TO 208)

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

BOYS DEAD__ __
GIRLS DEAD __ __

208) Sum answers to 203, 205, and 207 and enter total.
IF NONE, RECORD 00

TOTAL BIRHTS_____

209) CHECK 208:
Just to makes sure that I have this right: you have had in total ____births during your life. Is that correct?

YES
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210) CHECK 208:

ONE OR MORE BIRTHS
NO BIRTHS- SKIP TO 226

211) Now I would like to record the names of all 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 rows.
(IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

212) What name was given to you (First/Next) baby?

RECORD NAME______________
BIRTH HISTORY NUMBER __ __

01, 02, 03, etc…

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

BOY 1
GIRL 2

214) Were any of these births twins?

SING 1
MULT 2

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

MONTH __ __
YEAR __ __ __ __

216) Is (NAME) still alive?

YES 1
NO 2- SKIP TO 220

217) IF ALIVE:
How old was (Name) at his/her last birthday? Record age in completed years.

AGE IN YEARS __ __

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

YES 1
NO 2

219) IF ALIVE:
RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD)

HOUSEHOLD LINE NUMBER __ __

NEXT BIRTH, GO TO 221

220) IF 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.

DAYS 1
MONTHS 2
YEARS 3

221) Were there any other live births between (name of previous birth) and (name), including any children who died after birth?

YES 1-ADD BIRTH
NO 2-NEXT BIRTH

222) Have you had any live births since the birth of (name of last birth)? If yes, record birth(s) in table.

YES 1
NO 2

223) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK.

NUMBERS ARE THE SAME
NUMBERS ARE DIFFERENT-(PROBE AND RECONCILE)

224) CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2009 OR LATER.

NUMBER OF BIRTHS __ __
NONE 0

226) Are you pregnant now?

YES 1
NO 2-SKIP TO 230
UNSURE 8-SKIP TO 230

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

MONTHS __ __

228) When you got pregnant, did you want to get pregnant at that time?

YES 1 (SKIP TO 230)
NO 2

229) Did you want to have a baby later on or did you not want any (more) children?

LATER 1
NO MORE 2

230) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

YES 1
NO 2-SKIP TO 238

231) When did the last such pregnancy end?

MONTH __ __
YEAR __ __ __ __

232) CHECK 231:

LAST PREGNANCY ENDED IN JAN 2009 OR LATER
LAST PREGNANCY ENDED BEFORE JAN. 2009-SKIP TO 238

233) How many months pregnant were you when the last such pregnancy ended?

MONTHS __ __

234) Since January 2009, have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2

236) Did you have any miscarriages, abortions or stillbirths that ended before 2009?

YES 1
NO 2 (SKIP TO 238)

237) When did the last such pregnancy that terminated before 2009 end?

MONTH __ __
YEAR __ __ __ __

238) When did you last menstrual period start?
(DATE, IF GIVEN)

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

239) From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

YES 1
NO 2 (SKIP TO 301)
DON'T KNOW 8 (SKIP TO 301)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAD ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) 6
DON'T KNOW 8

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.

Have you ever heard of (METHOD)?

01) FEMALE STERILIZATION
PROBE: Women can have an operation to avoid having any more children
Have you ever heard of (method)?

YES 1
NO 2

02) Male Sterilization
PROBE: Men can have an operation to avoid having any more children
Have you ever heard of (method)?

YES 1
NO 2

03) IUD
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
Have you ever heard of (method)?

YES 1
NO 2

04) Injectables
PROBE: Women can have an injection by a heath provider that stops them from becoming pregnant for one or more months.
Have you ever heard of (METHOD)?

YES 1
NO 2

05) Implants

PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
Have you ever heard of (METHOD)?

YES 1
NO 2

06) Pill
Probe: Women can take a pill every day to avoid becoming pregnant
Have you ever heard of (METHOD)?

YES 1
NO 2

07) Condom
PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
Have you ever heard of (METHOD)?

YES 1
NO 2

08) FEMALE CONDOM
Probe: Women can place a sheath in their vagina before sexual intercourse.
Have you ever heard of (METHOD)?

Yes 1
No 2

09) Lactational amenorrhea method (LAM)
Have you ever heard of (Method)?

YES 1
NO 2

10) RHYTHM METHOD
PROBE: To avoid pregnancy, women do not have sexual intercourse on days of the month they think they can get pregnant.
Have you ever heard of (METHOD)?

YES 1
NO 2

11) WITHDRAWAL
PROBE: Men can be careful and pull out before climax.
Have you ever heard of (METHOD)?

YES 1
NO 2

12) EMERGENCY CONTRACEPTION
PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
Have you ever heard of (METHOD)?

YES 1
NO 2

13) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?

YES 1
(SPECIFY)_________
(SPECIFY)_________
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE
PREGNANT-SKIP TO 313

303) Are you currently doing something or using any method to delay or avoid getting pregnant?

YES 1
NO 2-SKIP TO 313

304) Which method are you using?
PROBE: Anything else?
CIRCLE ALL MENTIONED
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION A-SKIP TO 307
MALE STERILIZATION B-307
IUD C --SKIP TO 308A
INJECTABLES D--SKIP TO 308A
IMPLANTS E--SKIP TO 308A
PILL F
CONDOM G-SKIP TO 306
FEMALE CONDOM H
DIAPHRAGM I
FOAM/JELLY J
LACTATIONAL AMEN. METHOD K
RHYTHM METHOD L
WITHDRAWAL M
OTHER MODERN METHOD X
OTHER TRADITIONAL METHOD Y
H-Y SKIP TO 308A

305) What is the brand name of the pills you are using?
IF DON'T KNOW BRAND, ASK TO SEE THE PACKAGE.

MICROGYNON 01
MICROLUT 02
LOFEMENAL 03
OTHER (SPECIFY) 96
DON'T KNOW 98

ALL SKIP TO 308A

306) What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

PRUDENCE PLUS 01
PRUDENCE 02
LOVERS + 03
PROMESSE 04
MANIX 05
KAMASUTRA 06
SUPRATEX 07
SECURITE PLUS 08
CADEAU 09
DUEL 10
AMI3 MASULIN 11
SUPER DELUX 12
CAREZ 13
OTHER (SPECIFY) 96
DON'T KNOW 98
ALL SKIP TO 308A

307) In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
(NAME OF PLACE)

PUBLIC SECTOR
HOSPITAL/MATERNITY 11
MILITARY HOSPITAL/GARRISON 12
FREE CLINIC 13
POLYCLINIC 14
PHARMACY OF HOSPITAL/HEALTH CENTER 15
OTHER PUBLIC SECTOR (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/DOCTOR'S OFFICE 22
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING 23
PRIVATE HEALTH CENTER 24
BUSINESS HEALTH CENTER 25
CARE OFFICE/INFIRMARY 26
PHARMACY/PHARMACY DEPOT 27
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 28
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER 31
OTHER (SPECIFY) 96
DON'T KNOW 98

308) In what month and year was the sterilization performed?

308a) Since what month and year did you start using (CURRENT METHOD) without stopping?

Probe: For how long have you been using (CURRENT METHOD FIRST MENTIONED) now without stopping?

MONTH __ __ (SKIP TO 314)
YEAR __ __ __ __(SKIP TO 314)

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

YES 1 (SKIP TO 324)
NO 2 (SKIP TO 324)

314) CHECK 304:
CIRCLE METHOD CODE.
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01-SKIP TO 317A
MALE STERILIZATION 02-SKIP TO 326
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11-SKIP TO 315A
RHYTHM METHOD 12-SKIP TO 315A
WITHDRAWAL 13
OTHER MODERN METHOD 95
OTHER TRADITIONAL METHOD 96

13-96 SKIP TO 326

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?

315a) Where did you learn how to use the rhythm/lactational amenorrhea method?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE)

PUBLIC SECTOR
HOSPITAL/MATERNITY 11
MILITARY HOSPITAL/GARRISON 12
FREE CLINIC 13
POLYCLINIC 14
PHARMACY OF HOSPITAL/HEALTH CENTER 15
OTHER PUBLIC SECTOR (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/DOCTOR'S OFFICE 22
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING 23
PRIVATE HEALTH CENTER 24
BUSINESS HEALTH CENTER 25
CARE OFFICE/INFIRMARY 26
PHARMACY/PHARMACY DEPOT 27
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 24
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER 31
Other
SHOP/BAR/MARKET 41
FIRST AID WORKER 42
TRAVELING VENDOR 43
FRIENDS/NEIGHBORS/RELATIVES 44
OTHER (SPECIFY) 96
DON'T KNOW 98

316) CHECK 304:
CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 --SKIP TO 323
FEMALE CONDOM 08-SKIP TO 320
DIAPHRAGM 09-SKIP TO 320
FOAM/JELLY 10-SKIP TO 320
LACTATIONAL AMEN. METHOD 11-SKIP TO 326
RHYTHM METHOD 12-SKIP TO 326

317) At that time, where you told about side effects or problems you might have with the method?

317a) When you got sterilized, were you told about side effects or problems you might have with the method?

YES 1-SKIP TO 319
NO 2

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

YES 1
NO 2-SKIP TO 320

319) Were you told what to do if you experienced side effects or problems?

YES 1
NO 2

320) CHECK 317:
CODE 1 CIRCLED- At that time, were you told about other methods of family planning that you could use?

CODE '2' CIRCLED-When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

YES 1-322
NO 2

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

YES 1
NO 2

322) CHECK 304:
CIRCLE METHOD CODE. IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01-SKIP TO 326
MALE STERILIZATION 02-SKIP TO 326
IUD 03
INJECTABLES 04
IMPLANTS 05-SKIP TO 326
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11
RHYTHM METHOD 12
WITHDRAWAL 13
OTHER MODERN METHOD 95
OTHER TRADITIONAL METHOD 96

11-96 SKIP TO 326

323) Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE)_________
PUBLIC SECTOR
HOSPITAL/MATERNITY 11
MILITARY HOSPITAL/GARRISON 12
FREE CLINIC 13
POLYCLINIC 14
PHARMACY OF HOSPITAL/HEALTH CENTER 15
OTHER PUBLIC SECTOR (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/DOCTOR'S OFFICE 22
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING 23
PRIVATE HEALTH CENTER 24
BUSINESS HEALTH CENTER 25
CARE OFFICE/INFIRMARY 26
PHARMACY/PHARMACY DEPOT 27
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 28
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER 31
Other
SHOP/BAR/MARKET 41
FIRST AID WORKER 42
TRAVELING VENDOR 43
FRIENDS/NEIGHBORS/RELATIVES 44
OTHER (SPECIFY) 96
DON'T KNOW 98

ALL SKIP TO 326

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

YES 1
NO 2-SKIP TO 326

325) WHERE IS THAT?
ANY OTHER PLACE?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))_______________
PUBLIC SECTOR
HOSPITAL/MATERNITY A
MILITARY HOSPITAL/GARRISON B
FREE CLINIC C
POLYCLINIC D
PHARMACY OF HOSPITAL/HEALTH CENTER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING I
PRIVATE HEALTH CENTER J
BUSINESS HEALTH CENTER K
CARE OFFICE/INFIRMARY L
PHARMACY/PHARMACY DEPOT M
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) N
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER O
OTHER
SHOP/BAR/MARKET P
FIRST AID WORKER Q
TRAVELING VENDOR R
FRIENDS/NEIGHBORS/RELATIVES S
OTHER (SPECIFY) X

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

YES 1
NO 2

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

YES 1
NO 2-SKIP TO 401

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2009 OR LATER
NO BIRTHS IN 2009 OR LATER-SKIP TO 556

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 OR LATER. ASK THE QUESTIONS ABOUT ALL 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 SOME QUESTIONS ABOUT YOUR CHILDREN BORN IN THE LAST FIVE YEARS. (WE WILL TALK ABOUT EACH SEPARATELY).

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

LAST BIRTH_____
BIRTH HISTORY NUMBER____
NEXT-TO-LAST BIRTH ____________
BIRTH HISTORY NUMBER___________
SECOND-FROM-LAST BIRTH_________
BIRTH HISTORY NUMBER_________

404) FROM 212 AND 216

NAME_________
LIVING
DEAD

405) When you got pregnant with (NAME), did you want to become pregnant at that time?

YES 1-SKIP TO 408
NO 2

406) Did you want to have a baby later on, or did you not want any (more) children?

LATER 1
NO MORE 2-SKIP TO 408

407) How much longer did you want to wait?

MONTHS 1
YEARS 2
DON'T KNOW 998

408) Did you see anyone for antenatal care for this pregnancy?

YES 1
NO 2-SKIP TO 415

409) Whom did you see?
ANYONE ELSE?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEATH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
OTHER HEALTH PROFESSIONAL
MATRON/HOSPITAL/HEALTH CENTER AGENT C
TRAINED TRADITIONAL BIRTH ATTENDANT D
OTHER PERSON
UNTRAINED TRADITIONAL BIRTH ATTENDANT E
COMMUNITY/VILLAGE HEALTH WORKER F
OTHER (SPECIFY) X

410) Where did you receive this antenatal care for this pregnancy?
ANYWHERE ELSE?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))___________
HOME
YOUR HOME A
OTHER HOME B
PUBLIC SECTOR
GOVERNMENT HOSPITAL C
GOVERNMENT HEALTH CENTER D
OTHER PUBLIC SECTOR (SPECIFY) E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC F
OTHER PRIVATE MEDICAL G
OTHER (SPECIFY) X

411) How many months pregnant were you when you first received antenatal care for this pregnancy?

MONTHS __ __
DON'T KNOW 98

412) How many times did you receive antenatal care during this pregnancy?

NUMBER OF TIMES
DON'T KNOW 98

413) As part of your antenatal care during this pregnancy, were any of the following done at least once?

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

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (SKIP TO 418)
DON'T KNOW 8 (SKIP TO 418)

416) During this pregnancy, how many times did you a tetanus injection?

TIMES __ __
DON'T KNOW 8

417) CHECK 416:

2 OR MORE TIMES-SKIP TO 421
OTHER

418) At any time before this pregnancy, did you receive any tetanus injections?

YES 1
NO 2 (SKIP TO 421)
DON'T KNOW 8 (SKIP TO 421)

419) Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD 7

TIMES __ __
DON'T KNOW 8

420) How many years ago did you receive the last tetanus injection before this pregnancy?

YEARS AGO __ __

421) During this pregnancy, were you given or did you buy iron tablets?
SHOW TABLES/SYRUP

YES 1
NO 2-SKIP TO 423
DON'T KNOW 8- SKIP TO 423

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

DAYS __ __ __
DON'T KNOW 998

423) During this pregnancy, did you take any drug for intestinal worms?

YES 1
NO 2
DON'T KNOW 8

424) During this pregnancy, did you take any drugs to keep you from getting malaria?

YES 1
NO 2-SKIP TO 430
DON'T KNOW 8-SKIP TO 430

425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

SP/FANSIDAR A
CHLOROQUINE B
OTHER (SPECIFY) X
DON'T KNOW Z

426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION

CODE A CIRCLED
CODE A NOT CIRCLED-SKIP TO 430

427) How many times did you take (SP/Fansidar) during this pregnancy?

TIMES __ __

428) CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE A, B, OR C CIRCLED
OTHER-SKIP TO 430

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility, or from another source?

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

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

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8

431) Was (NAME) weighed at birth?

YES 1
NO 2-SKIP TO 433
DON'T KNOW 8-SKIP TO 433

432) How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE

GRAMS FROM CARD 1 __. __ __ __
GRAMS FROM RECALL 2__. __ __ __
DON'T KNOW 99998

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

HEATH PROFESSIONAL
DOCTOR A
NURSE/MIDWIFE B
OTHER HEALTH PROFESSIONAL
MATRON/HOSPITAL/HEALTH CENTER AGENT C
TRAINED TRADITIONAL BIRTH ATTENDANT D
OTHER PERSON
UNTRAINED TRADITIONAL BIRTH ATTENDANT E
COMMUNITY/VILLAGE HEALTH WORKER F
OTHER (SPECIFY) X
NO ONE ASSISTED Y

434) Where did you give birth to (NAME)?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.
(NAME OF PLACE(S))

HOME
YOUR HOME 11-SKIP TO 438
OTHER HOME 12-SKIP TO 438
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
OTHER PUBLIC SECTOR (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL 36
OTHER (SPECIFY) 96-SKIP TO 438

434a) How long after (name) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1
DAYS 2
WEEKS 3
DON'T KNOW 998

435) Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?

YES 1
NO 2

436) I would like to talk to you about check on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health while you were still in the facility?

YES 1-SKIP TO 439
NO 2

437) Did anyone check on your health after you left the facility?

YES 1-SKIP TO 439
NO 2-SKIP TO 442

438) I would like to talk to you about check on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?

YES 1
NO 2-SKIP TO 442

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

HEATH PROFESSIONAL
DOCTOR 11
NURSE/MIDWIFE 12
OTHER HEALTH PROFESSIONAL
MATRON/HOSPITAL/HEALTH CENTER AGENT 13
TRAINED TRADITIONAL BIRTH ATTENDANT 14
OTHER PERSON
UNTRAINED TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY/VILLAGE HEALTH WORKER 22
FIRST AID WORKER 23
HEALER 24
OTHER (SPECIFY) 96

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

HOURS 1
DAYS 2
WEEKS 3
DON'T KNOW 998

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

YES 1
NO 2-SKIP TO 446
DON'T KNOW 8-SKIP TO 446

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

HRS AFTER BIRTH 1
DAYS AFTER BIRTH 2
WKS AFTER BIRTH 3
DON'T KNOW 998

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

HEATH PROFESSIONAL
DOCTOR 11
NURSE/MIDWIFE 12
OTHER HEALTH PROFESSIONAL
MATRON/HOSPITAL/HEALTH CENTER AGENT 13
TRAINED TRADITIONAL BIRTH ATTENDANT 14
OTHER PERSON
UNTRAINED TRADITIONAL BIRTH ATTENDANT 21
COMMUNITY/VILLAGE HEALTH WORKER 22
FIRST AID WORKER 23
HEALER 24
OTHER (SPECIFY) 96

445) Where did this first check of (NAME) take place?
PROBE TO IDENTITY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))______________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC SECTOR (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL 36
OTHER (SPECIFY) 96

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1-SKIP TO 449
NO 2- SKIP TO 450

448) Did your period return between the birth of (name) and your next pregnancy?

YES 1
NO 2-SKIP TO 452

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

MONTHS __ __
DON'T KNOW 98

450) CHECK 226:
Is respondent pregnant?

NOT PREGNANT
PREGNANT OR NOT SURE-SKIP TO 452

451) Have you had sexual intercourse since the birth of (name)?

YES 1
NO 2-SKIP TO 453

452) For how many months after the birth of (Name) did you not have sexual intercourse?

MONTHS__ __
DON'T KNOW 98

453) Did you ever breastfeed (NAME)?

YES 1-SKIP TO 455
NO 2

454) CHECK 404: Child is living?

LIVING-SKIP TO 460
DEAD-GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

455) How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD 00 HOURS.
IF LESS THAN 24 HOURS, RECORD HOURS.
OTHERWISE, RECORD DAYS

IMMEDIATELY 000
HOURS 1 __ __
DAYS 2 __ __

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

YES 1
NO 2-SKIP TO 458

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

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
GRIPE WATER D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
COFFEE I
HONEY J
OTHER (SPECIFY) X

458) CHECK 404:
Is child living?

LIVING
DEAD- (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

459) Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

461) (GO BACK TO 405 IN NEXT COLUMN, OR, IF NO MORE BIRTHS, GO TO 501)

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2009 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) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

LAST BIRTH
BIRTH HISTORY NUMBER__ __
NEXT-TO-LAST BIRTH
BIRTH HISTORY NUMBER __ __
SECOND-FROM-LAST BIRTH
BIRTH HISTORY NUMBER __ __

503) FROM 212 AND 216

NAME___________
LIVING
DEAD-(GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 553)

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

YES, SEEN 1-SKIP TO 506
YES, NOT SEEN 2-SKIP TO 509
NO CARD 3

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

YES 1-SKIP TO 509
NO 2-SKIP TO 509

506)
1) COPY DATES FROM THE CARD
2) WRITE 44 IN DAY COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

LAST BIRTH
NEXT-TO-LAST BIRTH
SECOND-FROM-LAST BIRTH

BCG
DAY__ __
MONTH__ __
YEAR __ __ __ __
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY__ __
MONTH__ __
YEAR __ __ __ __
POLIO 1
DAY__ __
MONTH__ __
YEAR __ __ __ __
POLIO 2
DAY__ __
MONTH__ __
YEAR __ __ __ __
POLIO 3
DAY__ __
MONTH__ __
YEAR __ __ __ __
DTCOQ1/PENTA 1
DAY__ __
MONTH__ __
YEAR __ __ __ __
DTCOQ2/PENTA 2
DAY__ __
MONTH__ __
YEAR __ __ __ __
DTCOQ3/PENTA 3
DAY__ __
MONTH__ __
YEAR __ __ __ __
MEASLES
DAY__ __
MONTH__ __
YEAR __ __ __ __
YELLOW FEVER
DAY__ __
MONTH__ __
YEAR __ __ __ __
VITAMIN A (MOST RECENT)
DAY__ __
MONTH__ __
YEAR __ __ __ __

507) CHECK 506:

BCG TO YELLOW FEVER ALL RECORDED-GO TO 511
OTHER

508) Has (NAME) received any vaccines that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 -probe for vaccinations and write 66 in the corresponding day column in 506 (SKIP TO 511)
NO 2 (SKIP TO 511)
DON'T KNOW 8 (SKIP TO 511)

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

YES 1
NO 2-SKIP TO 511
DON'T KNOW 8-SKIP TO 511

510) Please tell me if (NAME) had any of the following vaccinations:

510a) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

YES 1
NO 2
DON'T KNOW 8

510b) Polio vaccine, that is, two drops in the mouth?

YES 1
NO 2-SKIP TO 510E
DON'T KNOW 8-SKIP TO 510E

510c) Was the first polio vaccine given in the first two weeks after birth or later?

FIRST TWO WEEKS 1
LATER 2

510d) How many times was the polio vaccine given?

NUMBER OF TIMES__ __

510e) A PENTA vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

YES 1
NO 2-SKIP TO 510G
DON'T KNOW 3-SKIP TO 510G

510f) How many times was the PENTA vaccination given?

NUMBER OF TIMES __ __

510g) An injection or an MMR injection- that is, a shot in the arm at the age of 9 months or older,- to prevent him/her from getting measles?

YES 1
NO 2
DON'T KNOW 8

510h) A yellow fever vaccination, that is, a shot in the arm at the age of 9 months or older,- to prevent him/her from getting yellow fever?

YES 1
NO 2
DON'T KNOW 8

511) Within the last six months, was (name) given a vitamin A dose like (this/any of these)?
Show common types of ampoules/capsules/syrups.

YES 1
NO 2
DON'T KNOW 8

512) In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like (this/any of these)?
SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.

YES 1
NO 2
DON'T KNOW 8

513) Was (NAME) given any drug for intestinal worms in the last six months?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2-SKIP TO 525
DON'T KNOW -SKIP TO 525

515) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

516) 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

517) 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

518) Did you seek advice or treatment for the diarrhea from any source?

YES 1
NO 2-SKIP TO 522

519) Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))___________
PUBLIC SECTOR
HOSPITAL/MATERNITY A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/FREE CLINIC/MILITARY INFIRMARY C
POLYCLINIC D
PHARMACY OF HOSPITAL/HEALTH CENTER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
HEALTH CENTER I
BUSINESS HEALTH CENTER J
CARE OFFICE/INFIRMARY K
PHARMACY/PHARMACY DEPOT L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER N
OTHER
SHOP/BAR/MARKET O
FIRST AID WORKER P
TRAVELING VENDOR Q
FRIENDS/RELATIVES R
OTHER (SPECIFY) X

520) CHECK 519:

TWO OR MORE CODES CIRCLED
ONLY ONE CODE CIRCLED-SKIP TO 522

521) Where did you first seek advice or treatment?
USE LETTER CODE FROM 519

First place __

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea?

a) A fluid made from a special packet called Orasel or Amasel?
YES 1
NO 2
DON'T KNOW 8
b) A pre-packaged ORS liquid?
YES 1
NO 2
DON'T KNOW 8

523) Was anything (else) given to treat the diarrhea?

YES 1
NO 2-SKIP TO 525
DON'T KNOW 8-SKIP TO 525

524) What (else) was given to treat the diarrhea?
ANYTHING ELSE?
RECORD ALL TREATMENTS GIVEN.

PILL OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
ZINC C
OTHER (NOT ANTIBIOTIC, ANTIMOTILITY OR ZINC) D
UNKNOWN PILL OR SYRUP E
INJECTION
ANTIBIOTIC F
NON-ANTIBIOTIC G
UNKNOWN INJECTION H
(IV) INTRAVENOUS I
HOME REMEDY/HERBAL MEDICINE J
OTHER (SPECIFY) X

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

YES 1
NO 2-SKIP TO 527
DON'T KNOW 8-SKIP TO 527

526) At any time during the illness, did (NAME) have blood taken from his/her finger or heal for testing?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2-SKIP TO 530
DON'T KNOW 8-SKIP TO 530

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

YES 1
NO 2-SKIP TO 531
DON'T KNOW 8-SKIP TO 531

529) Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose?

CHEST ONLY 1
NOSE ONLY 2
BOTH 3
OTHER (SPECIFY) 6
DON'T KNOW 8

ALL SKIP TO 531

530) CHECK 525: Had fever?

YES
NO OR DK-GO TO 551A)

531) 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON'T KNOW 8

532) 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?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON'T KNOW 8

533) Did you seek advice or treatment for the illness from any source?

YES 1
NO 2-SKIP TO 537

534) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

PUBLIC SECTOR
HOSPITAL/MATERNITY A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/FREE CLINIC/MILITARY INFIRMARY C
POLYCLINIC D
PHARMACY OF HOSPITAL/HEALTH CENTER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
HEALTH CENTER I
BUSINESS HEALTH CENTER J
CARE OFFICE/INFIRMARY K
PHARMACY/PHARMACY DEPOT L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER N
OTHER
SHOP/BAR/MARKET O
FIRST AID WORKER P
TRAVELING VENDOR Q
FRIENDS/RELATIVES R
OTHER (SPECIFY) X

535) CHECK 534:

TWO OR MORE CODES CIRCLED
ONLY ONE CODE CIRCLED-SKIP TO 537

536) Where did you first seek advice or treatment?
USE LETTER CODE FROM 534

FIRST PLACE __

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

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

538) What drugs did (Name) take?
Any other drugs?
RECORD ALL MENTIONED

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUINE B
AMODIAQUINE C
QUININE D
COMBINATION WITH ARTEMISININ E
OTHER ANTIMALARIAL (SPECIFY) F
ANTIBIOTIC
PILL/SYRUP G
INJECTION H
OTHER DRUGS
ASPIRIN I
ACETAMINOPHEN J
IBUPROFEN K
OTHER (SPECIFY) X
DON'T KNOW Z

539) CHECK 538: Any code A-F circled?

YES
NO-SKIP TO 551A

540) CHECK 538: SP/Fansidar (A) given

CODE A CIRCLED
CODE A NOT CIRCLED-SKIP TO 542

541) How long after the fever started did (NAME) first take SP/Fansidar?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

542) CHECK 538: Chloroquine (b) given

CODE B CIRCLED
CODE B NOT CIRCLED-SKIP TO 544

543) How long after the fever started did (name) first take Chloroquine?'

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

544) CHECK 538: Amodiaquine (c) given

CODE C CIRCLED
CODE C NOT CIRCLED-SKIP TO 546

545) How long after the fever started did (NAME) first take Amodiaquine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

546) CHECK 538: Quinine (d) given

CODE D CIRCLED
CODE D NOT CIRCLED-SKIP TO 548

547) How long after the fever started did (name) first take Quinine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

548) CHECK 538: Combination with artemisinin (e) given

CODE E CIRCLED
CODE E NOT CIRCLED-SKIP TO 550

549) How long after the fever started did (name) first take (Combination with artemisinin)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

550) CHECK 538: Other antimalarial (f) given

CODE F CIRCLED
CODE F NOT CIRCLED-(GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

551) How long after the fever started did (NAME) first take (Other antimalarial)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

551a) In Chad, some people have their children's uvula removed. Have you heard of this practice?

YES 1
NO 2-SKIP TO 552

551b) Did (NAME) get his/her uvula removed?

YES 1-SKIP TO 551D
NO 2
DON'T KNOW 8

551c) Do you intend to have (NAME)'s uvula removed?

YES 1-SKIP TO 551G
NO 2-SKIP TO 551G
DON'T KNOW 8-SKIP TO 551G

551d) How old was (NAME) when his/her uvula was removed?

LESS THAN ONE YEAR OLD 1
ONE YEAR OR OLDER 2
DON'T KNOW 8

551e) Who performed (NAME)'s uvula removal?

TRADITIONAL PRACTITIONER 1
SPECIALIZED MAN 2
SPECIALIZED WOMAN 3
MEDICAL PERSONNEL 4
RELATIVES/FRIENDS 5
OTHER 6
DON'T KNOW 8

551f) After the removal, did (name) have:

a) an infection
YES 1
NO 2
DON'T KNOW 8
b) bleeding?
YES 1
NO 2
DON'T KNOW 8
c) difficulty breastfeeding, drinking, or eating?
YES 1
NO 2
DON'T KNOW 8
d) difficulty breathing?
YES 1
NO 2
DON'T KNOW 8
e) difficulty speaking?
YES 1
NO 2
DON'T KNOW 8

551g) GO BACK TO 503 IN NEXT COLUMN OR IF NO MORE BIRTHS, GO TO 553.

551h) What are the benefits to removing a child's uvula?
PROBE: Anything else?
RECORD ALL MENTIONED.

REDUCES VOMITING A
REDUCES COUGHING B
PREVENTS STREP THROAT C
FACILITATES BREATHING D
FOLLOWS TRADITION E
OTHER (SPECIFY) X
NO BENEFITS Z

551i) What are the disadvantages of removing a child's uvula?
PROBE: Anything else?
RECORD ALL MENTIONED.

PAIN A
RISK OF INFECTION B
RISK OF BLEEDING C
DIFFICULTY BREATHING D
DIFFICULTY SPEAKING E
OTHER (SPECIFY) X
NO DISADVANTAGES Z

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2009 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE-RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 554
NONE-SKIP TO 556

554) The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN INTO GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER (SPECIFY) 96

555) CHECK 522A, ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (SKIP TO 557)

556) Have you ever heard of a special product called (Orasel or Amasel) you can get for the treatment of diarrhea?

YES 1
NO 2

557) CHECK 215 AND 218, ALL ROWS:
Number of children born in 2012 or later living with respondent

ONE OR MORE-RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 558
NONE-SKIP TO 601

558) Now I would like to ask you about liquids or foods that (name from 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (name from 557) (drink/eat):

a) plain water?
YES 1
NO 2
DON'T KNOW 8
b) juice or juice drinks?
YES 1
NO 2
DON'T KNOW 8
c) clear broth?
YES 1
NO 2
DON'T KNOW 8
d) milk such as tinned, powdered, or fresh animal milk?
IF YES, how many times did (Name) drink milk?
IF 7 OF MORE TIMES, RECORD 7
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES DRANK MILK __
e) Infant formula? IF YES, how many times did (name) drink infant formula?
IF 7 OR MORE TIMES, RECORD 7
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES DRANK FORMULA__
f) Any other liquids?
YES 1
NO 2
DON'T KNOW 8
g) Yogurt?IF YES, HOW MANY TIMES DID (NAME) EAT YOGURT?
IF 7 OR MORE TIMES, RECORD 7
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ATE YOGURT__
h) Anything similar to Cerelac?
YES 1
NO 2
DON'T KNOW 8
i) bread, rice, noodles, porridge, or any other foods made from grains
YES 1
NO 2
DON'T KNOW 8
j) pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
YES 1
NO 2
DON'T KNOW 8
k) white potatoes, white yams, manioc, cassava, or any other foods made from roots
YES 1
NO 2
DON'T KNOW 8
l) any dark green, leafy vegetables
YES 1
NO 2
DON'T KNOW 8
m) ripe mangoes, papayas?
YES 1
NO 2
DON'T KNOW 8
n) any other fruits or vegetables?
YES 1
NO 2
DON'T KNOW 8
o) liver, kidney, heart or any other organ meats?
YES 1
NO 2
DON'T KNOW 8
p) any meat, such as beef, pork, lamb, goat, chicken or duck?
YES 1
NO 2
DON'T KNOW 8
q) eggs?
YES 1
NO 2
DON'T KNOW 8
r) fresh or dried fish or shellfish
YES 1
NO 2
DON'T KNOW 8
s) Other foods based in beans, soy, peas, lentils, or nuts?
YES 1
NO 2
DON'T KNOW 8
t) cheese or other food made from milk?
YES 1
NO 2
DON'T KNOW 8
u) any other solid, semi-solid, or soft food?
YES 1
NO 2
DON'T KNOW 8

559) CHECK 558 (Categories g through u)

NOT A SINGLE YES
AT LEAST ONE YES-SKIP TO 561

560) Did (NAME) eat any solid, semi-solid or soft foods yesterday during the day or at night?
IF YES, probe: What kind of solid, semi-solid, or soft foods did (NAME FROM 557) eat?

YES 1-(GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY)
NO-2-SKIP TO 601

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD 7

NUMBER OF TIMES__ __
DON'T KNOW 8

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

601) Are you currently married or living together with a man as if married?

YES, CURRENTLY MARRIED 1-SKIP TO 604
YES, LIVING WITH A MAN 2-SKIP TO 604
NO, NOT IN UNION 3

602) Have you ever been married or lived together with a man as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2
NO 3-SKIP TO 612

603) What is your current marital status: are you a widow, divorced, or separated?

WIDOW 1 -- SKIP TO 609
DIVORCED 2-SKIP TO 609
SEPARATED 3- SKIP TO 609

604) Is your husband/partner living with you now or is he staying elsewhere?

LIVES WITH HER 1
STAYING ELSEWHERE 2

605) RECORD THE LINE NUMBER OF HER HUSBAND/PARTNER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT A LISTED IN THE HOUSEHOLD, RECORD '00'.

NAME______________
LINE NO. __ __

606) Does your husband/partner have other wives or does he live with other women as if married?

YES 1
NO 2-SKIP TO 609
DK 8-SKIP TO 609

607) Including yourself, in total how many wives or live-in partners does he have?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS__________
DON'T KNOW 98

608) Are you the first, second…wife?

RANK _____

609) Have you been married or have you lived with a man only once or more than once?

ONCE 1
MORE THAN ONCE 2

610) CHECK 609:
MARRIED/LIVED WITH MAN ONLY ONCE --in what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH MAN MORE THAN ONCE --Now I would like to talk about the your first (husband/partner) In what month and year did you start living with him?

MONTH _____
DON'T KNOW MONTH 98
YEAR ____ - SKIP TO 612
DON'T KNOW YEAR 9998

611) How old were you when you first started living with him?

AGE _____

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

613) 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?

NEVER HAD SEXUAL INTERCOURSE 00-SKIP TO 628
AGE IN YEARS
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

614) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.

615) When was the last time you had sexual intercourse.
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3
YEARS AGO 4-SKIP TO 627

616) When was the last time you had sexual intercourse with this person?

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3

617) The last time you had sexual intercourse (with this second/third) person, was a condom used?

YES 1
NO 2-SKIP TO 619

618) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

YES 1
NO 2

619) What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married?
IF YES, CIRCLE 2
IF NO, CIRCLE 3

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
CLIENT/PROSTITUTE 5
OTHER (SPECIFY) 6

3-6 SKIP TO 622

620) CHECK 609:

MARRIED ONLY ONCE
MARRIED MORE THAN ONCE (SKIP TO 622)

621) CHECK 613:

FIRST TIME WHEN STARTED LIVING WITH HUSBAND-SKIP TO 623
OTHER

622) How long ago did you first have sexual intercourse with this (second/third) person?

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3
YEARS AGO 4

623) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 96 OR MORE, WRITE 95.

NUMBER OF TIMES

624) How old is this person?

AGE OF PARTNER
DON'T KNOW 98

625) Apart from (this person/these two people), have you had sexual intercourse with any other persons in the last 12 months?

YES 1- (GO BACK TO 616 IN NEXT COLUMN)
NO 2 -- (SKIP TO 627)

626) In total, how many different people have you had sexual intercourse with in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE 95

NUMBER OF PARTNERS LAST 12 MONTHS __ __
DON'T KNOW 98

627) In total, how many different people have you had sexual intercourse with in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE 95

NUMBER OF PARTNERS IN LIFETIME__ __
DON'T KNOW 98

628) PRESENCE OF OTHERS DURING THIS SECTION

CHILDREN LESS THAN 10
YES 1
NO 2
MALE ADULTS
YES 1
NO 2
FEMALE ADULTS YES 1 NO 2
YES 1
NO 2

629) Do you know of a place where a person can get condoms

YES 1
NO 2-SKIP TO 632

630) Where is that?
Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))____________
PUBLIC SECTOR
HOSPITAL/MATERNITY A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/FREE CLINIC C
POLYCLINIC D
PHARMACY OF HOSPITAL/HEALTH CENTER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING I
PRIVATE HEALTH CENTER J
BUSINESS HEALTH CENTER K
CARE OFFICE/INFIRMARY L
PHARMACY/PHARMACY DEPOT M
CHADIAN SOCIAL MARKETING ASSOCIATION N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) O
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER P
OTHER
RELIGIOUS INSTITUTION Q
SHOP/BAR/MARKET R
FIRST AID WORKER S
TRAVELING VENDOR T
FRIENDS/NEIGHBORS/RELATIVES U
OTHER (SPECIFY) X

631) If you wanted to, could you yourself get a condom?

YES 1
NO 2
DON'T KNOW/UNSURE 8

632) CHECK 301 (08): KNOWS FEMALE CONDOM

YES
NO --SKIP TO 701

633) Do you know of a place where a person can get female condoms?

YES 1
NO 2-SKIP TO 701

634) Where is that?
Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))__________
PUBLIC SECTOR
HOSPITAL/MATERNITY A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/FREE CLINIC C
POLYCLINIC D
PHARMACY OF HOSPITAL/HEALTH CENTER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING I
PRIVATE HEALTH CENTER J
BUSINESS HEALTH CENTER K
CARE OFFICE/INFIRMARY L
PHARMACY/PHARMACY DEPOT M
CHADIAN SOCIAL MARKETING ASSOCIATION N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) O
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER P
OTHER
RELIGIOUS INSTITUTION Q
SHOP/BAR/MARKET R
FIRST AID WORKER S
TRAVELING VENDOR T
FRIENDS/NEIGHBORS/RELATIVES U
OTHER (SPECIFY) X

635) If You Wanted To, Could You Yourself Get A Female Condom?

YES 1
NO 2
DON'T KNOW/UNSURE 8

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

NEITHER STERILIZED
HE OR SHE STERILIZED --SKIP TO 712

702) CHECK 226:

PREGNANT
NOT PREGNANT OR UNSURE --SKIP TO 704

703) Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

HAVE ANOTHER CHILD 1-SKIP TO 705
NO MORE 2-SKIP TO 711
UNDECIDED/DON'T KNOW 8-SKIP TO 711

704) Now I have some question about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2-SKIP TO 707
SAYS SHE CAN'T GET PREGNANT 3-SKIP TO 712
UNDECIDED/DON'T KNOW --SKIP TO 710

705) CHECK 226:
NOT PREGNANT OR NOT SURE- How long would you like to wait from now before the birth of (a/another) child?

PREGNANT
After the birth of this child you are expecting now, how long would you like to wait before the birth of another child?

MONTHS 1
YEARS 2
SOON/NOW 993-SKIP TO 710
SAYS SHE CAN'T GET PREGNANT 994-SKIP TO 712
AFTER MARRIAGE 995
OTHER (SPECIFY) 996
DON'T KNOW 998

995-998-SKIP TO 710

706) CHECK 226:

NO PREGNANT OR UNSURE
PREGNANT-SKIP TO 711

707) CHECK 303:
Using a contraceptive method?

NOT CURRENTLY USING
CURRENTLY USING-SKIP TO 712

708) CHECK 705:

NOT ASKED-SKIP TO 709
24 OR MORE MONTHS OR 02 OR MORE YEARS-SKIP TO 709
00-23 MONTHS OR 00-01 YEARS-SKIP TO 711

709) CHECK 704:
WANTS TO HAVE A/ANOTHER CHILD--You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy?
Any other reason?

WANTS NO MORE/NONE--You have said that you do not want any (more) children Can you tell me why you are not using a method to prevent?
Any other reason?
RECORD ALL REASONS MENTIONED.

NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN'T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
OTHER (SPECIFY) X
DON'T KNOW Z

710) CHECK 303: Using a contraceptive method?

NOT ASKED
NO, NOT CURRENTLY USING
YES, CURRENTLY USING-SKIP TO 712

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

YES 1
NO 2
DON'T KNOW 8

712) CHECK 216:
HAS LIVING CHILDREN- If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00-SKIP TO 714
NUMBER
OTHER (SPECIFY) 96-SKIP TO 714

713) How many of these children would you like to be boys, how many would you like to be girls, and for how many would it not matter if it's a boy or a girl?

NUMBER OF BOYS __ __
NUMBER OF GIRLS__ __
EITHER__ __
OTHER (SPECIFY) 96

714) In the last few months have you:

Heard about family planning on the radio?
YES 1
NO 2
Seen anything about family planning on the television?
YES 1
NO 2
Read about family planning in a newspaper or magazine?
YES 1
NO 2
Seen any images about family planning on sign(s)?
YES 1
NO 2

716) CHECK 601:

YES, CURRENTLY MARRIED
YES, CURRENTLY LIVING WITH A MAN
NO, NOT IN UNION-SKIP TO 801

717) CHECK 303: Using a contraceptive method?

CURRENTLY USING
NOT CURRENTLY USING OR NOT ASKED-SKIP TO 720

718) Would you say that using contraception is mainly your decision, mainly your (HUSBAND'S/PARTNER'S) decision, or did you both decide together?

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

719) CHECK 304:

NEITHER STERILIZED
HE OR SHE STERILIZED --SKIP TO 801

720) Does your (HUSBAND/PARTNER) want the same number of children that you want, or does he want more or fewer than you want?

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8

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

801) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN
FORMERLY MARRIED/LIVING WITH A MAN-SKIP TO 803
NEVER MARRIED AND NEVER LIVED WITH A MAN-SKIP TO 807

802) How old was your (husband/partner) on his last birthday?

AGE_____

803) Did your (last) (husband/partner) ever attend school?

YES 1
NO 2-SKIP TO 806

804) What is the highest level of education he attended: primary, secondary, technical secondary, professional secondary, higher, or professional higher?

PRIMARY 1
SECONDARY 2
TECHNICAL SECONDARY 3
PROFESSIONAL SECONDARY 4
HIGHER 5
PROFESSIONAL HIGHER 6
DON'T KNOW 8-SKIP TO 806

805) What is the highest (grade/form/year) he completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

GRADE/FORM/YEAR___

806) CHECK 801:
CURRENTLY MARRIED/LIVING WITH A MAN
What is your (husband's/partner's) occupation? That is, what kind of work does he mainly do?

FORMERLY MARRIED/LIVED WITH A MAN
What was your (last) (husband's/partner's) occupation? That is, what kind of work did he mainly do?

________________________________ __ __

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

YES 1-SKIP TO 811
NO 2

808) 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?

YES 1-SKIP TO 811
NO 2

809) 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?

YES 1-SKIP TO 811
NO 2

810) Have you done any work in the last 12 months?

YES 1
NO 2-SKIP TO 815

811) What is your occupation, that is, what kind of work do you mainly do?

_______________

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

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

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

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

814) Are you paid or do you ear in cash or in kind for this work or are you not paid at all?

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4

815) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN
NOT IN UNION-SKIP TO 823

816) CHECK 814:

CODE 1 OR 2 CIRCLED
OTHER-SKIP TO 819

817) Who usually decides how the money you earn will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
OTHER (SPECIFY) 6

818) Would you say that the money that you earn is more than what your (husband/partner) earns, less than what he earns, or about the same?

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER HAS NO EARNINGS 4-SKIP TO 820
DON'T KNOW 8

819) Who usually decides how the money your (HUSBAND/PARTNER) earnings will be used: you, your (husband/partner), or you and your (HUSBAND/PARTNER) jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND HAS NO EARNINGS 4
OTHER (SPECIFY) 6

820) Who usually makes decisions about health care for yourself: you, your (HUSBAND/PARTNER), you and your (HUSBAND/PARTNER) jointly, or someone else?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY) 6

821) Who usually makes decisions about making major household purchases?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY) 6

822) Who usually makes decisions about visits to your family or relatives?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY) 6

823) Do you own this or any other house either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

824) Do you own any land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

825) Presence of others at this point (present and listening, present but not listening, or not present)

CHILDREN LESS THAN 10
PRES/LISTEN 1
PRES./NOT LISTEN 2
NOT PRES. 3
HUSBAND
PRES/LISTEN 1
PRES./NOT LISTEN 2
NOT PRES. 3
OTHER MALES
PRES/LISTEN 1
PRES./NOT LISTEN 2
NOT PRES. 3
OTHER FEMALES
PRES/LISTEN 1
PRES./NOT LISTEN 2
NOT PRES. 3

826) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
YES 1
NO 2
DON'T KNOW 8
If she neglects the children?
YES 1
NO 2
DON'T KNOW 8
If she argues with him?
YES 1
NO 2
DON'T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON'T KNOW 8
If she burns the food?
YES 1
NO 2
DON'T KNOW 8

Section 8a. Maternal Mortality

827) 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.
Did your mother give birth to any children other than yourself?

YES 1
NO 2-SKIP TO 834

828) How many boys did your mother have who are still living?

BOYS LIVING __ __

829) Other than yourself, how many girls did your mother have who are still living?

GIRLS LIVING__ __

830) How many boys did your mother have who died?

BOYS DIED__ __

831) How many girls did your mother have who died?

GIRLS DIED__ __

832) Did your mother give birth to any other children, who you don't know if they are living or dead?

YES 1
NO 2-SKIP TO 834

833) How many other children did your mother give birth to, who you don't know if they are living or dead?

OTHER CHILDREN __ __

834) ADD THE ANSWERS FORM 828, 829, 830, 831, AND 833
ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL

TOTAL__ __

835) CHECK 834:
Just to make sure that I've understood, including yourself, your mother gave birth to _____ children total. Is that correct?

YES
NO-PROBE AND CORRECT 827-834 AS NECESSARY

836) CHECK 834:

TWO OR MORE BIRTHS
ONLY ONE BIRTH (RESPONDENT ONLY)-SKIP TO 900

837) How many of these births did your mother have before you were born?

NUMBER OF PRECEDING BIRTHS __ __

Now I would like to make a list of all your brothers and sisters, whether they are still alive or not, starting with the oldest.
RECORD THE NAME OF ALL BROTHERS AND SISTERS FROM THE SAME BIOLOGICAL MOTHER.

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

839) Is (NAME) male or female?

MALE 1
FEMALE 2

840) Is (NAME) still alive?

YES 1
NO 2-GO TO 842
DK 8-GO TO [2,3,4, ETC]

841) How old is (NAME)?
GO TO [2,3,4,ETC]

__ __

842) How many years ago did (NAME) die?

__ __

843) How old was (NAME) when he/she died?
IF DON'T KNOW, PROBE:
Did (Name) die before the age of 12?

IF YES, RECORD 95.
IF NO, ASK OTHER QUESTIONS TO GET AN ESTIMATE, FOR EXAMPLE: Did (Name) die before getting married?

__ __

IF MAN, OR WOMAN DECEASED BEFORE AGED 12, GO TO 2, 3, 4,ETC

844) Was (NAME) pregnant when she died?

YES 1-GO TO 847
NO 2

845) Did (NAME) die during childbirth?

YES 1 -- GO TO 847
NO 2

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

YES 1
NO 2

847) How many live born children did (name) give birth to during her lifetime?
Go to 2, 3, 4, etc.

__ __

If no other brothers or sisters, go to 900 (HIV/AIDS section)

SECTION 9. HIV/AIDS

900) Check cover of questionnaire: Household selected for men's' survey and HIV test?

YES
NO 2-SKIP TO 1200

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

YES 1
NO 2-SKIP TO 937

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

906) Can people get the AIDS virus because of witchcraft or other supernatural means?

YES
NO 2
DON'T KNOW 8

907) Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

908) Can the virus that causes AIDS be transmitted from a mother to a baby?

During pregnancy?
YES 1
NO 2
DON'T KNOW 8
During delivery?
YES 1
NO 2
DON'T KNOW 8
By breastfeeding?
YES 1
NO 2
DON'T KNOW 8

909) CHECK 908:

AT LEAST ONE YES
OTHER-SKIP TO 911

910) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?

YES 1
NO 2
DK 8

911) CHECK 208 AND 215:

LAST BIRTH SINCE JANUARY 2012
NO BIRTHS --SKIP TO 926
LAST BIRTH BEFORE JANUARY 2012-SKIP TO 926

912) CHECK 408 FOR LAST BIRTH

HAD ANTENATAL CARE
NO ANTENATAL CARE-SKIP TO 920

913) CHECK FOR PRESENCE OF OTHERS, BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

914) During any of the antenatal visits for your last birth were you given any information about:

Babies getting the AIDS virus from their mother?
YES 1
NO 2
DON'T KNOW 8
Things that you can do to prevent getting the AIDS virus?
YES 1
NO 2
DON'T KNOW 8
Getting tested for the AIDS virus?
YES 1
NO 2
DON'T KNOW 8

915) Were you offered a test for that AIDS virus as part of your antenatal care?

YES 1
NO 2

916) I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

YES 1
NO 2-SKIP TO 920

917) Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)______________
PUBLIC SECTOR
VOLUNTARY TESTING CENTER 11
HOSPITAL/MATERNITY 12
MILITARY HOSPITAL/GARRISON 13
HEALTH CENTER/FREE CLINIC 14
POLYCLINIC 15
PHARMACY OF HOSPITAL/HEALTH CENTER 16
OTHER PUBLIC SECTOR (SPECIFY) 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/DOCTOR'S OFFICE 22
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING 23
PRIVATE HEALTH CENTER 24
BUSINESS HEALTH CENTER 25
CARE OFFICE/INFIRMARY 26
PHARMACY/PHARMACY DEPOT 27
CHADIAN SOCIAL MARKETING ASSOCIATION 28
DIOCESAN CENTER FOR MEDICAL ACTION (CEDIAM) 29
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 30
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER 31
COMMUNITY VOLUNTEER TESTING CENTER 40
OTHER (SPECIFY) 96
DON'T KNOW 98

918) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2-SKIP TO 924

919) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

YES 1
NO 2
DON'T KNOW 8

ALL SKIP TO 924

920) CHECK 434 FOR LAST BIRTH

ANY CODE 21-36 CIRCLED
OTHER-SKIP TO 926

921) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

YES 1
NO 2

922) I don't want to know the results, but were you tested for the AIDS virus at that time?

YES 1
NO 2-SKIP TO 926

923) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2

924) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

YES 1-SKIP TO 927
NO 2

925) How many months ago was your most recent HIV test?

MONTHS AGO__ __
TWO OR MORE YEAR AGO 96

ALL SKIP TO 932

926) I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

YES 1
NO 2-SKIP TO 930

927) How many months ago was your most recent HIV test?

MONTHS AGO
TWO OR MORE YEARS AGO 95

928) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2

929) Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE)___________
PUBLIC SECTOR
VOLUNTARY TESTING CENTER 11
HOSPITAL/MATERNITY 12
MILITARY HOSPITAL/GARRISON 13
HEALTH CENTER/FREE CLINIC 14
SECTOR-SPECIFIC PROGRAM FOR THE FIGHT AGAINST AIDS 15
POLYCLINIC 16
PHARMACY OF HOSPITAL/HEALTH CENTER 17
AL NADJMA CENTER [##TRANSLATOR NOTE: HIV/AIDS TESTING CENTER] 18
OTHER PUBLIC SECTOR (SPECIFY)_______ 19
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL 21
CLINIC/DOCTOR'S OFFICE 22
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING 23
PRIVATE HEALTH CENTER 24
BUSINESS HEALTH CENTER 25
CARE OFFICE/INFIRMARY 26
PHARMACY/PHARMACY DEPOT 27
CHADIAN SOCIAL MARKETING ASSOCIATION 28
DIOCESAN CENTER FOR MEDICAL ACTION (CEDIAM) 29
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 30
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER 31
COMMUNITY VOLUNTEER TESTING CENTER 40
OTHER (SPECIFY) 96

ALL SKIP TO 932

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

YES 1
NO 2-SKIP TO 932

931) Where is that?
PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE
ANY OTHER PLACE?
RECORD ALL MENTIONED

NAME OF PLACE(S)___________
PUBLIC SECTOR
VOLUNTARY TESTING CENTER A
HOSPITAL/MATERNITY B
MILITARY HOSPITAL/GARRISON C
HEALTH CENTER/FREE CLINIC D
SECTOR-SPECIFIC PROGRAM FOR THE FIGHT AGAINST AIDS E
POLYCLINIC F
PHARMACY OF HOSPITAL/HEALTH CENTER G
AL NADJMA CENTER [##TRANSLATOR NOTE: HIV/AIDS TESTING CENTER] H
OTHER PUBLIC SECTOR (SPECIFY) I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL J
CLINIC/DOCTOR'S OFFICE K
CHADIAN ASSOCIATION FOR FAMILY WELL-BEING L
PRIVATE HEALTH CENTER M
BUSINESS HEALTH CENTER N
CARE OFFICE/INFIRMARY O
PHARMACY/PHARMACY DEPOT P
CHADIAN SOCIAL MARKETING ASSOCIATION Q
DIOCESAN CENTER FOR MEDICAL ACTION (CEDIAM) R
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) S
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER T
COMMUNITY VOLUNTEER TESTING CENTER U
OTHER (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DK/NOT SURE/DEPENDS 8

934) If a member of your family became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

935) 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?

SHOULD BE ALLOWED 1
SHOULD BE ALLOWED 2
DK/NOT SURE/DEPENDS 8

936) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

YES 1
NO 2
DK/NOT SURE/DEPENDS 8

937) 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?

YES 1
NO 2

938) CHECK 613:

HAS HAD SEXUAL INTERCOURSE
NEVER HAD SEXUAL INTERCOURSE-SKIP TO 946

939) CHECK 937: Heard about other sexually transmitted infections?

YES
NO --SKIP TO 941

940) 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?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

943) CHECK 940, 941, AND 942:

HAS HAD AN INFECTION (ANY 'YES')
HAS NOT HAD AN INFECTION OR DOES NOT KNOW-SKIP TO 946

944) The last time you had (infection from 940/941/942), did you seek any kind of advice or treatment?

YES 1
NO 2-SKIP TO 946

945) Where did you go?

PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE(S))_______

ANY OTHER PLACE?
RECORD ALL MENTIONED

PUBLIC SECTOR
HOSPITAL/MATERNITY A
MILITARY HOSPITAL/GARRISON B
HEALTH CENTER/FREE CLINIC C
POLYCLINIC D
PHARMACY OF HOSPITAL/HEALTH CENTER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL G
CLINIC/DOCTOR'S OFFICE H
PRIVATE HEALTH CENTER I
BUSINESS HEALTH CENTER J
CARE OFFICE/INFIRMARY K
PHARMACY/PHARMACY DEPOT L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
PUBLIC/PRIVATE SECTOR
PHARMACY/VILLAGE HEALTH CENTER N
OTHER
SHOP/BAR/MARKET O
TRADITIONAL PRACTITIONER P
FIRST AID WORKER Q
FRIENDS/NEIGHBORS/RELATIVES R
OTHER (SPECIFY) X

946) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

YES 1
NO 2
DON'T KNOW 8

947) Is a wife justified in refusing to have sex with her husband when she knows he has sex with (another woman/women other than her co-spouse(s))?

YES 1
NO 2
DON'T KNOW 8

948) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A HUSBAND
NOT IN UNION-SKIP TO 1001

949) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?

YES 1
NO 2
DEPENDS/NOT SURE 8

950) Could you ask your (husband/partner) to use a condom if you wanted him to?

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 10. INJECTIONS
(Only for households selected for the men's survey and the HIV test)

1001) Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?

IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD 90.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS __ __
NONE 00-SKIP TO 1004

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?

IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

NUMBER OF INJECTIONS __ __
NONE 00 (SKIP TO 1004)

1003) The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

YES 1
NO 2
DON'T KNOW 8

1004) 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 to the doctor?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Getting money needed for advice or treatment
BIG PROBLEM 1
NOT A BIG PROBLEM 2
The distance to the health facility
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Not wanting to go alone?
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1005) Are you covered by any health insurance?

YES 1
NO 2-SKIP TO 1100

1006) What type of health insurance are you covered by?
RECORD ALL MENTIONED

MUTUAL HEALTH ORGANIZATION A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY) X

SECTION 11. DOMESTIC VIOLENCE
(Only for households selected for the men's survey and the HIV test)

1101) Check cover page of household questionnaire: Woman selected for domestic violence section

YES
NO (SKIP TO 1421)

1101) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
PRIVACY NOT POSSIBLE 2-SKIP TO 1132

READ TO THE RESPONDENT:
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Chad. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.

1102) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN
FORMERLY MARRIED/LIVED WITH A MAN (READ IN PAST TENSE AND USE 'LAST' WITH HUSBAND/PARTNER)
NEVER MARRIED/NEVER LIVED WITH A MAN-SKIP TO 1116

1103) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?

a) He (is/was) jealous or angry if you (talk/talked) to other men?
YES 1
NO 2
DON'T KNOW 8
b) He frequently (accuses/accused) you of being unfaithful?
YES 1
NO 2
DON'T KNOW 8
c) He (does/did) not permit you to meet your female friends?
YES 1
NO 2
DON'T KNOW 8
d) He (tries/tried) to limit your contact with your family?
YES 1
NO 2
DON'T KNOW 8
e) He (insists/insisted) on knowing where you (are/where) at all times?
YES 1
NO 2
DON'T KNOW 8

1104) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.
a) (Does/did) your last husband/partner ever:
b) How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) say or do something to humiliate you in front of others?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

b) Threaten to hurt or harm you or someone you care about?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

c) insult you or make you feel bad about yourself?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1105) a) Did your (last) (husband/partner) ever do any of the following things to you:
b) How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) push you, shake you, or throw something at you?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

b) slap you?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

c) twist your arm or pull your hair?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

d) punch you with his fist or with something that could hurt you?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

e) kick you, drag you, or beat you up?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

f) try to chock you or burn you?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

g) threaten you with a knife, gun, or other type of weapon?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

h) physically force you to have sexual intercourse with him even when you did not want to?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

i) physically force you to perform other sexual acts you did not want to?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

j) Force you with threats or in any other way to perform sexual acts you did not want to?

EVER
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1106) CHECK 1105 (a-j):

AT LEAST ONE YES
NOT A SINGLE YES-SKIP TO 1109

1107) How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD 00.

NUMBER OF YEARS __ __
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

1108) Did the following ever happen as a result of what your (last) husband/partner did to you:
a) You had cuts, bruises, or aches?

YES 1
NO 2

b) you had eye injuries, sprains, dislocations, or burns?

YES 1
NO 2

c) you had deep wounds, broken bones, broken teeth, or any other serious injury?

YES 1
NO 2

1109) Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?

YES 1
NO 2-SKIP TO 1111

1110) In the last 12 months, how often have you done this to your (last) husband/partner: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1111) Does (did) your husband/partner drink (alcohol)?

YES 1
NO 2 -SKIP TO 1113

1112) How often does (did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1113) Are (were) you afraid of your (last) (husband/partner): many times, sometimes, or never?

MANY TIMES AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1114) CHECK 609:

MARRIED MORE THAN ONCE
MARRIED ONLY ONCE-SKIP TO 1116

1115) A) So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

B) How long ago did this last happen?

a) Did any previous (husband/partner) ever hit, slap, kick or do anything else to hurt you physically?
B) How long ago did this last happen?\

EVER
YES 1
NO 2
0-11 Months Ago
YES 1
NO 2
12 Or More Months Ago
YES 1
NO 2
DON'T REMEMBER
YES 1
NO 2

b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
B) How long ago did this last happen?

EVER
YES 1
NO 2
0-11 Months Ago
YES 1
NO 2
12 Or More Months Ago
YES 1
NO 2
DON'T REMEMBER
YES 1
NO 2

1116) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN:
From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, or done anything else to hurt you physically?

NEVER MARRIED/NEVER LIVED WITH A MAN:
From the time you were 15 years old has anyone hit you, slapped you, kicked you, or done anything else to hurt you physically?

YES 1
NO 2-SKIP TO 1119
REFUSED TO ANSWER/NO ANSWER 6-SKIP TO 1119

1117) Who has physically hurt you in this way?
Anyone else?
RECORD ALL MENTIONED

MOTHER/FATHER'S WIFE A
FATHER/MOTHER'S HUSBAND B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT BOYFRIEND F
EX-BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAWS J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
CO-SPOUSE N
Other (specify) X

1118) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1119) CHECK 201, 226, AND 230:

EVER BEEN PREGNANT (YES TO 201 OR 226 OR 230)
NEVER BEEN PREGNANT-SKIP TO 1122

1120) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 -SKIP TO 1122

1121) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED

CURRENT HUSBAND/PARTNER A
MOTHER/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/PARTNER G
CURRENT BOYFRIEND H
EX-BOYFRIEND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
OTHER IN-LAWS L
TEACHER M
EMPLOYER/SOMEONE AT WORK N
POLICE/SOLDIER O
CO-SPOUSE P
OTHER (SPECIFY) X

1122) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN
NEVER MARRIED/NEVER LIVED WITH A MAN-SKIP TO 1122B

1122a) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).

At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1-SKIP TO 1123
NO 2-SKIP TO 1124A
REFUSED TO ANSWER/NO ANSWER 3-SKIP TO 1124A

1122b) At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1
NO 2-SKIP TO 1126
REFUSED TO ANSWER/NO ANSWER 3-SKIP TO 1126

1123) Who was the person who was forcing you the first time?

CURRENT HUSBAND/PARTNER 01
FORMER HUSBAND/ PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY) 96

1124) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?

YES 1-SKIP TO 1125
NO 2-SKIP TO 1125

1124a) CHECK 1105a (h-j) And 1115a (b):

AT LEAST ONE YES
NOT A SINGLE YES-SKIP TO 1126

1125) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: How old were you the first time someone, including (your/any) (husband/partner), physically forced you to have sexual intercourse or perform any other sexual acts when you did not want to?

NEVER MARRIED/NEVER LIVED WITH A MAN: How old were you the first time someone physically forced you to have sexual intercourse or perform any other sexual acts when you did not want to?

AGE IN COMPLETED YEARS __ __
DON'T KNOW 98

1126) CHECK 1105 (a-j), 1115a (a,b), 1116, 1120, 1122a, AND 1122b:

AT LEAST ONE YES
NOT A SINGLE YES-SKIP TO 1130

1127) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

YES 1
NO 2-SKIP TO 1129

1128) From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.

OWN FAMILY A
HUSBAND'S/PARTNER'S FAMILY B
CURRENT/FORMER HUSBAND/PARTNER C
CURRENT/FORMER BOYFRIEND D
FRIEND E
NEIGHBOR F
RELIGIOUS LEADER G
DOCTOR/MEDICAL PERSONNEL H
POLICE I
LAWYER J
SOCIAL SERVICE ORGANIZATION K
ASSOCIATION/NGO L
OTHER (SPECIFY) X

ALL SKIP TO 1130

1129) Have you ever told anyone about this?

YES 1
NO 2

1130) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1131) Did you have to interrupt the interview because some adult was trying to listen, or came into the room, or interfered in any other way?

HUSBAND
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT
YES ONCE 1
YES, MORE THAN ONCE 2
NO 3

1132) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

____________________
____________________
____________________

SECTION 12. FISTULA

1200) Check cover page of questionnaire: household selected for men's survey and HIV test?

YES 1-SKIP TO 1421
NO 2

1201) Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a sexual assault or after pelvic surgery. Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

YES 1-SKIP TO 1203
NO 2

1202) Have you ever heard of this problem?

YES 1-SKIP TO 1301
NO 2-SKIP TO 1301

1203) Did this problem start after you delivered a baby or had a stillbirth?

AFTER DELIVERY 1
AFTER STILLBIRTH 2
NO 3-SKIP TO 1205

1204) Did this problem start after a normal labor and delivery, or after a very difficult labor and delivery?

NORMAL LABOR/DELIVERY 1
VERY DIFFICULT LABOR/DELIVERY 2

BOTH SKIP TO 1206

1205) What do you think caused this problem?

SEXUAL ASSAULT 1
PELVIC SURGERY 2
OTHER (SPECIFY) 6
DON'T KNOW 8-SKIP TO 1207

1206) How many days after [CAUSE OF PROBLEM FROM 1203 OR 1205] did the leakage start?

NUMBER OF DAYS AFTER DELIVERY/OTHER EVENT __ __
ENTER 90 IF 90 DAYS OR MORE

1207) Have you sought treatment for this condition?

YES 1-SKIP TO 1209
NO 2

1208) Why have you not sought treatment?
PROBE AND RECORD ALL MENTIONED

DO NOT KNOW CAN BE FIXED A
DO NOT KNOW WHERE TO GO B
TOO EXPENSIVE C
TOO FAR D
POOR QUALITY OF CARE E
COULD NOT GET PERMISSION F
EMBARRASSMENT G
PROBLEM DISAPPEARED H
OTHER (SPECIFY) X

ALL SKIP TO 1301

1209) From whom did you last seek treatment?

HEALTH PROFESSIONAL
DOCTOR 1
NURSE/MIDWIFE 2
OTHER PERSON
COMMUNITY/VILLAGE HEALTH WORKER 3
OTHER 6

1210) Did you have an operation to fix the problem?

YES 1
NO 2

1211) Did the treatment stop the leakage completely?
If no, did the treatment reduce the leakage?

YES, STOPPED COMPLETELY 1
NOT STOPPED BUT REDUCED 2
NOT STOPPED AT ALL 3

SECTION 13. FEMALE GENITAL CUTTING

1301) Have you ever heard of female circumcision?

YES 1-SKIP TO 1303
NO 2

1302) In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

YES 1
NO 2-SKIP TO 1401

1303) Have you yourself ever been circumcised?

YES 1
NO 2-SKIP TO 1309

1304) Now I would like to ask you what was done to you at that time.
Was any flesh removed from the genital area?

YES 1 --SKIP TO 1306
NO 2
DON'T KNOW 8

1305) Was the genital area just nicked without removing any flesh?

YES 1
NO 2
DON'T KNOW 8

1306) Was your genital area sewn closed?

YES 1
NO 2
DON'T KNOW 8

1307) How old were you when you were circumcised?
IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE, PROBE TO GET AN ESTIMATE.

AGE IN COMPLETED YEARS__ __
AS A BABY/DURING INFANCY 95
DON'T KNOW 98

1308) Who performed the circumcision?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
MATRON/TRAD. BIRTH ATTENDANT 12
OTHER TRADITIONAL (SPECIFY) 16
HEALTH PROFESSIONAL
DOCTOR 21
MEDICAL ASSISTANT 22
NURSE/MID-WIFE 23
OTHER HEALTH PROFESSIONAL (SPECIFY) 26
DON'T KNOW 98

1309) CHECK 213, 215, 216:

HAS ONE OR MORE LIVING DAUGHTERS BORN IN 1999 OR LATER
HAS NO LIVING DAUGHTERS BORN IN 1999 OR LATER-SKIP TO 1316

CHECK 213, 215, AND 216: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1999 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE DAUGHTERS. BEGIN WITH THE YOUNGEST DAUGHTER. (IF THERE ARE MORE THAN 3 DAUGHTERS, USE ADDITIONAL QUESTIONNAIRES).
NOW I WOULD LIKE TO ASK YOU SOME QUESTIONS ABOUT YOUR (DAUGHTER/DAUGHTERS).

1310) BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1999 OR LATER

YOUNGEST LIVING DAUGHTER
BIRTH HISTORY NUMBER __ __
NAME______________
NEXT-TO-YOUNGEST LIVING DAUGHTER
BIRTH HISTORY NUMBER __ __
NAME______________
SECOND-TO-YOUNGEST LIVING DAUGHTER
BIRTH HISTORY NUMBER __ __
NAME______________

1311) Is (Name Of Daughter) circumcised?

YES 1
NO 2-(GO TO 1311 IN NEXT COLUMN OR IF NO MORE DAUGHTERS, GO TO 1316)

1312) How old was (NAME OF DAUGHTER) when she was circumcised?
IF THE RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE.

AGE IN COMPLETED YEARS __ __
DON'T KNOW 98

1313) Was her genital area sewn closed?
PROBE: was the genital area closed?

YES 1
NO 2
DON'T KNOW 8

1314) Who performed the circumcision?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
MATRON/TRAD. BIRTH ATTENDANT 12
OTHER TRADITIONAL (SPECIFY) 16
HEALTH PROFESSIONAL
DOCTOR 21
MEDICAL ASSISTANT 22
NURSE/MID-WIFE 23
OTHER HEALTH PROFESSIONAL (SPECIFY) 26
DON'T KNOW 98

1315) GO BACK TO 1311 IN NEXT COLUMN; OR, IF NO MORE DAUGHTERS, GO TO 1316

1316) Do you believe that female circumcision is required by your religion?

YES 1
NO 2
NO RELIGIONS 3
DON'T KNOW 8

1317) Do you think that female circumcision should be continued, or should it be stopped?

CONTINUED 1
STOPPED 2
DEPENDS 3
DON'T KNOW 8

SECTION 14. CHILD DEVELOPMENT AND EARLY LEARNING

1401) CHECK q. 217 AND 218:
Does a child between ages 0 and 4 live with his/her mother in this household (217=0-4 years completed and 218=1)?

YES
NO 2-SKIP TO 1421

1402) CHECK Q 217:
SELECT THE YOUNGEST CHILD BETWEEN AGES 0 AND 4, RECORD HIS/HER NAME AND LINE NUMBER

NAME OF YOUNGEST CHILD FROM Q. 212_____________
LINE NUMBER OF YOUNGEST CHILD FROM 219__ __

1403) Now I would like to ask you some questions about (name of child from q. 1402), your youngest child between ages 0 and 4.

1404) How many children's books and picture books do you have for (name)?

NONE 00
NUMBER OF CHILDREN'S BOOKS 0_
TEN OR MORE BOOK 10

1405) I would like to ask you what objects (name) uses to play with while at home.

Does he/she play with:

a) homemade toys (like dolls, cars, or other homemade toys)?
YES 1
NO 2
DON'T KNOW 8
b) Toys from a store or a manufacture?
YES 1
NO 2
DON'T KNOW 8
c) Household objects (like bowls or pots), or objects found outside (like sticks, stones, animals, shells, or leaves)?
YES 1
NO 2
DON'T KNOW 8

IF THE RESPONDENT SAYS "YES" TO ONE OF THE ABOVE CATEGORIES, PROBE TO DETERMINE PRECISELY WHAT THE CHILD PLAYS WITH TO BE CERTAIN OF THE RESPONSE.

1406) Sometimes the adults who take care of the children have to leave the house to go shopping, do the laundry, or for other reasons and have to leave the young children.

During the last week, how many days was (name):

a) Left alone for more than one hour?
NUMBER OF DAYS ALONE FOR MORE THAN ONE HOUR __ __
b) Left in the care of another child (meaning someone under 10 years old) for more than one hour?
NUMBER OF DAYS LEFT WITH CHILD FOR MORE THAN ONE HOUR__ __

IF "NEVER," RECORD 0. IF DON'T KNOW, RECORD 8.

1407) CHECK Q. 217 AND 218:
Does a child ages 3 or 4 live in this household (217=3 or 4 years completed and 218=1)?

YES-NAME OF OLDEST CHILD 3 OR 4 YEARS OLD_____________
NO-SKIP TO 1421
LINE NUMBER OF OLDEST CHILD IN Q. 219__ __

1408) Is (name) in a preschool education program or an early learning class, in a public or private establishment, including nursery school or a community child-care center?

YES 1
NO 2-SKIP TO 1410
DON'T KNOW 8-SKIP TO 1410

1409) During the last seven days, approximately how many hours did (name) spend at this place?

NUMBER OF HOURS__ __

1410) During the last three days did you or a member of your family age 15 or old participate with (name) in one of the following activities:
IF YES, ASK: Who participated in this activity with (name)?
CIRCLE ALL MENTIONED.

a) Read books or looked at illustrated books with (name)?

YES 1- Who participated in this activity with (name)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
NO 2

b)Told stories to (name)?

YES 1- Who participated in this activity with (name)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
NO 2

c) Sang songs to (name), or with (name), including lullabies?

YES 1- Who participated in this activity with (name)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
NO 2

d) Took (name) for a walk outside of the house, the residence, the courtyard or the enclosure wall?

YES 1- Who participated in this activity with (name)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
NO 2

e) Played with (name)?

YES 1- Who participated in this activity with (name)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
NO 2

f) Spent time with (name), naming, counting, and/or drawing?

YES 1- Who participated in this activity with (name)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
NO 2

1411) Now I would like to ask you some questions about the health and development of your child. Children do not all develop in the same manner and at the same speed. Some, for example, walk earlier than others. These questions relate to several aspects of your child's development.

Does (name) know or can he/she recite at least ten letters from the alphabet?

YES 1
NO 2
DK 8

1412) Can (name) read at least four simple, common words?

YES 1
NO 2
DK 8

1413) Can (name) list and recognize all digits from 1 to 10?

YES 1
NO 2
DK 8

1414) Can (name) grasp with two fingers a small object from the ground, like a stick or a pebble?

YES 1
NO 2
DK 8

1415) Is (name) ever too sick to play?

YES 1
NO 2
DK 8

1416) Is (name) able to follow simple instructions to do something correctly?

YES 1
NO 2
DK 8

1417) When you give (name) something to do, is he/she able to do it independently?

YES 1
NO 2
DK 8

1418) Does (name) get along well with other children?

YES 1
NO 2
DK 8

1419) Does (name) kick, bit, or hit other children or adults?

YES 1
NO 2
DK 8

1420) Is (name) easily distracted?

YES 1
NO 2
DK 8

1421) RECORD THE TIME

HOUR__ __
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 SUPERVISOR_______________
DATE______

EDITOR'S OBSERVATIONS

_____________________
_____________________
_____________________

NAME OF EDITOR___________
DATE________