REGION_____
DISTRICT_____
WARD______
E.A. NUMBER_______
TRCHS CLUSTER NUMBER_____
HOUSEHOLD NUMBER_____
DAR ES SALAAM, SMALL CITY, TOWN, RURAL/VILLAGE
SMALL CITY* 2
TOWN 3
RURAL/VILLAGE 4
*(Small cities are: Mwanza, Arusha, Morogoro, Dodoma, Moshi, Tanga, Iringa, Mbeya and Tabora. All other urban areas are towns.)
NAME OF HOUSEHOLD HEAD________
NAME AND LINE NUMBER OF MAN _____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME___
RESULT___
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) __________7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE___
TIME____
FINAL VISIT
DAY___
MONTH___
YEAR 19__
INTER. ID NUMBER___
RESULT_____
FIELD EDITOR
NAME____
DATE____
OFFICE EDITOR____
KEYED BY____
SECTION 1. RESPONDENT'S BACKGROUND
INTRODUCTION
Hello. My name is __________ and I am working with the National Bureau of Statistics. We are conducting a national survey about the health of women and men and children. We would very much appreciate your participation in this survey. I would like to ask you about your health. This information will help the government to plan health services. The survey usually takes between 20 and 45 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
Signature of interviewer: ________
Date: _______
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END SURVEY)
MINUTES_____
AFTERNOON 2
EVENING, NIGHT 3
102. First I would like to ask some questions about you and your household.
For most of the time until you were 12 years old, did you live in Dar es Salaam, another urban area or in a rural area?
OTHER URBAN AREA 2
RURAL AREA/VILLAGE 3
103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)
104. Just before you moved here, did you live in Dar es Salaam, another urban area or in a rural area?
OTHER URBAN AREA 2
RURAL AREA/VILLAGE 3
105. In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.
107. Have you ever attended school?
NO 2 (GO TO 111)
108. What is the highest formal school you completed?
STANDARD 1 01
STANDARD 2 02
STANDARD 3 03
STANDARD 4 04
STANDARD 5 05
STANDARD 6 06
STANDARD 7 07
STANDARD 8 08
FORM 1 09
FORM 2 10
FORM 3 11
FORM 4 12
FORM 5 13
FORM 6 14
UNIVERSITY 15
OTHER 96
FORM 1 OR HIGHER (GO TO 114)
111. Now I would like you to read out loud as much of this sentence as you can.
SHOW CARD TO RESPONDENT.
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD, REFUSED, OTHER 4
114. Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
115. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
116. Do you watch television almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
CATHOLIC 2
PROTESTANT 3
NONE 4
OTHER 6
118. Do you have any children? I mean your own children, not ones you may have adopted or are caring for but are not your own biological children.
NO 2 (GO TO 301)
119. How many sons do you have?
And how many daughters do you have?
IF NONE, RECORD '00'.
120. So you have TOTAL ___ children. Is that correct?
NOTE: THERE IS NO SECTION 2 IN THE MAN'S QUESTIONNAIRE
Now I would like to talk to you about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY.
CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.
301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK:
Have you ever heard of (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
302. Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE "YES" (EVER USED) (GO TO 310)
304. Have you ever used anything or tried in any way to delay or avoid getting pregnant?
NO 2 (GO TO 328)
306. What have you used or done?
CORRECT 302 AND 303 (AND 301 IF NECESSARY.)
310. Are you currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (GO TO 328)
311. Which method are you using?
311A. CIRCLE 'A' FOR FEMALE STERILIZATION.
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTIONS FOR HIGHEST METHOD ON LIST.
MALE STERILIZATION B
PILL C (GO TO 319)
IUD D (GO TO 319)
INJECTIONS E (GO TO 319)
IMPLANTS F (GO TO 319)
CONDOM G (GO TO 318)
FEMALE CONDOM H (GO TO 319)
DIAPHRAGM/FOAM/JELLY I (GO TO 319)
LACT. AMEN. METHOD J (GO TO 319)
PERIODIC ABSTINENCE K (GO TO 319)
WITHDRAWAL L (GO TO 319)
OTHER____________ (SPECIFY) X (GO TO 319)
313. Where did the sterilization take place?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
DISTRICT HOSPITAL 12
GOVT. HEALTH CENTER 13
DISPENSARY/PARASTATAL FACILITY 14
VILLAGE HEALTH POST 15
PRIVATE DOCTOR/CLINIC/HOSP 22
OTHER PRIVATE MEDICAL (SPECIFY)________________ 26
DON'T KNOW 98
316. In what month and year was the sterilization performed?
318. What brand of condoms did you use the last time?
DOES NOT KNOW 98
319. For how many months have you been using (METHOD) continuously?
IF LESS THAN 1 MONTH RECORD '00'.
8 YEARS OR LONGER 96
327. Where did you obtain (CURRENT METHOD) the last time?
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
DISTRICT HOSPITAL 12 (GO TO 333)
GOVT. HEALTH CENTER 13 (GO TO 333)
DISPENSARY/PARASTATAL FACILITY 14 (GO TO 333)
VILLAGE HEALTH POST/WORKER 15 (GO TO 333)
PRIVATE DOCTOR/CLINIC/HOSP 22 (GO TO 333)
PHARMACY/MEDICAL STORE 23 (GO TO 333)
CBD WORKER 24 (GO TO 333)
CHURCH 32 (GO TO 333)
FRIEND/RELATIVE/NEIGHBOR 33 (GO TO 333)
HEALTH EDUCATION/BAR GIRLS 34 (GO TO 333)
DON'T KNOW 98 (GO TO 333)
328. Do you know of a place where you can obtain a method of family planning?
NO 2 (GO TO 333)
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
DISTRICT HOSPITAL 12
GOVT. HEALTH CENTER 13
DISPENSARY/PARASTATAL FACILITY 14
VILLAGE HEALTH POST/WORKER 15
PRIVATE DOCTOR/CLINIC/HOSP 22
PHARMACY/MEDICAL STORE 23 (GO TO 330)
CBD WORKER 24
CHURCH 32
FRIEND/RELATIVE/NEIGHBOR 33
HEALTH EDUCATION/BAR GIRLS 34
DON'T KNOW 98
333. Have you seen or heard of the Green Star symbol?
NO 2 (GO TO 401)
DOES NOT KNOW 8 (GO to 401)
334. What does the Green Star symbol mean to you?
SOMETHING ELSE 2
DOES NOT KNOW 8
335. How did you learn about the Green Star?
POSTERS B
LEAFLETS C
RADIO D
CLINIC SIGN E
SERVICE PROVIDER F
OTHER (SPECIFY) ________X
401. When a woman is pregnant, what signs indicate that she may have a serious problem or complication and she should get medical treatment immediately?
SWOLLEN HANDS AND FEET B
SHE IS BLEEDING TOO MUCH C
OTHER_____ X
OTHER_____ Y
DOES NOT KNOW Z
402. How long should a mother breastfeed her baby without giving the baby any other food or liquid other than breast milk?
OTHER_____ 96
DOES NOT KNOW 98
SECTION 5. MARRIAGE AND SEXUAL ACTIVITY
501. Are you currently married or living with a woman?
YES, LIVING WITH A WOMAN 2 (GO TO 505)
NO, NOT IN UNION 3
502. Have you ever been married or lived with a woman?
YES, LIVED WITH A WOMAN 2 (GO TO 507)
NO 3 (GO TO 514)
504. What is your marital status now: are you widowed, divorced or separated?
DIVORCED 2 (GO TO 507)
SEPARATED 3 (GO TO 507)
505. Is your wife/partner living with you now or is she staying elsewhere?
STAYING ELSEWHERE 2
506. RECORD THE WIFE'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF SHE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.
IF THERE ARE TWO WIVES IN THE HOUSEHOLD, RECORD THE NAME AND LINE NUMBER OF BOTH.
507. Have you been married or lived with a woman only once, or more than once?
MORE THAN ONCE 2
MARRIED/LIVED WITH A WOMAN ONLY ONCE: In what month and year did you start living with you wife/partner?
MARRIED/LIVED WITH A WOMAN MORE THAN ONCE: Now, we will talk about your first wife/partner. In what month and year did you start living with her?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
509. How old were you when you started living with her?
514. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family life issues. How old were you when you first had sexual intercourse (if ever)?
AGE IN YEARS___
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 96
515. When was the last time you had sexual intercourse?
RECORD 'YEARS AGO' ONLY IF LAST INTERCOURSE WAS ONE OR MORE YEARS AGO.
WEEKS AGO 2_____
MONTHS AGO 3_____
YEARS AGO 4_____ (GO TO 524)
516. The last time you had sexual intercourse, did you use a condom?
NO 2
517. What is your relationship to the woman with whom you last had sex?
IF "GIRLFRIEND" OR "FIANCEE", ASK: Was your girlfriend/finance living with you when you last had sex?
IF YES, RECORD '1'. IF NO, RECORD '2'.
GIRLFRIEND/FIANCEE 2
OTHER FRIEND 3
CASUAL ACQUAINTANCE 4
COMMERCIAL SEX CUSTOMER 5
RELATIVE 6
OTHER_________ (SPECIFY) 7
518. For how long have you had a sexual relationship with this woman?
WEEKS 2___
MONTHS 3___
YEARS 4___
519. Have you had sex with anyone else in the last 12 months?
NO 2 (GO TO 524)
520. The last time you had sexual intercourse with another woman, did you use a condom?
NO 2
521. What is your relationship to this other woman?
IF 'GIRLFRIEND' OR 'FIANCEE', ASK: Was your girlfriend/fiancée living with you when you last had sex?
IF YES, RECORD '1'. IF NO, RECORD '2'.
GIRLFRIEND/FIANCEE 2
OTHER FRIEND 3
CASUAL ACQUAINTANCE 4
COMMERCIAL SEX CUSTOMER 5
RELATIVE 6
OTHER_________ (SPECIFY) 7
522. For how long have you had a sexual relationship with this woman?
WEEKS 2___
MONTHS 3___
YEARS 4___
523. In total, how many women have you had sex with in the last 12 months?
524. Do you know of a place where one can get condoms?
NO 2 (GO TO 601)
IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
DISTRICT HOSPITAL 12
GOVT. HEALTH CENTER 13
DISPENSARY/PARASTATAL FACILITY 14
VILLAGE HEALTH POST/WORKER 15
PRIVATE DOCTOR/CLINIC/HOSP 22
PHARMACY/MEDICAL STORE 23
CBD WORKER 24
CHURCH 32
FRIEND/RELATIVE/NEIGHBOR 33
HEALTH EDUCATION/BAR GIRLS 34
DON'T KNOW 98
526. Is it acceptable for a woman to ask a man to use a condom?
NO 2
DOES NOT KNOW 8
527. What if a woman's husband has a sexually transmitted disease. Would it be acceptable for her to ask him to use a condom or to refuse to have sex with him?
NO 2
DOES NOT KNOW 8
SECTION 6. FERTILITY PREFERENCES
601. CHECK 310:
USING A METHOD?
NOT CURRENTLY USING (GO TO 607)
CURRENTLY USING (GO TO 614)
607. Why are you not using a method of family planning?
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SUBFECUND/INFECUND E
POSTPARTUM AMENORRHEIC F
BREASTFEEDING G
FATALISTIC H
WIFE/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
KNOWS NO SOURCE N
FEAR OF SIDE EFFECTS P
LACK OF ACCESS/TOO FAR Q
COST TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY'S NATURAL PROCESS T
DON'T KNOW Z
610. Do you think you will use a method to delay or avoid pregnancy within the next 12 months?
NO 2
DOES NOT KNOW 8
612. What is the main reason that you think you will not use a method in the next 12 months?
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SUBFECUND/INFECUND E
POSTPARTUM AMENORRHEIC F
BREASTFEEDING G
FATALISTIC H
WIFE/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
KNOWS NO SOURCE N
FEAR OF SIDE EFFECTS P
LACK OF ACCESS/TOO FAR Q
COST TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY'S NATURAL PROCESS T
DON'T KNOW Z
HAS 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?
HAS NO 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.
OTHER______ (SPECIFY) 96
616. Would you say that you approve or disapprove of couples using a method to avoid getting pregnant?
DISAPPROVE 2
DON'T KNOW/UNSURE 3
617. In the last six months have you heard about family planning:
On the radio?
On the television?
In a newspaper or magazine?
From a poster?
From a leaflet or pamphlet?
From billboards?
At community events?
From live drama?
From a doctor or a nurse?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
618. In the last six months, what drama series have you listened to on the radio?
CIRCLE THE SERIES MENTIONED SPONTANEOUSLY. FOR THOSE NOT MENTIONED, ASK: In the last 6 months, have you listened to:
Zinduka, a radio show featuring a character named Dr. Kurwa?
Twende na Wakati, a show featuring a character named Mkwaju?
Geuza Mwendo?
Ukimwi Kifo?
Sema Naye?
Vijana wetu?
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
DID NOT LISTEN TO ZINDUKA (GO TO 618E)
618B. How often do you listen to Zinduka?
ONCE A WEEK 2
ONCE OR TWICE A MONTH 3
RARELY 4
DOES NOT KNOW 8
618C. As a result of listening to Zinduka, did you do anything or take any action related to family planning?
NO 2 (GO TO 618E)
DOES NOT KNOW 8(GO TO 618E)
618D. What did you do as a result of listening to Zinduka?
RECORD ALL MENTIONED.
TALKED TO HEALTH WORKER B
TALKED TO SOMEONE ELSE C
WENT TO CLINIC FOR FAM. PLAN D
BEGAN USING MODERN METHOD E
BEGAN USING CONDOMS F
OTHER______(SPECIFY) X
DID NOT LISTEN TO TWENDE (GO TO 618I)
618F. How often do you listen to Twende na Wakati?
ONCE A WEEK 2
ONCE OR TWICE A MONTH 3
RARELY 4
DOES NOT KNOW 8
618G. As a result of listening to Twende na Wakati did you do anything or take any action related to family planning?
NO 2 (GO TO 618I)
DOES NOT KNOW (GO TO 618I)
618H. What did you do as a result of listening to Twende na Wakati?
RECORD ALL MENTIONED.
TALKED TO HEALTH WORKER B
TALKED TO SOMEONE ELSE C
WENT TO CLINIC FOR FAM. PLAN D
BEGAN USING MODERN METHOD E
BEGAN USING CONDOMS F
OTHER______(SPECIFY) X
DID NOT LISTEN TO VIJANA WETU (GO TO 619)
618J. How often do you listen to Vijana Wetu?
ONCE A WEEK 2
ONCE OR TWICE A MONTH 3
RARELY 4
DOES NOT KNOW 8
618K. As a result of listening to Vijana Wetu, did you do anything or take any action related to family planning?
NO 2 (GO TO 619)
DOES NOT KNOW (GO TO 619)
618L. What did you do as a result of listening to Vijana Wetu?
RECORD ALL MENTIONED.
TALKED TO HEALTH WORKER B
TALKED TO SOMEONE ELSE C
WENT TO CLINIC FOR FAM. PLAN D
BEGAN USING MODERN METHOD E
BEGAN USING CONDOMS F
OTHER______(SPECIFY) X
619. In the last 6 months, have you heard or seen a message about Salama condoms?
NO 2 (GO TO 621)
DOES NOT KNOW (GO TO 621)
620. Where did you hear or see the message about Salama condoms?
DO NOT READ CODES. RECORD ALL MENTIONED.
TELEVISION B
NEWSPAPER OR MAGAZINE C
POSTER D
LEAFLET OR PAMPHLET E
BILLBOARD F
COMMUNITY EVENT G
LIVE DRAMA H
SALES REPRESENTATIVE I
OTHER X
YES, LIVING WITH A WOMAN (GO TO 622)
NO, NOT IN UNION (GO TO 701)
622. Now I want to ask you about you wife's/partner's views on family planning. Do you think that your wife/partner approves or disapproves of couples using a method to avoid pregnancy?
DISAPPROVES 2
DON'T KNOW 8
623. How often have you talked to your wife/partner about family planning in the past year?
ONCE OR TWICE 2
MORE OFTEN 3
701. Are you currently working?
NO 2
703. Have you done any work in the last 12 months?
NO 2 (GO TO 801)
704. What is your occupation, that is, what kind of work do you mainly do?
DOES NOT WORK IN AGRICULTURE (GO TO 707)
706. Do you work mainly on your own or family land, or do you work on land that you rent from someone else, or do you work on someone else's land?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
707. Do you do this work for a member of your family, for someone else, or are you self-employed?
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3
708. Do you usually work throughout the year, or do you work seasonally, or only once in a while?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3
709. Are you paid in cash or kind for this work or are you not paid at all?
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4
SECTION 8: AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES
801. Now I would like to talk about something else. Have you ever heard of the virus HIV or an illness called AIDS?
NO 2 (GO TO 821)
802. Is there anything a person can do to avoid getting infected with HIV, the virus that causes AIDS?
NO 2 (GO TO 809)
DON'T KNOW 8 (GO TO 809)
803. What can a person do?
Anything else?
RECORD ALL MENTIONED.
USE CONDOMS B
LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
INJECT DRUGS INTRAVENOUSLY H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID KISSING K
AVOID MOSQUITO BITES L
SEEK PROTECTION FROM TRADITIONAL HEALER M
AVOID SHARING RAZORS/BLADES N
OTHER__________ W
OTHER__________ X
DON'T KNOW Z
804. Can people protect themselves from getting the AIDS virus by having just one sex partner who has no other partners?
NO 2
DON'T KNOW 8
805. Can a person get the AIDS virus from mosquito bites?
NO 2
DON'T KNOW 8
806. Can people protect themselves from getting the AIDS virus by using a condom every time they have sex?
NO 2
DON'T KNOW 8
807. Can people protect themselves from getting the AIDS virus by not sharing food with a person who has AIDS?
NO 2
DON'T KNOW 8
808. Can people protect themselves from getting the AIDS virus by abstaining completely from sex?
NO 2
DON'T KNOW 8
809. Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
811. Do you know someone personally who has the virus that causes AIDS or someone who died from AIDS?
NO 2
812. Can the virus that causes AIDS be transmitted from a mother to a child?
NO 2 (GO TO 814)
DON'T KNOW 8 (GO TO 814)
813. When can the virus that causes AIDS be transferred from a mother to a child? Can it be transmitted?
During pregnancy?
During delivery?
During breastfeeding?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
814. Do you think your chances of getting AIDS are small, moderate, great or no risk at all?
MODERATE 2 (GO TO 816)
GREAT 3 (GOT TO 816)
NO RISK AT ALL 4
DOES NOT KNOW 8 (GO TO 817)
HAS AIDS 6 (GO TO 817)
815. Why do you think that you have (NO CHANCE/SMALL CHANCE) of getting AIDS?
Any other reasons?
RECORD ALL MENTIONED.
PARTNER HAS NO OTHER MEN B (GO TO 817)
SLEEPS ONLY WITH ONE PARTNER C (GO TO 817)
USES CONDOMS D (GO TO 817)
OTHER__________(SPECIFY) X (GO TO 817)
816. Why do you think that you have a (MODERATE/GREAT) risk of getting AIDS?
Any other reasons?
RECORD ALL MENTIONED.
PARTNER HAS OTHER MEN B
DOES NOT USE CONDOMS C
HAD INJECTION, BLOOD TRANSFUS D
OTHER__________(SPECIFY) X
817. Have you ever been tested to see if you have the AIDS virus?
NO 2
DOES NOT KNOW/NOT SURE 8
818. Would you like to be tested for the AIDS virus?
NO 2 (GO TO 820)
DOES NOT KNOW/NOT SURE 8 (GO TO 820)
819. Why haven't you gotten tested for the AIDS virus?
COSTS TOO MUCH B
AFRAID TO GET RESULTS C
DOES NOT HAVE TIME TO GO D
OTHER__________(SPECIFY) X
820. Do you know a place where you could go to get an AIDS test?
NO 2
821. Do you know any methods that can protect against pregnancy as well as protecting against sexual diseases?
CONDOM 2
OTHER__________(SPECIFY) 6
DOES NOT KNOW ANY METHODS 8
MINUTES___
AFTERNOON 2
EVENING, NIGHT 3
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:______