UGANDA BUREAU OF STATISTICS
MAN'S QUESTIONNAIRE -ENGLISH
REGION
DISTRICT
COUNTY
SUBCOUNTY/TOWN
PARISH/LC2 NAME
EA NAME
UDHS NUMBER
NAME OF HOUSEHOLD HEAD_______________________________________
HOUSEHOLD NUMBER
MAN SELECTED FOR QUESTIONS ON DOMESTIC VIOLENCE (SECTION 9)
NO 2
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY)
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY)
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY)
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 (SPECIFY)
LANGUAGE OF THE QUESTIONNAIRE: ENGLISH 7
LANGUAGE USED IN THE INTERVIEW
LUGANDA 2
LUGBARA 3
LUO 4
RUNYANKOLE-RUKIGA 5
RUNYORO-RUTORO 6
ENGLISH 7
OTHER 8
LUGANDA 2
LUGBARA 3
LUO 4
RUNYANKOLE-RUKIGA 5
RUNYORO-RUTORO 6
ENGLISH 7
OTHER 8
SOMETIMES 2
ALL THE TIME 3
LUGANDA 2
LUGBARA 3
LUO 4
RUNYANKOLE-RUKIGA 5
RUNYORO-RUTORO 6
ENGLISH 7
OTHER 8
FIELD EDITOR
NAME
DATE
OFFICE EDITOR
KEYED BY
SECTION 1. RESPONDENT'S BACKGROUND
INTRODUCTION AND CONSENT
INFORMED CONSENT
Hello. My name is ________________________________ and I am working with UGANDA BUREAU OF STATISTICS. We are conducting a national survey to ask men and women about various health issues. We would very much appreciate your participation in this survey. This information will help the government to plan health services. The survey usually takes about 60 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
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 (END INTERVIEW)
MINUTES___
102. 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 104)
VISITOR 96 (GO TO 104)
103. Just before you moved here, did you live in a city, in a town, or in the countryside?
TOWN 2
COUNTRYSIDE 3
104. In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?
NONE 00 (GO TO 106)
105. In the last 12 months, have you been away from your home community for more than one month at a time?
NO 2
106. In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998
107. How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.
108. Have you ever attended school?
NO 2 (GO TO 112)
109. What is the highest level of school you attended: primary, '0' level, 'A' level, or university or tertiary?
'O' LEVEL 2
'A' LEVEL 3
TERTIARY 4
UNIVERSITY 5
110. What is the highest (class/year) you completed at that level?
SECONDARY OR HIGHER (GO TO 115)
112. 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?
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE 4 (SPECIFY LANGUAGE)
BLIND/VISUALLY IMPAIRED 5
113. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?
NO 2
CODE '1' OR '5' CIRCLED (GO TO 116)
115. 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
116. 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
117. 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
117A. In which level and grade do you think children should start to be taught in English?
PROTESTANT 2
MUSLIM 3
PENTECOSTAL 4
SDA 5
OTHERS 6
201. Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name.
Have you ever fathered any children with any woman?
NO 2
DON'T KNOW 8 (GO TO 206)
202. Do you have any sons or daughters that you have fathered who are now living with you?
NO2 (GO TO 204)
203 How many sons live with you? And how many daughters live with you?
IF NONE, RECORD '00'.
204 Do you have any sons or daughters that you have fathered who are alive but do not live with you?
NO 2 (GO TO 206)
205. How many sons are alive but do not live with you? And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.
206. Have you ever fathered a son or a daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?
NO 2
DON'T KNOW 8 (GO TO 208)
207. How many boys have died? And how many girls have died?
IF NONE, RECORD '00'.
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'.
HAS HAD ONLY ONE CHILD (GO TO 212)
HAS NOT HAD ANY CHILDREN (GO TO 301)
210. Did all of the children you have fathered have the same biological mother?
NO 2
211. In all, how many women have you fathered children with?
212. How old were you when your (first) child was born?
NO LIVING CHILDREN (GO TO 301)
214. How many years old is your (youngest) child?
OTHER (GO TO 301)
216. What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD
217. When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?
NO 2 (GO TO 219)
DON'T KNOW 3 (GO TO 219)
218. Were you ever present during any of those antenatal check-ups?
NOT PRESENT 2
219. Was (NAME) born in a hospital or health facility?
OTHER 2
220. What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?
FACILITY CLOSED 02
TOO FAR/NO TRANSPORTATION 03
DON'T TRUST FACILITY/POOR QUALITY SERVICE 04
NO FEMALE PROVIDER 05
NOT THE FIRST CHILD 06
CHILD'S MOTHER DID NOT THINK IT WAS NECESSARY 07
HE DID NOT THINK IT WAS NECESSARY 08
FAMILY DID NOT THINK IT WAS NECESSARY 09
OTHER (SPECIFY) 96
DON"T KNOW 98
221. When a child has diarrhea, how much should he or she be given to drink: more than usual, the same amount as usual, less than usual, or should he or she not be given anything to drink at all?
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DON'T KNOW 8
301. Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.
Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK:
Have you ever heard of (METHOD)?
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 METHODS 02, 07, 10,
AND 11, ASK 302 IF 301 HAS CODE 1 CIRCLED.
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
before sexual intercourse
NO 2
NO 2
NO 2
303. In the last six months have you heard about family planning
NO 2
NO 2
NO 2
NO 2
304 In the last few months, have you discussed the practice of family planning with a health worker or health professional?
NO 2
305 Now I would like to ask you about a woman's risk of pregnancy. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?
NO 2
DON'T KNOW 8 (GO TO 307)
306. Is this time just before her period begins, during her period, right after her period has ended, or halfway between two periods?
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) 6
DON'T KNOW 8
307. Do you think that a woman who is breastfeeding her baby can become pregnant?
NO 2
DEPENDS 3
DON'T KNOW 8
308 I will now read you some statements about contraception. Please tell me if you agree or disagree with each one
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
309. CHECK 301 (07): KNOWS MALE CONDOM
NO (GO TO 401)
310. Do you know of a place where a person can get condoms?
NO 2 (GO TO 401)
311. Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER
OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVT. HEALTH CENTER B
FAMILY PLANNING CLINIC C
OUTREACH SERVICES D
GOVERNMENT COMMUNITY BASED DISTRIBUTOR E
OTHER PUBLIC (SPECIFY) F
PHARMACY/DRUG SHOP H
PRIVATE DOCTOR/NURSE/ MIDWIFE I
OUTREACH SERVICES J
NGO COMMUNITY BASED DISTRIBUTOR K
OTHER PRIVATE MEDICAL (SPECIFY) L
RELIGIOUS INSTITUTION N
FRIENDS/RELATIVES O
STREET VENDOR P
LODGE Q
OTHER (SPECIFY) X
312. If you wanted to, could you yourself get a condom?
NO 2
SECTION 4. MARRIAGE AND SEXUAL ACTIVITY
401. Are you currently married or living together with a woman as if married?
YES, LIVING WITH A WOMAN 2 (GO TO 404)
NO, NOT IN UNION 3
402. Have you ever been married or lived together with a woman as if married?
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 413)
403. What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)
404. Is your wife/partner living with you now or is she staying elsewhere?
STAYING ELSEWHERE 2
405. Do you have more than one wife or woman you live with as if married?
NO 2 (GO TO 407)
406. Altogether, how many wives do you have or other partners do you live with as if married?
ONE WIFE/ PARTNER:
Please tell me the name of your wife (the woman you are living with as if married).
LINE NUMBER____
MORE THAN ONE WIFE/PARTNER
Please tell me the name of each of your current wives (and/or of each woman you
are living with as if married).
LINE NUMBER____
RECORD THE NAME AND THE LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE AND LIVE-IN PARTNER. IF A WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.
ASK 408 FOR EACH PERSON.
408. How old was (NAME) on her last birthday?
MORE THAN ONE WIFE/ PARTNER (GO TO 411A)
410. Have you been married or lived with a woman only once or more than once?
MORE THAN ONCE 2 (GO TO 411A)
411. In what month and year did you start living with your wife (partner)?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998 (GO TO 413)
411A. Now I would like to ask a question about your first wife/partner. In what month and year did you start living with your first wife/ partner?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 9998 (GO TO 413)
412. How old were you when you first started living with her?
413. CHECK FOR THE PRESENCE OF OTHERS.
BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
414. Now I would like 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?
AGE IN YEARS___
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE/PARTNER 95 (GO TO 417)
415. CHECK 107: AGE OF RESPONDENT
AGE 25-54 (GO TO 501)
416. Do you intend to wait until you get married to have sexual intercourse for the first time?
NO 2 (GO TO 501)
DON'T KNOW/UNSURE 8 (GO TO 501)
417. CHECK 107: AGE OF RESPONDENT
AGE 25-54 (GO TO 419)
418. The first time you had sexual intercourse, was a condom used?
NO 2
DON'T KNOW/DON'T REMEMBER 8
419. 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.
WEEKS AGO 2____
MONTHS AGO 3____
YEARS AGO 4____ (GO TO 435)
420. 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. SKIP TO 422
421. When was the last time you had sexual intercourse with this person?
[Exclude Last Sexual Partner]
WEEKS 2___
MONTHS 3___
422. The last time you had sexual intercourse with this person, was a condom used?
NO 2 (GO TO 424)
423. Was a condom used every time you had sexual intercourse with this person in the last 12 months?
NO 2
424. What was your relationship to this (second/third) person with whom you had sexual intercourse?
IF GIRLFRIEND:
Were you living together as if married?
IF YES, CIRCLE '02'.IF NO, CIRCLE '03'.
LIVE-IN PARTNER 2 (GO TO 426)
GIRLFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
PROSTITUTE 5
OTHER (SPECIFY) 6
425. For how long (have you had/did you have) a sexual relationship with this (second/third) person?
IF ONLY HAD SEXUAL MONTHS RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.
MONTHS 2___
YEARS 3___
426. The last time you had sexual intercourse with this (second/third) person, did you or this person drink alcohol?
NO 2 (GO TO 428)
427. Were you or your partner drunk at that time?
IF YES: Who was drunk?
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4
428 Apart from [this person/these two people], have you had sexual intercourse with any other) person in the last 12 months?
[Last Sexual Partner and Second-To-Last Sexual Partner]
NO 2 (GO TO 430)
429. In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'
DON'T KNOW 98
NO PARTNERS ARE PROSTITUTES (GO TO 432)
431. CHECK 424 AND 422 (ALL COLUMNS):
OTHER (GO TO 435)
432. In the last 12 months, did you pay anyone in exchange for having sexual intercourse?
NO 2 (GO TO 434A)
433. The last time you paid someone in exchange for having sexual intercourse, was a condom used?
NO 2 (GO TO 435)
434. Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?
NO 2 (GO TO 435)
DON'T KNOW 8 (GO TO 435)
434A. In the past 12 months, did you ever give or receive money, gifts or favours in exchange for sex?
NO 2
435. In total, with how many different people have you had sexual intercourse in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'
DON'T KNOW 98
436. CHECK 422, MOST RECENT PARTNER (FIRST COLUMN):
CONDOM USED (GO TO 437)
NO CODE CIRCLED (GO TO 501)
437. You told me that a condom was used the last time you had sex. May I see the package of condoms you were using at that time?
RECORD NAME OF BRAND IF PACKAGE SEEN.
BRAND NAME (SPECIFY) (GO TO 439)
DOES NOT HAVE/NOT SEEN 2 (GO TO 439)
438. Do you know the brand name of the condom used at that time?
RECORD NAME OF BRAND.
DON'T KNOW 98
439. How many condoms did you get the last time?
DON'T KNOW 998
440. The last time you obtained the condoms, how much did you pay in total, including the cost of the condom(s) and any consultation you may have had?
FREE 999995
DON'T KNOW 999998
441. From where did you obtain the condom the last time?
PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVT. HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
OUTREACH 14
GOVERNMENT COMMUNITY BASED DISTRIBUTOR 15
OTHER PUBLIC (SPECIFY) 16
PHARMACY/DRUG SHOP 22
PRIVATE DOCTOR/NURSE/ MIDWIFE 23
OUTREACH 24
NGO COMMUNITY BASED DISTRIBUTOR 25
OTHER PRIVATE MEDICAL (SPECIFY) 26
RELIGIOUS INSTITUTION 32
FRIENDS/RELATIVES 33
STREET VENDOR 34
LODGE 35
OTHER (SPECIFY) 36
442. CHECK 302 (02): RESPONDENT EVER STERILIZED
YES (GO TO 501)
443. The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?
NO 2 (GO TO 501)
DON'T KNOW 8 (GO TO 501)
444 What method did you or your partner use?
PROBE: Did you use any other method to prevent pregnancy?
RECORD ALL MENTIONED.
PILL B
IUD C
INJECTABLES D
IMPLANTS E
FEMALE CONDOM F
DIAPHRAGM G
FOAM/JELLY H
RHYTHM METHOD I
WITHDRAWAL J
OTHER (SPECIFY) X
SECTION 5. FERTILITY PREFERENCES
501. CHECK 407:
QUESTION NOT ASKED (GO TO 508)
MAN STERILIZED (GO TO 508)
503. (Is your wife (partner)/Are any of your wives (partners)) currently pregnant?
NO 2
DON'T KNOW 8
NO WIFE/PARTNER PREGNANT OR DON'T KNOW
Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?
NO MORE/NONE 2 (GO TO 508)
COUPLE CAN'T GET PREGNANT 3 (GO TO 508)
WIFE (WIVES)/PARTNER(S) STERILIZED 4 (GO TO 508)
UNDECIDED/DON'T KNOW 8 (GO TO 508)
WIFE(WIVES)/ PARTNER(S) PREGNANT
Now I have some questions about the future. After the child(ren) you and your (wife(wives)/partners(s) are expecting now, would you like to have another child, or would you prefer not to have any more children?
NO MORE/NONE 2 (GO TO 508)
COUPLE CAN'T GET PREGNANT 3 (GO TO 508)
WIFE (WIVES)/PARTNER(S) STERILIZED 4 (GO TO 508)
UNDECIDED/DON'T KNOW 8 (GO TO 508)
MORE THAN ONE WIFE/PARTNER (GO TO 507)
WIFE/PARTNER NOT PREGNANT OR DON'T KNOW:
How long would you like to wait from now before the birth of (a/another) child?
YEARS 2 (GO TO 508)
SOON/NOW 993 (GO TO 508)
COUPLE CAN'T GET PREGNANT 994 (GO TO 508)
OTHER (SPECIFY) 996 (GO TO 508)
DON'T KNOW 998 (GO TO 508)
WIFE/PARTNER PREGNANT:
After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?
YEARS 2 (GO TO 508)
SOON/NOW 993 (GO TO 508)
COUPLE CAN'T GET PREGNANT 994 (GO TO 508)
OTHER (SPECIFY) 996 (GO TO 508)
DON'T KNOW 998 (GO TO 508)
507. How long would you like to wait from now before the birth of (a/another) child?
YEARS 2
SOON/NOW 993
HE/ALL HIS WIVES/PARTNERS CAN'T GET PREGNANT 994
OTHER (SPECIFY) 996
DON'T KNOW 998
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?
NUMBER___
OTHER (SPECIFY) 96 (GO TO 601)
NO LIVING CHILDREN
If you could choose exactly the number of children to have in your whole life, how many would that be?
NUMBER___
OTHER (SPECIFY) 96 (GO TO 601)
509. How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?
GIRLS____
EITHER___
OTHER (SPECIFY) 96
SECTION 6. EMPLOYMENT AND GENDER ROLES
601. Have you done any work in the last seven days?
NO 2
602. 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, or any other such reason?
NO 2
603. Have you done any work in the last 12 months?
NO 2 (GO TO 613)
604. What is your occupation, that is, what kind of work do you mainly do?
DOES NOT WORK IN AGRICULTURE (GO TO 607)
606. Do you work mainly on your own land or on 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 02
RENTED/BORROWED LAND 03
SOMEONE ELSE'S LAND 04
COMMUNAL LAND 05
PUBLIC LAND 06
607. 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
608. 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
609. 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
QUESTION NOT ASKED (GO TO 613)
OTHER (GO TO 613)
612. Who decides how the money you earn will be used: mainly you, mainly your (wife (wives)/partner(s)), or you and your (wife (wives)/partner(s)) jointly?
WIFE(WIVES)/PARTNER(S) 2
RESPONDENT AND WIFE (WIVES)/ PARTNER(S) JOINTLY 3
OTHER (SPECIFY) 4
613. In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally:
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
614. I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them.
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
615. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
616. Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to?
NO 2
DON'T KNOW/DEPENDS 8
NO 2
DON'T KNOW/DEPENDS 8
NO 2
DON'T KNOW/DEPENDS 8
NO 2
DON'T KNOW/DEPENDS 8
701. Now I would like to talk about something else. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 733)
702. Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?
NO 2
DON'T KNOW 8
703. Can people get the AIDS virus from mosquito bites?
NO 2
DON'T KNOW 8
704. Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?
NO 2
DON'T KNOW 8
705. Can people get the AIDS virus by sharing food with a person who has AIDS?
NO 2
DON'T KNOW 8
706. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?
NO 2
DON'T KNOW 8
707. Can people get the AIDS virus because of witchcraft or other supernatural means?
NO 2
DON'T KNOW 8
708. Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
709. Can the virus that causes AIDS be transmitted from a mother to her baby:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
OTHER (GO TO 712)
711. 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?
NO 2
DON'T KNOW 8
712. Have you heard about any drugs that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?
NO 2 (GO TO 712F)
DON'T KNOW 8 (GO TO 712F)
712A. In the past six months, have you seen or heard anything about drug treatments for AIDS
NO 2
NO 2
NO 2
NO 2
NO 2
712B. What drugs do you know about?
SEPTRINE B (GO TO 712F)
OTHER DRUGS (SPECIFY) X (GO TO 712F)
DON'T KNOW Z (GO TO 712F)
712C. Do you know of a place to get ARVs?
NO 2 (GO TO 712E)
712D Where is this place? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
OUTREACH D
GOVERNMENT COMMUNITY BASED WORKER E
OTHER PUBLIC (SPECIFY) F
PHARMACY/DRUG SHOP H
PRIVATE DOCTOR/NURSE/ MIDWIFE I
OUTREACH J
TASO K
AIDS INFORMATION CENTER L
OTHER PRIVATE/NGO MEDICAL (SPECIFY)
712E. Now I'd like to ask you some questions about the drug treatment (ART) that is available to people with AIDS virus. For each statement I read, please tell me if you agree or disagree
with it
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
DISAGREE 2
DON'T KNOW 8
712F. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.
713. I don't want to know the results, but have you ever been tested to know if you have the AIDS virus?
NO 2 (GO TO 718)
714. When was the last time you were tested?
12 - 23 MONTHS AGO 2
2 OR MORE YEARS AGO 3
715. The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?
OFFERED AND ACCEPTED 2
REQUIRED 3
716. I don't want to know the results, but did you get the results of the test?
NO 2
717. Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVT. HEALTH CENTER 12 (GO TO 720)
STAND-ALONE VCT CENTER 13 (GO TO 720)
FAMILY PLANNING CLINIC 14 (GO TO 720)
OUTREACH 15 (GO TO 720)
GOVERNMENT COMMUNITY BASED WORKER 16 (GO TO 720)
OTHER PUBLIC (SPECIFY) 17 (GO TO 720)
STAND-ALONE VCT CENTER 22 (GO TO 720)
PHARMACY/DRUG SHOP 23 (GO TO 720)
PRIVATE DOCTOR/NURSE/ MIDWIFE 24 (GO TO 720)
OUTREACH 25 (GO TO 720)
TASO 26 (GO TO 720)
AIDS INFORMATION CENTER 27 (GO TO 720)
OTHER PRIVATE/NGO MEDICAL (SPECIFY) 28 (GO TO 720)
718. Do you know of a place where people can go to get tested for the AIDS virus?
NO 2 (GO TO 720)
719. Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVT. HEALTH CENTER B
STAND-ALONE VCT CENTER C
FAMILY PLANNING CLINIC D
OUTREACH E
GOVERNMENT COMMUNITY BASED WORKER F
OTHER PUBLIC (SPECIFY) G
STAND-ALONE VCT CENTER I
PHARMACY/DRUG SHOP J
PRIVATE DOCTOR/NURSE/ MIDWIFE K
OUTREACH L
TASO M
AIDS INFORMATION CENTER N
OTHER PRIVATE/NGO MEDICAL (SPECIFY) O
OTHER (SPECIFY) X
720. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?
NO 2
DON'T KNOW 8
721. If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
722. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
722A. Should a child with the AIDS virus go to school?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
723. 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 NOT BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8
724. Do you personally know someone who has been denied health services in the last 12 months because he or she has or is suspected to have the AIDS virus?
NO 2
DON'T KNOW ANYONE WITH AIDS 8 (GO TO 733)
725. Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she has or is suspected to have the AIDS virus?
NO 2
726. Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she has or is suspected to have the AIDS virus?
NO 2
OTHER (GO TO 728)
728. Do you personally know someone who has or is suspected to have the AIDS virus?
NO 2
729. Do you agree or disagree with the following statement: People with the AIDS virus should be ashamed of themselves.
DISAGREE 2
DON'T KNOW/NO OPINION 8
730. Do you agree or disagree with the following statement: People with the AIDS virus should be blamed for bringing the disease into the community.
DISAGREE 2
DON'T KNOW/NO OPINION 8
HEARD ABOUT AIDS:
Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
NO 2
NOT HEARD ABOUT AIDS:
Have you heard about infections that can be transmitted through sexual contact?
NO 2
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 742)
735. CHECK 733: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?
NO (GO TO 737)
736. 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?
NO 2
DON'T KNOW 8
737. Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?
NO 2
DON'T KNOW 8
738. Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 742)
740. The last time you had (PROBLEM FROM 736/737/738), did you seek any kind of advice or treatment?
NO 2 (GO TO 742)
741 Where did you go? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER B
STAND-ALONE VCT CENTER C
FAMILY PLANNING CLINIC D
OUTREACH E
GOVERNMENT COMMUNITY BASED WORKER F
OTHER PUBLIC (SPECIFY) G
STAND-ALONE VCT CENTER I
PHARMACY/DRUG SHOP J
PRIVATE DOCTOR/NURSE/ MIDWIFE K
OUTREACH L
TASO M
AIDS INFORMATION CENTER N
OTHER PRIVATE/NGO MEDICAL (SPECIFY) O
OTHER (SPECIFY) X
742. Husbands and wives do not always agree on everything. If a wife knows that her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?
NO 2
DON'T KNOW 8
744. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?
NO 2
DON'T KNOW 8
745. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?
NO 2
DON'T KNOW 8
747. Do you think that most young men you know wait until they are married to have sexual intercourse?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
751 Do you think that most married men you know have sex only with their wives?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
753. Do you think that most young women you know wait until they are married to have sexual intercourse?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
757. Do you think that most married women you know have sex only with their husbands?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
SECTION 8. OTHER HEALTH ISSUES
801 Have you ever heard of an illness called tuberculosis or TB?
NO 2 (GO TO 805)
802. How does tuberculosis spread from one person to another? PROBE: Any other ways?
RECORD ALL MENTIONED.
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TB C
THROUGH FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
OTHER (SPECIFY) X
DON'T KNOW X
803. Can tuberculosis be cured?
NO 2
DON'T KNOW 8
804. If a member of your family got tuberculosis, would you want it to remain a secret or not?
NO 2
DON'T KNOW/NOT SURE/ DEPENDS 8
805 Some men are circumcised. Are you circumcised?
NO 2
DON'T KNOW 8
806. 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 GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
NONE 00 (GO TO 810)
807. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
NONE 00 (GO TO 810)
808. The last time you had an injection given to you by a health worker, where did you go to get the injection?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
GOVERNMENT HEALTH CENTER 12
OTHER PUBLIC (SPECIFY) 16
DENTAL CLINIC/OFFICE 22
PHARMACY/DRUG SHOP 23
OFFICE OR HOME OF NURSE/ HEALTH WORKER 24
OTHER PRIVATE MEDICAL (SPECIFY) 26
OTHER (SPECIFY) 96
809 Did the person who gave you that injection take the syringe and needle from a new, unopened package?
NO 2
DON'T KNOW 8
810. Do you currently smoke cigarettes?
NO 2 (GO TO 812)
811. In the last 24 hours, how many cigarettes did you smoke?
812. Do you currently smoke or use any other type of tobacco?
NO 2 (GO TO 816)
813. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.
CHEWING TOBACCO B
SNUFF C
OTHER (SPECIFY) X
OTHER (GO TO 818)
817. Now I would like to ask you about your own child(ren) who (is/are) under the age of 18.
Have you made arrangements for someone to care for (him/her/them) in the event that you fall sick or are unable to care for (him/her/them)?
NO 2
UNSURE 8
818. (Besides your own child/children), are you the primary caregiver for any children under the age of 18?
NO 2 (GO TO 900)
819. Have you made arrangements for someone to care for (this child/these children) in the event that you fall sick or are unable to care for (him/her/them)?
NO 2
UNSURE 8
900. CHECK FRONT COVER: MAN SELECTED FOR THIS SECTION?
MAN NOT SELECTED (GO TO 935)
901. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.
PRIVACY NOT POSSIBLE 2 (GO TO 934)
READ TO THE RESPONDENT
Now I would like to ask you questions about some other important aspects of a man's life. I know that some of these questions are very personal. However, your answers are crucial for helping to understand the condition of men in UGANDA. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else will know that you were asked these questions.
FORMERLY MARRIED/LIVED WITH A WOMAN (READ IN PAST TENSE) (GO TO 903)
NEVER MARRIED/NEVER LIVED WITH A WOMAN (GO TO 914)
903. First, I am going to ask you about some situations which happen to some men. Please tell me if these apply to your relationship with your (last) wife/partner?
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
904. Now if you will permit me, I need to ask some more questions about your relationship with your (last) wife/partner. If we should come to any question that you do not want to answer, just let me know and we will go on to the next question.
(Does/did) your (last) wife/partner ever:
NO 2 (GO TO 904b)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
NO 2 (GO TO 904c)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
NO 2 (GO TO 905)
905. (Does/did) your (last) wife/partner ever do any of the following things to you:
NO 2 (GO TO 905b)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
b) slap you?
NO 2 (GO TO 905c)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
c) twist your arm or pull your hair?
NO 2 (GO TO 905d)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
d) punch you with her fist or with something that could hurt you?
NO 2 (GO TO 905e)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
e) kick you, drag you or beat you up?
NO 2 (GO TO 905f)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
f) try to choke you or burn you on purpose?
NO 2 (GO TO 905g)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
g) threaten or attack you with a knife, gun, or any other weapon?
NO 2 (GO TO 905h)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
h) physically force you to have sexual intercourse with her even when you did not want to?
NO 2 (GO TO 905i)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
i) force you to perform any sexual acts you did not want to?
NO 2 (GO TO 906)
How often did this happen during the last 12 months: often, only sometimes, or not at all?
[ASK ONLY IF RESPONDENT IS NOT A WIDOWER]
SOMETIMES 2
NOT AT ALL 3
NOT A SINGLE 'YES' (GO TO 90
907. How long after you first got married to/started living with your (last) wife/partner did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD '00'.
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95
908. Did the following ever happen as a result of what your (last) wife/partner did to you:
NO 2
NO 2
NO 2
909. Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) wife/partner at times when she was not already beating or physically hurting you?
NO 2 (GO TO 912)
RESPONDENT IS NOT A WIDOWER (GO TO 912)
911. In the last 12 months, how often have you done this to your wife/partner: often, only sometimes, or not at all?
SOMETIMES 2
NOT AT ALL 3
912. Does (did) your wife/partner drink alcohol?
NO 2 (GO TO 914)
913. How often does (did) your wife/partner get drunk: often, only sometimes, or never?
SOMETIMES 2
NEVER 3
EVER MARRIED/LIVED WITH A WOMAN
From the time you were 15 years old has anyone other than your (current/last) wife/partner hit, slapped, kicked, or done anything else to hurt you physically?
NO 2 (GO TO 920)
REFUSED TO ANSWER/ NO ANSWER 3 (GO TO 920)
NEVER MARRIED/ NEVER WITH A WOMAN LIVED
From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you physically?
NO 2 (GO TO 920)
REFUSED TO ANSWER/ NO ANSWER 3 (GO TO 920)
915. Who has hurt you in this way? Anyone else?
RECORD ALL MENTIONED.
FATHER/STEP-FATHER B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
FORMER WIFE/PARTNER F
CURRENT GIRLFRIEND G
FORMER GIRLFRIEND H
MOTHER-IN-LAW I
FATHER-IN-LAW J
OTHER IN-LAW K
TEACHER L
EMPLOYER/SOMEONE AT WORK M
POLICE/SOLDIER N
OTHER (SPECIFY) X
916. In the last 12 months, how often have you been hit, slapped, kicked, or physically hurt by this/these person(s): often, only sometimes, or not at all?
SOMETIMES 2
NOT AT ALL 3
NEVER HAD SEX (GO TO 925)
921. The first time you had sexual intercourse, would you say that you had it because you wanted to, or because you were forced to have it against your will?
FORCED TO 2
REFUSED TO ANSWER/NO RESPONSE 3
EVER MARRIED/LIVED WITH A WOMAN:
In the last 12 months, has anyone other than your (current/last) wife/partner forced you to have sexual intercourse against your will?
NO 2
REFUSED TO ANSWER/ NO ANSWER 3
NEVER MARRIED/NEVER LIVED WITH A WOMAN:
In the last 12 months has anyone forced you to have sexual intercourse against your will?
NO 2
REFUSED TO ANSWER/NO ANSWER 3
OTHER (GO TO 926)
OTHER (GO TO 928)
925. 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?
NO 2
REFUSED TO ANSWER/ NO ANSWER 3 (GO TO 928)
926. How old were you the first first time you were forced to have sexual intercourse or perform any other sexual acts?
DON'T KNOW 98
927. Who was the person who was forcing you at that time?
FORMER WIFE/PARTNER 02
CURRENT/FORMER GIRLFRIEND 03
FATHER 04
STEP FATHER 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
928 CHECK '905A (a-i), 914, 922 AND 925:
NOT A SINGLE 'YES' (GO TO 932)
929. Thinking about what you yourself have experienced amongthe different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?
NO 2 (GO TO 932)
930. From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.
WIFE/PARTNER'S FAMILY B
CURRENT/LAST/LATE
WIFE/PARTNER C
CURRENT/FORMER GIRLFRIEND D
FRIEND E
NEIGHBOR F
RELIGIOUS LEADER G
DOCTOR/MEDICAL PERSONNEL H
POLICE I
LAWYER J
SOCIAL SERVICE ORGANIZATION K
OTHER (SPECIFY) X
932 As far as you know, did your father ever beat your mother?
NO 2
UNSURE 8
REASSURE THE RESPONDENT ABOUT THE CONFIDENTIALITY OF HIS ANSWERS.
FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.
933. 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?
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
YES, MORE THAN ONCE 2
NO 3
934. INTERVIEWER'S COMMENTS / EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE
MINUTES____
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:____