IDENTIFICATION

LOCALITY NAME ___________________ ___

NAME OF HOUSEHOLD HEAD ____________________ ___

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

PROVINCE _________________ ___

URBAN/RURAL

LUSAKA/OTHER CITY/TOWN/VILLAGE

NAME AND LINE NUMBER OF MAN _______________ ___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT____

RESULT* ______________

NEXT VISIT: (FOR INTERVIEWERS 1 AND 2)
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INT. NUMBER ___
RESULT ____

TOTAL NUMBER OF VISITS __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE USED IN INTERVIEW

RESPONDENT'S LOCAL LANGUAGE

TRANSLATOR USED

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 _______________ and I am working with Ministry of Health/CSO. We are conducting a national survey to ask men and women about various health issues. We would very much appreciate your participitation in this survey. This information will help the government to plan health services. The interview usually takes between 20 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 if we should come to 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. 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: _________

101. RECORD THE TIME.

102. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
IF LESS THAN ONE YEAR, RECORD '00' YEARS.

103. Just before you moved here, did you live in Lusaka, another city, in a town, or in a village?

104. In the last 12 months, on how many separate occasions have you travelled away from your home community and slept away?

105. In the last 12 months, have you been away from your home community for more than one month at a time?

106. In what month and year were you born?

107. How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.

108. Have you ever attended school?

109. What is the highest level of school you attended: primary, secondary, or higher?

110. What is the highest (grade/form/year) you completed at that level?

111. CHECK 109:

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?

113. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

114. CHECK 112:

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?

116. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

117. Do you watch television almost every day, at least once a week, less than once a week or not at all?

118. What is your religion?

119. What tribe do you belong to?

SECTION 2. REPRODUCTION

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?

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

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

204. Do you have any sons or daughters that you have fathered who are alive but do not live with you?

205. How many sons are alive but do not live with you? And how many daughters are alive but do not live with you?
IF NONE, 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?

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'.

209. CHECK 208:

210. Did all of the children you have fathered have the same biological mother?

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

212. How old were you when your (first) child was born?

212A. CHECK 203 AND 205:

213. How many years old is your (youngest) child?

214. CHECK 213:

215. What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD

216. When (NAME)'s mother was pregnant with (NAME), did she have any antenatal check-ups?

217. Were you ever present during any of those antenatal check-ups?

218. Was (NAME) born in a hospital or health facility?

219. What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?

220. When a child has diarrhea, how much fluid 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?

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.

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 EACH METHOD
WITH CODE 1 CIRCLED IN 301, ASK 302.

302. Have you ever used (METHOD)?

303. In the last few months have you heard about family planning:

On the radio?
On the television?
In a newspaper or magazine?

304. In the last few months, have you discussed the practice of family planning with a health worker or health professional?

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?

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

307. Do you think that a woman who is breastfeeding her baby can become pregnant?

308. I will now read to you some statements about contraception. Please tell me if you agree or disagree with each one.

a) Contraception is women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.

309. CHECK 301 (07):
KNOWS MALE CONDOM

310. Do you know of a place where a person can get condoms?

311. 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 OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

312. If you wanted to, could you yourself get a male condom?

313. CHECK 301 (08):
KNOWS FEMALE CONDOM

314. Do you know of a place where a person can get female condoms?

315. 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 OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

316. If you wanted to, could you yourself get a female condom?

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

401. Are you currently married or living together with a woman as if married?

402. Have you ever been married or lived together with a woman as if married?

403. What is your marital status now: are you widowed, divorced, or separated?

404. Is your wife/partner living with you now or is she staying elsewhere?

405. Do you have more than one wife or woman you live with as if married?

406. Altogether, how many wives do you have or other partners do you live with as if married?

407. CHECK 405:

ONE WIFE/PARTNER: Please tell me the name of your wife (the woman you are living with as if married).

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).

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?

409. CHECK 407:

410. Have you been married or lived with a woman only once or more than once?

411. In what month and year did you start living with your wife (partner)?
411B. 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?

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?

415. Do you intend to wait until you get married to have sexual intercourse for the first time?

416. CHECK 107:

417. The first time you had sexual intercourse, was a condom used?

421. 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.

421A. 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.

422. When was the last time you had sexual intercourse with this person?
[EXCLUDE LAST SEXUAL PARTNER]

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

424. Did you use a condom every time you had sexual intercourse with this person in the last
12 months?

425. 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'

426. For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

427. The last time you had sexual intercourse with this (second/third) person did you or this person drink alcohol?

428. Were you or your partner drunk at that time?
IF YES: Who was drunk?

429. Apart from [this person/these two people], have you had sexual intercourse with any other
person in the last 12 months?
[ONLY ASK FOR LAST SEXUAL PARTNER AND SECOND-TO-LAST SEXUAL PARTNER]

430. 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'

430A. CHECK 425 (ALL COLUMNS):

431. CHECK 425 AND 423 (ALL COLUMNS):

432. In the last 12 months, did you pay anyone in exchange for having sexual intercourse?

433. The last time you paid someone in exchange for having sexual intercourse, was a condom used?

434. Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?

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'

436. CHECK 423, MOST RECENT PARTNER (FIRST COLUMN):

437. You told me that a condom was used the last time you had sex. What brand name of the condoms did you use?
ASK TO SEE THE PACKAGE IF RESPONDENT DOES NOT REMEMBER NAME OF BRAND.

439. How many condoms did you get the last time?

440. 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.

441. CHECK 302 (02):
RESPONDENT EVER STERILIZED

442. The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?

443. What method did you or your partner use?
PROBE: Did you use any other method to prevent pregnancy?
RECORD ALL MENTIONED.

SECTION 5. FERTILITY PREFERENCES

501. CHECK 407:

502. CHECK 305:

503. (Is your wife (partner)/Are any of your wives (partners)) currently pregnant?

504. CHECK 503:

NO WIFE/PARTNER PREGNANT OR UNSURE: 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?

WIFE (WIVES)/PARTNER(S) PREGNANT: Now I have some questions about the future.
After the child(ren) you and your (wife(wives)/partner(s)) are expecting now, would you like to have another child, or would you prefer not to have any more children?

505. How long would you like to wait from now before the birth of (a/another) child?

506. CHECK 208:

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.

507. 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?

SECTION 6. EMPLOYMENT AND GENDER ROLES

601. Have you done any work in the last seven days?

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?

603. Have you done any work in the last 12 months?

604. What is your occupation, that is, what kind of work do you mainly do?

605. CHECK 604:

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?

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

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

609. Are you paid in cash or kind for this work or are you not paid at all?

610. CHECK 407:

611. CHECK 609:

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?

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:

a) making large household purchases?

b) making small daily household purchases?

c) deciding when to visit the wife's family or relatives?

d) deciding what to do with the money she earns for her work?

e) deciding how many children to have?

614. I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them.

a) Childbearing is a woman's concern and there is no need for the father to get involved.
b) It is crucial for the mother's and child's health that a woman have assistance from a doctor or nurse at delivery.

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:

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

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...

a) Get angry and reprimand her?

b) Refuse to give her money or other means of support?

c) Use force and have sex with her even if she doesn't want to?

d) Go ahead and have sex with another woman?

SECTION 7. HIV/AIDS

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

702. Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

703. Can people get the AIDS virus from mosquito bites?

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

705. Can people get the AIDS virus by sharing food with a person who has AIDS?

706. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

707. Can people get the AIDS virus because of witchcraft or other supernatural means?

708. Is it possible for a healthy-looking person to have the AIDS virus?

708A. Do you think your risk of getting infected with HIV is low, medium or high, or do you have no risk at all?

709. Can the virus that causes AIDS be transmitted from a mother to her baby:

During pregnancy?
During delivery?
By breastfeeding?

710. CHECK 709:

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?

712. Have you heard about special antiretroviral drugs (USE LOCAL NAME) that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

712A. CHECK FOR PRESENCE OF OTHER PERSONS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

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

714. When was the last time you were tested?

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?

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

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.

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

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.

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

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

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?

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?

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?

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?

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?

727. CHECK 724, 725, AND 726:

728. Do you personally know someone who has or is suspected to have the AIDS virus?

729. Do you agree or disagree with the following statement: People with the AIDS virus should be ashamed of themselves.

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.

731. Should children age 12-14 be taught about using a condom to avoid getting the AIDS virus?

732. Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS virus?

732A. Some individuals would choose not to go for HIV testing. Why in your opinion is this so?
(CIRCLE ALL THAT ARE MENTIONED)
(MORE THAN ONE ANSWER IS POSSIBLE)

733. CHECK 701:

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?

734. CHECK 414:

735. CHECK 733:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

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?

737. Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?

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?

739. CHECK 736, 737, AND 738:

740. The last time you had (PROBLEM FROM 736/737/738), did you seek any kind of advice or treatment?

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.

742. Husband and wives do not always agree in everything. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

743. 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?

744. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?

745. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?

746. Do you believe that young men should wait until they are married to have sexual intercourse?

747. Do you think that most young men you know wait until they are married to have sexual intercourse?

748. Do you believe that men who are not married and are having sex should only have sex with one partner?

749. Do you think that most men you know who are not married and are having sex have sex with only one partner?

750. Do you believe that married men should only have sex with their wives?

751. Do you think that most married men you know have sex only with their wives?

752. Do you believe that young women should wait until they are married to have sexual intercourse?

753. Do you think that most young women you know wait until they are married to have sexual intercourse?

754. Do you believe that women who are not married and are having sex should only have sex with one partner?

755. Do you think that most women you know who are not married and are having sex have sex with only one partner?

756. Do you believe that married women should only have sex with their husbands?

757. Do you think that most married women you know have sex only with their husbands?

SECTION 8. OTHER HEALTH ISSUES

801. Some men are circumcised. Are you circumcised?

802. At what age were you circumcised?

802A. Why were you circumcised?

803. Who performed the circumcision?

804. 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.

805. 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.

806. 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.

807. Did the person who gave you that injection take the syringe and needle from a new, unopened package?

808. Do you currently smoke cigarettes?

809. In the last 24 hours, how many cigarettes did you smoke?

810. Do you currently smoke or use any other type of tobacco?

811. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

812. Do you drink alcohol?

813. In the past one week, on how many days did you drink beer?

814. Have you ever heard of an illness called tuberculosis?

815. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

816. Can tuberculosis be cured?

817. If a member of your family got tuberculosis, would you want it to remain a secret or not?

818. Would you care for someone with TB?

819. Are you covered by any health insurance?

820. What type of health insurance/scheme?
RECORD ALL MENTIONED.

821. CHECK 213:

822. 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)?

823. Besides your own child/children, are you the primary caregiver for any children under the age of 18?

824. 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)?

SECTION 9. MATERNAL AND ADULT MORTALITY

901. 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, including those who are living with you, those living elsewhere and those who have died. How many children did your mother give birth to, including you?

902. CHECK 901:

903. How many of these births did your mother have before you were born?

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

905. Is (NAME) male or female?

906. Is (NAME) still alive?

907. How old is (NAME)?

908. How many years ago did (NAME) die?

909. How old was (NAME) when he/she died?

910. Was (NAME) pregnant when she died?

911. Did (NAME) die during childbirth?

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

913. Was (NAME)'S death due to an accident or violence?

IF NO MORE BROTHERS OR SISTERS, GO TO 914.

TICK HERE IF CONTINUATION SHEET USED __

914. RECORD THE TIME.

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: _______________________