1999 ZIMBABWE DEMOGRAPHIC AND HEALTH SURVEY
NAME OF HOUSEHOLD HEAD __________
WARD NAME __________
CLUSTER NUMBER ___
HOUSEHOLD NUMBER ___
PROVINCE ___
RURAL 2
LARGE CITY/SMALL CITY/TOWN/RURAL
SMALL CITY 2
TOWN 3
RURAL 4
FIRST VISIT
DATE _____
INTERVIEWER'S NAME __________
RESULT * __________
NEXT VISIT
DATE _____
TIME _____
SECOND VISIT
DATE _____
INTERVIEWER'S NAME __________
RESULT * __________
NEXT VISIT
DATE _____
TIME _____
THIRD VISIT
DATE _____
INTERVIEWER'S NAME __________
RESULT * __________
FINAL VISIT
DAY ___
MONTH __________
YEAR _____
NAME __________
RESULT * __________
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) __________
NDEBELE 2
ENGLISH 3
OTHER 4
SUPERVISOR
NAME __________
DATE _____
FIELD EDITOR
NAME __________
DATE _____
OFFICE EDITOR ___
KEYED BY ___
SECTION 1. RESPONDENT'S BACKGROUND
Hello. My name is __________ and I am working with the Central Statistical Office. We are conducting a national survey about the health of women and children. We would very much appreciate your participation in this survey.
I would like to ask you about your health and that of your children. This information may help the country plan health services. Whatever answers you provide will be confidential and will not be shown to other persons.
We hope you will participate in this survey since your views are important. Shall we proceed with the interview?
RESPONDENT DOES NOT AGREE ___ 2 (END)
SIGNATURE OF INTERVIEWER __________
MINUTES ___
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 a city, in a town, on a commercial farm or in another rural area?
TOWN 2
COMMERCIAL FARM 3
OTHER RURAL 4
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 (SKIP TO 105)
VISITOR 96 (SKIP TO 105)
104) Just before you moved here, did you live in a city, in a town, on a commercial farm or in another rural area?
TOWN 2
COMMERCIAL FARM 3
OTHER RURAL 4
105) In what month and year were you born?
DON'T KNOW MONTH 98
YEAR _____
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 (SKIP TO 114)
108) What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
HIGHER 3
109) What is the highest (grade/form/year) you completed at that level?
SECONDARY OR HIGHER ___ (SKIP TO 115)
114) Can you read and understand a letter or newspaper easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3 (SKIP 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
CHRISTIAN 2
MUSLIM 3
NONE 4
OTHER (SPECIFY) __________ 6
120) Have you ever drank an alcohol-containing beverage?
NO 2 (SKIP TO 123)
121) In the last 30 days, on how many days did you drink an alcohol-containing beverage?
NONE/NEVER 997 (SKIP TO 123)
122) In the last 30 days, on how many occasions did you get "drunk"?
NONE/NEVER 997
123) In the last 3 months, have you had any kind of injection?
NO 2 (SKIP TO 201)
124) In the last 3 months, how many times did you have an injection?
EVERY DAY 998
124A) What was the injection for?
RECORD ALL RESPONSES.
OTHER B
125) The last time you had an injection, who was the person who gave you the injection?
PHARMACIST 2
TRADITIONAL HEALER 3
FRIEND/RELATIVE 4
SELF 5
OTHER (SPECIFY) __________ 6
201) Now I would like to ask about all the births you have had during your life. Have you ever given birth?
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?
NO 2 (SKIP TO 204)
203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'.
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?
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, RECORD '00'.
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 survived only a few hours or days?
NO 2 (SKIP TO 208)
207) How many boys have died?
And how many girls have died?
IF NONE, RECORD '00'.
GIRLS DEAD ___
208) SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
IF NONE, RECORD '00'.
Just to make sure that I have this right: you have had in TOTAL ___ births during your life. Is that correct?
NO ___ (PROBE AND CORRECT 201-208 AS NECESSARY.)
NO BIRTHS ___ (SKIP TO 227)
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 LINES.
212) What name was given to your (first/next) baby?
213) Were any of these births twins?
MULTIPLE 2
214) Is (NAME) a boy or a girl?
GIRL 2
215) In what month and year was (NAME) born?
PROBE: What is his/her birthday?
YEAR _____
NO 2 (SKIP TO 219)
217) IF ALIVE:
How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.
218) IF ALIVE:
Is (NAME) living with you?
NO 2
218A) IF ALIVE:
RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD)
219) 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.
MONTHS 2 ___
YEARS 3 ___
220) Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?
NO 2
223) Have you had any live births since the birth of (NAME OF LAST BIRTH)?
NO 2
224) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED. ___
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED. ___
FOR AGE AT DEATH 12 MONTHS OR 1 YR.: PROBE TO DETERMINE EXACT NUMBER OF MONTHS. ___
225) CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN JANUARY 1994 OR LATER. IF NONE, RECORD '0'.
226) FOR EACH BIRTH SINCE JANUARY 1994 ENTER 'B' IN THE MONTH OF BIRTH IN COLUMN 1 OF THE CALENDAR.
FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)
WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE.
227) Are you currently pregnant?
NO 2 (SKIP TO 230)
UNSURE 8 (SKIP TO 230)
228) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P's IN COLUMN 1 OF CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR TOTAL NUMBER OF COMPLETED MONTHS.
229) At the time you became pregnant did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?
LATER 2
NOT AT ALL 3
230) Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?
NO 2 (SKIP TO 235)
231) When did the last such pregnancy end?
YEAR _____
LAST PREGNANCY ENDED BEFORE JANUARY 1994 ___ (SKIP TO 236)
233) How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN COLUMN 1 OF CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.
234) Have you ever had any other pregnancies which did not result in a live birth?
NO 2 (SKIP TO 236)
235) ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 1994.
ENTER 'T' IN COLUMN 1 OF CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.
235A) IN THE BOXES AT THE BOTTOM OF THE CALENDAR, FILL IN THE MONTH AND YEAR OF TERMINATION OF THE LAST NON-LIVE BIRTH PREGNANCY PRIOR TO JANUARY 1994.
236) When did your last menstrual period start?
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___
IN MENOPAUSE 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996
237) From one menstrual period to next, is there a time when a woman is more likely to become pregnant if she has sexual relations?
NO 2 (SKIP TO 301)
DON'T KNOW 8 (SKIP TO 301)
238) Is this time during her period, right after her period has ended, just before her period begins or in the middle of her menstrual cycle?
RIGHT AFTER HER PERIOD HAS ENDED 2
JUST BEFORE HER PERIOD BEGINS 3
IN THE MIDDLE OF THE CYCLE 4
OTHER (SPECIFY) __________ 6
DON'T KNOW 8
Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED 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 303.
301) Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?
01 FEMALE STERILIZATION Women can have an operation to avoid having any more children.
NO 2 (SKIP TO NEXT METHOD)
02 MALE STERILIZATION Men can have an operation to avoid having any more children.
NO 2 (SKIP TO NEXT METHOD)
03 PILL Women can take a pill every day.
NO 2 (SKIP TO NEXT METHOD)
04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse.
NO 2 (SKIP TO NEXT METHOD)
05 INJECTIONS Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
NO 2 (SKIP TO NEXT METHOD)
06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
NO 2 (SKIP TO NEXT METHOD)
07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
NO 2 (SKIP TO NEXT METHOD)
08 FEMALE CONDOM Women can place a rubber sheath in their vagina before sexual intercourse.
NO 2 (SKIP TO NEXT METHOD)
09 DIAPHRAGM Women can place a diaphragm in their vagina before intercourse.
NO 2 (SKIP TO NEXT METHOD)
10 FOAM OR JELLY Women can place a suppository, jelly, or cream in their vagina before intercourse.
NO 2 (SKIP TO NEXT METHOD)
11 LACTATIONAL AMENORRHEA METHOD (LAM) Women can use a specially taught method of pregnancy avoidance to delay the return of the menstrual period by feeding their child nothing but breast milk for up to six months after a birth.
NO 2 (SKIP TO NEXT METHOD)
12 RHYTHM OR PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
NO 2 (SKIP TO NEXT METHOD)
13 WITHDRAWAL Men can be careful and pull out before climax.
NO 2 (SKIP TO NEXT METHOD)
14 EMERGENCY CONTRACEPTION Women can take pills the day after sexual intercourse to avoid becoming pregnant.
NO 2 (SKIP TO NEXT METHOD)
15 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
(SPECIFY) __________
303) Have you ever used (METHOD)?
01 FEMALE STERILIZATION Have you ever had an operation to avoid having any (more) children?
NO 2
02 MALE STERILIZATION Have you ever had a partner who had an operation to avoid having children?
NO 2
03 PILL Women can take a pill every day.
NO 2
04 IUD Women can have a loop or coil placed inside them by a doctor or a nurse.
NO 2
05 INJECTIONS Women can have an injection by a doctor or nurse which stops them from becoming pregnant for several months.
NO 2
06 IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for several years.
NO 2
07 CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
NO 2
08 FEMALE CONDOM Women can place a rubber sheath in their vagina before sexual intercourse.
NO 2
09 DIAPHRAGM Women can place a diaphragm in their vagina before intercourse.
NO 2
10 FOAM OR JELLY Women can place a suppository, jelly, or cream in their vagina before intercourse.
NO 2
11 LACTATIONAL AMENORRHEA METHOD (LAM) Women can use a specially taught method of pregnancy avoidance to delay the return of the menstrual period by feeding their child nothing but breast milk for up to six months after a birth.
NO 2
12 RHYTHM OR PERIODIC ABSTINENCE Every month that a woman is sexually active she can avoid having sexual intercourse on the days of the month she is most likely to get pregnant.
NO 2
13 WITHDRAWAL Men can be careful and pull out before climax.
NO 2
14 EMERGENCY CONTRACEPTION Women can take pills the day after sexual intercourse to avoid becoming pregnant.
NO 2
15 Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
(SPECIFY) __________
AT LEAST ONE "YES" (EVER USED) ___ (SKIP TO 309)
305) Have you ever used anything or tried in any way to delay or avoid getting pregnant?
NO 2
306) ENTER '0' IN COLUMN 1 OF CALENDAR IN EACH BLANK MONTH (SKIP TO 332)
307) What have you used or done?
CORRECT 303 AND 304 (AND 301 IF NECESSARY).
309) Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.
How many living children did you have at that time, if any?
IF NONE, RECORD '00'.
WOMAN STERILIZED ___ (SKIP TO 314A)
PREGNANT ___ (SKIP TO 325)
313) Are you currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (SKIP TO 325)
314) Which method are you using?
MALE STERILIZATION B
PILL C (SKIP TO 324)
IUD D (SKIP TO 324)
INJECTIONS E (SKIP TO 324)
IMPLANTS F (SKIP TO 324)
CONDOM G (SKIP TO 324)
FEMALE CONDOM H (SKIP TO 324)
DIAPHRAGM I (SKIP TO 324)
FOAM/JELLY J (SKIP TO 324)
LACTATIONAL AMENORRHEA METHOD K (SKIP TO 324)
PERIODIC ABSTINENCE L (SKIP TO 324)
WITHDRAWAL M (SKIP TO 324)
OTHER (SPECIFY) __________ X (SKIP TO 324)
314A) CIRCLE 'A' FOR FEMALE STERILIZATION.
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD.
318) 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.
NAME OF PLACE __________
PROVINCIAL HOSPITAL 12
DISTRICT/RURAL HOSPITAL 13
OTHER PUBLIC (SPECIFY) __________ 16
PRIVATE DOCTOR 32
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
DON'T KNOW 98
318A) Before the sterilization operation, were (you/your husband/your partner) told that you would not be able to have any (more) children?
NO 2
DON'T KNOW 8
321) In what month and year was the sterilization performed?
YEAR _____
STERILIZED BEFORE JANUARY 1994 ___
STERILIZED IN JANUARY 1994 OR LATER ___
ENTER METHOD SOURCE CODE IN COLUMN 2 OF CALENDAR IN MONTH OF DATE OF OPERATION. (THEN SKIP TO 325)
324) ENTER METHOD CODE FROM 314 IN CURRENT MONTH IN COLUMN 1 OF CALENDAR. THEN DETERMINE WHEN SHE STARTED USING METHOD THIS TIME.
ENTER METHOD CODE IN EACH MONTH OF USE.
IF CURRENT METHOD STARTED IN JANUARY 1994 OR LATER, ENTER THE METHOD SOURCE CODE IN COLUMN 2 OF CALENDAR IN THE SAME MONTH THAT USE OF CURRENT METHOD BEGAN.
ILLUSTRATIVE QUESTIONS:
How long have you been using this method continuously?
When you started using this method, where did you obtain it?
325) I would like to ask you some questions about the times you or your partner may have used a method to avoid getting pregnant during the last few years.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 1994.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.
IN COLUMN 1, ENTER METHOD CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.
COLUMN 1:
When did you start using that method? How long after the birth of (NAME)?
How long did you use the method then?
IN COLUMN 2, ENTER METHOD SOURCE CODE IN FIRST MONTH OF EACH USE.
COLUMN 2:
Where did you get advice on how to use the method [for LAM, rhythm, or withdrawal]?
IN COLUMN 3, ENTER CODES FOR DISCONTINUATION NEXT TO LAST MONTH OF USE.
NUMBER OF CODES IN COLUMN 3 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.
ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OR DELIBERATELY STOPPED TO GET PREGNANT.
COLUMN 3:
Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?
IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK:
327) CHECK 314/314A:
CIRCLE CODE:
IF MORE THAN ONE METHOD CIRCLED IN 314/314A, CIRCLE CODE FOR HIGHEST METHOD ON LIST
FEMALE STERILIZATION 01
MALE STERILIZATION 02 (SKIP TO 334)
PILL 03
IUD 04
INJECTIONS 05
IMPLANTS 06
CONDOM 07 (SKIP TO 328I)
FEMALE CONDOM 08 (SKIP TO 328I)
DIAPHRAGM 09 (SKIP TO 328I)
FOAM/JELLY 10 (SKIP TO 328I)
LACTATIONAL AMENORRHEA METHOD 11 (SKIP TO 328I)
PERIODIC ABSTINENCE 12 (SKIP TO 334)
WITHDRAWAL 13 (SKIP TO 334)
OTHER METHOD 96 (SKIP TO 334)
328B) CHECK COLUMN 1 OF CALENDAR FOR LENGTH OF USE OF CURRENT METHOD:
STARTED USING IN JANUARY 1994 OR BEFORE ___ (SKIP TO 328K)
328G) You first obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM CALENDAR) on (DATE).
At that time, were you told about side effects or problems you might have with the method?
NO 2 (SKIP TO 328I)
328H) Were you told what to do if you experienced side effects?
NO 2
328I) When you were given the (CURRENT METHOD), were you told about other methods of family planning which you could use?
NO 2
328K) CHECK 314/314A:
CIRCLE METHOD CODE:
FEMALE STERILIZATION 01 (SKIP TO 334)
MALE STERILIZATION 02 (SKIP TO 334)
PILL 03
IUD 04
INJECTIONS 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMENORRHEA METHOD 11 (SKIP TO 334)
PERIODIC ABSTINENCE 12 (SKIP TO 334)
WITHDRAWAL 13 (SKIP TO 334)
OTHER METHOD 96 (SKIP TO 334)
328L) 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.
NAME OF PLACE __________
RURAL/MUNICIPAL CLINIC 12 (SKIP TO 334)
RURAL HEALTH CENTER 13 (SKIP TO 334)
ZNFPC (FIXED) CLINIC 14 (SKIP TO 334)
ZNFPC MOBILE CLINIC 15 (SKIP TO 334)
MOH MOBLIE CLINIC 16 (SKIP TO 334)
ZNFPC CBD 17 (SKIP TO 334)
MOH CBD 18 (SKIP TO 334)
OTHER PUBLIC (SPECIFY) __________ 19 (SKIP TO 334)
PHARMACY 32 (SKIP TO 334)
PRIVATE DOCTOR 33 (SKIP TO 334)
CBD 34 (SKIP TO 334)
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36 (SKIP TO 334)
CHURCH 42 (SKIP TO 334)
FRIENDS/RELATIVES 43 (SKIP TO 334)
332) Do you know of a place where you can obtain a method of family planning?
NO 2 (SKIP TO 334)
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.
NAME OF PLACE __________
RURAL/MUNICIPAL CLINIC 12
RURAL HEALTH CENTER 13
ZNFPC (FIXED) CLINIC 14
ZNFPC MOBILE CLINIC 15
MOH MOBLIE CLINIC 16
ZNFPC CBD 17
MOH CBD 18
OTHER PUBLIC (SPECIFY) __________ 19
PHARMACY 32
PRIVATE DOCTOR 33
CBD 34
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
CHURCH 42
FRIENDS/RELATIVES 43
334) In the last 12 months, were you visited by a CBD who talked to you about family planning?
NO 2
335) In the last 12 months, have you attended a health facility for care for yourself (or your children)?
NO 2 (SKIP TO 401)
336) Did any staff member at the health facility speak to you about family planning methods?
NO 2
SECTION 4A. PREGNANCY, POSTNATAL CARE AND BREASTFEEDING
NO BIRTHS IN JANUARY 1994 OR LATER ___ (SKIP TO 470)
402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1994 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 2 BIRTHS, USE ADDITIONAL QUESTIONNAIRES).
Now I would like to ask you some questions about the health of all your children born in the last five years. (We will talk about each separately)
403) LINE NUMBER FROM QUESTION 212
404) FROM QUESTION 212 AND QUESTION 216
DEAD ___
404A) Has (NAME) been registered?
NO 2 (SKIP TO 405)
DON'T KNOW 8 (SKIP TO 405)
404B) Does (NAME) have a birth certificate?
IF YES: May I see it, please?
YES, NOT SEEN 2
NO CERTIFICATE 3
405) At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you want no (more) children at all?
LATER 2
NO MORE 3 (SKIP TO 407)
406) How much longer would you like to have waited?
YEARS 2 ___
DON'T KNOW 998
[FOR QUESTIONS 407-411F, COMPLETE COLUMNS FOR LAST BIRTH]
407) Did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see?
Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.
NURSE/MIDWIFE B
UNTRAINED D
TRAINING UNCERTAIN E
NO ONE Y (SKIP TO 410)
408) How many months pregnant were you when you first received antenatal care for this pregnancy?
DON'T KNOW 98
409) How many times did you receive antenatal care during this pregnancy?
DON'T KNOW 98
409A) CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE
MORE THAN ONCE OR DK ___
409B) How many months pregnant were you the last time you received antenatal care?
DON'T KNOW 98
409C) During this pregnancy, were any of the following done at least once?
NO 2
NO 2
NO 2
NO 2
NO 2
409D) Were you told about the signs of pregnancy complications?
NO 2 (SKIP TO 410)
DON'T KNOW 8 (SKIP TO 410)
409E) Were you told where to go if you had these problems?
NO 2
DON'T KNOW 8
410) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
NO 2 (SKIP TO 411A)
DON'T KNOW 8 (SKIP TO 411A)
410A) During this pregnancy, how many times did you get this injection?
DON'T KNOW 8
411A) During this pregnancy, were you given or did you buy any iron tablets?
SHOW TABLET.
NO 2 (SKIP TO 411C)
DON'T KNOW (SKIP TO 411C)
411B) During the whole pregnancy, how many tablets did you take?
DON'T KNOW 998
411C) During this pregnancy, did you have difficulty with your vision during the daylight?
NO 2
DON'T KNOW 8
411D) During this pregnancy, did you suffer from night blindness?
NO 2
DON'T KNOW 8
411E) During this pregnancy, were you given or did you buy any drugs in order to prevent malaria?
NO 2 (SKIP TO 412)
DON'T KNOW 8 (SKIP TO 412)
411F) Which drug was that?
RECORD ALL MENTIONED.
FANSIDAR B
CHLOROQUINE C
DELTAPRIM D
NOROLON E
QUININE F
OTHER (SPECIFY) __________ X
412) When (NAME) was born, was he/she:
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON'T KNOW 8
413) Was (NAME) weighed at birth?
NO 2 (SKIP TO 415)
DON'T KNOW 8 (SKIP TO 415)
414) How much did (NAME) weigh?
RECORD WEIGHT FROM HEALTH CARD OR MOTHER'S CARD, IF AVAILABLE.
GRAMS FROM RECALL 2 ___
DON'T KNOW 99998
415) Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.
NURSE/MIDWIFE B
UNTRAINED D
TRAINING UNCERTAIN E
NO ON Y (SKIP TO 417)
416) Where did you give birth to (NAME)?
OTHER HOME 12 (SKIP TO 418A)
PROVINCIAL HOSPITAL 22
DISTRICT/RURAL HOSPITAL 23
RURAL HEALTH CENTRE 24 (SKIP TO 418A)
RURAL/MUNICIPAL CLC. 25 (SKIP TO 418A)
OTHER PUBLIC (SPECIFY) __________ 26
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
OTHER (SPECIFY) __________ 96 (SKIP TO 418A)
417) Was (NAME) delivered by caesarian section?
NO 2
418A) After (NAME) was born, did anyone check on your health?
NO 2 (SKIP TO 419)
418B) How many days or weeks after the delivery did the first check take place? [ANSWER FOR LAST BIRTH]
RECORD '00' DAYS IF SAME DAY.
WEEKS AFTER DELIVERY 2 ___
DON'T KNOW 998
418C) Who checked on your health at that time?
[ANSWER FOR LAST BIRTH]
PROBE FOR MOST QUALIFIED PERSON.
NURSE/MIDWIFE 2
UNTRAINED 4
TRAINING UNCERTAIN 5
418D) Where did this first check take place?
[ANSWER FOR LAST BIRTH]
OTHER HOME 12
PROVINCIAL HOSPITAL 22
DISTRICT/RURAL HOSPITAL 23
RURAL HEALTH CENTRE 24
RURAL/MUNICIPAL CLC. 25
OTHER PUBLIC (SPECIFY) __________ 26
PRIVATE DOCTOR 32
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
419) Has your period returned since the birth of (NAME)?
[ANSWER FOR LAST BIRTH]
NO (SKIP TO 422)
420) Did your period return between the birth of (NAME) and your next pregnancy?
[ANSWER FOR NEXT-TO-LAST BIRTH]
NO 2 (SKIP TO 424)
421) For how many months after birth of (NAME) did you not have a period?
DON'T KNOW 98
422) CHECK 227:
RESPONDENT PREGNANT?
PREGNANT OR UNSURE ___ (SKIP TO 424)
423) Have you resumed sexual relations since the birth of (NAME)?
[MOST RECENT BIRTH WITHIN THE LAST FIVE YEARS]
NO 2 (SKIP TO 425)
424) For how many months after the birth of (NAME) did you not have sexual relations?
DON'T KNOW 98
425) Did you ever breastfeed (NAME)?
NO 2 (SKIP TO 431)
426) 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.
HOURS 1 ___
DAYS 2 ___
DEAD ___ (SKIP TO 429)
428) Are you still breastfeeding (NAME)?
NO 2
429) For how many months did you breastfeed (NAME)?
DON'T KNOW 98
DEAD ___ (GO BACK TO 404 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 440)
432) How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.
433) How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.
434) Did (NAME) drink anything from a bottle with a teat yesterday or last night?
NO 2
DON'T KNOW 8
437) Now I would like to ask you about the types of foods [NAME] has been fed over the last seven days, including yesterday.
How many days during last seven days was [NAME] given each of the following?
FOR EACH ITEM GIVEN AT LEAST ONCE IN LAST SEVEN DAYS, ASK: How many times yesterday or last night was [NAME] given [ITEM]?
IF 7 OR MORE TIMES, RECORD '7'.
IF DON'T KNOW, RECORD '8'.
A. Plain water?
B. Commercially prepared baby formula?
C. Fresh cow or goat milk?
D. Any other milk such as tinned or powdered milk?
E. Fruit juice?
F. Any other liquids such as glucose water, tea, herbal teas/roots, or mahewu?
G. Any other foods made from grains such as sadza, bread, porridge or thin gruel?
H. Pumpkin, squash, sweet potatoes, or carrots?
I. Potatoes or other food made from tubers?
J. Any green leafy vegetables?
K. Mango or pawpaw?
L. Beans, groundnuts, or peanut butter?
M. Any other fruits and vegetables such as oranges, bananas or tomatoes?
N. Meat, poultry, fish, or eggs?
O. Cheese or yogurt?
438) How many times was (NAME) fed solid or semi-solid (mashed or pureed) food yesterday or last night?
IF 7 OR MORE TIMES, RECORD '7'.
DON'T KNOW 8
439) GO BACK TO 404A IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 440.
SECTION 4B. IMMUNIZATION AND HEALTH
440) ENTER THE NAME AND LINE NUMBER OF EACH LIVING CHILD BORN SINCE JANUARY 1994 IN THE TABLE.
ASK THE QUESTIONS ABOUT ALL OF THESE CHILDREN.
BEGIN WITH THE YOUNGEST CHILD. (IF THERE ARE MORE THAN 2 LIVING CHILDREN, USE ADDITIONAL QUESTIONNAIRES).
441) LINE NUMBER FROM QUESTION 212
442) FROM QUESTION 212 AND QUESTION 216
DEAD ___ (SKIP TO 442 IN NEXT COLUMN OR, IF NO MORE BIRTHS, SKIP TO 464A)
443) Do you have a card where (NAME'S) vaccinations are written down?
IF YES: May I see it please?
YES, NOT SEEN 2 (SKIP TO 447)
NO CARD 3
444) Did you ever have a vaccination card for (NAME)?
NO 2 (SKIP TO 447)
445) (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
MONTH __________
YEAR _____
446) Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 1-3, DPT 1-3, AND/OR MEASLES VACCINE(S).
NO 2 (SKIP TO 448H)
DON'T KNOW 8 (SKIP TO 448H)
447) Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign?
NO 2 (SKIP TO 449)
DON'T KNOW 8 (SKIP TO 449)
448) Please tell me if (NAME) received any of the following vaccinations:
448A. A BCG vaccination against tuberculosis, that is, an injection in the right arm or shoulder that caused a scar?
NO 2
DON'T KNOW 8
448B. Polio vaccine, that is, drops in the mouth?
NO 2 (SKIP TO 448E)
DON'T KNOW 8 (SKIP TO 448E)
448D. How many times was the polio vaccine received?
448E. DPT vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?
NO 2 (SKIP TO 448G)
DON'T KNOW 8 (SKIP TO 448G)
448G. An injection to prevent measles?
NO 2
DON'T KNOW 8
448H. Were any of the vaccinations (NAME) received during the last two years given as a part of a national immunization day campaign?
NO 2
DON'T KNOW 8
449) Has (NAME) been ill with a fever at any time in the last 2 weeks?
NO 2
DON'T KNOW 8
450) Has (NAME) had an illness with a cough at any time in the last 2 weeks?
NO 2 (SKIP TO 451A)
DON'T KNOW 8 (SKIP TO 451A)
451) When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, fast breaths?
NO 2
DON'T KNOW 8
451A) CHECK 449 AND 450:
FEVER OR COUGH?
OTHER ___ (SKIP TO 454)
452) Did you seek advice or treatment for the illness?
NO 2 (SKIP TO 454)
453) Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.
PROVINCIAL HOSPITAL B
DISTRICT/RURAL HOSPITAL C
RURAL HEALTH CENTRE D
RURAL/MUNICIPAL CLC E
VILLAGE COMMUNITY WORKER F
OTHER PUBLIC (SPECIFY) __________ G
PRIVATE DOCTOR J
PHARMACY K
VILLAGE COMMUNITY WORKER L
OTHER PRIVATE MEDICAL (SPECIFY) __________ M
TRADITIONAL PRACTITIONER O
"NO"/"DK" IN 449 ___ (SKIP TO 454)
453B) Did (NAME) take any antimalarial drugs for the fever?
NO 2 (SKIP TO 454)
DON'T KNOW (SKIP TO 454)
453C) What drug was that?
RECORD ALL MENTIONED.
ASPIRIN B
FANSIDAR C
CHLOROQUINE D
DELTAPRIM E
NOROLON F
OTHER (SPECIFY) __________ X
DON'T KNOW Z
454) Has (NAME) had diarrhea in the last 2 weeks?
NO 2 (SKIP TO 464)
DON'T KNOW 8 (SKIP TO 464)
457) When (NAME) had diarrhea, was he/she given less than usual to drink, about the same amount, or more than usual to drink?
SAME 2
MORE 3
DON'T KNOW 8
458) Was he/she given less than usual to eat, about the same amount, or more than usual to eat?
SAME 2
MORE 3
DON'T KNOW 8
459) Was he/she given any of the following to drink:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
460) Was anything (else) given to treat the diarrhea?
NO 2 (SKIP TO 462)
DON'T KNOW 8 (SKIP TO 462)
461) What was given to treat the diarrhea?
Anything else?
RECORD ALL MENTIONED.
INJECTION B
(I.V.) INTRAVENOUS C
HOME REMEDIES/HERBAL MEDICINES D
OTHER (SPECIFY) __________ X
462) Did you seek advice or treatment for the diarrhea?
NO 2 (SKIP TO 464)
463) Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.
PROVINCIAL HOSPITAL B
DISTRICT/RURAL HOSPITAL C
RURAL HEALTH CENTRE D
RURAL/MUNICIPAL CLC E
VILLAGE COMMUNITY WORKER F
OTHER PUBLIC (SPECIFY) __________ G
PRIVATE DOCTOR J
PHARMACY K
VILLAGE COMMUNITY WORKER L
OTHER PRIVATE MEDICAL (SPECIFY) __________ M
TRADITIONAL PRACTITIONER O
464) GO BACK TO 442 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, SKIP TO 464A.
464A) CHECK 442, ALL COLUMNS:
NUMBER OF LIVING CHILDREN BORN SINCE JANUARY 1994
NONE ___ (SKIP TO 470)
464B) The last time you fed your children, did you wash your hands immediately before feeding them?
NO 2
NEVER FED CHILDREN 3
464C) The last time you had to clean (your child/one of your children) after (he/she) defecated, did you wash your hands immediately afterwards?
NO 2
NEVER CLEANED CHILDREN 3
464D) What usually happens with your child(ren)'s stools when they do not use any toilet facility?
DISPOSED OF IN TOILET/LATRINE 02
DISPOSED OF OUTSIDE DWELLING 03
DISPOSED OF OUTSIDE YARD 04
BURY IN THE YARD 05
WASHED AWAY 06
NOT DISPOSED OF 07
OTHER (SPECIFY) __________ 96
ANY CHILD RECEIVED SSS ___ (SKIP TO 470A)
470) Have you ever heard of a special solution prepared using sugar, salt and water that is used for the treatment of diarrhea?
NO 2
HAS NO CHILDREN LIVING WITH HER ___ (SKIP TO 470C)
470B) When (your child/one of your children) is seriously ill, can you decide by yourself whether the child should be taken for medical treatment?
NO 2
DEPENDS 3
470C) 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, a small problem, or no problem for you?
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
SMALL PROBLEM 2
NO PROBLEM 3
470D) Do you currently smoke cigarettes or tobacco?
IF YES: What type of tobacco do you smoke?
YES, PIPE B
YES, OTHER TOBACCO C
NO E (SKIP TO 470F)
470E) In the last 24 hours, how many times did you smoke?
470F) The last time you prepared a meal for your family, before starting, did you wash your hands?
NO 2
NEVER PREPARED MEALS 3
SECTION 5. MARRIAGE AND SEXUAL ACTIVITY
502) Are you currently married or living with a man?
YES, LIVING WITH A MAN 2 (SKIP TO 507)
NO, NOT IN UNION 3
504) Have you ever been married or lived with a man?
YES, LIVED WITH A MAN 2 (SKIP TO 511)
NO 3
505) ENTER '0' IN COLUMN 4 OF CALENDAR IN THE MONTH OF INTERVIEW, AND IN EACH MONTH BACK TO JANUARY 1994 (SKIP TO 515)
506) What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (SKIP TO 511)
SEPARATED 3 (SKIP TO 511)
507) Is your husband/partner living with you now or is he staying elsewhere?
STAYING ELSEWHERE 2
507A) RECORD THE HUSBAND'S LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.
508) Besides yourself, how many wives does your husband have?
511) Have you been married or lived with a man only once, or more than once?
MORE THAN ONCE 2
512) Now we will talk about your (first) husband/partner.
In what month and year did you start living with him?
DON'T KNOW MONTH 98
YEAR _____ (SKIP TO 514)
DON'T KNOW YEAR 9998
513) How old were you when you started living with him?
514) DETERMINE MONTHS MARRIED OR LIVING WITH A MAN SINCE JANUARY 1994. ENTER 'X' IN COLUMN 4 OF CALENDAR FOR EACH MONTH MARRIED OR LIVING WITH A MAN, AND ENTER '0' FOR EACH MONTH NOT MARRIED/NOT LIVING WITH A MAN, SINCE JANUARY 1994.
FOR WOMEN WITH MORE THAN ONE UNION: PROBE FOR DATE WHEN CURRENT UNION STARTED AND, IF APPROPRIATE, FOR STARTING AND TERMINATION DATES OF ANY PREVIOUS UNIONS.
FOR WOMEN NOT CURRENTLY IN UNION: PROBE FOR DATE WHEN LAST UNION STARTED AND FOR TERMINATION DATE AND, IF APPROPRIATE, FOR THE STARTING AND TERMINATION DATES OF ANY PREVIOUS UNIONS
.
NOT CURRENTLY MARRIED AND NOT CURRENTLY LIVING WITH A MAN ___ (SKIP TO 515)
NOT ASKED (NO CODE CIRCLED) ___ (SKIP TO 515)
514C) You have told me that you are using contraception. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision or did you both decide together?
HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) __________ 6
515) 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 MARRIED 96
517) When was the last time you had sexual intercourse?
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___ (SKIP TO 525)
518) The last time you had sexual intercourse, was a condom used?
NO 2 (SKIP TO 519)
518A) What was the main reason you used a condom on that occasion?
OWN CONCERN TO PREVENT PREGNANCY 2
OWN CONCERN TO PREVENT BOTH STD/HIV AND PREGNANCY 3
DID NOT TRUST PARTNERS/FEELS PARTNER HAS OTHER PARTNERS 4
PARTNER INSISTED 5
OTHER (SPECIFY) __________ 6
DON'T KNOW 8
519) What is your relationship to the man with whom you last had sex?
IF "GIRLFRIEND OR FIANCEE", ASK "the last time you had sex with this partner, were you living with him?"
IF "YES", RECORD '1'
IF "NO", RECORD '2'
GIRL FRIEND/FIANCEE 2
OTHER FRIEND 3
CASUAL ACQUAINTANCE 4
COMMERCIAL SEX WORKER 5
RELATIVE 6
OTHER (SPECIFY) __________ 7
519A) How long have you had a sexual relationship with this man?
WEEKS 2 ___
MONTHS 3 ___
YEARS 4 ___
520) Have you had sex with anyone else in the last 12 months?
NO 2 (SKIP TO 525)
522) The last time you had sexual intercourse with this other man, was a condom used?
NO 2 (SKIP TO 523)
522A) What was the main reason you used a condom on that occasion?
OWN CONCERN TO PREVENT PREGNANCY 2
OWN CONCERN TO PREVENT BOTH STD/HIV AND PREGNANCY 3
DID NOT TRUST PARTNERS/FEELS PARTNER HAS OTHER PARTNERS 4
PARTNER INSISTED 5
OTHER (SPECIFY) __________ 6
DON'T KNOW 8
523) What is your relationship to this man?
IF "GIRLFRIEND OR FIANCEE", ASK "the last time you had sex with this partner, were you living with him?"
IF "YES", RECORD '1'
IF "NO", RECORD '2'
GIRL FRIEND/FIANCEE 2
OTHER FRIEND 3
CASUAL ACQUAINTANCE 4
COMMERCIAL SEX WORKER 5
RELATIVE 6
OTHER (SPECIFY) __________ 7
523A) How long have you had a sexual relationship with this man?
WEEKS 2 ___
MONTHS 3 ___
YEARS 4 ___
524) Altogether, with how many different men have you had sex in the last 12 months?
525) Do you know of a place where one can get condoms?
NO 2 (SKIP TO 527)
526) Where is that?
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.
NAME OF PLACE __________
RURAL/MUNICIPAL CLINIC 12
RURAL HEALTH CENTRE 13
ZNFPC (FIXED) CLINIC 14
ZNFPC MOBILE CLINIC 15
MOH MOBILE CLINIC 16
ZNFPC CBD 17
MOH CBD 18
OTHER PUBLIC (SPECIFY) __________ 19
PHARMACY 32
PRIVATE DOCTOR 33
CBD 34
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
CHURCH 42
FRIENDS/RELATIVES 43
526A) If you wanted to, could you easily get a condom?
NO 2
DON'T KNOW/UNSURE 8
527) Do you know of a place where one can get female condoms?
NO 2 (SKIP TO 601)
528) Where is that?
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.
NAME OF PLACE __________
RURAL/MUNICIPAL CLINIC 12
RURAL HEALTH CENTRE 13
ZNFPC (FIXED) CLINIC 14
ZNFPC MOBILE CLINIC 15
MOH MOBILE CLINIC 16
ZNFPC CBD 17
MOH CBD 18
OTHER PUBLIC (SPECIFY) __________ 19
PHARMACY 32
PRIVATE DOCTOR 33
CBD 34
OTHER PRIVATE MEDICAL (SPECIFY) __________ 36
CHURCH 42
FRIENDS/RELATIVES 43
528A) If you wanted to, could you yourself easily get a female condom?
NO 2
DON'T KNOW/UNSURE 8
SECTION 6. FERTILITY PREFERENCES
HE OR SHE STERILIZED ___ (SKIP TO 612)
NO MORE/NONE 2 (SKIP TO 604)
SAYS SHE CAN'T GET PREGNANT 3 (SKIP TO 606)
UNDECIDED/DON'T KNOW AND PREGNANT 8 (SKIP TO 605)
UNDECIDED/DON'T KNOW AND NOT PREGNANT (SKIP TO 606)
YEARS 2 ___
SOON/NOW 993 (SKIP TO 606)
SAYS SHE CAN'T GET PREGNANT 994 (SKIP TO 606)
AFTER MARRIAGE 995 (SKIP TO 606)
OTHER (SPECIFY) __________ 996 (SKIP TO 606)
DON'T KNOW 998 (SKIP TO 606)
PREGNANT ___ (SKIP TO 608)
604A) CHECK 313: USING A METHOD?
NOT CURRENTLY USING ___
CURRENTLY USING (SKIP TO 605)
24 OR MORE MONTHS OR 02 OR MORE YEARS ___
0-23 MONTHS OR 01 YEAR ___ (SKIP TO 608)
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SUBFECUND/INFECUND E
POSTPARTUM AMENORRHEIC F
BREASTFEEDING G
FATALISTIC H
HUSBAND 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 PROCESSES T
605) In the next few weeks, if you discovered that you were pregnant, would it be a big problem, a small problem, or no problem for you?
SMALL PROBLEM 2
NO PROBLEM 3
SAYS SHE CAN'T GET PREGNANT 4
606) CHECK 313:
USING A METHOD?
NOT CURRENTLY USING ___
CURRENTLY USING ___ (SKIP TO 612)
608) Do you think you will use a method to delay or avoid pregnancy at any time in the future?
NO 2 (SKIP TO 610)
DON'T KNOW 8 (SKIP TO 610)
609) Which method would you prefer to use?
MALE STERILIZATION 02 (SKIP TO 612)
PILL 03 (SKIP TO 612)
IUD 04 (SKIP TO 612)
INJECTIONS 05 (SKIP TO 612)
IMPLANTS 06 (SKIP TO 612)
CONDOM 07 (SKIP TO 612)
FEMALE CONDOM 08 (SKIP TO 612)
DIAPHRAGM 09 (SKIP TO 612)
FOAM/JELLY 10 (SKIP TO 612)
LACTATIONAL AMENORRHEA METHOD 11 (SKIP TO 612)
PERIODIC ABSTINENCE 12 (SKIP TO 612)
WITHDRAWAL 13 (SKIP TO 612)
OTHER (SPECIFY) __________ 96 (SKIP TO 612)
UNSURE 98 (SKIP TO 612)
610) What is the main reason that you think you will not use a method at any time in the future?
MENOPAUSAL/HYSTERECTOMY 23 (SKIP TO 612)
SUBFECUND/INFECUND 24 (SKIP TO 612)
WANTS AS MANY CHILDREN AS POSSIBLE 26 (SKIP TO 612)
HUSBAND OPPOSED 32 (SKIP TO 612)
OTHERS OPPOSED 33 (SKIP TO 612)
RELIGIOUS PROHIBITION 34 (SKIP TO 612)
KNOWS NO SOURCE 42 (SKIP TO 612)
FEAR OF SIDE EFFECTS 52 (SKIP TO 612)
LACK OF ACCESS/TOO FAR 53 (SKIP TO 612)
COST TOO MUCH 54
INCONVENIENT TO USE 55 (SKIP TO 612)
INTERFERES WITH BODY'S NORMAL PROCESSES 56 (SKIP TO 612)
611) Would you ever use a method if you were married?
NO 2
DON'T KNOW 8
PROBE FOR A NUMERIC RESPONSE.
OTHER (SPECIFY) __________ 96 (SKIP TO 614)
613) 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?
OTHER (SPECIFY) __________ 96
OTHER (SPECIFY) __________ 96
OTHER (SPECIFY) __________ 96
614) Would you say that you approve or disapprove of couples using a method to delay or avoid getting pregnant?
DISAPPROVE 2
DON'T KNOW/UNSURE 3
616) In the last few months have you heard about family planning:
NO 2
NO 2
NO 2
618) In the last few months, have you discussed the practice of family planning with your friends, neighbors, or relatives?
NO 2 (SKIP TO 620)
619) With whom?
Anyone else?
RECORD ALL MENTIONED.
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
SON G
MOTHER-IN-LAW H
FRIENDS/NEIGHBORS I
OTHER (SPECIFY) __________ X
YES, LIVING WITH A MAN ___
NO, NOT IN UNION ___ (SKIP TO 623A)
621) Husbands and wives do not always agree on everything. Now I want to ask about your husband's/partner's views on family planning.
Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy?
DISAPPROVES 2
DON'T KNOW 8
622) How often have you talked to your husband/partner about family planning in the past year?
ONCE OR TWICE 2
MORE OFTEN 3
623) Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer that you?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
623A) Husbands and wives do not always agree on everything. Please tell me if you think a wife is justified in refusing to have sex with her husband when:
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
NO 2
DON'T KNOW 8
SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK
FORMERLY MARRIED/LIVED WITH A MAN ___ (SKIP TO 703)
NEVER MARRIED AND NEVER LIVED WITH A MAN ___ (SKIP TO 709)
702) How old was your husband/partner on his last birthday?
703) Did your (last) husband/partner ever attend school?
NO 2 (SKIP TO 706)
704) What was the highest level of school he attended?
SECONDARY 2
HIGHER 3
DON'T KNOW 8 (SKIP TO 706)
705) What was the highest (grade/form/year) he completed at that level?
DON'T KNOW 98
What is your husband's/partner's occupation? That is, what kind of work does he mainly do?
What was your (last) husband's/partner's occupation? That is, what kind of work did he mainly do?
709) Aside from your own housework, are you currently working?
NO 2
710) 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.
Are you currently doing any of these things or any other work?
NO 2
711) Have you done any work in the last 12 months?
NO 2 (SKIP TO 723A)
712) What is your occupation, that is, what kind of work do you mainly do?
DOES NOT WORK IN AGRICULTURE ___ (SKIP TO 715)
714) Do you work mainly on your own land, do you work on communal land, or do you rent land, or work on someone else's land?
COMMUNAL/RESETTLEMENT 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
715) 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
716) 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
720) 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 (SKIP TO 723)
NOT PAID 4 (SKIP TO 723)
720A) Who mainly decides how the money you earn will be used?
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
722A) On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, HER INCOME IS ALL SAVED 6
723) Do you usually work at home or away from home?
AWAY 2
723A) Who in your family usually has the final say on the following decisions:
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
728A) PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING OR NOT PRESENT)
PRESENT/NOT LISTENING 2
NOT PRESENT 8
PRESENT/NOT LISTENING 2
NOT PRESENT 8
PRESENT/NOT LISTENING 2
NOT PRESENT 8
PRESENT/NOT LISTENING 2
NOT PRESENT 8
728B) Sometimes a husband is annoyed or angered by things which 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
SECTION 8: AIDS AND OTHER SEXUALLY TRANSMITTED DISEASES
801) Now I would like to talk about something else. Have you ever heard of an illness called AIDS?
NO 2 (SKIP TO 816)
802) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?
NO 2 (SKIP TO 810)
DON'T KNOW (SKIP TO 810)
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
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVEN 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 (SPECIFY) __________ W
OTHER (SPECIFY) __________ X
DON'T KNOW Z
CODE 'C' AND/OR CODE 'D' CIRCLED ___ (SKIP TO 807)
805) In your view, is a person's chance of getting AIDS influenced by the number of partners he or she has?
NO 2 (SKIP TO 807)
DON'T KONW (SKIP TO 807)
806) If a person has sex with only one partner, does this person have a greater or lesser chance of getting AIDS than a person who has sex with many partners?
LESSER CHANCE OF AIDS 2
MENTIONED USE OF A CONDOM DURING SEX (CODE 'B' CIRCLED) ___ (SKIP TO 810)
808) In your view, is a person's chance of getting AIDS affected by using a condom every time he or she has sexual intercourse?
NO 2 (SKIP TO 810)
UNSURE/DON'T KNOW 8 (SKIP TO 810)
809) If a person uses a condom every time he or she is engaged in sexual intercourse, does this person have a greater or a lesser chance of getting AIDS than someone who doesn't use a condom?
LESSER CHANCE OF AIDS 2
810) 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 (SKIP TO 813)
DON'T KNOW 8 (SKIP TO 813)
812A) When can the virus that causes AIDS be transmitted from a mother to a child?
Any other times?
RECORD ALL RESPONSES.
AT DELIVERY B
DURING BREASTFEEDING C
OTHER TIMES D
DON'T KNOW Z
NOT CURRENTLY MARRIED/NOT LIVING WITH A MAN ___ (SKIP TO 814A)
814) Have you ever talked about ways to prevent getting the virus that causes AIDS with (your husband/the man you're living with)?
NO 2
814A) In your opinion, is it acceptable or unacceptable for AIDS to be discussed:
UNACCEPTABLE 2
UNACCEPTABLE 2
UNACCEPTABLE 2
815A) If a person learns that he/she is infected with the virus that causes AIDS, should the person be allowed to keep this fact private or should this information be available to the community?
AVAILABLE TO COMMUNITY 2
DON'T KNOW/NOT SURE 8
815B) If a relative of yours became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
815C) Should persons with the AIDS virus who work with other persons such as in a shop, office, or farm be allowed to continue their work or not?
SHOULD NOT CONTINUE WORK 2
DON'T KNOW/NOT SURE/DEPENDS 8
815D) Should children aged 12-14 be taught about using a condom to avoid AIDS?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
815E) Have you ever been tested to see if you have the AIDS virus?
NO 2 (SKIP TO 815HX)
815F) Would you want to be tested for the AIDS virus?
NO 2
DON'T KNOW/UNSURE 3
815G) Do you know a place where you could go to get an AIDS test?
NO 2 (SKIP TO 816)
815H) Where can you go for the test?
PROVINCIAL HOSPITAL B
DISTRICT HOSPITAL C
RURAL HEALTH CENTRE D
RURAL/MUNICIPAL CLINIC E
OTHER PUBLIC (SPECIFY) __________ G
PRIVATE DOCTOR J
OTHER PRIVATE MEDICAL (SPECIFY) __________ K
815HX) Where did you go for the test?
Any other places?
RECORD ALL MENTIONED.
PROVINCIAL HOSPITAL B
DISTRICT HOSPITAL C
RURAL HEALTH CENTRE D
RURAL/MUNICIPAL CLINIC E
OTHER PUBLIC (SPECIFY) __________ G
PRIVATE DOCTOR J
OTHER PRIVATE MEDICAL (SPECIFY) __________ K
816) (Apart from AIDS), have you heard about (other) infections that can be transmitted through sexual contact?
NO 2 (SKIP TO 901)
817) In a man, what signs and symptoms would lead you to think that he has such an infection?
Any others?
RECORD ALL MENTIONED.
GENITAL DISCHARGE/DRIPPING B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
BLOOD IN URINE I
LOSS OF WEIGHT J
IMPOTENCE/STERILITY K
NO SIGNS/SYMPTOMS L
OTHER (SPECIFY) __________ W
OTHER (SPECIFY) __________ X
DON'T KNOW Z
818) In a woman, what signs and symptoms would lead you to think that she has such an infection?
Any others?
RECORD ALL MENTIONED.
GENITAL DISCHARGE/DRIPPING B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
BLOOD IN URINE I
LOSS OF WEIGHT J
INFERTILITY/STERILITY K
NO SIGNS/SYMPTOMS L
OTHER (SPECIFY) __________ W
OTHER (SPECIFY) __________ X
DON'T KNOW Z
HAS NOT HAD SEXUAL INTERCOURSE ___ (SKIP TO 901)
820) Now I would like to ask some questions about your health in the last 12 months. During the last 12 months, have you had a sexually transmitted disease?
NO 2
DON'T KNOW 8
820A) Sometimes women experience a discharge from their vagina. During the last 12 months have you had a discharge from your vagina?
NO 2
DON'T KNOW 8
820B) Sometimes women experience a sore or ulcer in or near their vagina. During the last 12 months have you had a sore or ulcer in or near your vagina?
NO 2
DON'T KNOW 8
822) CHECK 820, 820A AND 820B:
DID NOT HAVE STI ___ (SKIP TO 901)
825) The last time you had (INFECTION FROM 820/820A/820B), did you seek advice or treatment?
NO 2 (SKIP TO 827)
826) Where did you seek advice or treatment?
RECORD ALL MENTIONED.
PROVINCIAL HOSPITAL B
DISTRICT HOSPITAL C
RURAL HEALTH CENTRE D
RURAL/MUNICIPAL CLINIC E
VILLAGE COMMUNITY WORKER F
OTHER PUBLIC (SPECIFY) __________ G
PHARMACY J
PRIVATE DOCTOR K
VILLAGE COMMUNITY WORKER L
OTHER PRIVATE MEDICAL (SPECIFY) __________ M
RELATIVE/FRIENDS O
TRADITIONAL HEALER P
827) When you had (INFECTION FROM 820/820A/820B), did you inform the persons with whom you have been having sex?
NO 2
SOME/NOT ALL 3
828) When you had (INFECTION FROM 820/820A/820B) did you do something to avoid infecting your sexual partner(s)?
NO 2 (SKIP TO 901)
PARTNER ALREADY INFECTED 3 (SKIP TO 901)
829) What did you do?
Anything else?
RECORD ALL RESPONSES.
USED CONDOMS B
TOOK MEDICINES C
OTHER (SPECIFY) __________ X
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?
ONLY ONE BIRTH (RESPONDENT ONLY) ___ (SKIP TO 916)
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?
FEMALE 2
NO 2 (SKIP TO 908)
DON'T KNOW 8 (SKIP TO NEXT BROTHER/SISTER)
908) In what year did (NAME) die?
DON'T KNOW 9998
909) How many years ago did (NAME) die?
910) How old was (NAME) when he/she died?
911) Was (NAME) pregnant when she died?
NO 2
912) Did (NAME) die during childbirth?
NO 2
913) Did (NAME) die within 2 months after the end of a pregnancy or childbirth?
NO 2
915) How many children did (NAME) give birth to during her lifetime?
IF NO MORE BROTHERS OR SISTERS, SKIP TO 916
MINUTES ___
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT RESPONDENT:
COMMENTS ON SPECIFIC QUESTIONS:
ANY OTHER COMMENTS:
NAME OF THE SUPERVISOR: __________
DATE: _____
NAME OF EDITOR: __________
DATE: _____
INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX.
FOR COLUMNS 1 AND 4, ALL MONTHS SHOULD BE FILLED IN.
INFORMATION TO BE CODED FOR EACH COLUMN
COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE
P PREGNANCIES
T TERMINATIONS
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 PILL
4 IUD
5 INJECTIONS
6 IMPLANTS
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
F FOAM OR JELLY
L LACTATIONAL AMENORRHEA METHOD
A PERIODIC ABSTINENCE
W WITHDRAWAL
X OTHER (SPECIFY) __________
COLUMN 2: SOURCE OF CONTRACEPTION
2 GOVERNMENT RURAL/MUNICIPAL CLINIC
3 GOVERNMENT RURAL HEALTH CENTRE
4 ZNFPC FIXED CLINIC
5 ZNFPC MOBILE CLINIC
6 MOH MOBILE CLINIC
7 ZNFPC CBD
8 MOH CBD
9 OTHER PUBLIC
A MISSION FACILITY
B PRIVATE HOSPITAL/CLINIC
C PHARMACY
D PRIVATE DOCTOR
E PRIVATE CBD/FIELD WORKER
F OTHER PRIVATE MEDICAL
G SHOP
H CHURCH
I FRIENDS/RELATIVES
X OTHER (SPECIFY) __________
COLUMN 3: DISCONTINUATION OF CONTRACEPTIVE USE
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5 HEALTH CONCERNS
6 SIDE EFFECTS
7 LACK OF ACCESS/TOO FAR
8 COST TOO MUCH
9 INCONVENIENT TO USE
F FATALISTIC
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
X OTHER (SPECIFY) __________
Z DON'T KNOW
0 NOT IN UNION
TERMINATION OF LAST NON-LIVE BIRTH PREGNANCY PRIOR TO JANUARY 1994
IF NO PREVIOUS NON-LIVE BIRTH PREGNANCY, RECORD '00' FOR MONTH AND '0000' FOR YEAR
YEAR _____
1999 (FILL COLUMNS 1 2 3 and 4 WITH APPROPRIATE CODES)
DEC ___ ___ ___ ___
NOV ___ ___ ___ ___
OCT ___ ___ ___ ___
SEP ___ ___ ___ ___
AUG ___ ___ ___ ___
JUL ___ ___ ___ ___
JUN ___ ___ ___ ___
MAY ___ ___ ___ ___
APR ___ ___ ___ ___
MAR ___ ___ ___ ___
FEB ___ ___ ___ ___
JAN ___ ___ ___ ___
1998 (FILL COLUMNS 1 2 3 and 4)
DEC ___ ___ ___ ___
NOV ___ ___ ___ ___
OCT ___ ___ ___ ___
SEP ___ ___ ___ ___
AUG ___ ___ ___ ___
JUL ___ ___ ___ ___
JUN ___ ___ ___ ___
MAY ___ ___ ___ ___
APR ___ ___ ___ ___
MAR ___ ___ ___ ___
FEB ___ ___ ___ ___
JAN ___ ___ ___ ___
1997 (FILL COLUMNS 1 2 3 and 4)
DEC ___ ___ ___ ___
NOV ___ ___ ___ ___
OCT ___ ___ ___ ___
SEP ___ ___ ___ ___
AUG ___ ___ ___ ___
JUL ___ ___ ___ ___
JUN ___ ___ ___ ___
MAY ___ ___ ___ ___
APR ___ ___ ___ ___
MAR ___ ___ ___ ___
FEB ___ ___ ___ ___
JAN ___ ___ ___ ___
1996 (FILL COLUMNS 1 2 3 and 4)
DEC ___ ___ ___ ___
NOV ___ ___ ___ ___
OCT ___ ___ ___ ___
SEP ___ ___ ___ ___
AUG ___ ___ ___ ___
JUL ___ ___ ___ ___
JUN ___ ___ ___ ___
MAY ___ ___ ___ ___
APR ___ ___ ___ ___
MAR ___ ___ ___ ___
FEB ___ ___ ___ ___
JAN ___ ___ ___ ___
1995 (FILL COLUMNS 1 2 3 and 4)
DEC ___ ___ ___ ___
NOV ___ ___ ___ ___
OCT ___ ___ ___ ___
SEP ___ ___ ___ ___
AUG ___ ___ ___ ___
JUL ___ ___ ___ ___
JUN ___ ___ ___ ___
MAY ___ ___ ___ ___
APR ___ ___ ___ ___
MAR ___ ___ ___ ___
FEB ___ ___ ___ ___
JAN ___ ___ ___ ___
1994 (FILL COLUMNS 1 2 3 and 4)
DEC ___ ___ ___ ___
NOV ___ ___ ___ ___
OCT ___ ___ ___ ___
SEP ___ ___ ___ ___
AUG ___ ___ ___ ___
JUL ___ ___ ___ ___
JUN ___ ___ ___ ___
MAY ___ ___ ___ ___
APR ___ ___ ___ ___
MAR ___ ___ ___ ___
FEB ___ ___ ___ ___
JAN ___ ___ ___ ___