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DEMOGRAPHIC AND HEALTH SURVEY - 2015 ZIMBABWE - MAN'S QUESTIONNAIRE (ENGLISH)

ZIMBABWE

IDENTIFICATION

PLACE NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

NAME AND LINE NUMBER OF MAN:

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

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

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY ___
MONTH ___
YEAR ___
INTERVIEWER'S NUMBER
RESULT*

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE

01 ENGLISH
02 NDEBELE
03 SHONA

LANGUAGE OF INTERVIEW

01 ENGLISH
02 NDEBELE
03 SHONA

TRANSLATOR USED?

YES 1
NO 2

SUPERVISOR
NAME
NUMBER

OFFICE EDITOR
NAME
NUMBER

KEYED BY
NAME
NUMBER

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the Central Statistical Office/ZIMSTAT, in collaboration with the Ministry of Health. We are conducting a survey about health and other topics all over Zimbabwe. The information we collect will help the government to plan health services. Your household was randomly selected for the survey. The questions usually take about 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. Participation in the survey is completely voluntary. It's up to you if you want to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

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

Do you have any questions?

SIGNATURE OF INTERVIEWER ___
DATE ___

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (GO TO END)
SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME.

HOURS ___
MINUTES ___

102. How long have you been living continuously in (NAME OF CURRENT CITY, TOWN OR VILLAGE OF RESIDENCE)?

IF LESS THAN ONE YEAR, RECORD '00'.

YEARS ___
ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)

103. Just before you moved here, did you live in an urban or rural area?

URBAN AREA 1
RURAL AREA 2

104. Before you moved here, which province did you live in?

BULAWAY 00
HARARE 09
MANICALAND 01
MASHONALAND CENTRAL 02
MASHONALAND EAST 03
MASVINGO 08
MATABELELAND NORTH 05
MATABELELAND SOUTH 06
MIDLANDS 07
OUTSIDE OF ZIMBABWE 96

105. In what month and year were you born?

MONTH ___
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.

AGE IN COMPLETED YEARS ___

107. Have you ever attended school?

YES 1
NO 2 (GO TO 111)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

109. What is the highest (GRADE/FORM/YEAR) you completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

(GRADE/FORM/YEAR) ___

110. CHECK 108:

PRIMARY OR SECONDARY (GO TO 111)
HIGHER (GO TO 113)

111. Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT.

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

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

112. CHECK 111:

CODE '2', '3', OR '4' CIRCLED (GO TO 113)
CODE '1' OR '5' CIRCLED (GO TO 114)

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

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

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

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

115. Do you watch television at least once a week, less than once a week or not at all?

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

116. Do you own a mobile telephone?

YES 1
NO 2 (GO TO 118)

117. Do you use your mobile phone for any financial transactions?

YES 1
NO 2

118. Do you have an account in a bank or other financial institution that you yourself use?

YES 1
NO 2

119. Have you ever used the internet?

YES 1
NO 2

120. In the last 12 months, have you used the internet?

IF NECESSARY, PROBE FOR USE FORM ANY LOCATION, WITH ANY DEVICE.

YES 1
NO 2 (GO TO 122)

121. During the last once month, how often did you use the internet: almost every day, at least once a week, less than once a week, or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

122. What is your religion?

TRADITIONAL 1
ROMAN CATHOLIC 2
PROTESTANT 3
PENTECOSTAL 4
APOSTOLIC SECT 5
OTHER CHRISTIAN 6
MUSLIM 7
NONE 8
OTHER (SPECIFY) 96

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

NUMBER OF TIMES ___
NONE 00 (GO TO 201)

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

YES 1
NO 2

SECTION 2. REPRODUCTION

201. Now I would like to ask 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?

YES 1
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

203. How many sons live with you? And how many daughters live with you?

IF NONE, RECORD '00'.

SONS AT HOME ___
DAUGHTERS AT HOME ___

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

YES 1
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'.

SONS ELSEWHERE ___
DAUGHTERS ELSEWHERE ___

206. Have you ever fathered a son or a daughter who was born alive but later died?

IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

YES 1
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)

207. How many boys have died? And how many girls have died?

IF NONE, RECORD '00'.

BOYS DEAD ___
GIRLS DEAD ___

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.

TOTAL CHILDREN ___

209. CHECK 208:

HAS HAD MORE THAN ONE CHILD (GO TO 210)
HAS HAD ONLY ONE CHILD (GO TO 211)
HAS NOT HAD ANY CHILDREN (GO TO 301)

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

YES 1
NO 2

211. CHECK 208:

HAS HAD MORE THAN ONE CHILD: How old were you when your first child was born?

HAS HAD ONLY ONE CHILD: How old were you when your child was born?

AGE IN YEAR ___

212. CHECK 203 AND 205:

AT LEAST ONE LIVING CHILD (GO TO 213)
NO LIVING CHILDREN (GO TO 301)

213. CHECK 203 AND 205

MORE THAN ONE LIVING CHILD: How old is your youngest child?

ONLY ONE LIVING CHILD: How old is your child?

AGE IN YEARS ___

214. CHECK 213:

(YOUNGEST) CHILD IS AGE 0-2 YEARS (GO TO 215)
(YOUNGEST) CHILD IS AGE 3 YEARS OR OLDER (GO TO 301)

215. CHECK 203 AND 205:

MORE THAN ONE LIVING CHILD: What is the name of your youngest child?

ONLY ONE LIVING CHILD: What is the name of your child?

NAME OF (YOUNGEST) CHILD ___

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

YES 1
NO 2 (GO TO 218)
DON'T KNOW 8 (GO TO 218)

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

PRESENT 1
NOT PRESENT 2

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

HOSPITAL/HEALTH FACILITY 1
OTHER 2

219. When a child has diarrhea, how much should he or she be given to drink: more than usual, about the same as usual, less than usual, or nothing to drink at all?

MORE THAN USUAL 1
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DON'T KNOW 8

SECTION 3. CONTRACEPTION

301. Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. Have you ever heard of (METHOD)?

01. FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2
02. MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2
03. IUCD: Women can have a loop or coil placed inside them by a doctor or a nurse which can
prevent pregnancy for one or more years.
YES 1
NO 2
04. INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
05. IMPLANTS: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
06. PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
07. MALE CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08. FEMALE CONDOM: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2
09. EMERGENCY CONTRACEPTION (MORNING-AFTER PILL): As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
10. LACTATIONAL AMENORRHEA METHOD (LAM): Up to six months after child birth, before the menstrual period has returned, women use a method requiring frequent breastfeeding day and night.
YES 1
NO 2
11. RHYTHM METHOD (SAFE DAYS): To avoid pregnancy, women do not have sexual intercourse on the days of the month they think they can get pregnant.
YES 1
NO 2
12. WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2
13. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES, MODERN METHOD (SPECIFY) 1
YES, TRADITIONAL METHOD (SPECIFY) 2
NO 3

302. In the last few months have you:

a. Heard about family planning on the radio?
YES 1
NO 2
b. Seen anything about family planning on the television?
YES 1
NO 2
c. Read about family planning in a newspaper or magazine?
YES 1
NO 2
d. Received a voice or text message about family planning on a mobile phone?
YES 1
NO 2
e. Received pamphlets or posters on family planning?
YES 1
NO 2

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

YES 1
NO 2

304. 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 when she has sexual relations?

YES 1
NO 2 (GO TO 306)
DON'T KNOW 8 (GO TO 306)

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

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

306. After the birth of a child, can a woman become pregnant before her menstrual period has returned?

YES 1
NO 2
DON'T KNOW 8

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

a. Contraception is a woman's concern and a man should not have to worry about it.
AGREE 1
DISAGREE 2
DON'T KNOW 8
b. Women who use contraception may become promiscuous.
AGREE 1
DISAGREE 2
DON'T KNOW 8

307A. CHECK 301 (07): KNOWS MALE CONDOM

YES (GO TO 307B)
NO (GO TO 307E)

307B. Do you know of a place where a person can get condoms?

YES 1
NO 2 (GO TO 307E)

307C. Where is that? Any other place?

PROBE TO IDENTIFY TYPE OF SOURCE.

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

NAME OF PLACE ___
PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC A
RURAL HEALTH CENTER B
MUNICIPAL CLINIC C
ZNFPC CLINIC D
ZNFPC CBD/DEPOT HOLDER E
VILLAGE HEALTH WORKER F
MOHCC MOBILE CLINIC G
OTHER PUBLIC SECTOR (SPECIFY) H
MISSION HOSPITAL/CLINIC I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
PHARMACY K
PRIVATE DOCTOR L
CBD M
PRIVATE OUTREACH CLINIC N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) O
RETAIL OUTLET
GENERAL DEALER P
SUPERMARKET/TUCK SHOP Q
SERVICE STATION R
BOTTLE STORE/BAR S
OTHER SOURCE
CHURCH T
FRIEND/RELATIVE U
PUBLIC TOILET V
STREET VENDOR W
WORKPLACE X
OTHER (SPECIFY) Y

307D. If you wanted to, could you yourself get a condom?

YES 1
NO 2
DON'T KNOW 8

307E. CHECK 301 (08): KNOWS FEMALE CONDOM

YES (GO TO 307F)
NO (GO TO 401)

307F. Do you know of a place where a person can get female condoms?

YES 1
NO 2 (GO TO 401)

307G. Where is that? Any other place?

PROBE TO IDENTIFY TYPE OF SOURCE.

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

NAME OF PLACE ___
PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC A
RURAL HEALTH CENTER B
MUNICIPAL CLINIC C
ZNFPC CLINIC D
ZNFPC CBD/DEPOT HOLDER E
VILLAGE HEALTH WORKER F
MOHCC MOBILE CLINIC G
OTHER PUBLIC SECTOR (SPECIFY) H
MISSION HOSPITAL/CLINIC I
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC J
PHARMACY K
PRIVATE DOCTOR L
CBD M
PRIVATE OUTREACH CLINIC N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) O
RETAIL OUTLET
GENERAL DEALER P
SUPERMARKET/TUCK SHOP Q
SERVICE STATION R
BOTTLE STORE/BAR S
OTHER SOURCE
CHURCH T
FRIEND/RELATIVE U
PUBLIC TOILET V
STREET VENDOR W
WORKPLACE X
OTHER (SPECIFY) Y

307H. If you wanted to, could you yourself get a female condom?

YES 1
NO 2
DON'T KNOW 8

SECTION 4. MARRIAGE AND SEXUAL ACTIVITY

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

YES, CURRENTLY MARRIED 1 (GO TO 404)
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, FORMERLY MARRIED 1
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 413)

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

WIDOWED 1 (GO TO 410)
DIVORCED 2 (GO TO 410)
SEPARATED 3 (GO TO 410)

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

LIVING WITH HIM 1
STAYING ELSEWHERE 2

405. Do you have other wives or do you live with other women as if married?

YES (MORE THAN ONE WIFE) 1
NO (ONLY ONE WIFE) 2 (GO TO 407)

406. Altogether, how many wives or live-in partners do you have?

TOTAL NUMBER OF WIVES AND LIVE IN PARTNERS ___

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 wives or 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 WOMAN IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'. ASK 408 FOR EACH PERSON.

NAME ___
LINE NUMBER ___

408. How old was (NAME) on her last birthday?

AGE ___

409. CHECK 407:

ONE WIFE/PARTNER (GO TO 410)
MORE THAN ONE WIFE/PARTNER (GO TO 411)

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

MORE THAN ONCE 1
ONLY ONCE 2

411. CHECK 405 AND 410:

BOTH ARE CODE '2': In what month and year did you start living with you (wife/partner)?

OTHER: Now I would like to ask about your first (wife/partner). In what month and year did you start living with her?

MONTH ___
DON'T KNOW MONTH 98
YEAR ___ (GO TO 413)
DON'T KNOW YEAR 9998

412. How old were you when you first started living with her?

AGE ___

413. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVER EFFORT TO ENSURE PRIVACY.

414. I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any questions that you don't want to answer, just let me know and we will go to the next questions. How old were you when you had sexual intercourse for the very first time?

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 501)
AGE IN YEARS ___

415. Now I would like to ask you about your recent sexual activity. 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 RECORD IN YEARS.

DAYS AGO 1 ___ (GO TO 418)
WEEKS AGO 2 ___ (GO TO 418)
MONTHS AGO 3 ___ (GO TO 418)
YEARS AGO 4 ___ (GO TO 428)

416. When was the last time you had sexual intercourse with this person?

DAYS AGO 1 ___
WEEKS AGO 2 ___
MONTHS AGO 3 ___

417. The last time you had sexual intercourse with this person, was a condom used?

YES 1
NO 2 (GO TO 419)

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

YES 1
NO 2

419. What was your relationship to this person with whom you had sexual intercourse?

IF GIRLFRIEND: Were you living together as if married?

IF YES, RECORD '2'.

WIFE 1
LIVE-IN PARTNER 2
GIRLFRIEND NOT LIVING WITH RESPONDENT 3
CASUAL ACQUAINTANCE 4
CLIENT/SEX WORKER 5
OTHER (SPECIFY) 6

420. How long ago did you first have sexual intercourse with this person?

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

421. How many times during the last 12 months did you have sexual intercourse with this person?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, RECORD '95'.

NUMBER OF TIMES ___

422. How old is this person?

AGE OF PARTNER ___
DON'T KNOW 98

422A. The last time you had sexual intercourse with this person, did you or this person drink alcohol?

YES 1
NO 2 (GO TO 423)
DON'T KNOW 8 (GO TO 423)

422B. Were you or your partner drunk at that time?

IF YES: Who was drunk?

RESPONDENT ONLY 1
PARTNER ONLY 2
BOTH, RESPONDENT AND PARTNER 3
NEITHER 4

423. Apart from this person, have you had sexual intercourse with any other person in the last 12 months?

YES 1 (GO TO 416 IN NEXT COLUMN)
NO 2 (GO TO 425)

424. 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 95 OR MORE, RECORD '95'.

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

425. CHECK 420 (ALL COLUMNS):

AT LEAST ONE PARTNER IS A SEX WORKER (GO TO 426)
NO PARTNERS ARE SEX WORKERS (GO TO 427)

426. CHECK 420 AND 418 (ALL COLUMNS):

CONDOM USED WITH EVER SEX WORKER (GO TO 430)
OTHER (GO TO 431)

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

YES 1 (GO TO 429)
NO 2

428. Have you ever paid anyone in exchange for having sexual intercourse?

YES 1 (GO TO 431)
NO 2 (GO TO 431)

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

YES 1
NO 2 (GO TO 431)

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

YES 1
NO 2
DON'T KNOW 8

431. In the past 12 months have you given any gifts or other goods in order to have sex or to become sexually involved with anyone?

YES 1 (GO TO 433)
NO 2

432. Have you ever given any gifts or other goods in order to have sex or to become sexually involved with anyone?

YES 1
NO 2

433. 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 95 OR MORE, RECORD '95'.

NUMBER OF PARTNERS IN LIFETIME ___
DON'T KNOW 98

434. CHECK 418: MOST RECENT PARTNER (FIRST COLUMN)

CONDOM USED (GO TO 435)
NO CONDOM USED (GO TO 438)
NOT ASKED (GO TO 438)

435. You told me that a condom was used the last time you had sex. What is the brand name of the condom used at that time?

IF BRAND NOT KNOWN, ASK TO SEE THE PACKAGE.

PROTECTOR PLUS 01
PANTHER (PUBLIC SECTOR) 02
CAREX CHOICE ASSORTED 03
DUREX 04
VIBE 05
ECSTASY 06
CASANOVA 07
MOODS 08
OTHER (SPECIFY) 96
DON'T KNOW 98

436. From where did you obtain the condom the last time?

PROBE TO IDENTIFY TYPE OF SOURCE.

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

NAME OF PLACE ___
PUBLIC SECTOR
GOVERNMENT HOSPITAL/CLINIC 11
RURAL HEALTH CENTRE 12
MUNICIPAL CLINIC 13
ZNFPC CLINIC 14
ZNFPC CLINIC 15
VILLAGE HEALTH WORKER 16
MOHCC MOBILE CLINIC 17
OTHER PUBLIC SECTOR (SPECIFY) 18
MISSION HOSPITAL/CLINIC 21
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
PHARMACY 32
PRIVATE DOCTOR 33
CBD 34
PRIVATE OUTREACH CLINIC 35
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 36
RETAIL OUTLET
GENERAL DEALER 41
SUPERMARKET/TUCK SHOP 42
SERVICE STATION 43
BOTTLE STORE/BAR 44
OTHER SOURCE
CHURCH 51
FRIEND/RELATIVE 52
PUBLIC TOILET 53
STREET VENDOR 54
WORKPLACE 55
OTHER (SPECIFY) 96
DON'T KNOW 98

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

YES 1 (GO TO 439)
NO 2 (GO TO 440)
DON'T KNOW 8 (GO TO 440)

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

YES 1
NO 2 (GO TO 440)
DON'T KNOW 8 (GO TO 440)

439. What method did you or your partner use?

PROBE: Did you or your partner use any other method to prevent pregnancy?

RECORD ALL MENTIONED.

FEMALE STERILIZATION A (GO TO 501)
MALE STERILIZATION B (GO TO 501)
IUD C (GO TO 501)
INJECTABLES D (GO TO 501)
IMPLANTS E (GO TO 501)
PILL F (GO TO 501)
CONDOM G (GO TO 501)
FEMALE CONDOM H (GO TO 501)
EMERGENCY CONTRACEPTION I (GO TO 501)
LACTATIONAL AMENORRHEA METHOD J (GO TO 501)
RHYTHM METHOD K (GO TO 501)
WITHDRAWAL L (GO TO 501)
OTHER MODERN METHOD X (GO TO 501)
OTHER TRADITIONAL METHOD Y (GO TO 501)

440. Do you know of a place where you can obtain method of family planning?

YES 1
NO 2

SECTION 5. FERTILITY PREFERENCES

501. CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 502)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 514)

502. CHECK 440:

MAN NOT STERILIZED (GO TO 503)
MAN STERILIZED (GO TO 514)

503. CHECK 407:

ONE WIFE/PARTNER (GO TO 504)
MORE THAN ONE WIFE/PARTNER (GO TO 509)

504. Is your (wife/partner) currently pregnant?

YES 1
NO 2 (GO TO 507)
DON'T KNOW 8 (GO TO 507)

505. Now I have some questions about the future. After the child you and your (wife/partner) are expecting now, would you like to have another child, or would you prefer not to have any more children?

HAVE ANOTHER CHILD 1
NO MORE 2 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)

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

MONTH 1 ___ (GO TO 514)
YEARS 2 ___ (GO TO 514)
SOON/NOW 993 (GO TO 514)
OTHER (SPECIFY) 996 (GO TO 514)
DON'T KNOW 998 (GO TO 514)

507. CHECK 208:

HAS FATHERED CHILDREN: Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?

HAS NOT FATHERED CHILDREN: Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 514)
SAYS COUPLE CAN'T GET PREGNANT 3 (GO TO 514)
WIFE/PARTNER STERILIZED 4 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)

508. CHECK 206:

HAS FATHERED CHILDREN: How long would you like to wait from now before the birth of another child?

HAS NOT FATHERED CHILDREN: How long would you like to wait from now before the birth of a child?

MONTH 1 ___ (GO TO 514)
YEARS 2 ___ (GO TO 514)
SOON/NOW 993 (GO TO 514)
SAYS COUPLE CAN'T GET PREGNANT 994 (GO TO 514)
OTHER (SPECIFY) 996 (GO TO 514)
DON'T KNOW 998 (GO TO 514)

509. Are any of your (wives/partners) currently pregnant?

YES 1
NO 2 (GO TO 512)
DON'T KNOW 8 (GO TO 512)

510. Now I have some questions about the future. After the (child/children) you and your (wives/partners) are expecting now, would you like to have another child, or would you prefer not have any more children?

HAVE ANOTHER CHILD 1
NO MORE 2 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)

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

MONTH 1 ___ (GO TO 514)
YEARS 2 ___ (GO TO 514)
SOON/NOW 993 (GO TO 514)
OTHER (SPECIFY) 996 (GO TO 514)
DON'T KNOW 998 (GO TO 514)

512. CHECK 208:

HAS FATHERED CHILDREN: Now I have some questions about the future. Would you like to have another child, or would you prefer not to have any more children?

HAS NOT FATHERED CHILDREN: Now I have some questions about the future. Would you like to have a child, or would you prefer not to have any children?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 514)
SAYS COUPLE CAN'T GET PREGNANT 3 (GO TO 514)
(WIFE/WIVES/PARTNER(S)) STERILIZED 4 (GO TO 514)
UNDECIDED/DON'T KNOW 8 (GO TO 514)

513. CHECK 208:

HAS FATHERED CHILDREN: How long would you like to wait from now before the birth of another child?

HAS NOT FATHERED CHILDREN: How long would you like to wait from now before the birth of a child?

MONTH 1 ___
YEARS 2 ___
SOON/NOW 993
SAYS COUPLE CAN'T GET PREGNANT 994
OTHER (SPECIFY) 996
DON'T KNOW 998

514. CHECK 203 AND 205:

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

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

PROBE FOR A NUMERIC RESPONSE.

NONE 00 (GO TO 601)
NUMBER ___
OTHER (SPECIFY) 96 (GO TO 601)

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

NUMBER OF BOYS ___
NUMBER OF GIRLS___
EITHER ___
OTHER (SPECIFY) 96

SECTION 6. EMPLOYMENT AND GENDER ROLES

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

YES 1 (GO TO 604)
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?

YES 1 (GO TO 604)
NO 2

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

YES 1
NO 2 (GO TO 607)

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

___

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

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

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

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

607. CHECK 401:

CURRENTLY MARRIED OR LIVING WITH A PARTNER (GO TO 608)
NOT CURRENTLY MARRIED AND NOT LIVING WITH A PARTNER (GO TO 612)

608. CHECK 606:

CODE '1' OR '2' CIRCLED (GO TO 609)
OTHER (GO TO 610)

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

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

610. Who usually makes decisions about health care for yourself: you, your (wife/partner), you and your (wife/partner) jointly, or someone else?

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

611. Who usually makes decisions about making major household purchases?

RESPONDENT 1
WIFE/PARTNER 2
RESPONDENT AND WIFE/PARTNER 3
SOMEONE LESE 4
OTHER (SPECIFY) 6

612. Do you own this or any other house either alone or jointly with someone else?

ALONE 1
JOINTLY ONLY 2
BOTH ALONG AND JOINTLY 3
DOES NOT OWN 4 (GO TO 615)

613. Do you have a title deed for any house you own?

YES 1
NO 2 (GO TO 615)
DON'T KNOW 8 (GO TO 615)

614. Is your name on the title deed?

YES 1
NO 2
DON'T KNOW 8

615. Do you own any agricultural or non-agricultural land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4 (GO TO 618)

616. Do you have a title deed for any land you own?

YES 1
NO 2 (GO TO 618)
DON'T KNOW 8 (GO TO 618)

617. Is your name on the title deed?

YES 1
NO 2
DON'T KNOW 8

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

a. If she goes out without telling him?
YES 1
NO 2
DON'T KNOW 8
b. If she neglects the children?
YES 1
NO 2
DON'T KNOW 8
c. If she argues with him?
YES 1
NO 2
DON'T KNOW 8
d. If she refuses to have sex with him?
YES 1
NO 2
DON'T KNOW 8
e. If she burns the food?
YES 1
NO 2
DON'T KNOW 8
f. If she commits infidelity?
YES 1
NO 2
DON'T KNOW 8

SECTION 7. HIV AND AIDS

701. Now I would like to talk about something else. Have you ever heard of HIV or AIDS?

YES 1
NO 2 (GO TO 727)

702. HIV is the virus that can lead to AIDS. Can people reduce their chance of getting HIV by having just one uninfected sex partner who has no other sex partners?

YES 1
NO 2
DON'T KNOW 8

703. Can people get HIV from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

705. Can people get HIV by sharing food with a person who has HIV?

YES 1
NO 2
DON'T KNOW 8

706. Can people get HIV because of witchcraft or other supernatural means?

YES 1
NO 2
DON'T KNOW 8

707. Is it possible for a healthy-looking person to have HIV?

YES 1
NO 2
DON'T KNOW 8

707A. Can men reduce their chance of getting HIV by getting circumcised?

YES 1
NO 2
DON'T KNOW 8

707B. Can circumcised men who have sex without a condom get HIV during sex?

YES 1
NO 2
DON'T KNOW 8

707C. Can an HIV-negative woman get HIV if she has sex without a condom with a circumcised HIV-positive man?

YES 1
NO 2
DON'T KNOW 8

708. Can HIV be transmitted from a mother to her baby:

a. During pregnancy?
YES 1
NO 2
DON'T KNOW 8
b. During delivery?
YES 1
NO 2
DON'T KNOW 8
c. By breastfeeding?
YES 1
NO 2
DON'T KNOW 8

709. CHECK 708:

AT LEAST ONE 'YES' (GO TO 710)
OTHER (GO TO 711)

710. Are there any special medicines that a doctor or a nurse can give to a woman infected with HIV to reduce the risk of transmission to the baby?

YES 1
NO 2
DON'T KNOW 8

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

712. I don't want to know the results, but have you ever been tested for HIV?

YES 1
NO 2 (GO TO 716)

713. How many months ago was your most recent HIV test?

MONTHS AGO ___
TWO OR MORE YEARS 95

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

YES 1
NO 2

715. Where was the test done?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ___
PUBLIC SECTOR
CENTRAL HOSPITAL 11 (GO TO 718)
PROVINCIAL HOSPITAL 12 (GO TO 718)
DISTRICT HOSPITAL 13 (GO TO 718)
RURAL HOSPITAL 14 (GO TO 718)
RURAL HEALTH CENTER/COUNCIL CLINIC 15 (GO TO 718)
URBAN MUNICIPAL CLINIC 16 (GO TO 718)
FAMILY PLANNING CLINIC 17 (GO TO 718)
SCHOOL BASED CLINIC 18 (GO TO 718)
OTHER PUBLIC SECTOR (SPECIFY) 19 (GO TO 718)
MISSION HOSPITAL/CLINIC 21 (GO TO 718)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR 31 (GO TO 718)
NEW START CENTER 32 (GO TO 718)
SCHOOL BASED CLINIC 33 (GO TO 718)
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 36 (GO TO 718)
OTHER SOURCE
HOME 41 (GO TO 718)
WORKPLACE 42 (GO TO 718)
MOBILE VAN 43 (GO TO 718)
UNIFORMED FORCES FACILITY 44 (GO TO 718)
OTHER (SPECIFY) 96 (GO TO 718)

716. Do you know of a place where people can go to get an HIV test?

YES 1
NO 2 (GO TO 718)

717. Where is that? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ___
PUBLIC SECTOR
CENTRAL HOSPITAL A
PROVINCIAL HOSPITAL B
DISTRICT HOSPITAL C
RURAL HOSPITAL D
RURAL HEALTH CENTER/COUNCIL CLINIC E
URBAN MUNICIPAL CLINIC F
FAMILY PLANNING CLINIC G
SCHOOL BASED CLINIC H
OTHER PUBLIC SECTOR (SPECIFY) I
MISSION HOSPITAL/CLINIC J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR K
NEW START CENTER L
SCHOOL BASED CLINIC M
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) N
OTHER SOURCE
HOME O
WORKPLACE P
MOBILE VAN Q
UNIFORMED FORCES FACILITY R
OTHER (SPECIFY) X

718. Have you heard of test kits people can use to test themselves for HIV?

YES 1
NO 2 (GO TO 719A)

719. Have you ever tested yourself for HIV using a self-test kit?

YES 1
NO 2

719A. If a self-test kit was available, would you be willing to test yourself for HIV?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

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

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

721. Do you think children living with HIV should be allowed to attend school with children who do not have HIV?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

722. Do you think people hesitate to take an HIV test because they are afraid of how other people will react if the test result is positive for HIV?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

723. Do people talk badly about people living with HIV, or who are thought to be living with HIV?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

724. Do people living with HIV, or thought to be living with HIV, lose the respect of other people?

YES 1
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8

725. Do you agree or disagree with the following statement: I would be ashamed if someone in my family had HIV.

AGREE 1
DISAGREE 2
DON'T KNOW/NOT SURE/DEPENDS 8

726. Do you fear that you could get HIV if you come into contact with the saliva of a person living with HIV?

YES 1
NO 2
SAYS HE HAS HIV 3
DON'T KNOW/NOT SURE/DEPENDS 8

727. CHECK 701:

HEARD ABOUT HIVE OR AIDS: Apart from HIV, have you heard about other infection that can be transmitted through sexual contact?

NOT HEARD ABOUT HIV OR AIDS: Have you heard about infections that can be transmitted through sexual contact?

YES 1
NO 2

728. CHECK 414:

HAS HAD SEXUAL INTERCOURSE (GO TO 729)
NEVER HAD SEXUAL INTERCOURSE (GO TO 736)

729. CHECK 727: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES 1 (GO TO 730)
NO (GO TO 731)

730. Now I would like to ask you some questions about your health in the last 12 months. During the last 12 months, have you had a disease which you got through sexual contact?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

732. Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer on or near your penis?

YES 1
NO 2
DON'T KNOW 8

733. CHECK 730, 731, AND 732:

HAS HAD AN INFECTION (ANY 'YES') (GO TO 734)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 736)

734. The last time you had (PROBLEM FROM 730/731/732) did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 736)

735. Where did you go? Any other place?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

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

NAME OF PLACE ___
PUBLIC SECTOR
CENTRAL HOSPITAL A
PROVINCIAL HOSPITAL B
DISTRICT HOSPITAL C
RURAL HOSPITAL D
RURAL HEALTH CENTER/COUNCIL CLINIC E
URBAN MUNICIPAL CLINIC F
FAMILY PLANNING CLINIC G
OTHER PUBLIC SECTOR (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/PRIVATE DOCTOR I
PHARMACY J
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) K
OTHER SOURCE
SHOP L
MOBIL VAN M
WORKPLACE N
TRADITIONAL HERBALIST O
OTHER (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

SECTION 8. OTHER HEALTH ISSUES

801. Some men are circumcised, that is, the foreskin is completely removed from the penis. Are you circumcised?

YES 1
NO 2 (GO TO 805)
DON'T KNOW 8 (GO TO 805)

802. How old were you when you got circumcised?

AGE IN COMPLETED YEARS ___
DURING CHILDHOOD (LESS THAN 5 YEARS) 95
DON'T KNOW 8

803. Who did the circumcision?

TRADITIONAL PRACTITIONER/FAMILY/FRIEND 1
HEALTH WORKER/PROFESSIONAL 2
OTHER 3
DON'T KNOW 8

804. Where was it done?

HEALTH FACILITY 1
HOME OF A HEALTH WORKER/PROFESSIONAL 2
CIRCUMCISION DONE AT HOME 3
RITUAL SITE 4
OTHER HOME/PLACE 5
DON'T KNOW 8

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

IF YES: How many injections have you had?

IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS ___
NONE 00 (GO TO 808)

806. 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 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS ___
NONE 00 (GO TO 808)

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

YES 1
NO 2
DON'T KNOW 8

808. Do you currently smoke tobacco every day, some days, or not at all?

EVERY DAY 1 (GO TO 811)
SOME DAYS 2
NOT AT ALL 3 (GO TO 810)

809. In the past, have you smoked tobacco every day?

YES 1 (GO TO 812)
NO 2 (GO TO 812)

810. In the past, have you ever smoked tobacco every day, some days, or not at all?

EVER DAY 1 (GO TO 813)
SOME DAYS 2 (GO TO 813)
NOT AT ALL 3 (GO TO 813)

811. On average, how many of the following products do you currently smoke each day? Also, let me know if you use the product, but not every day.

IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVER DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a. Manufactured cigarettes?
NUMBER DAILY ___ (GO TO 813)
b. Hand-rolled cigarettes?
NUMBER DAILY ___ (GO TO 813)
c. Pipes full of tobacco?
NUMBER DAILY ___ (GO TO 813)
d. Any others?
NUMBER DAILY ___ (GO TO 813)

812. On average, how many of the following products do you currently smoke each week? Also, let me know if you use the product but not ever week.

IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVER WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a. Manufactured cigarettes?
NUMBER WEEKLY ___
b. Hand-rolled cigarettes?
NUMBER WEEKLY ___
c. Pipes full of tobacco?
NUMBER WEEKLY ___
d. Any others?
NUMBER WEEKLY ___

813. Do you currently use smokeless tobacco every day, some days, or not at all?

EVERY DAY 1
SOME DAYS 2 (GO TO 815)
NOT AT ALL 3 (GO TO 816)

814. On average, how many times a day do you use the following products? Also, let me know if you use the products, but not every day.

IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY DAY, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a. Snuff?
NUMBER DAILY ___ (GO TO 816)
b. Chewing tobacco?
NUMBER DAILY ___ (GO TO 816)
c. Any others?
NUMBER DAILY ___ (GO TO 816)

815. On average, how many times a week do you use the following products? Also, let me know if you use the product, but every week.

IF RESPONDENT REPORTS USING THE PRODUCT BUT NOT EVERY WEEK, RECORD '888'. IF THE PRODUCT IS NOT USED AT ALL, RECORD '000'.

a. Snuff?
NUMBER WEEKLY ___
b. Chewing tobacco?
NUMBER WEEKLY ___
c. Any others?
NUMBER WEEKLY ___

816. Are you covered by any medical aid?

YES 1
NO 2 (GO TO 819)

817. What type of medical aid are you covered by?

RECORD ALL MENTIONED.

MUTUAL HEALTH ORGANIZATION/COMMUNITY-BASED HEALTH INSURANCE A
HEALTH INSURANCE THROUGH EMPLOYMENT B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY) X

817A. Have you ever drank alcohol?

YES 1
NO 2 (GO TO 819)

817B. In the last 30 days, on how many days did you have at least one drink of alcohol?

IF NONE, RECORD '00'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

DAYS ___
DON'T KNOW 998

817C. In the last 30 days, how many alcoholic drinks did you have on a typical day when you drank alcohol?

IF NONE, RECORD '00'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

DRINKS ___
DON'T KNOW 998

817D. In the last 30 days, on how many days did you get drunk?

IF NONE, RECORD '00'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

DAYS ___
DON'T KNOW 998

THANK THE RESPONDENT FOR HIS COOPERATION AND REASSURE HIM ABOUT THE CONFIDENTIALITY OF HIS ANSWERS.

818. RECORD THE TIME.

HOURS ___
MINUTES ___

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS:

EDITOR'S OBSERVATIONS: