DIVISION:
DISTRICT:
UPAZILA OR THANA:
UNION:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE:
SMALL CITY 2
TOWN 3
VILLAGE 4
NAME OF HOUSEHOLD HEAD:
NAME AND LINE NUMBER OF HUSBAND:
NAME AND LINE NUMBER OF WIFE:
INTERVIEWER VISITS
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT *
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
NEXT VISIT
DATE TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
FINAL VISIT
DAY
MONTH
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER
YEAR 199_
NAME
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY) 7
NAME
DATE
FIELD EDITED BY:
OFFICE EDITED BY:
KEYED BY:
SECTION 1. RESPONDENT'S BACKGROUND
101. RECORD THE TIME.
MINUTES ___
102. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
ALWAYS 95 (GO TO 103)
VISITOR 96 (GO TO 103)
102A. Just before you moved here, did you live in a city, in a town, or in the countryside?
TOWN 2
COUNTRYSIDE 3
103. In what month and year were you born?
USE CODES BELOW FOR MONTHS.
IF HE DOES NOT KNOW, WRITE 'D K' IN BOXES.
BENGALI 1
YEAR 13__
02 JAISTHA
03 ASHAR
04 SRABAN
05 BADHRA
06 ASHWIN
07 KARTIK
08 AGRAHAYAN
09 POUSH
10 MAGH
11 FALGUN
12 CHOITRA
ENGLISH 2
YEAR 19__
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER
104. How old are you?
COMPARE AND CORRECT 103 AND/OR 104 IF INCONSISTENT.
105. Have you ever attended school?
NO 2 (GO TO 109)
106. What is the highest level of school you attended: primary, secondary, or higher?
SECONDARY 2
COLLEGE OR UNIVERSITY 3
107. What is the highest class you completed?
SECONDARY OR COLLEGE (GO TO 110)
109. Can you read and write a letter in any language easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3 (GO TO 111)
110. Do you usually read a newspaper or magazine at least once a week?
NO 2
111. Do you usually listen to the radio at least once a week?
NO 2
112. Do you usually watch television at least once a week?
NO 2
CHRISTIANITY 2
HINDUISM 3
BUDDHISM 4
OTHER (SPECIFY) 5
114. What kind of work do you mainly do?
DOES NOT WORK IN AGRICULTURE (GO TO 201)
116. Do you work mainly on your own land, or do you rent land, or do you work on someone else's land?
RENTED LAND 2
SOMEONE ELSE'S LAND 3
201. Do you have any sons or daughters who are now living with you?
NO 2
202. How many sons live with you? And how many daughters live with you?
IF NONE ENTER '00'.
DAUGHTERS AT HOME ___
203. Do you have any sons or daughters who do not live with you?
NO 2 (GO TO 205)
204. 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 ENTER '00'.
DAUGHTERS ELSEWHERE ___
205. Have you ever had a son or daughter who was born alive but later died?
NO 2 (GO TO 207)
206. In all, how many boys have died? And how many girls have died?
IF NONE ENTER '00'.
GIRLS DEAD ___
207. SUM ANSWERS TO 202, 204, AND 206, AND ENTER TOTAL.
IF NONE ENTER '00'.
Just to make sure that I have this right: you have had TOTAL ___ children born alive during your life. Is that correct?
NO (PROBE AND CORRECT 201-206 AS NECESSARY)
301. Now I would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy. Which ways or methods have you heard about?
CIRCLE CODE 1 IN 3-2 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN THE COLUMN, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY.
CIRCLE CODE 2 IF METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 302, ASK 303-304 BEFORE PROCEEDING TO THE NEXT METHOD.
302. Have you ever heard of (METHOD)?
READ DESCRIPTION OF EACH METHOD.
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
PROBED YES 2
NO 3
NO 3
303. Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
304. Do you know where a person could go to get (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE "YES" (EVER USED) (GO TO 309)
306. Have you or your wife ever used anything or tried in any way to delay or avoid getting pregnant?
NO (GO TO 386G)
308. What have you used or done?
CORRECT 303-305 (AND 302 IF NECESSARY).
309. What was the first method you ever used?
IUD 02
INJECTIONS 03
CONDOM 04
FEMALE STERILIZATION 05
MALE STERILIZATION 06
SAFE PERIOD, COUNTING DAYS 07
WITHDRAWAL 08
OTHER (SPECIFY) 09
311. How many living children did you have at the time, if any?
IF NONE, RECORD '00'.
MAN STERILIZED (GO TO 315A)
314. Are you or your wife currently doing something or using any method to delay or avoid getting pregnant?
NO 2 (GO TO 322C)
315. Which method are you using?
315A. CIRCLE '06' FOR MALE STERILIZATION.
IUD 02
INJECTIONS 03
CONDOM 04
FEMALE STERILIZATION 05 (GO TO 321)
MALE STERILIZATION 06 (GO TO 321)
SAFE PERIOD, COUNTING DAYS 07
WITHDRAWAL 08
OTHER (SPECIFY) 09
316. At any time during the same month, do you regularly use any method other than (CURRENT METHOD)?
NO 2 (GO TO 318)
IUD 02
INJECTIONS 03
CONDOM 04
SAFE PERIOD, COUNTING DAYS 08
WITHDRAWAL 08
OTHER (SPECIFY) 09
USING PILL, IUD, OR INJECTION (GO TO 323)
USING SAFE PERIOD, WITHDRAWAL, OR OTHER TRADITIONAL METHOD (GO TO 326)
320. Please show me the package of condoms that you are using.
320A. Why can't you show me the package of condoms that you are using?
RAN OUT 2
OTHER (SPECIFY) 3
320B. SHOW BRAND CHART FOR CONDOMS:
Please tell me which of these is the brand of condoms that you are using.
DOES NOT KNOW 98
320C. How much did the condom you last used cost?
PARTNER OBTAINED 9995
FREE 9996
DOES NOT KNOW 9998
320D. Do you use a condom every time that you have sexual intercourse or only sometimes?
ONLY SOMETIMES 2
320E. How many times have you used condoms during the last one month?
321. In what month and year was the sterilization operation performed?
USE CODES BELOW FOR MONTHS.
BENGALI 1
YEAR 1___
02 JAISTHA
03 ASHAR
04 SRABAN
05 BADHRA
06 ASHWIN
07 KARTIK
08 AGRAHAYAN
09 POUSH
10 MAGH
11 FALGUN
12 CHOITRA
ENGLISH 2
YEAR 19__
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER
322A. Do you regret that (you or your wife) had the operation not to have any more children?
NO 2 (GO TO 323A)
PARTNER WANTS ANOTHER CHILD 2 (GO TO 323A)
SIDE EFFECTS 3 (GO TO 323A)
OTHER REASON (SPECIFY) 4 (GO TO 323A)
322C. Which method of family planning did you use most recently?
IUD 02
INJECTIONS 03
CONDOMS 04
SAFE PERIOD, COUNTING DAYS 07 (GO TO 325J)
WITHDRAWAL 08 (GO TO 325J)
OTHER (SPECIFY) 09 (GO TO 325J)
323. Where did you obtain (METHOD) the last time?
323A. Where did the sterilization take place?
NAME OF PLACE ___
FAMILY WELFARE CENTRE 12
THANA HEALTH COMPLEX 13
SATELLITE CLINIC 14
TRADITIONAL DOCTOR 22
PHARMACY 23
FRIENDS OR RELATIVES 32
OTHER (SPECIFY) 51
DOES NOT KNOW 98
323B. Did you pay for the service you received there?
NO 2
DOES NOT KNOW 8
USING (USED) OTHER METHOD (GO TO 325J)
325. Who obtained the (pills or condoms) the last time you got them?
WIFE 2
SON OR DAUGHTER 3
OTHER RELATIVE 4
OTHER (SPECIFY) 5
325A. Have you yourself ever been to a health facility, a doctor, or a shop to get (pills or condoms?
NO 2 (GO TO 325J)
325B. Did anyone there ever tell you about side effects or other problems that you might have using this method?
NO 2
CANNOT REMEMBER 8
325C. Did anyone there ever tell you about other methods that you might use?
NO 2
CANNOT REMEMBER 8
325H. Did you get the method that you wanted?
NO 2
325I. Which method did you want?
IUD 02
INJECTIONS 03
CONDOM 04
FEMALE STERILIZATION 05
MALE STERILIZATION 06
SAFE PERIOD, COUNTING DAYS 07
WITHDRAWAL 08
OTHER (SPECIFY) 09
325J. When a couple is making a decision, sometimes the husband has more influence, sometimes the wife has more influence and sometimes other people have more influence. In your family, who had the most influence in deciding to use family planning the first time you used a method?
WIFE HAD MORE INFLUENCE 2
BOTH HUSBAND AND WIFE EQUAL 3
OTHER RELATIVE 4
OTHER (SPECIFY) 5
NOT USING A METHOD (OR BLANK) (GO TO 328G)
326. What is the main reason you decided to us (CURRENT METHOD FROM 315) rather than some other method of family planning?
FRIEND OR RELATIVE RECOMMENDED 02 (GO TO 347)
SIDE EFFECTS OF OTHER METHODS 03 (GO TO 347)
CONVENIENCE 04 (GO TO 347)
ACCESS OR AVAILABILITY 05 (GO TO 347)
COST 06 (GO TO 347)
WANTED PERMANENT METHOD 07 (GO TO 347)
HUSBAND PREFERRED 08 (GO TO 347)
WANTED MORE EFFECTIVE METHOD 09 (GO TO 347)
OTHER (SPECIFY) 10 (GO TO 347)
DOES NOT KNOW 98 (GO TO 347)
328G. What is the main reason you are not using a method to delay or avoid pregnancy?
LACK OF KNOWLEDGE 02
PARTNER OPPOSED 03
COST TOO MUCH 04
SIDE EFFECTS 05
HEALTH CONCERNS 06
HARD TO GET METHODS 07
RELIGION 08
OPPOSED TO FAMILY PLANNING 09
FATALISTIC 10
OTHER PEOPLE OPPOSED 11
INFREQUENT SEX OR WIFE AWAY 12
DIFFICULT TO GET PREGNANT 13
MENOPAUSAL OR HAD HYSTERECTOMY 14
INCONVENIENT 15
BREASTFEEDING 17
OTHER (SPECIFY) 18
DON'T KNOW 98
328H. Do you know where you can obtain a method of family planning?
NO 2 (GO TO 347)
FAMILY WELFARE CENTRE 12
THANA HEALTH COMPLEX 13
SATELLITE CLINIC 14
QUALIFIED DOCTOR 22
PHARMACY 23
FRIENDS OR RELATIVES 32
OTHER (SPECIFY) 51
DOES NOT KNOW 98
347. CHECK 310, 323, AND 328G:
SATELLITE CLINIC MENTIONED (GO TO 348)
347A. In some places, there is a clinic set up for a day or part of a day in someone's house or in a school. This is called a satellite clinic. During the past 3 months was there any such clinic in you village or mohalla?
NO 2 (GO TO 348)
DOES NOT KNOW 8 (GO TO 348)
347B. Did you ever visit such a clinic?
NO 2 (GO TO 348)
347C. What services did they provide?
CIRCLE ALL MENTIONED.
IMMUNIZATION B
CHILD GROWTH MONITORING C
OTHER (SPECIFY) D
DOES NOT KNOW E
348. In the last month, have you heard or seen a message about family planning on:
NO 2
NO 2
NO 2
NO 2
349. Is it acceptable or not acceptable to you for information to be provided on the radio about:
NO 2
NO 2
NO 2
NO 2
NO 2
350. During the last six months has anyone visited you in your house to talk to you about family planning or to give you any family planning method?
NO 2
DOES NOT KNOW 8
351. Has a family planning worker visited you in the last six months for another reason?
NO 2 (GO TO 358)
DOES NOT KNOW 8 (GO TO 358)
352. How many times did a family planning worker visit you in the last six months?
DOES NOT KNOW 98
IF LESS THAN ONE MONTH AGO, WRITE '00'.
DOES NOT KNOW 98
354. Did you receive any family planning supplies from the fieldworker during the last visit?
NO 2 (GO TO 357)
355. What supplies did you receive?
CONDOMS 2
WIFE GOT INJECTION 3 (GO TO 357)
OTHER (SPECIFY) 4 (GO TO 357)
356. How many cycles or condoms?
357. Thinking back to all the visits you have ever had from family planning workers, which method of avoiding pregnancy did they discuss with you?
CIRCLE ALL MENTIONED.
IUD, LOOP B
INJECTIONS C
CONDOMS D
FEMALE STERILIZATION E
MALE STERILIZATION F
NEVER DISCUSSED G
358. Do you think that most of the men you know use some kind of family planning method?
NO 2
DOES NOT KNOW 8
359. Have you ever recommended family planning to a friend, relative, or anyone else?
NO 2
360. In the past 12 months, have you visited a health facility for any reason?
NO 2 (GO TO 401)
361. Did anyone at the health facility speak to you about family planning methods?
NO 2
SECTION 4. MARRIAGE
401. Have you been married only once or more than once?
MORE THAN ONCE 2
402. In what month and year did you start living with your (first) wife?
BENGALI 1
YEAR 13__
02 JAISTHA
03 ASHAR
04 SRABAN
05 BADHRA
06 ASHWIN
07 KARTIK
08 AGRAHAYAN
09 POUSH
10 MAGH
11 FALGUN
12 CHOITRA
ENGLISH 2
YEAR 19__
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER
403. How old were you when you started living with her?
DOES NOT KNOW AGE 98
406. Now we need some details about you sexual activity in order to get a better understanding of family planning and fertility. When was the last time you had sexual intercourse?
DAYS AGO 1 ___
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___
BEFORE LAST BIRTH 996
408. PRESENCE OF OTHERS AT THIS POINT.
NO 2
NO 2
NO 2
NO 2
SECTION 5. FERTILITY PREFERENCES
501. CHECK 315:
SHE OR HE STERILIZED (GO TO 510)
502. Now I have some questions about the future. Would you like to have a (another) child or would you prefer not to have any more children?
NO MORE OR NONE 2 (GO TO 504)
SAYS WIFE CAN'T GET PREGNANT 3 (GO TO 504)
UNDECIDED OR DON'T KNOW 8 (GO TO 504)
503. How long would you like to wait from now before the birth of a (another) child?
YEARS 2 ___
SOON OR NOW 995
OTHER (SPECIFY) 996
DON'T KNOW 998
504. CHECK 314: USING A METHOD?
YES (GO TO 510)
505. Do you intend to use a method to delay or avoid pregnancy within the next 12 months?
NO 2
DON'T KNOW 8
506. Do you intend to use a method at any time in the future?
NO 2 (GO TO 509)
DON'T KNOW 8 (GOT O 509)
507. When you use a method, which method would you prefer to use?
IUD 02
INJECTIONS 03
CONDOM 04
FEMALE STERILIZATION 05
MALE STERILIZATION 06
CALENDAR, COUNTING DAYS 07 (GO TO 510)
WITHDRAWAL 08 (GO TO 510)
OTHER (SPECIFY) 09 (GO TO 510)
UNSURE 98 (GO TO 510)
508. Where can you get (METHOD MENTIONED IN 507)?
FAMILY WELFARE CENTRE 12 (GO TO 510)
THANA HEALTH COMPLEX 13 (GO TO 510)
SATELLITE CLINIC 14 (GO TO 510)
QUALIFIED DOCTOR 22 (GO TO 510)
PHARMACY 23 (GO TO 510)
FRIENDS OR RELATIVES 32 (GO TO 510)
OTHER (SPECIFY) 51 (GO TO 510)
DOES NOT KNOW 98 (GO TO 510)
509. What is the main reason you do not intend to use a method?
LACK OF KNOWLEDGE 02
PARTNER OPPOSED 03
COST TOO MUCH 04
SIDE EFFECTS 05
HEALTH CONCERNS 06
HARD TO GET METHODS 07
RELIGION 08
OPPOSED TO FAMILY PLANNING 09
FATALISTIC 10
OTHER PEOPLE OPPOSED 11
INFREQUENT SEX 12
DIFFICULT TO GET PREGNANT 13
MENOPAUSAL OR HAD HYSTERECTOMY 14
INCONVENIENT 15
OTHER (SPECIFY) 16
DON'T KNOW 98
510. Do you think that your wife approves or disapproves of couples using a method to avoid pregnancy?
DISAPPROVES 2
DOES NOT KNOW 8
511. How often have you talked to you wife about family planning in the last year?
ONCE OR TWICE 2
MORE OFTEN 3
512. Have you and your wife ever discussed the number of children you would like to have?
NO 2
513. Do you think your wife wants the same number of children that you want, or does she want more or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
514. Do you allow your wife to go out alone (or with your children) to buy household items or visit relatives?
YES, WITH CHILDREN 2
NOT ALLOWED TO GO OUT 3
OTHER (SPECIFY) 4
515. In general, do you approve or disapprove of couples using a method to avoid pregnancy?
DISAPPROVES 2
HAS LIVING CHILD(REN): 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 CHILD(REN): If you could choose exactly the number of children to have in your whole life, how many would that be?
RECORD SINGLE NUMBER OR OTHER ANSWER.
OTHER ANSWER (SPECIFY) 96
517. How many of these would you like to be boys and how many would you like to be girls?
GIRLS ___
EITHER ___
UP TO GOD 95
OTHER (SPECIFY) 96
MINUTES ___
INTERVIEWER'S OBSERVATIONS
(TO BE FILLED IN AFTER COMPLETING THE INTERVIEW)
COMMENTS ABOUT RESPONDENT: ___
COMMENTS ON SPECIFIC QUESTIONS: ___
ANY OTHER COMMENTS: ___
SUPERVISOR'S OBSERVATIONS ___
NAME OF SUPERVISOR: ___
DATE: ___
EDITOR'S OBSERVATIONS ___