DEPARTMENT NAME___
SUB-PREFECTURE NAME___
CENSUS DISTRICT__
CLUSTER NUMBER___
STRUCTURE NUMBER___
HOUSEHOLD NUMBER___
URBAN/RURAL
RURAL 2
LARGE CITY, SMALL CITY, OR COUNTRYSIDE?
SMALL CITY 2
COUNTRYSIDE 3
NAME AND LINE NUMBER OF MAN___
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
RESULT___
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)____ 7
NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE____
TIME____
FINAL VISIT
DAY____
MONTH___
YEAR 94
NAME____
RESULT___
TOTAL NUMBER OF VISITS____
LANGUAGE OF INTERVIEW_____
INTERPRETER USED?
NO
SUPERVISOR
NAME___
DATE___
FIELD EDITOR
NAME___
DATE____
KEYED BY
NAME____
DATE____
SECTION 1. RESPONDENT'S BACKGROUND
101) RECORD TIME
MINUTES____
102) In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.
104) Have you ever attended school?
NO 2 (GO TO 108)
105) What is the highest level of school you attended: primary, post-primary, secondary, or higher?
SECONDARY 1ST CYCLE 2
SECONDARY 2ND CYCLE 3
HIGHER 4
106) What is the highest (grade/form/year) you completed at this level?
GRADE___
CP2 02
CE1 03
CE2 04
CM1 05
CM2 06
5TH 02
4TH 03
3RD 04
1ST 02
FINAL 03
02
03
04
ETC
107) Did you finish this level (primary, post-primary, secondary, higher)?
NO 2
108) What kind of work do you do?
PROTESTANT 2
MUSLIM 3
TRADITIONAL 4
NO RELIGION 5
OTHER (SPECIFY)____6
111) Now I would like to ask you some questions about marriage. Are you currently married or living with a woman?
NO 2 (GO TO 114)
112) How many spouses/wives do you currently have?
113) LINE NUMBER OF THE WIFE/WIVES IN HOUSEHOLD QUESTIONNAIRE
114) Have you ever been married?
NO 2 (GO TO 118)
115) Are you widowed, divorced, or separated?
DIVORCED 2
SEPARATED 3
116) In what month and year did you get married or start living with a woman for the first time?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
117) How old were you when you got married or started living with a woman for the first time?
DON'T KNOW AGE 98 (GO TO 119)
118) Do you currently have a regular sexual partner, an occasional sexual partner, or no sexual partner at all?
OCCASIONAL SEXUAL PARTNER 2
NO SEXUAL PARTNER 3
119) Do you have any children?
NO 2 (GO TO 201)
120) How many boys do you have? How many girls do you have?
201) 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 202 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN THE COLUMN READING THE NAME AND DESCRIPTION OF EACH METHOD MENTIONED SPONTANEOUSLY. CIRCLE CODE 2 IF THE METHOD IS RECOGNIZED, AND CODE 3 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 OR 2 CIRCLED IN 202, ASK 203 BEFORE CONTINUING ON TO THE NEXT METHOD.
202) Have you ever heard of (METHOD)?
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
YES, DESCRIPTION 2
NO 3
NO 3
203) Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE 'YES' (EVER USED) (GO TO 207)
205) Have you ever used anything or tried in any way to delay or avoid a pregnancy?
NO 2
206) What have you done or used?
CORRECT 203, 204, 205 (AND 202 IF NECESSARY)
207) Are you or your partner(s) currently doing something or using any method to delay or avoid a pregnancy?
NO 2 (GO TO 209)
208) Which method are you using?
IUD 02 (GO TO 212)
INJECTABLES 03 (GO TO 212)
IMPLANTS 04 (GO TO 212)
DIAPHRAGM/FOAM/JELLY 05 (GO TO 212)
CONDOM 06 (GO TO 212)
FEMALE STERILIZATION 07 (GO TO 212)
MALE STERILIZATION 08 (GO TO 212)
PERIODIC ABSTINENCE 09 (GO TO 212)
WITHDRAWAL 10 (GO TO 212)
OTHER (SPECIFY)____ 11 (GO TO 212)
209) Do you or your wife/wives/partner(s) intend to use a method to avoid a pregnancy in the future?
NO 2 (GO TO 211)
DON'T KNOW 3 (GO TO 212)
210) What method would you prefer to use?
IUD 02 (GO TO 212)
INJECTABLES 03 (GO TO 212)
IMPLANTS 04 (GO TO 212)
DIAPHRAGM/FOAM/JELLY 05 (GO TO 212)
CONDOM 06 (GO TO 212)
FEMALE STERILIZATION 07 (GO TO 212)
MALE STERILIZATION 08 (GO TO 212)
PERIODIC ABSTINENCE 09 (GO TO 212)
WITHDRAWAL 10 (GO TO 212)
OTHER (SPECIFY)____ 11 (GO TO 212)
NOT SURE 98 (GO TO 212)
211) What is the main reason that you do not intend to use a method?
LACK OF INFORMATION 02
PARTNER DOES NOT APPROVE 03
COSTS TOO HIGH 04
SIDE EFFECTS 05
HEALTH PROBLEMS 06
DIFFICULT TO OBTAIN 07
RELIGION 08
OPPOSED TO FAMILY PLANNING 09
FATALISTIC 10
OTHER PEOPLE DISAPPROVE 11
INFREQUENT SEXUAL RELATIONS 12
WOMAN HAS DIFFICULTY GETTING PREGNANT 13
WOMAN IN MENOPAUSE/STERILIZED 14
INCONVENIENT 15
NOT MARRIED 16
OTHER (SPECIFY)____ 17
DON'T KNOW 98
212) Are you for or against information on family planning being provided on the radio or on television?
AGAINST 2
DON'T KNOW 8
SECTION 3. FERTILITY PREFERENCES
301) CHECK 203 (07):
STERILIZED (GO TO 307)
302) Would you like to have a/another child, or would you prefer not have any (more) children?
NO (MORE) CHILDREN 2
SAYS WIFE CANNOT GET PREGNANT 3
SAYS HE CANNOT HAVE ANY (MORE) CHILDREN 4
UNDECIDED/DON'T KNOW 8
303) Have you discussed with your spouse(s)/wife/wives how many children you would like to have?
NO 2
304) How many times have you discussed this with your spouse(s)/wife/wives in the last year?
ONE OR TWO TIMES 2
MORE OFTEN 3
305) Do you think your spouse(s)/wife/wives want the same number of children that you want, more, or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
306) Do you think your wife/wives/partner(s) approve(s) of couples using a contraceptive method to avoid pregnancy?
NO 2
DON'T KNOW 8
307) For how long should a couple wait before having sexual intercourse after the birth of a baby?
YEARS 2_____
OTHER (SPECIFY)_____ 996
308) Should a mother wait until she has completely stopped breastfeeding before starting to have sexual relations again, or does it not matter?
NOT IMPORTANT 2
309) In general, do you approve of couples using a method to avoid pregnancy?
NO 2
310) CHECK 119-120 AND CHECK BOX:
NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?
HAS LIVING CHILDREN: If you could go back to the time when 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?
PROBE FOR A NUMERIC RESPONSE.
OTHER (SPECIFY)_____
SECTION 4. KNOWLEDGE AND ATTITUDES ABOUT AIDS
401) Now I would like to ask you some questions about a very important subject. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 415)
402) Who have you heard talking about it?
RECORD ALL MENTIONED.
HEALTH WORKER B
RADIO/TELEVISION C
NEWSPAPERS D
FRIEND/RELATIVE/NEIGHBOR E
POSTER/AD CAMPAIGN F
OTHER (SPECIFY)_____ G
DON'T KNOW H
403) Have you ever gone to conferences or talks about AIDS?
NO 2
DON'T KNOW 8
404) In your opinion, how can you get AIDS?
RECORD ALL MENTIONED.
BLOOD TRANSFUSIONS B
USE OF NON-STERILIZED SYRINGES AND NEEDLES C
FROM MOTHER TO CHILD D
EATING FROM THE SAME PLATE AS SOMEONE WITH AIDS E
WEARING THE CLOTHES OF SOMEONE WITH AIDS F
MOSQUITO/INSECT BITES G
OTHER (SPECIFY)___ H
DON'T KNOW L
DID NOT MENTION SEXUAL INTERCOURSE (GO TO 406)
405) From what type of sexual relations can you get AIDS?
RECORD ALL MENTIONED.
WITH PROSTITUTES C
HOMOSEXUAL RELATIONS D
CASUAL RELATIONS E
OTHER (SPECIFY)____ F
DON'T KNOW G
406) Do you think that a woman with AIDS can give birth to a baby with AIDS?
NO 2
DON'T KNOW 3
407) In your opinion, is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 3
408) Do you think that a person with AIDS can be cured?
NO 2
DON'T KNOW 3
409) What do you think a person can do to avoid getting AIDS?
RECORD ALL MENTIONED.
HAVE ONLY ONE PARTNER B
AVOID SEX WITH PROSTITUTES C
ABSTAIN FROM SEXUAL INTERCOURSE D
AVOID USING NON-STERILIZED SYRINGES AND NEEDLES E
AVOID ALL CONTACT WITH PEOPLE INFECTED WITH AIDS F
AVOID TOUCHING CONTAMINATED BLOOD G
OTHER (SPECIFY)____ H
DON'T KNOW I
410) How can one recognize someone who has AIDS?
CIRCLE ALL MENTIONED.
DIARRHEA B
VOMITING C
SHIVERS AND FEVER D
BLOOD ANALYSIS E
SPOTS ON THE SKIN F
PERSISTENT COUGH G
OTHER (SPECIFY)___ H
DON'T KNOW I
411) What do you think should be done with people who have AIDS?
KEEP THEM AT HOME 2
ISOLATE THEM 3
OTHER (SPECIFY)_____ 4
DON'T KNOW 8
412) Do you know or did you know someone with AIDS?
NO 2
DON'T KNOW 8
413) Where can one get information on methods to prevent AIDS?
RECORD ALL MENTIONED.
HEALTH CENTER/MOTHER-INFANT CENTER B
PHARMACY D
FRIENDS/RELATIVES/PARTNERS F
OTHER (SPECIFY)____ G
414) Where can one go to get tested for AIDS?
RECORD ALL MENTIONED.
HEALTH CENTER/MOTHER-INFANT CENTER B
PHARMACY D
DON'T KNOW F
415) Have you had sexual relations in the last 2 months?
NO 2 (GO TO 422)
416) Did you use condoms during the sexual relations you had in the last 2 months?
NO 2 (GO TO 421)
417) Did you use them each time, sometimes, or rarely?
SOMETIMES 2
RARELY 3
418) Why did you use condoms?
RECORD ALL MENTIONED.
AVOID SEXUALLY TRANSMITTED INFECTIONS B
AVOID AIDS C
OTHER (SPECIFY)____ D
DON'T KNOW E
419) Where did you get the condoms?
HEALTH CENTER/MOTHER-INFANT CENTER 12
PHARMACY 22
HOTEL/BAR/DANCE CLUB 32
FRIENDS/RELATIVES/PARTNERS 33
DON'T KNOW 98
420) What is the brand name of the condoms that you use?
SULTAN 2
OTHER (SPECIFY)_____ 3
421) With how many partners have you had sexual relations in the last 2 months?
ONLY WITH WIFE/PARTNER95
SEVERAL 96
422) RECORD TIME AT END OF INTERVIEW
MINUTES____
(To be filled out after completing interview)
Comments about respondent:_______
Comments on specific questions:______
Any other comments:______
Supervisor's observations_______
Name of supervisor:_____
Date:_____
Editor's observations_______
Name of editor:____
Date:____