IDENTIFICATION

STATE_________ __ __
DISTRICT_____________ __ __ __
TEHSIL/TALUK__________
CITY/TOWN/VILLAGE_____________

TYPE OF PSU

PSU NUMBER __ __
STRUCTURE NUMBER __ __ __
HOUSEHOLD NUMBER __ __
NAME AND LINE NUMBER OF MAN ______________ __ __
ADDRESS OF HOUSEHOLD____________

INTERVIEWER VISITS

FIRST VISIT
DATE_______
INTERVIEWER'S NAME________
RESULT*________

SECOND VISIT
DATE_______
INTERVIEWER'S NAME________
RESULT*________

THIRD VISIT
DATE_______
INTERVIEWER'S NAME________
RESULT*________

FINAL VISIT
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __
RESULT* __

NEXT VISIT:
DATE____
TIME ____

TOTAL NUMBER OF VISITS __

SUPERVISOR'S NAME____________
SUPERVISOR NUMBER __ __ __

*RESULT CODES:

**LANGUAGE CODES:

LANGUAGE OF QUESTIONNAIRE: HINDI 04
** RESPONDENT'S MOTHER TONGUE_________ __ __

**LANGUAGE OF INTERVIEW________ ___ __

TRANSLATOR USED?

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND INFORMED CONSENT

Namaste. My name is _______. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over India. The information on family welfare and health that we collect from households and individuals will help the government to plan health services. Your household was selected for the survey. The questions usually take about 30-40 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. Your participation in the survey is voluntary. 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.

If you have any questions about this survey you may ask me.
ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S CONCERNS.

Do you agree to participate in this survey?

101. RECORD THE TIME.

102. In what month and year were you born?

103. How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.

104. How long have you been living continuously in (CURRENT PLACE OF RESIDENCE)?
IF LESS THAN 1 YEAR, RECORD '00'

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

106. In the last 12 months, have you been away from home for six months or more at a time?

107. Have you ever attended school?

108. What is the highest standard you completed?

109. CHECK 108:

110. SHOW A SENTENCE FROM THE LITERACY CARD TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE:
Now I would like you to read this sentence to me, SHOW A SENTENCE FROM THE LITERACY CARD TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

111. CHECK 110:

112. Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?

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

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

115. Do you usually go to a cinema hall or theatre to see a movie at least once a month?

116. What is your religion?

117. What is your caste or tribe?

118. Do you belong to a scheduled caste, a scheduled tribe, other backward class, or none of these?

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

120. Although you did not work in the last seven days, do you have any job or business from which you were absent or leave, illness, vacation, or any other such reason?

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

122. What have you been doing for most of the time over the last 12 months?

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

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

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

SECTION 2A. REPRODUCTION

201. Now I would like to ask about any children you have had during your life. I am interested only in the children that are biologically yours. Have you ever fathered any children with any woman?

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

203. a) How many sons live with you?
b) Any how many daughters live with you?
IF NONE, RECORD '00'.

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

205. a) How many sons are alive but do not live with you?
b) And how many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

206. Have you ever fathered a son or a daughter who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

207. a) How many boys have died?
b) And how many girls have died?
IF NONE, RECORD '00'.

208. (In addition to the children that you have just told me about), do you have:

208A. CHECK 208:

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

210. CHECK 209:

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

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

213. What is your current marital status?

214. Do you currently have one wife or more than one wife?

215. In total, how many wives do you have?

216. WRITE THE NUMBERS FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE. IF A WIFE IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, RECORD '00' IN THE BOXES FOR LINE NUMBER. THE NUMBER OF LINES FILLED IN MUST BE EQUAL TO THE NUMBER OF WIVES.
(IF RESPONDENT HAS MORE THAN FOUR WIVES, USE SPACE AT THE END OF THE QUESTIONNAIRE.)

CHECK 214:

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

218. (Is your wife/Are your wives) living with you now or (is she/are they) staying elsewhere?

219. For how long have you not been living with (your wife/any of your wives)?
IF LESS THAN 1 YEAR, RECORD MONTHS; OTHERWISE, RECORD COMPLETED YEARS.

220. CHECK 214:

221. Have you been married once or more than once?

222. CHECK 214 AND 220:

223. In what month and year did you get married?

223A. Now I would like to ask about when you married your first wife.
In what month and year was that?

224. How old were you when you (first) got married?

225. CHECK 213:

226. CHECK 214 AND 220:
IF 214 AND 220 NOT ASKED, CHECK 221:

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

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

Now I need to ask you some questions about sexual life in order to gain a better understanding of some family life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. If you do not want to answer, just let me know and I will skip to the next question.

Have you ever had sexual intercourse?

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

(Now I need to ask you some questions about sexual life in order to gain a better understanding of some family life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. If you do not want to answer, just let me know and I will skip to the next question.)

How old were you when you had sexual intercourse for the very first time?

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)?

301A. CHECK 228: EVER HAD SEXUAL INTERCOURSE

302. Have you or your (partner/partners) ever used any method?

303. What have you or your (partner/partners) used or done?

RECORD ALL MENTIONED. CORRECT 301 (IF NECESSARY)

304. CHECK 303: RESPONDENT IS STERILIZED?

305. Now I would like to talk about when you were sterilized. In what facility did the sterilization take place?

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, WRITE THE NAME OF THE PLACE.

306. In what month and year was the sterilization performed?

307. How much did you pay in total for the sterilization, including any consultation you may have had?

308. Did you receive compensation for the sterilization?

309. How much compensation did you receive?

310. Do you regret that you had the sterilization?

311. In the last few months have you:

312. 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 is she has sexual relations?

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

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

315. CHECK 301 (06): KNOWS MALE CONDOM

316. If a male condom is used correctly, do you think that it protects against pregnancy most of the time, only sometimes, or not at all?

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

318. Where is that?
Any other place?

RECORD ALL PLACES MENTIONED.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, WRITE THE NAME OF THE PLACE(S).

319. In the last three months, have you visited a health facility or camp for any reason for yourself (or for your children)?

320. What type of health facility did you visit most recently for yourself (or for your children)?
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, WRITE THE NAME OF THE PLACE.

321. What service did you go for? Any other service?
RECORD ALL MENTIONED.

322. CHECK 212:

323. What is the name of your (youngest) child?
WRITE NAME OF (YOUNGEST) CHILD AND ENTER THE LINE NUMBER OF THE CHILD FROM THE HOUSEHOLD SCHEDULE.
IF CHILD IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, WRITE '00' IN THE BOXES FOR THE LINE NUMBER.

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

325. Were you ever present during any antenatal check-up?

326. What was the main reason why (NAME)'s mother did not have any antenatal check-up?

327. At any time when (NAME)'s mother was pregnant with (NAME), did any health provider or health worker ever tell you about the following signs of pregnancy complications?

328. Were you ever told what to do if (NAME)'s mother had any pregnancy complication?

329. At any time during the pregnancy did any health provider or health worker speak to you about:

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

331. At any time during the pregnancy did any health provider or health worker speak to you about:

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

333. When a child has diarrhoea, how much should he or she be given to drink: more than usual, the same amount as usual, less than usual, or should he or she not be given anything to drink at all?

SECTION 4. FERTILITY PREFERENCES

401. CHECK 213:

402. (Is your wife/Are any of your wives) currently pregnant?

403. CHECK 303: RESPONDENT EVER STERILIZED?

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

405. CHECK 303: RESPONDENT EVER STERILIZED?

406. 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?

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

408. CHECK 203 AND 205:

HAS LIVING CHILDREN (a. 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 (b. If you could choose exactly the number of children to have in your whole life, how many would that be?)

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

SECTION 5: SEXUAL LIFE

501. CHECK 228 AND 229:

501A. CHECK FOR THE PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY. READ TO RESPONDENTS:

Now I need to ask you some more questions about relationships and sexual life. Once again, let me assure you that your answers are completely confidential. If we should come to any question that you don't want to answer, just let me know and I will skip to the next question.

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

503. When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

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

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

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

507. What was this person's relationship to you?

508. CHECK 214, 220, AND 221:

509. CHECK 229:

510. How long ago did you first have sexual intercourse with this (second/third) person?

511. 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, WRITE '95'.

512. CHECK 103:

513. How old is this person?

514. Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

515. In total, with how many different people have you had sex in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

516. CHECK 507, ALL COLUMNS:

517. CHECK 507 AND 505 (ALL COLUMNS):

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

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

520. The last time you paid someone in exchange for sex, was a condom used?

521. Was a condom used every time you paid someone in exchange for sex in the last 12 months?

522. In total, with how many different people have you had a sex in your lifetime?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

523. CHECK 505, COLUMN 1 (CONDOM USE WITH LAST SEXUAL PARTNER):

524. You told me that the last time you had intercourse you used a condom. What brand of condom did you use the last time?

525. Who obtained the condom: you, your partner, or someone else?

526. How many condoms did you get last time?

527. The last time you obtained condoms, how much did you pay in total, including the cost of the method and any consultation you may have had?

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

529. This is the last time you used a condom, did you use it to avoid pregnancy, to avoid a sexually transmitted disease, or for some other reason?
PROBE: Any other reason?
RECORD ALL MENTIONED.

530. CHECK 303: RESPONDENT EVER STERILIZED?

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

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

533. CHECK 505, ALL COLUMNS, AND 520:

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

535. Where is that? Any other place?

RECORD ALL SOURCES MENTIONED.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, WRITE THE NAME OF THE PLACE(S).

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

SECTION 6. OTHER HEALTH ISSUES

601. Now I would like to you ask you some questions about any injections you have had any injections you have had in the last 12 months. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?

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

602. The last time you had an injection, was a disposable syringe used?

603. Have you ever had a blood transfusion?

604. Do you currently smoke cigarettes?

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

606. Do you currently smoke bidis?

607. In the last 24 hours, how many bidis did you smoke?

608. Do you currently smoke or use tobacco in any other form?

609. In what other form do you currently smoke or use tobacco?
Any other form?

610. CHECK 604, 606, AND 608:

611. During the past 12 months, have you ever tried to stop smoking or using tobacco in any other form?

612 . In the last 12 months, have you visited a doctor or other health care provider?

613. During any of these visits, were you advised to quit smoking or using tobacco in any other form?

614. In the last 30 days, did someone (other than you) smoke in your home or anywhere else when you were present?

615. Do you drink alcohol?

616. How often do you drink alcohol: almost every day, about once a week, or less than once a week?

617. What type of alcohol do you usually drink?

RECORD ALL MENTIONED.

618. Have you ever heard of an illness called tuberculosis or TB?

619. How does tuberculosis spread from one person to another? Any other ways?

RECORD ALL MENTIONED.

620. Can tuberculosis be cured?

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

622A. Do you currently have:

624. Are you covered by any health scheme or any health insurance?

625. What type of health scheme or health insurance? Any other type?
RECORD ALL MENTIONED.

626. How often do you yourself eat the following food items: daily, weekly, occasionally, or never?

627. Have you ever undergone an oral cavity examination?

SECTION 7. ATTITUDES TOWARDS GENDER ROLES

701. In a couple, who do you think should have the greater say in each of the following decisions: the husband, the wife or both equally:

701A. CHECK 213:

702. Who usually makes decisions about healthcare for yourself: mainly you, mainly your wife, you and your wife jointly, or someone else?

703. Who usually makes decisions about making major household purchases: mainly you, mainly your wife, you and your wife jointly, or someone else?

704. Do you own this or any other house either alone or jointly

705. Do you own any land alone or jointly with someone else?

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

707. When a wife knows her husband has a sexually transmitted disease, is she justified in asking that they use a condom?

708. Please tell me if you think a wife is justified in refusing to have sex with her husband when:

709. Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to:

710. CHECK 213:

711. (Is your wife/Are any of your wives) currently employed for cash?

712. Who decides how the money your wife earns will be used: mainly you, mainly your wife, or you and your wife jointly?

713. CHECK 125:

714. Would you say that the money you earn is more than what your wife earns, less than what she earns, or about the same?

715. Who decides how your earnings will be used: mainly you, mainly your wife, or you and your wife jointly?

716. As far as your know, did your father ever beat your mother?

SECTION 8. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

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

802. Have you ever heard of HIV?

803. CHECK 801 AND 802: KNOWS ABOUT HIV/AIDS

804. From which sources of information have you learned about AIDS? Any other source?

RECORD ALL MENTIONED.

805. Can people reduce their chances of getting HIV/AIDS by using a condom every time they have sex?

806. Can people get HIV/AIDS from mosquito bites?

807. Can people reduce their chances of getting HIV/AIDS by using a condom every time they have sex?

808. Can people get HIV/AIDS by blood products or blood transfusion?

809. Can people get HIV/AIDS by injecting drugs?

810. Can people get HIV/AIDS by sharing food with a person who has AIDS?

811. Is there anything else a person can do to avoid or reduce the chances of getting HIV/AIDS?

812. What can a person do? Anything else?

RECORD ALL WAYS MENTIONED.

813. Is it possible for a healthy-looking person to have HIV/AIDS?

814. Can HIV/AIDS be transmitted from a mother to hear baby:

815. CHECK 814:

816. Are there any special medications that a doctor or a nurse can give a woman infected with HIV/AIDS can get from a doctor or a nurse to help them live longer?

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

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

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

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

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

822. Where was the test done?
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, WRITE THE NAME OF THE PLACE.

823. Do you know of a place where people can go to get tested for HIV/AIDS?

824. Where is that? Any other place?

RECORD ALL PLACES MENTIONED.

IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE HEALTH SECTOR, WRITE THE NAME OF THE PLACE(S).

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

826. Do you think a child with HIV should be allowed to attend school with students who are HIV negative?

827. If a member of your family got infected with HIV/AIDS, would you want it to remain a secret or not?

828. If a relative of yours became sick with the virus that causes HIV/AIDS, would you be willing to care for her or him in your own household?

829. In your opinion, if a female teacher has HIV/AIDS but is not sick, should she be allowed to continue teaching in the school?

830. In your opinion, if a male teacher has HIV/AIDS but is not sick, should he be allowed to continue teaching in the school?

831. Do you think that people living with HIV should be treated in the same public hospital with patients who are HIV negative?

832. Do you think that people living with HIV should be allowed to work in the same office with people who are HIV negative?

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

834. CHECK 801 AND 802:

HEARD ABOUT HIV/AIDS (a. Apart from HIV/AIDS, have you heard about other infections that can be transmitted through sexual contact?)
NOT HEARD ABOUT HIV/AIDS (Have you heard about infections that can be transmitted through sexual contact?)

835. CHECK 228 AND 229: HAS HAD SEXUAL INTERCOURSE

836. CHECK 834: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS

837. 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?

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

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

840. CHECK 837, 838, AND 839: HAS HAD AN STI

841. The last time you had (PROBLEM FROM 837/838/839), did you seek any kind of advice or treatment?

842. Where did you go? Anywhere else?

RECORD ALL PLACES MENTIONED.

843. RECORD THE TIME

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS:

NAME OF SUPERVISOR:______________
DATE: ______________