IDENTIFICATION
DISTRICT NAME AND NUMBER
VILLAGE/MUNICIPALITY NAME AND NUMBER
WARD NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
CITY/TOWN/COUNTRYSIDE
Town 2
Countryside 3
NAME OF HOUSEHOLD HEAD
NAME AND LINE NUMBER OF WOMAN
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
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER 7 _____________
(SPECIFY)
NATIVE LANGUAGE OF RESPONDENT**
LANGUAGE OF INTERVIEW**
TRANSLATOR USED
NO 2
**LANGUAGE CODES
NEPALI 1
BHOJPURI 2
MAITHILI 3
THARU 4
OTHER (SPECIFY) 5 _____________
SUPERVISOR
NAME _________
DATE ____________
FIELD EDITOR
NAME _______________
DATE _______________
OFFICE EDITOR ____________
KEYED BY _____________
SECTION 1. RESPONDENT'S BACKGROUND
100. RECORD THE TIME.
MINUTES__
101. COLLECT ANY RELEVANT DOCUMENTS THAT MAY HAVE INFORMATION ON THE RESPONDENT'S AGE AND HER CHILDREN'S AGE AND IMMUNIZATION.
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, or in the countryside?
TOWN 2
COUNTRYSIDE 3
103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?
ALWAYS (SINCE BIRTH) 95 (SKIP TO 105)
VISITOR 96 (SKIP TO 105)
104. Just before you moved here, did you live in a city, in a town, or in the countryside?
TOWN 2
COUNTRYSIDE 3
105. In what month and year were you born?
DON'T KNOW MONTH 98
YEAR ________________
DON'T KNOW YEAR 98
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 113)
108. What is the highest grade you completed?
AGE 25 OR ABOVE (SKIP TO 112)
110. Are you currently attending school?
NO 2
111. What was the main reason you stopped attending school?
GOT MARRIED 02
TO CARE FOR YOUNGER CHILDREN 03
FAMILY NEEDED HELP ON FARMOR IN BUSINESS 04
COULD NOT PAY SCHOOL FEES 05
NEEDED TO EARN MONEY 06
GRADUATED/HAD ENOUGH SCHOOLING 07
FAILED SLC/DID NOT PASS
ENTRANCE EXAMS 08
DID NOT LIKE SCHOOL 09
SCHOOL NOT ACCESSIBLE/
TOO FAR 10
OTHER (SPECIFY)__________________________96
DON'T KNOW 98
GRADE 6 AND ABOVE (SKIP TO 115)
113. Can you read and understand a letter or newspaper?
NO 2 (SKIP TO 116)
114. Can you read this sentence? (SHOW SENTENCE TO BE READ)
READS WITH DIFFICULTY 2
IS NOT ABLE TO READ 3 (SKIP TO 116)
115. Do you usually read a newspaper or magazine at least once a week?
NO 2
116. Do you usually listen to a radio every day?
NO 2
117. Do you usually watch television at least once a week?
NO 2
BUDDHIST 02
MUSLIM 03
CHRISTIAN 04
OTHER (SPECIFY)________________ 96
119. What is your caste?
WRITE CASTE IN SPACE PROVIDED. CODE WILL BE ENTERED BY FIELD EDITOR.
(CASTE)
120. What is your current marital status?
WIDOWED 2 (SKIP TO 125)
DIVORCED 3 (SKIP TO 125)
SEPARATED 4 (SKIP TO 125)
121. Is your husband living with you now or is he staying elsewhere?
STAYING ELSEWHERE 2
122. Does your husband have any other wives besides yourself?
NO 2 (SKIP TO 125)
123. How many other wives does he have?
DON'T KNOW 98 (SKIP TO 125)
124. Are you the first, second, ... wife?
125. Have you been married only once, or more than once?
MORE THAN ONCE 2
126. How old were you when you (first) got married?
127. CHECK 125:
MARRIED ONLY ONCE
In what month and year did you first start living with your husband?
PROMPT: At gauna?
MARRIED MORE THAN ONCE
Now we will talk about your first husband. In what month and year did you first start living with him?
DON'T KNOW WHAT MONTH 98
YEAR ____ (SKIP TO 129)
DON'T KNOW YEAR 98
HAS NOT STARTED LIVING WITH HUSBAND 95 (SKIP TO END)
128. How old were you when you first started living with him?
PROMPT: At gauna?
129. CHECK COLUMN 6 OF THE INTERVIEWER'S ASSIGNMENT SHEET.
THE WOMAN INTERVIEWED IS A USUAL RESIDENT (SKIP TO 201)
130. Now I would like to ask about the place in which you usually live. What is the name of the place in which you usually live?
Is that a city, town, or countryside?
TOWN 2
COUNTRYSIDE 3
131. In which district is that located?
(NAME OF DISTRICT)
132. Now I would like to ask about the household in which you usually live. What is the main source of drinking water for members of your household?
PUBLIC TAP 12
PUBLIC WELL 22
PUBLIC 32
RIVER/STREAM 42
POND/LAKE 43
STONE TAP (OHARA) 44
133. How long does it take to get there, get water, and come back?
ON PREMISES 996
134. What kind of toilet facility does your husband have?
PIT TOILET/LATRINE
VENTILATED IMPROVED PIT 22
NO FACILITY/BUSH/FIELD 41
OTHER________________________________96
135. Does your household have:
Electricity?
A radio?
A television?
A telephone?
A bicycle?
NO 2
NO 2
NO 2
NO 2
NO 2
136. Could you describe the main material of the floor of your home?
CEMENT 32
LINOLEUM 33
MARBLE CHIPS 34
CARPET 35
Now I would like to talk to you about all the pregnancies that you have had in your lifetime. By this I mean all the children born to you, whether they were born alive or dead, whether still living or not, whether living with you or elsewhere, and all the pregnancies that you have had that did not result in a live birth. I understand that it is not easy to talk about children who have died, or pregnancies that have terminated before full term, but it is extremely important that you tell us about all of them, so that we can develop programs that would help the Government of Nepal improve children's health in the future.
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 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. Women sometimes have pregnancies that do not result in a live born child. That is, a pregnancy can end very early, in a miscarriage, or the child can be born dead. Have you had any such pregnancy that did not result in a live birth?
NO 2 (SKIP TO 210)
209. In all, how many such pregnancies have there been?
210. SUM ANSWERS TO 203, 205, 207, AND 209, AND ENTER TOTAL.
IF NONE, RECORD '00'.
211. Just to make sure that I have this right: you have had
________ children who are still living (CHECK 203 and 205)
________ children who have died (CHECK 207), and
________ pregnancies which did not result in a live birth (CHECK 209).
Is that correct?
NO (PROBE AND CORRECT 201-210 AS NECESSARY).
NO PREGNANCIES (SKIP TO 234)
213. Now I would like to ask you about all of your pregnancies, whether born alive, born dead, or lost before full term, starting with the first one you had.
RECORD ALL THE PREGNANCIES. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.
214. Think back to the time of your (first/next) pregnancy
215. Was that a single or multiple pregnancy?
MULTIPLE 2
216. Was the baby born alive, born dead, or lost before full term?
BORN DEAD 2
LOST BEFORE FULL TERM 3 (SKIP TO 225)
217. Did that baby cry, move, or breathe when it was born?
NO 2 (SKIP TO 225)
218. What was the name given to that child?
219. Is (NAME) a boy or a girl?
GIRL 2
220. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
OR: In what season was he/she born?
YEAR ____________
NO 2 (SKIP TO 224)
222. IF BORN ALIVE AND STILL LIVING: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.
223. IF BORN ALIVE AND STILL LIVING: Is (NAME) living with you?
NO 2
(1ST: SKIP TO NEXT PREGNANCY, 2ND AND ON: GO TO 228)
IF BORN ALIVE BUT NOW DEAD:
224. 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 _________
(1ST: SKIP TO NEXT PREG., 2ND AND ON: SKIP TO 228)
225. IF BORN DEAD OR LOST BEFORE FULL TERM: In what year and month did this pregnancy end?
YEAR _________
226. IF BORN DEAD OR LOST BEFORE FULL TERM: How many months did the pregnancy last?
RECORD COMPLETED MONTHS.
LOST BEFORE FULL TERM:
227. Did you or a doctor or someone else do anything to end this pregnancy?
NO 2
228. FROM YEAR OF THIS PREGNANCY SUBTRACT YEAR OF PREVIOUS PREGNANCY. IS THE DIFFERENCE 4 OR MORE YEARS?
NO 2 (SKIP TO NEXT PREG.)
229. Were there any other pregnancies between the previous pregnancy mentioned and this pregnancy?
NO 2
230. FROM YEAR OF INTERVIEW SUBTRACT YEAR OF LAST PREGNANCY.
IS THE DIFFERENCE 4 YEARS OR MORE?
NO 2 (SKIP TO 232)
231. Have you had any pregnancies since the last pregnancy mentioned?
NO 2
232. COMPARE 210 WITH NUMBER OF PREGNANCIES IN HISTORY ABOVE AND MARK:
FOR EACH PRENANCY: YEAR IS RECORDED IN 220 AND 225.
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED IN 222.
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED IN 224.
FOR EACH PREGNANCY LOSS: DURATION IS RECORDED IN 226.
FOR AGE AT DEATH 12 MONTHS OR 1 YR.: PROBE TO DETERMINE EXACT NUMBER OF MONTHS.
233. CHECK 220 AND ENTER THE NUMBER OF BIRTHS SINCE BAISAKH 2049.
WIDOWED, DIVORCED, SEPARATED (SKIP TO 301)
NO 2 (SKIP TO 238)
UNSURE (SKIP TO 238)
236. How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
237. 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 become pregnant at all?
LATER 2
NOT AT ALL 3
238. When did your last menstrual period start?
(DATE, IF GIVEN)
WEEKS AGO 2 ______
MONTHS AGO 3 ______
YEARS AGO 4 _______
IF MENOPAUSE 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996
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 302, 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 301 OR 302, ASK 303.
301. Which ways or methods have you heard about?
NO (GO TO 302 01)
NO (GO TO 302 02)
NO (GO TO 302 03)
NO (GO TO 302 04)
NO (GO TO 302 05)
NO (GO TO 302 06)
NO (GO TO 302 07)
NO (GO TO 302 08)
NO (GO TO 302 09)
NO (GO TO 302 10)
(SPECIFY)
302. Have you ever heard of (METHOD)?
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
NO 3
303. Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
Have you ever had an operation to avoid having any more children?
NO 2
Has your husband ever had an operation to avoid having children?
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE "YES" (EVER USED) (SKIP TO 307A)
305. Have you ever used anything or tried in any way to delay or avoid getting pregnant?
NO 2 (SKIP TO 326)
306. What have you used or done?
CORRECT 303 AND 304 (AND 302 IF NECESSARY).
307A. Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.
What was the first method you ever used?
IUD 02
INJECTIONS 03
NORPLANT 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
OTHER (SPECIFY)________________________96
307B. What is the main reason you chose to use this method?
CONVENIENT TO USE 02
INEXPENSIVE METHOD 03
DON'T LIKE STERILIZATION 04
PERMANENT METHOD 05
TEMPORARY METHOD 06
EFFECTIVE METHOD 07
RECOMMENDED BY HEALTH WORKER 08
HEALTH REASONS 09
NO/LITTLE SIDE EFFECTS 10
OTHER (SPECIFY)____________________________96
308. How many living sons did you have at the time you first used contraception (family planning), if any?
How many living daughters did you have at that time, if any?
IF NONE, RECORD '00'.
NUMBER OF DAUGHTERS ___________
309. When you first used family planning, did you want to have another child but at a later time, or did you not want to have another child at all?
DID NOT WANT ANOTHER CHILD 2
OTHER (SPECIFY)_____________________________6
WIDOWED, DIVORCED, SEPARATED (SKIP TO 401)
WOMAN STERILIZED (SKIP TO 314A)
PREGNANT (SKIP TO 327)
313. Are you or your husband currently doing something or using any method to delay or avoid your getting pregnant?
NO 2 (SKIP TO 326)
314. Which method are you using? (NOTE: probably # tag these 2 together)
314A. CIRCLE '07' FOR FEMALE STERILIZATION
IUD 02 (SKIP TO 321)
INJECTIONS 03 (SKIP TO 321)
NORPLANT 04 (SKIP TO 321)
DIAPHRAGM/FOAM/JELLY 05 (SKIP TO 321)
CONDOM 06 (SKIP TO 321)
FEMALE STERILIZATION 07 (SKIP TO 316)
MALE STERILIZATION 08 (SKIP TO 316)
PERIODIC ABSTINENCE 09 (SKIP TO 320)
WITHDRAWAL 10 (SKIP TO 321)
OTHER (SPECIFY)________________________96 (SKIP TO 321)
315A. At the time you first started using the pill, did you consult a doctor or a nurse or a health worker or not?
NO 2
315B. At the time you last got the pills, did you consult a doctor or a nurse or a health worker or not?
NO 2 (SKIP TO 321)
316. Where did the sterilization take place?
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
PRIMARY/HEALTH CENTRE 12
MOBILE CAMP 13
OTHER PUBLIC (SPECIFY)_____________________16
CLINIC/NURSING HOME 22
FPAN 23
OTHER PRIVATE (SPECIFY)____________________26
DON'T KNOW 98
317. Do you regret that (you/your husband) had the operation not to have any (more) children?
NO 2 (SKIP TO 319)
318. Why do you regret the operation?
SPOUSE WANTS ANOTHER CHILD 02
SIDE EFFECTS 03
CHILD DIED 04
OTHER (SPECIFY)__________________________________96
319. In what month and year was the sterilization performed?
IF DON'T KNOW YEAR
PROBE: How many years ago?
DON'T KNOW MONTH 98
YEAR _____ (SKIP TO 322)
DON'T KNOW YEAR 98
319A. How old were you at the time of sterilization?
320. How do you determine which days of your monthly cycle not to have sexual relations?
BASED ON BODY TEMPERATURE 02
BASED ON CERVICAL MUCUS (BILLINGS METHOD) 03
BASED ON BODY TEMPERATURE AND CERVICAL MUCUS 04
NO SPECIFIC SYSTEM 05
OTHER (SPECIFY)___________________________________96
321. For how many months have you been using (METHOD) continuously?
IF LESS THAN 1 MONTH, RECORD '00'.
8 YEARS OR LONGER 96
322. CHECK 314:
CIRCLE METHOD CODE:
IUD 02
INJECTIONS 03
NORPLANT 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07 (SKIP TO 324A)
MALE STERILIZATION 08 (SKIP TO 324A)
PERIODIC ABSTINENCE 09 (SKIP TO 327)
WITHDRAWAL 10 (SKIP TO 327)
OTHER (SPECIFY)____________________________96 (SKIP TO 327)
323. Where did you obtain (METHOD) the last time?
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
(NAME OF PLACE) _____________
PRIMARY/HEALTH CENTRE 12
FAMILY PLANNING CLINIC 13
HEALTH POST 14
SUB-HEALTH POST 15
MOBILE CLINIC 17
OTHER PUBLIC (SPECIFY)___________________16
CLINIC/NURSING HOME 22
PHARMACY 23
CHW 24
FPAN 25
OTHER PRIVATE (SPECIFY)___________________26
SHOP 32
FRIEND/RELATIVE 33
323A. How long does it usually take to travel from your home to this place?
DON'T KNOW 998
323B. Is it easy or difficult to get there?
DIFFICULT 2
DON'T KNOW 8
324. Do you know another place where you could have obtained (METHOD) the last time?
NO 2 (SKIP TO 329)
324A. At the time of the sterilization operation, did you know another place where you could have received the operation?
NO 2 (SKIP TO 329)
325. People select the place where they get family planning services for various reasons.
What was the main reason you went to (NAME OF PLACE IN Q.323 OR Q.316) instead of the other place you know about?
RECORD RESPONSE AND CIRCLE CODE. _______________
CLOSER TO MARKET/WORK 12
AVAILABILITY OF TRANSPORT 13
CLEANER FACILITY 22
OFFERS MORE PRIVACY 23
SHORTER WAITING TIME 24
LONGER HRS OF SERVICE 25
USE OTHER SERVICES AT THE FACILITY 26
WANTED ANONYMITY 41
OTHER (SPECIFY)___________________________________96
DON'T KNOW 98
326. What is the main reason you are not using a method of contraception to avoid pregnancy?
INFREQUENT SEX 22
MENOPAUSAL/HYSTERECTOMY 23
SUBFECUND/INFECUND 24
POSTPARTUM/BREASTFEEDING 25
WANTS (MORE) CHILDREN 26
HUSBAND OPPOSED 32
OTHERS OPPOSED 33
RELIGIOUS PROHIBITION 34
KNOWS NO SOURCE 42 (SKIP TO 329)
FEAR OF SIDE EFFECTS 52
LACK OF ACCESS/TOO FAR 53
COST TOO MUCH 54
INCONVENIENT TO USE 55
INTERFERES WITH BODY'S NATURAL PROCESS 56
DON'T KNOW 98
327. Do you know of a place where you can obtain a method of family planning?
NO 2 (SKIP TO 329)
328. Where is that?
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
PRIMARY/HEALTH CENTRE 12
FAMILY PLANNING CLINIC 13
HEALTH POST 14
SUB-HEALTH POST 15
MOBILE CLINIC 17
OTHER PUBLIC_____________________16
CLINIC/NURSING HOME 22
PHARMACY 23
CHW 24
FPAN 25
OTHER PRIVATE____________________26
SHOP 32
FRIEND/RELATIVE 33
OTHER (SPECIFY)_____________________________36
329. Were you visited by a family planning programme worker or health worker in the last 12 months?
NO 2
330. Have you visited a health facility for any reason in the last 12 months?
NO 2 (SKIP TO 332)
331. Did any staff member at the health facility speak to you about family planning methods?
NO 2
332. Do you think that breastfeeding can affect a woman's chance of becoming pregnant?
NO 2 (SKIP TO 401)
DON'T KNOW 8 (SKIP TO 401)
333. Do you think a woman's chance of becoming pregnant is increased or decreased by breastfeeding?
DECREASED 2
DEPENDS 3
DON'T KNOW 8
NO BIRTHS (SKIP TO 401)
335. Have you ever relied on breastfeeding as a method of avoiding pregnancy?
NO 2 (SKIP TO 401)
EITHER PREGNANT OR STERILIZED (SKIP TO 401)
337. Are you currently relying on breastfeeding to avoid getting pregnant?
NO 2
SECTION 4A. PREGNANCY AND BREASTFEEDING
401. CHECK 233:
NO BIRTHS SINCE BAISKH 2049 (SKIP TO 465)
402. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE BAISAKH 2049 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 QUESTIONNARES).
Now I would like to ask you some questions about the health of all your children born in the last three years. We will talk about one child at a time.
NEXT-TO-LAST LINE NUMBER__
404. NAME FROM Q218 AND SURVIVAL STATUS FROM Q221
ALIVE
DEAD
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. At the time you became pregnant with (NAME) how much longer would you like to have waited?
YEARS 2 ___________
DON'T KNOW 998
407. When you were pregnant with (NAME), 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/ANM B
MATERNAL AND CHILD HEALTH WORKER D
NO ONE Y (SKIP TO 410)
407A. How long did it take to get from your home to the nearest place where you saw a person?
SEEN AT HOME 990
408. How many months pregnant were you when you first received antenatal care?
DON'T KNOW 98
409. How many times did you receive antenatal care during this pregnancy?
DON'T KNOW 98
410. When you were pregnant with (NAME) were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
NO 2 (SKIP TO 412A)
DON'T KNOW 8
411. During this pregnancy, how many times did you get this injection?
DON'T KNOW 8
412. When you were pregnant with (NAME) did you receive any iron tablets?
SHOW IRON TABLETS.
NO 2
DON'T KNOW 8
412B. When you were pregnant with (NAME) did you receive a combined iron and folic acid tablets?
SHOW COMBINED IRON AND FOLIC ACID TABLETS.
NO 2
DON'T KNOW 8
412C. When you were pregnant with (NAME) did you suffer from [local term for night blindness]?
IF 'NO' OR 'DON'T KNOW' PROBE: Did you have any difficulty seeing at dusk, at night, or in a room with poor light?
RESPONDENT BLIND 2
NO 3
DON'T KNOW 8
413. Where did you go to give birth to (NAME)?
OTHER HOME 12 (GO TO 413B)
PRY./ HEALTH CENTRE 22
HEALTH POST 23
OTHER PUBLIC (SPECIFY)____________________26
CLINIC/NURSING HOME 32
OTHER PRIVATE (SPECIFY)___________________36
413B. Was a special safe delivery kit used?
SHOW SAFE DELIVERY KIT THAT IS MARKETED BY CRS.
NO 2
DON'T KNOW 8
414. Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSONS AND RECORD ALL PERSONS ASSISSTING.
NURSE/ANM B
MATERNAL AND CHILD HEALTH WORKER D
RELATIVE/FRIEND E
NO ONE Y
414A. Did you receive a check-up (postpartum care) from anyone within 24 hours following the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSONS AND RECORD ALL PERSONS ASSISTING.
NURSE/ANM B
MATERNAL AND CHILD HEALTH WORKER D
RELATIVE/FRIEND E
OTHER (SPECIFY)_____________________________X
415. Around the time of the birth of (NAME), did you have any of the following problems:
Long labour, that is, did your regular contractions last more than 12 hours?
Excessive bleeding that was so much that you feared it was life threatening?
A high fever with bad smelling vaginal discharge?
Convulsions?
NO 2
NO 2
NO 2
NO 2
416. Was (NAME) delivered by caesarian section?
NO 2
417. When (NAME) was born, was he/she: very large, large, average, small, or very small?
LARGE 2
AVERAGE 3
SMALL 4
VERY SMALL 5
DON'T KNOW 8
418. Has your period returned since the birth of (NAME)?
NO 2 (SKIP TO 421)
419. Did your period return between the birth of (NAME) and your next pregnancy?
NO 2 (SKIP TO 423)
420. For how many months after the birth of (NAME) did not have a period?
DON'T KNOW 98
421. CHECK 235:
RESPONDENT PREGNANT?
PREGNANT OR UNSURE (SKIP TO 423)
422. Have you resumed sexual relations since the birth of (NAME)?
NO 2 (SKIP TO 424)
423. For how many months after the birth of (NAME) did you not have sexual relations?
DON'T KNOW 98
424. Did you ever breastfeed (NAME)?
NO 2 (SKIP TO 430)
425. 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 ___________
425A. Did you squeeze out the milk from the breast before you first put (NAME) to the breast?
NO 2
DEAD (SKIP TO 428)
427. Are you still breastfeeding (NAME)?
NO 2
428. For how many months did you breastfeed (NAME)?
DON'T KNOW 98
429. Why did you stop breastfeeding (NAME)?
CHILD ILL/WEAK 02
CHILD DEAD 03
NIPPLE/BREAST PROBLEM 04
NOT ENOUGH MILK 05
MOTHER WORKING 06
CHILD REFUSED 07
WEANING AGE/AGE TO STOP 08
BECAME PREGNANT 09
STARTED USING CONTRACEPTION 10
OTHER (SPECIFY)_____________________________96
DEAD (GO BACK TO 405 IN NEXT COL. OR, IF NO MORE BIRTHS, GO TO 439)
431. How many times did you breastfeed (NAME) last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC PROBE FOR APPROXIMATE NUMBER.
432. How many times did you breastfeed (NAME) yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC PROBE FOR APPROXIMATE NUMBER.
433. Did (NAME) drink anything from a bottle with a nipple yesterday or last night?
NO 2
DON'T KNOW 8
434. At any time yesterday or last night, was (NAME) given any of the following:
Plain water?
Sugar water?
Juice?
Tea?
Baby formula?
Tinned or powdered milk?
Fresh milk?
Any other liquid?
Any food made from wheat, maize, rice, or other grain, such as porridge, bread, or noodles?
Any food made from potatoes, yams, or local tuber?
Eggs, fish or poultry?
Meat?
Any other solid or semi-solid foods?
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
435. CHECK 434:
FOOD OR LIQUID GIVEN YESTERDAY?
"NO/DK" TO ALL (SKIP TO 437)
436. (Aside from breastfeeding,) how many times did (NAME) eat yesterday, including both meals and snacks?
IF 7 OR MORE TIMES, RECORD "7"
DON'T KNOW 8
437. On how many days during the last seven days was (NAME) given any of the following:
Plain water?
Any kind of milk (other than breast milk)?
Liquids other than plain water or milk?
Food made from wheat, maize, rice, or other grain?
Food made from potatoes, yams, or tuber?
Eggs, fish, or poultry?
Meat?
Any other solid or semi-solid foods?
IF DON'T KNOW, RECORD '8'.
RECORD THE NUMBER OF DAYS.
MILK __________
OTHER LIQUIDS ___________
FOOD MADE FROM GRAIN ___________
FOOD MADE FROM TUBER ______________
EGGS/FISH/POULTRY __________
MEAT ______________
OTHER SOLIDS/SEMI-SOLID FOODS ___________
438. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 439.
SECTION 4B. IMMUNIZATION AND HEALTH
439. ENTER THE NAME, LINE NUMBER, AND SURVIVAL STATUS OF EACH BIRTH SINCE BAISAKH 2049 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).
441. NAME FROM Q218
AND SURVIVAL STATUS FROM Q221
ALIVE
DEAD (GO TO 441 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465.)
442. 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 446)
NO CARD 3
443. Did you ever have a vaccination card for (NAME)?
NO 2
444.
(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.
BCG
DPT 1
DPT 2
DPT 3
Polio 1
Polio 2
Polio 3
Measles
MONTH ___________
YEAR _________
MONTH ____________
YEAR ___________
MONTH _________________
YEAR __________
MONTH __________
YEAR ____________
MONTH ____________
YEAR _______________
MONTH _____________
YEAR ______________
MONTH _______________
YEAR _____________
MONTH _______________
YEAR _____________
NAME_________________
445. Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 1-3, DPT 1-3, AND/OR MEASLES VACCINE(S).
NO 2 (SKIP TO 448A)
DON'T KNOW 8 (SKIP TO 448A)
446. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?
NO 2 (SKIP TO 448A)
DON'T KNOW 8 (SKIP TO 448A)
447. Please tell me if (NAME) received any of the following:
447A. A BCG vaccination against tuberculosis, that is, an injection in the arm that caused a scar?
NO 2
DON'T KNOW 8
447B. Polio vaccine, that is, drops in the mouth?
NO 2 (SKIP TO 447D)
DON'T KNOW 8 (SKIP TO 447D)
447C. How many times?
447D. DPT vaccination, that is, an injection usually given at the same time as polio drops?
NO 2 (SKIP TO 447F)
DON'T KNOW 8 (SKIP TO 447F)
447E. How many times?
447F. An injection to prevent measles?
NO 2
DON'T KNOW 8
448A. Did (NAME) receive Vitamin A during the last 6 months?
SHOW VITAMIN A CAPSULE.
NO 2
DON'T KNOW 8
448B. Did (NAME) receive iodine capsules during the last 6 months?
SHOW IODINE CAPSULES.
IF YES: How many times?
NO 2
NUMBER OF TIMES _____________________
448C. Does (NAME) suffer from (local term for night blindness)?
IF NO OR DON'T KNOW PROBE: Does (NAME) have any difficulty (more difficulty than usual) seeing at dusk, at night, or in a room with poor light?
CHILD BLIND 2
NO 3
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) been ill with a cough at any time in the last 2 weeks?
NO 2 (SKIP TO 454)
DON'T KNOW 8 (SKIP TO 454)
451. When (NAME) was ill with a cough, did he/she breathe faster than usual with short, fast breaths?
NO 2
DON'T KNOW 8
452. Did you seek advice or treatment for the cough or difficult breathing?
NO 2 (SKIP TO 454)
453. Where did you seek advice or treatment? Anywhere else?
RECORD ALL MENTIONED.
PRY./HEALTH CENTRE B
HEALTH/SUB-HEALTH POST C
MOBILE CLINIC D
FIELD WORKER E
OTHER PUBLIC (SPECIFY)_________________________F
CLINIC/NURSING HOME H
PHARMACY I
MOBILE CLINIC J
COMM. HEALTH WORKER K
OTHER PRIVATE (SPECIFY)________________________L
TRAD. PRACTITIONER O
OTHER (SPECIFY)_________________________________X
454. Has (NAME) had diarrhea, that is, loose or watery stool in the last 2 weeks?
NO 2 (SKIP TO 464)
DON'T KNOW 8 (SKIP TO 464)
455. Was there any blood in the stools?
NO 2
DON'T KNOW 8
456. On the worst day of the diarrhea, how many bowel movements did (NAME) have?
DON'T KNOW 98
457. Was he/she given the same amount to drink as before the diarrhea, or more, or less?
MORE 2
LESS 3
DON'T KNOW 8
458. Was he/she given the same amount of food to eat as before the diarrhea, or more, or less?
MORE 2
LESS 3
DON'T KNOW 8
459. Was (NAME) given a fluid made from a special packet such as Jeevan Jal to drink?
NO 2
DON'T KNOW 8
460. Was anything (else) given to treat the diarrhea?
NO 2 (SKIP TO 464)
DON'T KNOW 8 (SKIP TO 464)
461. What was given to treat the diarrhea?
Anything else?
RECORD ALL MENTIONED.
PILL OR SYRUP B
INJECTION C
(I.V.) INTRAVENOUS D
HOME REMEDIES/HERBAL MEDICINES E
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.
PRY./HEALTH CENTRE B
HEALTH/SUB-HEALTH POST C
MOBILE CLINIC D
FIELD WORKER E
OTHER PUBLIC (SPECIFY)_________________________F
CLINIC/NURSING HOME H
PHARMACY I
MOBILE CLINIC J
COMM. HEALTH WORKER K
OTHER PRIVATE (SPECIFY)________________________L
TRAD. PRACTITIONER O
OTHER (SPECIFY)_________________________________X
464. GO BACK TO 441 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 465.
465. When a child has diarrhea, should he/she be given the same amount to drink, more or less than usual?
MORE 2
LESS 3
DON'T KNOW 8
466. When a child has diarrhea, should he/she be given the same amount to eat, more or less than usual?
MORE 2
LESS 3
DON'T KNOW 8
467. When a child is sick with diarrhea, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED.
ANY WATERY STOOLS B
REPEATED VOMITING C
ANY VOMITING D
BLOOD IN STOOLS E
FEVER F
MARKED THIRST G
NOT EATING/NOT DRINKING WELL H
GETTING SICKER/VERY SICK I
NOT GETTING BETTER J
OTHER (SPECIFY)___________________________________X
DON'T KNOW Z
468. When a child is sick with a cough, what signs of illness would tell you that he or she should be taken to a health facility or health worker?
RECORD ALL MENTIONED.
DIFFICULT BREATHING B
NOISY BREATHING C
FEVER D
CHEST IN DRAWING E
UNABLE TO DRINK F
NOT EATING/NOT DRINKING WELL G
GETTING SICKER/VERY SICK H
NOT GETTING BETTER I
OTHER (SPECIFY)___________________________________X
DON'T KNOW Z
ANY CHILD RECEIVED ORS (SKIP TO 470B)
470. Have you ever heard of a special product called ORS such as Jeevan Jal you can get for treatment for diarrhea?
NO 2
470A. Have you ever seen (a) packet(s) like this?
SHOW PACKET OF JEEVAN JAL OR OTHER ORS PACKETS LIKELY TO BE USED IN THE LOCALITY OF THE INTERVIEW.
NO 2 (SKIP TO 501)
470B. Have you ever prepared the contents of a packet of Jeevan Jal or a packet of any other ORS with water, either for yourself or for someone else?
YES, OTHER ORS 2 (SKIP TO 472A)
NO 3 (SKIP TO 472A)
471A. Did you prepare the whole packet at once or only part of the packet?
ONLY PART OF PACKET 2 (SKIP TO 472A)
471B. How much water did you mix with a packet of Jeevan Jal?
MANA 2
TEA GLASS 3
OTHER (SPECIFY)_________________4
DON'T KNOW 998
472A. Where can you buy or obtain a packet of ORS like Jeevan Jal?
PROBE: Where else?
RECORD ALL MENTIONED.
PRY./HEALTH CENTRE B
HEALTH/SUB-HEALTH POST C
MOBILE CLINIC D
FIELD WORKER E
OTHER PUBLIC (SPECIFY)_________________________F
CLINIC/NURSING HOME H
PHARMACY I
MOBILE CLINIC J
COMM. HEALTH WORKER K
OTHER PRIVATE (SPECIFY)________________________L
TRAD. PRACTITIONER O
472B. How long does it take to get from your home to the nearest source of ORS?
SECTION 5. FERTILITY PREFERENCES
501. CHECK 120:
WIDOWED, DIVORCED, SEPARATED (SKIP TO 512)
HE OR SHE STERILIZED (SKIP TO 512)
NOT PREGNANT OR UNSURE
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?
PREGNANT
Now I have some questions about the future. After the child you are expecting now, would you like to have another child or would you prefer not to have any more children?
NO MORE/NONE 2 (SKIP TO 507)
SAYS SHE CAN'T GET PREGNANT (SKIP TO 507)
UNDECIDED/DON'T KNOW 8 (SKIP TO 505)
504. CHECK 235:
NOT PREGNANT OR UNSURE
How long would you like to wait from now before the birth of (a/another) child?
PREGNANT
After the child you are expecting now, how long would you like to wait before the birth of another child?
YEARS 2 ____________
SOON/NOW 993 (SKIP TO 507)
SAYS SHE CAN'T GET PREGNANT 994 (SKIP TO 507)
OTHER (SPECIFY) ___________________________________996
DON'T KNOW 998
PREGNANT (SKIP TO 508)
506. If you became pregnant in the next few weeks, would you be happy, unhappy, or would it not matter very much?
UNHAPPY 2
WOULD NOT MATTER 3
507. CHECK 313: USING A METHOD.
NOT CURRENTLY USING
CURRENTLY USING (SKIP TO 512)
508. Do you think you will use a method to delay or avoid pregnancy within the next 12 months?
NO 2
DON'T KNOW 8
509. Do you think you will use a method of family planning at any time in the future?
NO 2 (SKIP TO 511)
DON'T KNOW 8 (SKIP TO 511)
510. Which method would you prefer to use?
(ALL ANSWERS SKIP TO 512)
IUD 02
INJECTION 03
NORPLANT 04
DIAPHRAGM/FOAM/JELLY 05
CONDOM 06
FEMALE STERILIZATION 07
MALE STERILIZATION 08
PERIODIC ABSTINENCE 09
WITHDRAWAL 10
OTHER (SPECIFY)____________________________96
UNSURE 98
511. What is the main reason that you think you will never use a method?
MENOPAUSAL/HYSTERECTOMY 12
SUBFECUND/INFECUND 13
WANTS MORE CHILDREN 14
HUSBAND OPPOSED 22
OTHERS OPPOSED 23
RELIGIOUS PROHIBITION 24
KNOWS NO SOURCE 32
FEAR OF SIDE EFFECTS 42
LACK OF ACCESS/TOO FAR 43
COST TOO MUCH 44
INCONVENIENT TO USE 45
INTERFERES WITH BODY'S NORMAL PROCESSES 46
DON'T KNOW 98
512. CHECK 221:
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 how many would that be?
PROBE FOR A NUMERIC RESPONSE.
OTHER (SPECIFY)_______________________96 (SKIP TO 514)
513. How many of these children would you like to be boys, how many would you like to be girls and how many would it not matter?
OTHER (SPECIFY)______________________96
NUMBER (GIRLS)
OTHER (SPECIFY)______________________96
NUMBER (EITHER)
OTHER (SPECIFY)______________________96
514. Would you say that you approve or disapprove of couples using a method to avoid getting pregnant?
DISAPPROVE 2
NO OPINION 3
515. Is it acceptable or not acceptable to you for information on family planning to be provided:
On the radio?
On the television?
NOT ACCEPTABLE 2
DON'T KNOW 8
NOT ACCEPTABLE 2
DON'T KNOW 8
516. In the last few months have you heard about family planning:
On the radio?
On the television?
In a newspaper or magazine?
From a poster?
From leaflets or brochures?
NO 2
NO 2
NO 2
NO 2
NO 2
516A. In the last few months have you heard the following programs on the radio:
Jana Swastha Karyakram?
Ghanti Heri Had Nilaun, the drama?
Ghanti Heri Had Nilaun, the song?
Shriman Shrimatile Pariwarbare Kurakani Gareko Chhoto Radio
Natak?
NO 2
NO 2
NO 2
NO 2
517. In the last few months have you discussed the practice of family planning with your friends, neighbours, or relatives?
NO 2 (SKIP TO 519)
518. With whom? Anyone else?
RECORD ALL MENTIONED.
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER F
MOTHER-IN-LAW G
FRIENDS/NEIGHBOURS H
OTHER (SPECIFY)_______________________X
WIDOWED, DIVORCED, SEPARATED (SKIP TO 601)
520. Spouses do not always agree on everything. Now I want to ask you about your husband's views on family planning.
Do you think that your husband approves or disapproves of couples using a method to avoid pregnancy?
DISAPPROVES 2
DON'T KNOW 8
521. How often have you talked to your husband about family planning in the past year?
ONCE OR TWICE 2
MORE OFTEN 3
522. Do you think your husband wants the same number of children that you want, or does he want more or fewer than you want?
MORE CHILDREN 2
FEWER CHILDREN 3
DON'T KNOW 8
SECTION 6. HUSBAND'S BACKGROUND AND WOMAN'S WORK
601. CHECK 120:
WIDOWED, DIVORCED, SEPARATED (SKIP TO 603)
602. How old was your husband on his last birthday?
603. Did your (last) husband ever attend school?
NO 2 (SKIP TO 605)
604. What was the highest grade he completed?
DON'T KNOW 98
605. What (is/was) your (last) husband's occupation?
That is, what kind of work (does/did) he mainly do?
________________________________________
DOES (DID) NOT WORK IN AGRICULTURE (SKIP TO 608)
607. (Does/did) your husband work mainly on his own land or on family land, or (does/did) he rent land or does he work on someone else's land?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
608. Aside from your own housework, are you currently working?
NO 2
609. 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
610. Have you done any work in the last 12 months?
NO 2 (SKIP TO 701)
611. What is your occupation, what is what kind of work do you mainly do?
_______________________________________
DOES NOT WORK IN AGRICULTURE (SKIP TO 614)
613. Do you work mainly on your own land or on family land, or do you rent land or work on someone else's land?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
614. 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
615. Do you usually work throughout the year, or do you work seasonally/part of the year, or only once in a while?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3 (SKIP TO 618)
616. During the last 12 months, how many months did you work?
617. During the last 12 months (in the months you worked,) how many days a week did you usually work?
618. During the last 12 months, approximately how many days did you work?
619. Do you earn cash for your work?
PROBE: Do you make money for working?
NO 2 (SKIP TO 622)
620. How much do you usually earn for this work?
PROBE: Is this by the day, by the week, or by the month?
PER DAY 2
PER WEEK 3
PER MONTH 4
PER YEAR 5
OTHER (SPECIFY)__________________999996
621. CHECK 120:
CURRENTLY MARRIED: Who mainly decides how the money you earn will be used: you, your husband, you and your husband jointly, or someone else?
WIDOWED, DIVORCED, SEPARATED: Who mainly decides how the money you earn will be used: you, someone else, or you and someone else jointly?
HUSBAND DECIDES 2
JOINTLY WITH HUSBAND 3
SOMEONE ELSE DECIDES 4
JOINTLY WITH SOMEONE ELSE 5
622. Do you usually work at home or away from home?
AWAY 2
623. CHECK 222 AND 223: HAS A CHILD LIVING AT HOME WHO IS AGE 5 OR LESS?
NO (SKIP TO 701)
624. Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?
HUSBAND 02
OLDER FEMALE CHILD 03
OLDER MALE CHILD 04
OTHER RELATIVES 05
NEIGHBOURS 06
FRIENDS 07
SERVANTS/HIRED HELP 08
CHILD IS IN SCHOOL 09
INSTITUTIONAL CHILD CARE 10
HAS NOT WORKED SINCE LAST BIRTH 95
OTHER (SPECIFY)________________________________96
701. Have you ever heard of an illness called AIDS?
NO 2 (SKIP TO 711)
702. From which sources of information have you learned most about AIDS?
Any other sources? RECORD ALL MENTIONED.
TELEVISION B
NEWSPAPERS/MAGAZINES C
PAMPHLETS/POSTERS D
HEALTH WORKERS E
TEMPLES/MOSQUES F
SCHOOLS/TEACHERS G
COMMUNITY MEETINGS H
FRIENDS/RELATIVES I
WORK PLACE J
OTHER (SPECIFY) ___ X
703. Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?
NO 2 (SKIP TO 707)
DON'T KNOW 8
704. What can a person do? Any other ways? RECORD ALL MENTIONED.
ABSTAIN FROM SEX B
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
AVOID BLOOD TRANSFUSIONS G
AVOID INJECTIONS H
AVOID KISSING I
AVOID MOSQUITO BITES J
SEEK PROTECTION FROM TRADITIONAL HEALER K
OTHER (SPECIFY)_________________________________W
OTHER (SPECIFY)_________________________________X
DON'T KNOW Z
DID NOT MENTION SAFE SEX (SKIP TO 707)
706. What does "safe sex" mean to you?
USE CONDOMS C
HAVE ONLY ONE SEX PARTNER D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH HOMOSEXUALS F
OTHER (SPECIFY)_______________________________X
DON'T KNOW Z
707. Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
708. Do you think that persons with AIDS almost never die from the disease, sometimes die, or almost always die from the disease?
SOMETIMES 2
ALMOST ALWAYS 3
DON'T KNOW 8
709. Do you think your chances of getting AIDS are small, moderate, great, or that you have no risk at all?
MODERATE 2
GREAT 3
NO RISK AT ALL 4
HAS AIDS 5
DON'T KNOW 8
710. Has your knowledge of AIDS influenced or changed your decisions about having sex or your sexual behavior?
IF YES, PROBE: In what way?
RECORD ALL MENTIONED.
STARTED USING CONDOMS C
RESTRICTED SEX TO ONE PARTNER D
REDUCED NUMBER OF PARTNERS E
OTHER (SPECIFY)_________________________________X
NO CHANGE IN SEXUAL BEHAVIOR Y
DON'T KNOW Z
WIDOWED, DIVORCED, SEPARATED (SKIP TO 801)
712. Now I need to ask you some questions about sexual activity in order to gain a better understanding of some family planning issues.
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
713. CHECK 301 AND 302:
KNOWS CONDOM: The last time you had sex, was a condom used?
DOES NOT KNOW CONDOM: Some men us a condom which means that they put a rubber sheath on their penis during sexual intercourse. The last time you had sex, was a condom used?
NO 2
DON'T KNOW 8
714. Do you know of a place where you can get condoms?
NO 2 (SKIP TO 716)
IF SOURCE IS HOSPITAL, HEALTH CENTRE, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
(NAME OF PLACE) ______________________
PRIMARY HEALTH CENTRE 12
FAMILY PLANNING CLINIC 13
HEALTH POST 14
SUB-HEALTH POST 15
MOBILE CLINIC 17
OTHER PUBLIC (SPECIFY)___________________16
CLINIC/NURSING HOME 22
PHARMACY 23
CHW 24
FPAN 25
OTHER PRIVATE (SPECIFY)__________________26
SHOP 32
FRIEND/RELATIVE 33
OTHER (SPECIFY)___________________________36
716. How old were you when you first had sexual intercourse?
FIRST TIME WHEN MARRIED 95
FIRST TIME AT GAUNA 96
717. PRESENCE OF OTHERS AT THIS POINT.
NO 2
NO 2
NO 2
NO 2
804. What was the name given to your next oldest brother?
805. Is (NAME) male or female?
FEMALE 2
NO 2 (GO TO 808)
DK 8 (GO TO [8])
808. In what year did (NAME) die?
DK 58
809. How many years ago did (NAME) die?
810. How old was (NAME) when he/she died?
811. Was (NAME) pregnant when she died?
NO 2
812. Did (NAME) die during childbirth?
NO 2
813. Did (NAME) die within two months after the end of a pregnancy or childbirth?
NO 2 (GO TO 815)
814. Was her death due to complications of pregnancy or childbirth?
NO 2
815. How many children did (NAME) give birth to during her lifetime?
IF NO MORE BROTHERS OR SISTERS, GO TO 816
816. RECORD THE TIME.
MINUTES ______________
901. CHECK 233:
NO BIRTHS SINCE BAISAKH 2049 (SKIP TO END)
IN 902 (COLUMNS 2 AND 3) RECORD THE LINE NUMBER FOR EACH CHILD BORN SINCE BAISAKH 2049 AND STILL ALIVE. IN 903 AND 904 RECORD THE NAME (ALL COLUMNS) AND BIRTH DATE (COLUMNS 2 AND 3) FOR THE RESPONDENT AND FOR ALL LIVING CHILDREN BORN SINCE BAISAKH 2049. IN 906 AND 908 RECORD HEIGHT AND WEIGHT OF THE RESPONDENT AND THE LIVING CHILDREN. (NOTE: ALL RESPONDENTS WITH ONE OR MORE BIRTHS SINCE BAISAKH 2049 SHOULD BE WEIGHED AND MEASURED EVEN IF ALL OF THE CHILDREN HAVE DIED. IF THERE ARE MORE THAN 2 LIVING CHILDREN SINCE BAISAKH 2049, USE ADDITIONAL QUESTIONNAIRES).
902. LINE NO. FROM Q214
903. NAME FROM Q218 FOR CHILDREN
904. DATE OF BIRTH FROM Q220, AND ASK FOR DAY OF BIRTH
MONTH _____________
YEAR _____________
905. BCG SCAR ON TOP OF SHOULDER
NO SCAR 2
907. WAS LENGTH/HEIGHT OF CHILD MEASURED LYING DOWN OR STANDING UP?
STANDING 2
909. DATE WEIGHED AND MEASURED
MONTH _____________
YEAR ________________
NOT PRESENT 3
REFUSED 4
OTHER (SPECIFY) 6
CHILD SICK 2
CHILD NOT
PRESENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY) _________________6
CHILD SICK 2
CHILD NOT
PRESENT 3
CHILD REFUSED 4
MOTHER REFUSED 5
OTHER (SPECIFY) _________________6
NAME OF ASSISTANT: ________________
INTERVIEWER'S OBSERVATIONS
To be filled in after completing interview
Comments about Respondent ___________________
Comments on Specific Questions _______________________
Any Other Comments _______________________
Name of Supervisor _________________
Date __________________
Name of Editor __________________
Date _____________________