NAME AND CODE OF DISTRICT
NAME AND CODE OF VILLAGE/MUNICIPALTY
WARD NUMBER
CLUSTER NUMBER
CITY/TOWN/RURAL
TOWN 2
RURAL 3
NAME AND LINE NUMBER OF MAN
NAME OF HOUSEHOLD HEAD
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY)_________ 9
TOTAL NUMBER OF VISITS
LANGUAGE OF QUESTIONNAIRE: ENGLISH 5
LANGUAGE OF INTERVIEW
BHOJPURI 2
MAITHILI 3
THARU 4
OTHER 5
NATIVE LANGUAGE OF RESPONDENT
BHOJPURI 2
MAITHILI 3
THARU 4
OTHER 5
TRANSLATOR USED
NO 2
NAME ____
DATE ____
FIELD EDITOR
NAME ____
DATE ____
OFFICE EDITOR
___
KEYED BY
___
Hello. My name is _______________________________________ and I am working with the MINISTRY OF HEALTH AND POPULATION. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey.
The survey usually takes between 20 and 30 minutes to complete.
As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.
At this time, do you want to ask me anything about the survey? May I begin the interview now?
SIGNATURE OF INTERVIEWER:____________________________ DATE:______________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES ___
102. HOW LONG HAVE YOU BEEN LIVING CONTINOUSLY IN (NAME OF CURRENT PLACE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.
ALWAYS 95 (GO TO 104)
VISITOR 96 (GO TO 104)
103. Just before you moved here, did you live in a city, in a town, or in the countryside?
TOWN 2
COUNTRYSIDE 3
104. Have you travelled away from your home community at any time in the last 12 months?
NO 2
105. How many months in total have you been in the last 12 months? IF LESS THAN 1 MONTH RECORD '00'.
106. Where have you travelled in the last 12 months?
PROBE: Anywhere else? RECORD ALL PLACES MENTIONED
INDIA (SPECIFY CITY/STATE) ____ B
OTHER (SPECITY COUNTRY) ____ X
107. In what month and year were you born?
DON'T KNOW MONTH 98
YEAR ___
DON'T KNOW YEAR 9998
108. How old were you at your last birthday? COMPARE AND CORRECT 107 AND/OR 106 IF INCONSISTENT.
109. Have you ever attended school?
NO 2 (GO TO 112)
110. What is the highest grade you completed?
GRADE 6 OR HIGHER (GO TO 115)
112. Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT. IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?)
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) ____ 4
BLIND/VISUALLY IMPARED 5
113. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?
NO 2
CODE '1' OR '5' CIRCLED (GO TO 116)
115. Do you read a newspaper or magazine almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
116. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
117. Do you watch television almost every day, at least once a week, less than once a week or not at all?
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4
BUDDHIST 2
MUSLIM 3
KRAT 4
CHRISTIAN 5
OTHER (SPECIFY) ___
119. What is your caste/ethnicity? WRITE CASTE/ETHNICITY ON LINE PROVIDED. LEAVE BOX BLANK. CODE WILL BE FILLED BY FIELD EDITOR.
201. Now I would like to ask about any children you have had during your life. I am interested in all of the children that are biologically yours, even if they are not legally yours or do not have your last name. Have you ever fathered any children with any woman?
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)
202. Do you have any sons or daughters that you have fathered who are now living with you?
NO 2 (GO 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 that you have fathered who are alive but do not live with you?
NO 2 (GO TO 206)
205. How many sons are alive but do not live with you? And how many daughters are live but do not live with you? (IF NONE, RECORD '00').
DAUGHTERS ELSEWEHRE ___
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?)
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)
207. How many boys have died?
And how many girls have died? (IF NONE, RECORD '00')
GIRLS DEAD ___
208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.
HAS HAD ONLY ONE CHILD (GO TO 212)
HAS NOT HAD ANY CHILDREN (GO TO 301)
210. Did all of the children you have fathered have the same biological mother?
NO 2
211. In all, how many women have you fathered children with?
212. How old were you when your (first) child was born?
NO LIVING CHILDREN (GO TO 301)
213. How many years old is your (youngest) child?
OTHER (GO TO 301)
215. What is the name of your (youngest) child? WRITE NAME OF (YOUNGEST) CHILD.
216. When (NAME)'s mother was pregnant with (NAME) did she have any antenatal check-ups?
NO 2 (GO TO 218)
DON'T KNOW 3 (GO TO 218)
217. Were you present during any antenatal check-up?
NOT PRESENT 2
217A. Were you ever told what to do if (NAME)'s mother had any pregnancy complication?
NO 2
217B. At any time during the pregnancy did any health provider or health worker speak to you about:
a. The importance of delivering the baby in a hospital or health facility?
b. The importance of proper nutrition for the mother during pregnancy?
c. Family planning or delaying your next child?
NO 2
NO 2
NO 2
218. Was (NAME) born in a hospital or a health facility?
OTHER 2
219. What was the main reason why (NAME)'s mother did not deliver in a hospital or health facility?
FACILITY CLOSED 02
TOO FAR/NO TRANSPORTATION 03
DON'T TRUST FACILITY/POOR QUALITY SERVICE 04
NO FEMALE PROVIDER 05
NOT THE FIRST CHILD 06
SECURITY CONCERNS CHILD'S MOTHER DID NOT THINK IT WAS NECESSARY 08
HE DID NOT THINK IT WAS NECESSARY 09
FAMILY DID NOT THINK IT WAS NECESSARY 10
OTHER (SPECIFY) ___ 96
DON'T KNOW 98
219A. What kind of preparation did you make beforehand for the delivery of (NAME)? Anything else? CIRCLE ALL MENTIONED.
ARRAGED FOR TRANSPORT B
FOUND BLOOD DONOR C
CONTACTED HEALTH WORKER TO HELP WITH DELIVER D
BOUGHT SAFE DELIVERY KIT E
OTHER (SPECIFY) ___ X
NO PREPARATION Y
220. When a child has diarrhea, 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?
ABOUT THE SAME 2
LESS THAN USUAL 3
NOTHING TO DRINK 4
DON'T KNOW 8
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?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?
CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY
THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE 1 IF METHOD IS RECOGNIZED, AND CODE 2 IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE 1 CIRCLED IN 301, ASK 302.
302. Have you ever used (METHOD)?
01. FEMALE STERILIZATION Women can have an operation to avoid having any more children
NO 2 (GO TO 02)
02. MALE STERILIZATION Men can have an operation to avoid having any more children.
NO 2 (GO TO 03)
Have you ever had an operation to avoid having any more children?
NO 2
03. PILL Women can take a pill every day to avoid becoming pregnant.
NO 2 (GO TO 04)
04. IUD Women can have a loop or coil placed inside them by a doctor or a nurse.
NO 2 (GO TO 05)
05. INJECTABLES Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
NO 2 (GO TO 06)
06. IMPLANTS Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
NO (GO TO 07)
07. CONDOM Men can put a rubber sheath on their penis before sexual intercourse.
NO 2 (GO TO 08)
Have you ever had an operation to avoid having any more children?
NO 2
08. RHYTHM METHOD. Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
NO (GO TO 09)
Have you ever had an operation to avoid having any more children?
NO 2
09. WITHDRAWAL Men can be careful and pull out before climax.
NO (GO TO 10)
Have you ever had an operation to avoid having any more children?
NO 2
10. EMERGENCY CONTRACEPTION Women can take pills up to three days after sexual intercourse to avoid becoming pregnant.
NO 2 (GO TO 11)
11. Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
NO 2
303. CHECK 302 (02) RESPONDENT IS STERILIZED
NO (GO TO 310)
304. Now I would like to talk about when you were sterilized.
In what facility did the sterilization take place? PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE
THE NAME OF THE PLACE.
PHC CENTER 12
MOBILE CLINIC 13
OTHER PUBLIC (SPECIFY) ___
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER NGO (SPECIFY) 26
OTHER PRIVATE MEDICAL (SPECIFY) ___ 36
DON'T KNOW 98
305. In what month and year was the sterilization performed?
YEAR ___
306. How much did you pay in total for the sterilization, including any consultation you may have had?
FREE 9995
DON'T KNOW 9998
307. Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?
NO 2
DON'T KNOW 8
308. Do you regret that you had the operation?
NO 2 (GO TO 310)
DON'T KNOW 8
309. Why do you regret that you had the operation?
WIFE WANTS ANOTHER CHILD 2
SIDE EFFECTS 3
MARTIAL STATUS HAS CHANGED 4
OPERATION FAILED 5
CHILD DIED 7
OTHER (SPECIFY) ___ 6
310. In the last few months have you heard or seen any message about family planning:
a. On the radio?
b. On the television?
c. In a newspaper, magazine or brochure?
d. On a poster or billboard?
e. Street drama?
NO 2
NO 2
NO 2
NO 2
NO 2
311. In the last few months, have you discussed the practice of family planning with a health worker or health professional?
NO 2
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 if she has sexual relations?
NO 2 (GO TO 314)
DON'T KNOW (GO TO 314)
313. Is this time just before her period, during her period, right after her period has ended, or halfway between two periods?
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) ___ 6
DON'T KNOW 8
314. Do you think that a woman who is breast feeding her baby can become pregnant?
NO 2
DEPENDS 3
DON'T KNOW 8
315. I will now read you some statements about contraception. Please tell me if you agree or disagree with each one.
a) Contraception is women's business and a man should not have to worry about it.
b) Women who use contraception may become promiscuous.
c) Being sterilized for a man is the same as castration.
DISAGREE 2
DK 8
DISAGREE 2
DK 8
DISAGREE 2
DK 8
316. CHECK 301 (07) KNOWS MALE CONDOM
NO (GO TO 401)
317. Do you know of a place where a person can get condoms?
NO 2 (GO TO 401)
318. Where is that?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE NAME OF PLACES
PHC CENTER B
HEALTH POST C
SUB-HEALTH PO D
PHC OUTREACH 3
MOBILE CLNIIC G
FCHV G
OTHER PUBLIC (SPECIFY) ___ H
MARIE STOPES J
ADRA K
NEPAL RED CROSS L
UMN M
OTHER NGO. (SPECIFY) ___ N
PHARMACY P
OTHER PRIVATE MEDICAL (SPECIFY) Q
FRIENDS/RELATIVES S
OTHER (SPECIFY) X
319. If you wanted to, could you yourself get a condom?
NO 2
SECTION 4. MARRIAGE AND SEXUAL LIFE
401. What is your current marital status?
MARRIED, GAUNA NOT PERFORMED 2 (GO TO 407)
WIDOWED 3 (GO TO 407)
DIVORCED 4 (GO TO 407)
SEPARATED 5 (GO TO 407)
NEVER MARRIED 6 (GO TO 414)
402. Do you currently have one wife or more than one wife?
IF ONLY ONE WIFE, RECORD '01'. IF MORE THAN ONE, ASK: How many wives do you currently have?
403. WRITE THE LINE NUMBERS FROM THE HOUSEHOLD QUESTIONNAIRE FOR EACH WIFE. IF A WIFE IS NOT LISTED IN THE HOUSEHOLD SCHEDULE, RECORD '00' IN THE LINE NUMBER BOXES.
THE NUMBER OF LINES FILLED IN MUST BE EQUAL TO THE NUMBER OF WIVES.
(IF RESPONDENT HAS MORE THAN FOUR WIVES, USE ADDITIONAL QUESTIONNAIRE(S).)
CHECK 402:
MORE THAN ONE WIFE: Please tell me the name of each of your wives, starting with the one you married with first.
NAME __
LINE NUMBER IN HOUSEHOLD SCHEDULE ___
404. Are you living with your wife/wives now, or is she/are they staying elsewhere?
LIVING WITH WIFE/AT LEAST ONE WIFE 1 (GO TO 406)
NOT LIVING WITH WIFE/ANY WIVES 2
405. 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
YEARS __ 2
ONLY ONE WIFE: Have you ever been married to any woman other than your current wife?
MORE THAN ONE WIFE: Have you ever been married to any other woman in addition to those you have told me about?
NO (GO TO 408)
407. Have you been married once or more than once?
MORE THAN ONCE 2 (GO TO 409A)
OTHER (GO TO 409A)
409. In what month and year did you get married?
DON'T KNOW MONTH 98
YEAR __ (GO TO 411)
DON'T KNOW YEAR 9998
409A. Now I would like to ask about when you married your first wife. In what month and year was that?
DON'T KNOW MONTH 98
YEAR __ (GO TO 411)
DON'T KNOW YEAR 9998
410. How old were you when you first got married?
OTHER (GO TO 412)
412. CHECK 402 AND 406 AND, IF 402 AND 406 NOT ASKED,
IF MARRIED ONLY ONCE (402=01 AND 406='2') OR (407='1')
In what month and year did you start living with your wife?
IF MARRIED MORE THAN ONCE (402>01 OR 406='1') OR (407 = '2')
Now I would like to ask about when you started living with your first wife. In what month and year was that?
DON'T KNOW MONTH 98
YEAR ___ (GO TO 415)
DON'T KNOW YEAR 9998
413. How old were you when you first started living with her?
414. 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 important 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?
NO 2 (GO TO 416)
415. 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 important 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?
AGE IN YEARS ___ (GO TO 418)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) WIFE 95 (GO TO 418)
OTHER (GO TO 501)
417. Do you intend to wait until you get married/after gauna to have sexual intercourse for the first time?
NO 2
DON'T KNOW/UNSURE 8
418. The first time you had sexual intercourse, was a condom used?
NO 2
418A. What was this person's relationship to you?
IF GIRLFRIEND: Were you living together as if married? IF YES, CIRCLE '02'. IF NO, CIRCLE '03'.
LIVE-IN PARTNER 02
GIRLFRIEND NOT LIVING WITH RESPONDENT 03
RELATIVE 04
CASUAL ACQUAINTANCE 05
SEX WORKER 06
OTHER (SPECIFY) ___ 96
419. 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.
WEEKS AGO ___ 2 (GO TO 422)
MONTHS AGO ___ 3 (GO TO 422)
YEARS AGO ___ 4 (GO TO 435)
421. When was the last time you had sexual intercourse with this person?
WEEKS AGO __ 2
MONTHS AGO ___ 3
422. The last time you had sexual intercourse (with this second/third person), was a condom used?
NO 2
423. Did you use a condom every time you had sexual intercourse with this person in the last 12 months?
NO 2
424. What was this (second/third) person's relationship to you? IF GIRLFRIEND: Were you living together as if married? IF YES, CIRCLE '02'. IF NO, CIRCLE '03'.
LIVE-IN PARTNER 02 (SKIP TO 428)
GIRLFRIEND NOT LIVING WITH RESPONDENT 03
RELATIVE 04
CASUAL ACQUAINTANCE 05
PROSTITUTE 06
OTHER (SPECIFY) ___ 96
425. For how long (have you had/did you have) a sexual relationship with this (second/third) person? IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.
MONTHS __ 2
YEARS __ 3
426. The last time you had sexual intercourse with this (second/third) person, did you or this person drink alcohol?
NO 2 (SKIP TO 428)
427. Were you or your partner drunk at that time? IF YES: Who was drunk?
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4
428. Apart from [this person/these two people], have you had sexual intercourse with any other person in the last 12 months? IF FILLING FOR THIRD-TO-LAST SKIP THIS QUESTION.
NO 2 (SKIP TO 432)
429. In total, with how many different people have you had sexual intercourse in the last 12 months? IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'
DON'T KNOW 96
NO PARTNERS ARE PROSTITUTE (GO TO 432)
431. CHECK 422 AND 424 (ALL COLUMNS:
OTHER (GO TO 435)
432. In the last 12 months, did you pay anyone in exchange for having sexual intercourse?
NO 2 (GO TO 435)
433. The last time you paid someone in exchange for having sexual intercourse, was a condom used?
NO 2 (GO TO 435)
434. Was a condom used during sexual intercourse every time you paid someone in exchange for having sexual intercourse in the last 12 months?
NO 2
DK 8
435. In total, with how many different people have you had sexual intercourse in your lifetime? IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'
DON'T KNOW 98
436. CHECK 422, MOST RECENT PARTNER (FIRST COLUMN):
NO CONDOM USED OR NOT ASKED (GO TO 442)
437. You told me that a condom was used the last time you had sex. May I see the package of condoms you were using at the time? RECORD NAME OF BRAND IF PACKAGE SEEN.
BRAND NAME (SPECIFY) ___
DOES NOT HAVE/NOT SEEN 2
438. Do you know the brand name of the condom used at that time? RECORD NAME OF BRAND.
DON'T KNOW 98
438A. Which condom brand do you use regularly?
PANTHER 2
NUMBER 1 3
JODI 4
OTHER (SPECIFY) ___ 6
439. How many condoms did you get the last time?
DON'T KNOW 998
439A. How many of the condoms you got last time did you use?
DON'T KNOW 998
440. The last time you obtained the condoms, how much did you pay in total, including the cost of the method and any consultation you may have had?
FREE 995
DON'T KNOW 998
441. From where did you obtain the condom the last time? PROBE TO IDENTIFY TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE. IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE
PHC CENTER 12
HEALTH POST 13
SUB-HELATH POST 14
PHC OUTREACH 15
MOBILE CLINCI 17
FCHV 18
CONDOM BOX 19
OTHER GOVT. (SPECIFY) ___ 16
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER NGO. (SPECIFY) ____ 26
PHARMACY 32
OTHER PRIVATE MEDICAL (SPECIFY) ___ 36
FRIENDS/RELATIVES 42
442. CHECK 302 (02): RESPONDENT EVER STERILIZED
NO (GO TO 443)
443. The last time you had sex did you or your partner use any method (other than a condom) to avoid or prevent a pregnancy?
NO 2 (GO TO 501)
DON'T KNOW (GO TO 501)
444. What method di you or your partner use? PROBE: Did you use any other method to prevent pregnancy? RECORD ALL MENTIONED
PILL B
IUD C
INJECTABLES D
IMPLANTS E
FEMALE CONDOM F
DIAPHRAGM G
FOAM/JELLY H
RHYTHM METHOD I
WITHDRAWAL J
OTHER (SPECIFY) ___ X
501. CHECK 401:
GAUNA NOT PERFORMED (GO TO 504)
OTHER (GO TO 506)
502. CHECK 302(02): EVER STERILIZED?
NO (GO TO 503)
HAS ONE WIFE: Is your wife currently pregnant?
NO 2
DK 8
HAS MORE THAN ONE WIFE:
Are any of your wives currently pregnant?
NO 2
DK 8
NO WIFE PREGNANT OR UNSURE QUESTION NOT ASKED: 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/NONE 2 (GO TO 506)
COUPE INFECUND 3 (GO TO 506)
WIFE (WIVES) STERILIZED 4 (GO TO 506)
UNDECIDED/DON'T KNOW 5 (GO TO 506)
WIFE(WIVES) PREGNANT: Now I have some questions about the future.
After the child(ren) 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?
NO MORE/NONE 2 (GO TO 506)
COUPE INFECUND 3 (GO TO 506)
WIFE (WIVES) STERILIZED 4 (GO TO 506)
UNDECIDED/DON'T KNOW 5 (GO TO 506)
NO WIFE PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?
YEARS __ 2
SOON/NOW 993
COUPLE INFECUND 994
AFTER GAUNA 995
OTHER (SPECIFY) ___ 996
DON'T KNOW 998
WIFE(WIVES) PREGNANT: After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?
YEARS __ 2
SOON/NOW 993
COUPLE INFECUND 994
AFTER GAUNA 995
OTHER (SPECIFY) ___ 996
DON'T KNOW 998
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? PROBE FOR A NUMERIC RESPONSE.
NUMBER ___
OTHER (SPECIFY) ___ 96 (GO TO 601)
NO LIVING CHILDREN:
If you could choose exactly the number of children to have in your whole life, how many would that be? PROBE FOR A NUMERIC RESPONSE.
NUMBER ___
OTHER (SPECIFY) ___ 96 (GO TO 601)
507. How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?
NUMBER OF GIRLS ___
NUMBER OF EITHER ___
OTHER (SPECIFY) ___ 96
SECTION 6. EMPLOYMENT AND GENDER ROLES
601. Have you done any work in the last seven days?
NO 2
602. Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, or any other such reason?
NO 2
603. Have you done any work in the last 12 months?
NO 2 (GO TO 613)
604. What is your occupation, that is, what kind of work do you mainly do?
____
____
DOESN'T WORK IN AGRICULTURE (GO TO 607)
606. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4
607. 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
608. Do you usually work throughout the year, or do you work seasonally, or only once in a while?
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3
609. Are you paid in cash or kind for this work or are you not paid at all?
CASH AND KIND 2
IN KIND ONLY 3
NOT PAID 4
QUESTION NO ASKED (GO TO 613)
OTHER (GO TO 613)
612. Who decides how the money you earn will be used: mainly you, mainly your (wife/wives), or you and your (wife/wives) jointly?
WIFE(WIVES) 2
RESPONDENT AND WIFE (WIVES JOINTLY 3
OTHER (SPECIFY) ___ 6
613. 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:
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
WIFE 2
BOTH EQUALLY 3
DON'T KNOW/DEPENDS 8
614. I will now read you some statements about pregnancy. Please tell me if you agree or disagree with them.
DISAGREE 2
DK 8
DISAGREE 2
DK 8
615. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
NO 2
DK 8
616. Do you think that if a woman refuses to have sex with her husband when he wants her to, he has the right to?.
NO 2
DON'T KNOW/DEPENDS 8
NO 2
DON'T KNOW/DEPENDS 8
NO 2
DON'T KNOW/DEPENDS 8
NO 2
DON'T KNOW/DEPENDS 8
701. Now I would like to talk about something else. Have you ever heard of an illness called AIDS?
NO 2 (GO TO 715)
702. Can people reduce their chances of getting the AIDS virus by having just one uninfected sex partner who has sexual intercourse with no other partners?
NO 2
DON'T KNOW 8
703. Can people get the AIDS virus from mosquito bites?
NO 2
DON'T KNOW 8
704. Can people reduce their chances of getting the ADIS virus by using a condom every time they have sex?
NO 2
DON'T KNOW 8
705. Can people get the AIDS virus by sharing food with a person who has AIDS?
NO 2
DON'T KNOW 8
706. Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?
NO 2
DON'T KNOW 8
707. Can people get the AIDS virus by touching someone who has AIDS?
NO 2
DON'T KNOW 8
708. Is it possible for a healthy-looking person to have the AIDS virus?
NO 2
DON'T KNOW 8
709. Do you know of a place where people can go to get tested for the AIDS virus?
NO 2 (GO TO 711)
710. Where is that? Any other place? PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
VCT CENTER B
OTHER GOVT. (SPECIFY) ___ C
AMDA E
INF F
NEPAL RED CROSS G
OTHER GOVT. (SPECIFY) ___
OTHER PRIVATE MEDICAL (SPECIFY) ___ J
711. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?
NO 2
DON'T KNOW 8
712. If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?
NO 2
DK/NOT SURE/DEPENDS 8
713. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?
NO 2
DK/NOT SURE/DEPENDS 8
714. In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?
SHOULD NOT BE ALLOWED 2
DK/NOT SURE/DEPENDS 8
HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
NO 2
NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?
NO 2
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 724)
717. CHECK 715: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INECTIONS
NO (GO TO 719)
718. 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?
NO 2
DON'T KNOW 8
719. Sometimes men experience an abnormal discharge from their penis. During the last 12 months, have you had an abnormal discharge from your penis?
NO 2
DON'T KNOW 8
720. Sometimes men have a sore or ulcer near their penis. During the last 12 months, have you had a sore or ulcer near your penis?
NO 2
DON'T KNOW 8
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 724)
722. The last time you had (PROBLEM FROM 736/737/738), did you seek any kind of advice or treatment?
NO 2 (GO TO 724)
723. Where did you go?
Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
PRIMARY HEALTH CARE B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH E
FAMILY PLANNING CLINIC F
MOBILE CLINIC G
FIELDWORKER H
OTHER GOVT. (SPECIFY) ___ I
AMDA K
INF L
NEPAL RED CROSS M
UMN N
OTHER NON-GOVT. (SPECIFY) ___ O
OTHER PRIVATE MEDICAL (SPECIFY) ___ Q
724. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?
NO 2
DON'T KNOW 8
725. Is a wife justified in refusing to have sex with her husband when she is tired or not in the mood?
NO 2
DON'T KNOW 8
726. Is a wife justified in refusing to have sex with her husband when she knows her husband has sex with other women?
NO 2
DON'T KNOW 8
SECTION 8. OTHER HEALTH ISSUES
801. Have you ever heard of an illness called tuberculosis or TB?
NO 2 (GO TO 805)
802. How does tuberculosis spread from one person to another?
PROBE: Any other ways? RECORD ALL MENTIONED.
THROUGH SHARING UTENSILS B
THROUGH TOUCHING A PERSON WITH TB C
THROUGH FOOD D
THROUGH SEXUAL CONTACT E
THROUGH MOSQUITO BITES F
THROUGH SPIT G
OTHER (SPECIFY) ___ X
DON'T KNOW Z
803. Can tuberculosis be cured?
NO 2
DON'T KNOW 8
804. If a member of your family got tuberculosis, would you want it to remain a secret or not?
NO 2
DON'T KNOW/NOT SURE/DEPENDS 8
805. Do you currently smoke cigarettes?
NO 2 (GO TO 807)
806. In the last 24 hours, how many cigarettes did you smoke?
807. Do you currently smoke or use any other type of tobacco?
NO 2 (GO TO 809)
808. What (other) type of tobacco do you currently smoke or use? RECORD ALL MENTIONED.
CHEWING TOBACCO B
SNUFF C
OTHER (SPECIFY) ___ X
809. In the last few months have you heard or seen the following programs on the radio and/or television:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
MINUTES __
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT RESPONDENT ___________
COMMENTS ON SPECIFIC QUESTIONS: __________
ANY OTHER COMMENTS: _________
SUPERVISOR'S OBSERVATION _____________
NAME OF SUPERVISOR: ________
DATE: ____________
EDITOR'S OBSERVATIONS ___________
NAME OF EDITOR: __________
DATE: _________