NATIONAL INSTITUTE OF STATISTICS OF RWANDA
REPUBLIC OF RWANDA
LOCALITY NAME __________
NAME OF HOUSEHOLD HEAD ____________
PROVINCE _____________
DISTRICT _______________
CLUSTER NUMBER _____________
STRUCTURE NUMBER ______________
HOUSEHOLD NUMBER ______________
URBAN/RURAL
RURAL 2
CITY/LARGE TOWN/SMALL TOWN/VILLAGE
OTHER CITY 2
RURAL 3
NAME AND LINE NUMBER OF MAN ____________
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 200______
NAME________
RESULT________
TOTAL NO. OF VISITS ________
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) ______________
OTHER LANGUAGE 2 (SPECIFY) _________
NO 2
SUPERVISOR
NAME __________
DATE ___________
FIELD EDITOR
NAME ____________
DATE ____________
SECTION 1. RESPONDENT'S BACKGROUND
INFORMED CONSENT
Hello. My name is _____________ and I am working with the National Institute of Statistics. We are conducting a national survey about the health of women, men, and children. We would very much appreciate your participation in this survey. I would like to ask you some questions about yourself and your family. This information will help the government to plan health services. The survey usually takes between 10 and 15 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Participation in this survey is voluntary and you can choose not to answer any individual question or all of the questions. However, we hope that you will participate in this 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 ______
101) In what month and year were you born?
MONTH ________
DOES NOT KNOW MONTH 98
YEAR ____________
DON'T KNOW YEAR 9998
102) How old were you at your last birthday? COMPARE AND CORRECT 101 AND/OR 102 IF INCONSISTENT.
AGE IN COMPLETED YEARS ________
103) How you ever attended school?
NO 2 (GO TO 106)
104) What is the highest level of school you attended: primary, middle/JSS, seconday/SSS, or higher?
SECONDAY 2
HIGHER 3
105) What is the highest grade you completed at that level?
PROTESTANT 2
ADVENTIST 3
MUSLIM 4
TRADITIONAL 5
OTHER 6 (SPECIFY) _____________
NO RELIGION 7
107) Are you currently married or living with a woman?
YES, LIVING WITH A WOMAN 2 (GO TO 110)
NO, NOT IN UNION 3
108) Have you ever been married or lived with a woman?
YES, LIVED WITH A WOMAN 2
NO 3 (GO TO 201)
109) What is your marital status now: are you widowed, divorced, or separated?
DIVORCED 2 (GO TO 201)
SEPARATED 3 (GO TO 201)
110) Is your wife/partner living with you or elsewhere?
ELSEWHERE 2
111) Are there any other women with whom you live as if married?
NO 2 (GO TO 201)
112) In total, how many women are you living with as if you were married?
201) Now I would like to ask about any children you have had. I am interested only in the children that are biologically yours. Have you ever fathered any children with any woman?
NO 2
DON'T KNOW 8
202) Do you have any sons or daughters that you have fathered who are now living with you?
NO 2
203) How many sons live with you? And how many daughters live with you? IF NONE, WRITE '00.'
DAUGHTERS AT HOME __________
204) Do you have any sons or daughters you have fathered who are alive but do not live with you?
NO 2
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, WRITE '00.'
DAUGHTERS ELSEWHERE _________
206) Have you ever fathered a boy or girl 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, WRITE '00.'
GIRLS DEAD ____________
208) SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, WRITE '00.'
HAS HAD ONLY ONE CHILD (GO TO 301)
HAS NOT HAD ANY CHILDREN (301)
210) Do the children that you have fathered all have the same biological mother?
NO 2
211) In all how many women have you fathered children with?
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 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTAEOUSLY. 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.
301) Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
302) Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
303) CHECK 301(07), KNOWLEDGE OF MALE CONDOM
NO (GO TO 401)
304) Do you know of a place where a person can get male condoms?
NO 2 (GO TO 401)
305) Where is that?
IF SOURCE IS A HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
Any other place? RECORD ALL SOURCES MENTIONED.
DISTRICT HOSPITAL B
HEALTH CENTER C
FIELDWORKER D
OTHER PUBLIC E (SPECIFY) _____________
PHARMACY G
PRIVATE DOCTOR H
ARBEF CLINIC I
NURSE J
OTHER PRIVATE MEDICAL K (SPECIFY) _____________
CHURCH M
FRIENDS/RELATIVES N
401) Some men are circumcised. Are you circumcised?
NO 2 (GO TO 405)
402) How old were you when you were circumcised?
13-19 YEARS OLD 2
20 YEARS OR OLDER 3
403) Who performed your circumcision?
HEALTH PROFESSIONAL 2
DON'T KNOW 3
404) What is the main reason for you circumcision?
HEALTH/HYGIENE 2 (GO TO 408)
SEXUAL SATISFACTION 3 (GO TO 408)
EASIER TO PUT ON A CONDOM 4 (GO TO 408)
OTHER X (SPECIFY) _____________ (GO TO 408)
DON'T KNOW 8 (GO TO 408)
405) Would you like to be circumcised?
NO 2 (GO TO 407)
DON'T KNOW 8 (GO TO 408)
406) What is the main reason that you would like to be circumcised?
HEALTH/HYGIENE 2 (GO TO 408)
SEXUAL SATISFACTION 3 (GO TO 408)
EASIER TO PUT ON A CONDOM 4 (GO TO 408)
OTHER X (SPECIFY) ___________ (GO TO 408)
DON'T KNOW 8 (GO TO 408)
407) What is the main reason you would not like to be circumcised?
HEALTH/HYGIENE 02
SEXUAL SATISFACTION 03
COST 04
PAIN 05
OTHER 96 (SPECIFY) ____________
DON'T KNOW 98
HOURS ______
MINUTES _________
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 THE SUPERVISOR: ________________
DATE: _____________
EDITOR'S OBSERVATIONS ______________
NAME OF EDITOR: ________________
DATE: _____________