IDENTIFICATION

PROVINCE _________________ ___

DISTRICT _____________________ ___

CSA NUMBER ___

SEA NUMBER ___

HOUSEHOLD NUMBER ___

NAME OF HOUSEHOLD HEAD _______________ ___

URBAN/RURAL

LUSAKA/OTHER CITY/TOWN/VILLAGE

NAME AND LINE NUMBER OF WOMAN _______________ ___

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______________
INTERVIEWER'S NAME _______________
RESULT

RESULT* ______________

NEXT VISIT:
DATE ______
TIME _____

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
NAME ___
RESULT ____

TOTAL NUMBER OF VISITS __

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE USED IN INTERVIEW

RESPONDENT'S LOCAL LANGUAGE

TRANSLATOR USED

FIELD EDITED BY
NAME ________
DATE ________

OFFICE EDITED BY
NAME ________
DATE ________

KEYED BY
NAME ________ ___
DATE ________

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME

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 a village?

103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)?

104. Just before you moved here, did you live in a city, in a town, or in a village?

105. In what month and year were you born?

106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

107. Have you ever attended school?

108. What is the highest level of school you attended: primary, secondary, or higher?

109. How many years did you complete at that level?

110. CHECK 108:

111. Can you read and understand a letter or newspaper easily, with difficulty, or not at all?

112. Do you usually read a newspaper or magazine at least once a week?

113. Do you usually listen to a radio at least once a week?

114. Do you usually watch television at least once a week?

115. What is your religion?

116. What tribe do you belong to?

117. CHECK Q.4 IN THE HOUSEHOLD QUESTIONNAIRE

118. Now I would like to ask about the place in which you usually live. Do you usually live in a city, in a town, or in a village?

119. In which province is that located?

120. Now I would like to ask about the household in which you usually live. What is the source of water your household uses for handwashing and dishwashing?

121. How long does it take to go there, get water, and come back?

122. Does your household get drinking water from this same source?

123. What is the source of drinking water for members of your household?

124. What kind of toilet facility does your household have?

125. Does your household have:

Electricity?
A radio?
A television?
A refrigerator?

126. How many rooms in your household are used for sleeping?

127. Could you describe the main material of the floor of your home?

128. Does any member of your household own:

A bicycle?
A motorcycle?
A car?

SECTION 2. REPRODUCTION

201. Now I would like to ask about all the births you have had during your life. Have you ever given birth?

202. Do you have any sons or daughters to whom you have given birth who are now living with you?

203. How many sons live with you? And how many daughters live with you?
IF NONE, RECORD '00'.

204. Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

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'

206. Have you ever given birth to a boy or a girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed any sign of life but only survived a few hours or days?

207. In all, how many boys have died? And how many girls have died?
IF NONE, RECORD '00'.

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

209. CHECK 208:
Just to make sure that I have this right: you have had in TOTAL _____ births during your life. Is that correct?

210. CHECK 208:

211. Now I would like to talk to you about all of your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

212. What name was given to your (first, next) baby?

213. RECORD SINGLE OR MULTIPLE BIRTH STATUS.

214. Is (NAME) a boy or a girl?

215. In what month and year was (NAME) born?
PROBE: What is his/her birthday?
OR: In what season was he/she born?

216. Is (NAME) still alive?

217. IF ALIVE: How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLETED YEARS.

218. IF ALIVE: Is (NAME) living with you?

219. IF LESS THAN 15 YRS. OF AGE: With whom does he/she live?
IF MORE THAN 15 YRS. OF AGE: GO TO NEXT BIRTH.

220. IF DEAD: How old was he/she 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.

221. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

222. CHECK 215 AND ENTER THE NUMBER OF BIRTHS SINCE JANUARY 1987.
IF NONE, RECORD '0'.

223. Are you pregnant now?

224. How many months pregnant are you?

225. 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?

226. When did your last menstrual period start?

227. Between the first day of a woman's period and the first day of her next period, are there certain times when she has a greater chance of becoming pregnant than other times?

228. During which times of the monthly cycle does a woman have the greatest chance of becoming pregnant?

SECTION 3. CONTRACEPTION

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. Which ways or methods have you heard about?

CIRCLE CODE 1 IN 302 FOR EACH METHOD MENTIONED SPONTANEOUSLY.
THEN PROCEED DOWN THE COLUMN, 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 302, ASK 303-304 BEFORE PROCEEDING TO THE NEXT METHOD.

302. Have you ever heard of (METHOD)?
READ DESCRIPTION OF EACH METHOD.

303. Have you ever used (METHOD)?

304. Do you know where a person could go to get (METHOD)?

305. CHECK 303:

306. Have you ever used anything or tried in any way to delay or avoid getting pregnant?

307. What have you used or done?
CORRECT 303-305 (AND 302 IF NECESSARY).

308. Now I would like to ask you about the time when you first did something or used a method to avoid getting pregnant. How many living children did you have at that time, if any?
IF NONE, RECORD '00'.

308A. CHECK 303 (B):

308B. You said that sometimes you have avoided having sexual intercourse on certain days of the month to avoid getting pregnant. How did you know which days to avoid sexual intercourse?

309. CHECK 223:

310. CHECK 303:

311. Are you currently doing something or using any method to delay or avoid getting pregnant?

312. Which method are you using?
312A. CIRCLE '06' FOR FEMALE STERILIZATION.

313. At the time you first started using the pill, did you consult a doctor or a nurse?

314. At the time you last got pills, did you consult a doctor or a nurse?

315. May I see the package of pills you are using now?
RECORD NAME OF BRAND.

316. Do you know the brand name of the pills you are using now?
RECORD NAME OF BRAND.

317. How much does one (packet/cycle) of pills cost you?

318. CHECK 312:

SHE/HE STERILIZED: Where did the sterilization take place?

USING ANOTHER METHOD: Where did you obtain (METHOD) the last time?

RECORD MINES HOSPITAL OR CLINIC AS PRIVATE ('21')

319. How long does it take to travel from your home to this place?
IF LESS THAN 2 HOURS, RECORD MINUTES. OTHERWISE, RECORD HOURS.

320. Is it easy or difficult to get there?

321. CHECK 312:

322. In what month and year was the sterilization operation performed?

323. For how many months have you been using (CURRENT METHOD) continuously?
IF LESS THAN 1 MONTH, RECORD '00'.

324. Do you intend to use a method to delay or avoid pregnancy at any time in the future?

325. What is the main reason you do not intend to use a method?

326. Do you intend to use a method within the next 12 months?

327. When you use a method, which method would you prefer to use?

328. Where can you get (METHOD MENTIONED IN 327)?

329. CHECK 312:

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

331. Where is that?

332. How long does it take to travel from your home to this place?
IF LESS THAN 2 HOURS, RECORD MINUTES. OTHERWISE, RECORD HOURS.

333. Is it easy or difficult to get there?

334. In the last month, have you heard a message about family planning on:

the radio?
television?

335. Is it acceptable to you for family planning information to be provided on:

the radio?
television?

SECTION 4A. PREGNANCY AND BREASTFEEDING

401. CHECK 222:

402. ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1985* IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).

Now I would like to ask you some more questions about the health of all your children born in the past 5 years. (We will talk about one child at a time.)

LINE NUMBER FROM Q.212

FROM Q.212

403. 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?

404. How much longer would you like to have waited?

405. When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
RECORD ALL PERSONS SEEN.

406. Were you given an antenatal card for this pregnancy?

407. How many months pregnant were you when you first saw someone for an antenatal check on this pregnancy?

408. How many antenatal visits did you have during this pregnancy?

409. 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?

410. During this pregnancy, how many times did you get this injection?

411. Where did you give birth to (NAME)?

412. Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS ASSISTING.

413. Was (NAME) born on time or prematurely?

414. Was (NAME) delivered by caesarian section?

415. When (NAME) was born, was he/she: very large, larger than average, average, smaller than average, or very small?

416. Was (NAME) weighed at birth?

417. How much did (NAME) weigh?

418. Has your period returned since the birth of (NAME)?
[Last Birth Only]

419. Did your period return between the birth of (NAME) and your next pregnancy?
[Exclude Last Birth]

420. For how many months after the birth of (NAME) did you not have a period?

421. CHECK 223:
RESPONDENT PREGNANT?

422. Have you resumed sexual relations since the birth of (NAME)?
[Last Birth Only]

423. For how many months after the birth of (NAME) did you not have sexual relations?

424. Did you ever breastfeed (NAME)?

425. Why did you not breastfeed (NAME)?

426. 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.
[Last Birth Only]

427. CHECK 216:
CHILD ALIVE?

428. Are you still breastfeeding (NAME)?
[Last Birth Only]

429. How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.
[Last Birth Only]

430. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER.
[Last Birth Only]

431. At any time yesterday or last night was (NAME) given any of the following:
[Last Birth Only]

Plain water?
Sugar water?
Juice?
Tea?
Baby formula?
Fresh milk?
Tinned or powdered milk?
Other liquids?
Any solid or mushy food?

432. CHECK 431:
FOOD OR LIQUID GIVEN YESTERDAY?
[Last Birth Only]

433. For how many months did you breastfeed (NAME)?

434. Why did you stop breastfeeding (NAME)?

435. CHECK 216:
CHILD ALIVE?

436. Was (NAME) ever given water or anything else to drink or eat (other than breastmilk)?

437. How many months old was (NAME) when you started giving the following on a regular basis?:
IF LESS THAN 1 MONTH, RECORD '00'.

438. CHECK 216:
CHILD ALIVE?

439. Did (NAME) drink anything from a bottle with a nipple yesterday or last night?

440. GO BACK TO 403 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO FIRST COLUMN OF 441.

SECTION 4B. IMMUNIZATION AND HEALTH

441. ENTER THE LINE NUMBER AND NAME OF EACH BIRTH SINCE JANUARY 1987 IN THE TABLE. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS, BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL FORMS).

LINE NUMBER FROM Q.212

442. Do you have a card where (NAME'S) vaccinations are written down?
IF YES: May I see it, please?

443. Did you ever have a vaccination card for (NAME)?

444. (1) COPY VACCINATION DATES FOR EACH VACCINE FROM THE CARD.
(2) WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS A VACCINE WAS GIVEN BUT NO DATE WAS RECORDED.

445. Has (NAME) received any vaccinations that are not recorded on this card?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, DPT 1-3, POLIO 1-3 AND/OR MEASLES VACCINE(S).

446. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases?

447. Please tell me if (NAME) (has) received any of the following vaccinations:

A BCG vaccination against tuberculosis, that is, an injection in the left forearm that caused a scar?

Polio vaccine, that is, drops in the mouth?

IF YES: How many times?

DPT vaccine, given in the right thigh or buttock to prevent whooping cough?

IF YES: How many times?

An injection against measles?

448. CHECK 216:
CHILD ALIVE?

449. GO BACK TO 442 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 480.

450. Has (NAME) been ill with a fever at any time in the last 2 weeks?

451. Has (NAME) been ill with a cough at any time in the last 2 weeks?

452. Has (NAME) been ill with a cough in the last 24 hours?

453. For how many days has the cough lasted/did the cough last?
IF LESS THAN 1 DAY, WRITE '00'.

454. When (NAME) had the illness with a cough, did he/she breathe faster than usual with short, rapid breaths?

455. CHECK 450 AND 451:
FEVER OR COUGH?

456. Was anything given to treat the fever/cough?

457. What was given to treat the fever/cough?
Anything else?
RECORD ALL MENTIONED.

458. Did you seek advice or treatment for the fever/cough?

459. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.

460. Has (NAME) had diarrhea in the last 2 weeks?

461. GO BACK TO 442 FOR NEXT BIRTH OR, IF NO MORE BIRTHS, GO TO 480.

462. Has (NAME) had diarrhea in the last 24 hours?
(3 OR MORE WATERY STOOLS)

463. For how many days (has the diarrhea lasted/did the diarrhea last)?
IF LESS THAN 1 DAY, WRITE '00'.

464. Was there any blood in the stools?

465. CHECK 424/428:
LAST CHILD STILL BREASTFED?

466. During (NAME)'s diarrhea, did you change the frequency of breastfeeding?
[Last Birth Only]

467. Did you increase the number of breastfeeds or reduce them, or did you stop completely?
[Last Birth Only]

468. (Aside from breastmilk) Was he/she given the same amount to drink as before the diarrhea, or more, or less?

469. Was anything given to treat the diarrhea?

470. What was given to treat the diarrhea?
Anything else?
RECORD ALL MENTIONED.

471. Did you seek advice or treatment for the diarrhea?

472. Where did you seek advice or treatment?
Anywhere else?
RECORD ALL MENTIONED.

473. CHECK 470:
ORS FLUID FROM PACKET MENTIONED?

474. Was (NAME) given Madzi a Moyo (or UNICEF ORS packet) when he/she had the diarrhea?

475. For how many days was (NAME) given Madzi a Moyo?
IF LESS THAN 1 DAY, RECORD '00'.

476. CHECK 470:
HOMEMADE SUGAR/SALT SOLUTION MENTIONED?

477. Was (NAME) given a homemade fluid made from sugar, salt and water when he/she had the diarrhea?

478. For how many days was (NAME) given the fluid made from sugar, salt and water?
IF LESS THAN 1 DAY, WRITE '00'.

479. GO BACK TO 442 FOR NEXT BIRTH; OR, IF NO MORE BIRTHS, GO TO 480.

480. CHECK 470 AND 474 (ALL COLUMNS):

481. Have you ever heard of a special product called Madzi a Moyo you can get for the treatment of diarrhea?

482. Have you ever seen a packet like this before?
SHOW PACKET.

483. Have you ever prepared a solution with one of these packets to treat diarrhea in yourself or someone else?
SHOW PACKET.

484. The last time you prepared Madzi a Moyo, did you prepare the whole packet at once or only part of the packet?

485. How much water did you use to prepare Madzi a Moyo the last time you made it?

486. Where can you get Madzi a Moyo packet?
PROBE: Anywhere else?
RECORD ALL PLACES MENTIONED.

487. CHECK 470 AND 477 (ALL COLUMNS):

488. Where did you learn to prepare the home fluid made from sugar, salt and water that was given to (NAME) when he/she had the diarrhea?

SECTION 5. MARRIAGE

501. Have you ever been married or lived with a man?

502. Are you now married or living with a man, or are you now widowed, divorced, or no longer living together?

503. Is your husband/partner living with you now or is he staying elsewhere?

504. Does your husband/partner have any other wives besides yourself?

505. How many other wives does he have?

506. Are you the first, second,... wife?

507. Have you been married or lived with a man only once, or more than once?

508. In what month and year did you start living with your (first) husband/partner?

509. How old were you when you started living with him?

510. CHECK 508 AND 509:
YEAR AND AGE GIVEN?

511. CHECK CONSISTENCY OF 508 AND 509:

YEAR OF BIRTH (105) ___ PLUS + AGE AT MARRIAGE (509) ___ =
CALCULATED YEAR OF MARRIAGE ___

IF NECESSARY, CALCULATE YEAR OF BIRTH:

CURRENT YEAR 92 MINUS - CURRENT AGE (106) ___ =
CALCULATED YEAR OF BIRTH ___

IS THE CALCULATED YEAR OF MARRIAGE WITHIN ONE YEAR OF THE REPORTED YEAR OF MARRIAGE (508)?

512. IF NEVER IN UNION: Have you ever had sexual intercourse?

513. Now we need some details about your sexual activity in order to get a better understanding of family planning and fertility. How many times did you have sexual intercourse in the last four weeks?

514. How many times in a month do you usually have sexual intercourse?

515. When was the last time you had sexual intercourse?

516. How old were you when you first had sexual intercourse?

517. PRESENCE OF OTHERS AT THIS POINT.

SECTION 6. FERTILITY PREFERENCES

601. CHECK 312:

602. CHECK 502:

603. CHECK 223:

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, would you like to have another child or would you prefer not to have any more children?

604. CHECK 223:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?

PREGNANT: How long would you like to wait after the birth of the child you are expecting before the birth of another child?

605. CHECK 216 AND 223:
HAS LIVING CHILD(REN) OR PREGNANT?

606. CHECK 223:

NOT PREGNANT OR UNSURE: How old would you like your youngest child to be when your next child is born?

PREGNANT: How old would you like the child you are expecting to be when your next child is born?

607. Given your present circumstances, if you had to do it over again, do you think (you/your husband) would make the same decision to have an operation not to have any more children?

608. Do you regret that (you/your husband) had the operation not to have any (more) children?

609. Why do you regret it?

610. Do you think that your husband/partner approves or disapproves of couples using a method to avoid pregnancy?

611. How often have you talked to your husband/partner about family planning in the past year?

612. Have you and your husband/partner ever discussed the number of children you would like to have?

613. Do you think your husband/partner wants the same number of children that you want, or does he want more or fewer than you want?

614. How long should a couple wait before starting sexual intercourse after the birth of a baby?

615. Should a mother wait until she has completely stopped breastfeeding before starting to have sexual relations again, or doesn't it matter?

616. In general, do you approve or disapprove of couples using a method to avoid getting pregnant?

617. CHECK 216:

HAS LIVING CHILD(REN): 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 in your whole life, how many would that be?

RECORD SINGLE NUMBER OR OTHER ANSWER.

618. What do you think is the best number of months or years between the birth of one child and the birth of the next child?

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 501:

702. Did your (last) husband/partner ever attend school?

703. What was the highest level of school he attended: primary, secondary, or higher?

704. How many years did he complete at that level?

705. What kind of work does (did) your (last) husband/partner mainly do?

706. CHECK 705:

707. (Does/Did) your husband/partner work mainly on his own land or family land, or (does/did) he rent land, or (does/did) he work on someone else's land?

708. Aside from your own housework, are you currently working?

709. 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?

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

711. In your current work, do you work for a member of your family, for someone else, or are you self-employed?

712. Do you earn cash for this work?
PROBE: Do you make money for working?

713. Do you do this work at home or away from home?

714. CHECK 215/216/218:
HAS CHILD BORN SINCE JAN. 1987 AND LIVING AT HOME?

715. While you are working, do you usually have (NAME OF YOUNGEST CHILD AT HOME) with you, sometimes have him/her with you, or never have him/her with you?

716. Who usually takes care of (NAME OF YOUNGEST CHILD AT HOME) while you are working?

717. RECORD THE TIME

SECTION 8. AIDS KNOWLEDGE

801. Now I have a few questions about a very important topic. Have you heard of an illness called AIDS?

802. From which sources of information or persons have you heard about AIDS in the last month?
CIRCLE ALL MENTIONED.

803. How is the AIDS virus transmitted?
CIRCLE ALL MENTIONED.

804. Do you think that you can get AIDS from:

shaking hands with someone who has AIDS?
kissing someone who has AIDS?
wearing the clothes of someone who has AIDS?
sharing eating utensils with someone who has AIDS?
stepping on the urine or stool of someone who has AIDS?
mosquito, flea or bedbug bites?

805. Is it possible for a healthy looking person to be carrying the AIDS virus?

806. Is it possible for a woman who has the AIDS virus to give birth to a child with the AIDS virus?

807. Can AIDS be prevented?

808. How can AIDS be prevented?
CIRCLE ALL MENTIONED.

809. What do you suggest is the most important thing the government should do for people who have AIDS?

810. If your relative is suffering with AIDS, who would you prefer to care for him/her?

SECTION 9. HEIGHT AND WEIGHT

901. CHECK 222:

902. LINE NO. FROM Q.212
[Children born within the last 5 years only]

903. NAME FROM Q.212 FOR CHILDREN

904. DATE OF BIRTH:
FROM Q.l05 FOR RESPONDENT
FROM Q.215 FOR CHILDREN, AND ASK FOR DAY OF BIRTH

905. BCG SCAR ON LEFT FOREARM
[Children born within the last 5 years only]

906. HEIGHT (in centimeters)

907. WAS HEIGHT/LENGTH OF CHILD MEASURED LYING DOWN OR STANDING UP?
[Children born within the last 5 years only]

908. WEIGHT (in kilograms)

909. DATE WEIGHED AND MEASURED

910. RESULT

911. NAME OF MEASURER: __________ __
NAME OF ASSISTANT: _________ __

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: _________________

EDITOR'S OBSERVATIONS
_________________________________