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MICS questionnaire for individual women


[Chad]

Woman's information panel: WM

This questionnaire is to be administered to all women age 15 through 49 (see Household Listing Form, column HL7). A separate questionnaire should be used for each eligible woman.

WM1. Cluster number: _ _ _

WM2. Household number: _ _

WM3. Woman's name:
Name ____

WM4. Woman's line number: _ _

WM5. Interviewer name and number
Name ____ _ _

WM6. Day/month/year of interview _ _ / _ _ / _ _ _ _

Repeat greeting if not already read to this woman:
We are from the National Institute of Statistics. We are working on a project concerned with family health and education. I would like to talk to you about these subjects. The interview will take about 30 minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team.

May I start now?

[] Yes, permission is given (Go to WM10 to record the time and then begin the interview.)
[] No, permission is not given (Complete WM7. Discuss this result with your supervisor.)

WM7. Result of woman's interview

[] 01 Completed
[] 02 Not at home
[] 03 Refused
[] 04 Partly completed
[] 05 Incapacitated
[] 96 Other (specify) ____

WM8. Field edited by (name and number):
Name ____ _ _

WM9. Data entry clerk (name and number):
Name ____ _ _

WM10. Record the time.
Hours and minutes _ _ : _ _

Woman's Background: WB

WB1. In what month and year were you born?

Date of birth
_ _ Month
[] 98 DK Month
_ _ _ _ Year
[] 9998 DK Year

WB2. How old are you?
Probe: How old were you at your last birthday? Compare and correct WB1 and/or WB2 if inconsistent.
Age (in completed years) _ _

WB3. Have you ever attended school or preschool?

[] 1 Yes
[] 2 No (Go to WB7)

WB4. What is the highest level of school you attended?

[] 0 Preschool (Go to WB7)
[] 1 Primary
[] 2 Secondary
[] 3 Higher

WB5. What is the highest grade you completed at that level?
If less than 1 grade, enter "00"
Grade _ _

WB6. Check WB4:
[] Secondary or higher. (Go to next module)
[] Primary (Continue with WB7)

WB7. Now I would like you to read this sentence to me.
Show sentence on the card to the respondent. If respondent cannot read whole sentence, probe: Can you read part of the sentence to me?
[] 1 Cannot read at all
[] 2 Able to read only parts of sentence
[] 3 Able to read whole sentence
[] 4 No sentence in required language (specify language) ____
[] 5 Blind / visually impaired

Child mortality: CM

All questions refer only to live births.

CM1. Now I would like to ask about all the births you have had during your life. Have you ever given birth?

[] 1 Yes
[] 2 No (Go to CM8)

CM2. What was the date of your first birth?
I mean the very first time you gave birth, even if the child is no longer living, or whose father is not your current partner.
Skip to CM4 only if year of first birth is given. Otherwise, continue with CM3.
Date of first birth
_ _ Day
[] 98 DK day
_ _ Month
[] 98 DK month
_ _ _ _ Year (Go to CM4)
[] 9998 DK year

CM3. How many years ago did you have your first birth?

Completed years since first birth _ _

CM4. Do you have any sons or daughters to whom you have given birth who are now living with you?

[] 1 Yes
[] 2 No (Go to CM6)

CM5. How many sons live with you? How many daughters live with you?
If none, record '00'.
_ _ Sons at home
_ _ Daughters at home

CM6. Do you have any sons or daughters to whom you have given birth who are alive but do not live with you?

[] 1 Yes
[] 2 No (Go to CM8)

CM7. How many sons are alive but do not live with you? How many daughters are alive but do not live with you?
If none, record '00'.
_ _ Sons elsewhere
_ _ Daughters elsewhere

CM8. Have you ever given birth to a boy or girl who was born alive but later died?
If "no" probe by asking: I mean, to a child who ever breathed or cried or showed other signs of life ? even if he or she lived only a few minutes or hours?
[] 1 Yes
[] 2 No (Go to CM10)

CM9. How many boys have died? How many girls have died?
If none, record '00'.
_ _ Boys dead
_ _ Girls dead

CM10. Sum answers to CM5, CM7, and CM9.
Sum _ _

CM11. Just to make sure that I have this right, you have had in total (total number in cm10) live births during your life. Is this correct?

[] Yes. Check below:
[] No live births (Go to illness symptoms module)
[] One or more live births (Continue with CM12 or birth history module)
[] No (Check responses to CM1-CM10 and make corrections as necessary before proceeding to CM12, the birth history module, or illness symptoms module)

CM12. Of all these (total number) births that when did you give birth to the last one (even if he/she is deceased)?
Month and year must be recorded.
Date of last birth
_ _ Day
[] 98 DK day
_ _ Month
_ _ _ _ Year

CM12A. Is he/she still alive?

[] 1 Yes
[] 2 No

CM12A. Check CM12 and CM12A: Did the woman have her last birth within the last 2 years, i.e. since (day and month of interview) in 2010.
[] No live birth in the last 2 years. (Go to SYMPTOMS OF DISEASE module)
[] Yes, live birth in the past 2 years (Ask for child's name)
Child's name ____

If the child is deceased, be tactful when referring to the child by name in the following modules.
Continue with the next module.

Maternal and newborn health: MN

This module is to be administered to all women with a live birth in the 2 years preceding date of interview.
Check child mortality module CM13 and record name of last-born child here ____
Use this child's name in the following questions, where indicated.


MN1. Did you see anyone for antenatal care during your pregnancy with (name)?

[] 1 Yes
[] 2 No (Go to MN5)

MN2. Whom did you see?
Probe: Anyone else? Probe for the type of person seen and circle all answers given.
Health professional
[] A Doctor
[] B Nurse
[] C Auxiliary midwife
[] E Midwife
Other person
[] F Traditional birth attendant
[] G Community health worker
[] X Other (specify) ____

MN3. How many times did you receive antenatal care during this pregnancy?

_ _ Number of times
[] 98 DK

MN4. As part of your antenatal care during this pregnancy, were any of the following done at least once:

[A] Was your blood pressure measured?

[] 1 Yes
[] 2 No

[B] Did you give a urine sample?

[] 1 Yes
[] 2 No

[C] Did you give a blood sample?

[] 1 Yes
[] 2 No

MN5. Do you have a card or other document with your own immunizations listed?
May I see it please?
If a card is presented, use it to assist with answers to the following questions.
[] 1 Yes (card seen)
[] 2 Yes (card not seen)
[] 3 No
[] 8 DK

MN6. When you were pregnant with (name), did you receive any injection in the arm or shoulder to prevent the baby from getting tetanus, that is convulsions after birth?

[] 1 Yes
[] 2 No (Go to MN9)
[] 8 DK (Go to MN9)

MN7. How many times did you receive this tetanus injection during your pregnancy with (name)?
If 7 or more times, record '7'.
_ Number of times
[] 8 DK (Go to MN9)

MN8. How many tetanus injections during last pregnancy were reported in MN7?
[] At least two tetanus injections during last pregnancy (Go to MN12)
[] Only one tetanus injection during last pregnancy (Continue with MN9)

MN9. Did you receive any tetanus injection at any time before your pregnancy with (name), either to protect yourself or another baby?

[] 1 Yes
[] 2 No (Go to MN12)
[] 8 DK (Go to MN12)

MN10. How many times did you receive a tetanus injection before your pregnancy with (name)?
If 7 or more times, record '7'.
_ Number of times
[] 8 DK (Go to MN12)

MN11. How many years ago did you receive the last tetanus injection before your pregnancy with (name)?

_ _ Years ago

MN12. Check MN1 for presence of antenatal care during this pregnancy:
[] Yes, antenatal care received (Continue with MN13)
[] No antenatal care received (Go to MN17)

MN13. During any of these antenatal visits for the pregnancy, did you take any medicine in order to prevent you from getting malaria?

[] 1 Yes
[] 2 No (Go to MN17)
[] 8 DK (Go to MN17)

MN14. Which medicines did you take to prevent malaria?
Circle all medicines taken. If type of medicine is not determined, show typical anti-malarial to respondent.
[] A SP/Fansidar
[] B Chloroquine
[] C Amodiaquine
[] D Quinine
[] E Malaxin
[] F Malaritab
[] G Arinate
[] H Artesunate
[] I Mefloquine
[] X Other (specify)____
[] Z DK

MN15. Check MN14 for medicine taken:
[] SP/Fansidar taken. (Go to MN16)
[] SP/Fansidar not taken (Go to MN17)

MN16. During this pregnancy, how many times did you take SP/Fansidar?

_ _ Number of times
[] 98 DK

MN17. Who assisted with the delivery of (name)?
Probe: Anyone else? Probe for the type of person assisting and circle all answers given. If respondent says no one assisted, probe to determine whether any adults were present at the delivery.
Health professional
[] A Doctor
[] B Nurse
[] C Auxiliary midwife
[] E Midwife
Other person
[] F Traditional birth attendant
[] G Community health worker
[] H Relative/Friend
[] X Other (specify) ____
[] Y No one

MN18. Where did you give birth to (name)?
Probe to identify the type of source. If unable to determine whether public or private, write the name of the place.
(Name of place) ____

Home
[] 11 Your home (Go to MN19A)
[] 12 Other home (Go to MN19A)
Public sector
[] 21 Govt. hospital
[] 22 Govt. clinic/health centre
[] 23 Govt. health post
[] 26 Other public (specify) ____
Private medical sector
[] 31 Private hospital
[] 32 Private clinic
[] 33 Private maternity home
[] 36 Other private medical (specify) ____
[] 96 Other (specify) ____ (Go to MN19A)

MN19. Was (name) delivered by caesarean section? That is, did they cut your belly open to take the baby out?

[] 1 Yes
[] 2 No

MN19A. After (name)?s birth, did a health professional or villager midwife examine you?

[] 1 Yes
[] 2 No (Go to MN20)

MN19B. How many days or weeks after the birth did you have your first health exam?

_ _ Number of days after delivery
_ _ Number of weeks after delivery
[] 998 DK

MN20. When (name) was born, was he/she very large, larger than average, average, smaller than average, or very small?

[] 1 Very large
[] 2 Larger than average
[] 3 Average
[] 4 Smaller than average
[] 5 Very small
[] 8 DK

MN21. Was (name) weighed at birth?

[] 1 Yes
[] 2 No (Go to MN23)
[] 8 DK (Go to MN23)

MN22. How much did (name) weigh?
Record weight from health card, if available.
[] 1 From card (kg) _ _ _ _
[] 2 From recall (kg) _ _ _ _
[] 99998 DK

MN23. Has your menstrual period returned since the birth of (name)?

[] 1 Yes
[] 2 No

MN24. Did you ever breastfeed (name)?

[] 1 Yes
[] 2 No (Go to next module)

MN25. 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.
[] 000 Immediately
[] 1 Hours _ _
[] 2 Days _ _
[] 998 Don't know/remember

MN26. In the first three days after delivery, was (name) given anything to drink other than breast milk?

[] 1 Yes
[] 2 No (Go to next module)

MN27. What was (name) given to drink?
Probe: Anything else?
[] A Milk (other than breast milk)
[] B Plain water
[] C Sugar or glucose water
[] D Gripe water
[] E Sugar-salt-water solution
[] F Fruit juice
[] G Infant formula
[] H Tea/Infusions
[] I Honey
[] X Other (specify) ____

Illness Symptoms: IS

IS1. Check Household Listing, column HL9
Is the respondent the mother or caretaker of any child under age 5?

[] Yes (Continue with IS2)
[] No (Go to next module)

IS2. Sometimes children have severe illnesses and should be taken immediately to a health facility. What types of symptoms would cause you to take your child to a health facility right away?
Probe: Any other symptoms? Keep asking for more signs or symptoms until the mother/caretaker cannot recall any additional symptoms. Circle all symptoms mentioned, but do not prompt with any suggestions
[] A Child not able to drink or breastfeed
[] B Child becomes sicker
[] C Child develops a fever
[] D Child has fast breathing
[] E Child has difficult breathing
[] F Child has blood in stool
[] G Child is drinking poorly
[] H Child has diarrhea
[] I Child is vomiting
[] X Other (specify) ____
[] Y Other (specify) ____
[] Z Other (specify) ____

Contraception: CP

CP1. I would like to talk with you about another subject ? family planning.
Are you pregnant now?

[] 1 Yes, currently pregnant (Go to next module)
[] 2 No
[] 8 Unsure or DK

CP2. Couples use various ways or methods to delay or avoid a pregnancy. Are you currently doing something or using any method to delay or avoid getting pregnant?

[] 1 Yes
[] 2 No (Go to next module)

CP3. What are you doing to delay or avoid a pregnancy?
Do not prompt. If more than one method is mentioned, circle each one.
[] A Female sterilization
[] B Male sterilization
[] C IUD
[] D Injectables
[] E Implants
[] F Pill
[] G Male condom
[] H Female condom
[] I Diaphragm
[] J Foam/jelly
[] K Lactational amenorrhoea method (LAM)
[] L Periodic abstinence/rhythm
[] M Withdrawal
[] X Other (specify) ____

CP2. Whose idea was it to use this method of contraception?

[] 1 Respondent
[] 2 Husband/partner
[] 3 Respondent and husband/partner together
[] 4 A health worker
[] 5 A relative

Unmet need: UN

UN1. Check CP1. Currently pregnant?
[] Yes, currently pregnant (Continue with UN2)
[] No, unsure or DK (Go to UN5)

UN2. Now I would like to talk to you about your current pregnancy. When you got pregnant, did you want to get pregnant at that time?

[] 1 Yes (Go to UN4)
[] 2 No

UN3. Did you want to have a baby later on or did you not want any (more) children?

[] 1 Later
[] 2 No More

UN4. Now I would like to ask some questions about the future. After the child you are now expecting, would you like to have another child, or would you prefer not to have any more children?

[] 1 Have another child (Go to UN7)
[] 2 No more/none (Go to UN13)
[] 8 Undecided/don't know (Go to UN13)

UN5. Check CP3. Currently using "female sterilization"
[] Yes (Go to UN13)
[] No (Continue with UN6)

UN6. Now I would like to ask you some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

[] 1 Have (a/another) child
[] 2 No more/none (Go to UN9)
[] 3 Says she cannot get pregnant (Go to UN11)
[] 8 Undecided/don't know (Go to UN9)

UN7. How long would you like to wait before the birth of (a/another) child?

[] 1 Months _ _
[] 2 Years _ _
[] 993 Soon/now
[] 994 Says she cannot get pregnant (Go to UN11)
[] 995 After Marriage
[] 996 Other
[] 998 Don't know

UN8. Check CP1. Currently pregnant?
[] Yes, currently pregnant (Go to UN13)
[] No, unsure or DK (Continue with UN9)

UN9. Check CP2. Currently using a method?
[] Yes (Go to UN13)
[] No (Continue with UN10)

UN10. Do you think you are physically able to get pregnant at this time?

[] 1 Yes (Go to UN13)
[] 2 No
[] 8 DK (Go to UN13)

UN11. Why do you think you are not physically able to get pregnant?

[] A Infrequent sex/no sex
[] B Menopausal
[] C Never menstruated
[] D Hysterectomy (surgical removal of uterus)
[] E Has been trying to get pregnant for 2 years or more without result
[] F Postpartum amenorrheic
[] G Breastfeeding
[] H Too old
[] I Fatalistic
[] X Other (specify) ____
[] Z Don't know

UN12. Check UN11. "Never menstruated" mentioned?
[] Mentioned (Go to next module)
[] Not mentioned (Continue with UN13)

UN13. When did your last menstrual period start?
Record the answer using the same unit stated by the respondent
[] 1 Days ago _ _
[] 2 Weeks ago _ _
[] 3 Months ago _ _
[] 4 Years ago _ _
[] 994 In menopause/has had hysterectomy
[] 995 Before last birth
[] 996 Never menstruated

Attitudes toward domestic violence: DV

DV1. 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:

[A] If she goes out without telling him?

[] 1 Yes
[] 2 No
[] 8 DK

[B] If she neglects the children?

[] 1 Yes
[] 2 No
[] 8 DK

[C] If she argues with him?

[] 1 Yes
[] 2 No
[] 8 DK

[D] If she refuses to have sex with him?

[] 1 Yes
[] 2 No
[] 8 DK

[E] If she burns the food?

[] 1 Yes
[] 2 No
[] 8 DK

Marriage/union: MA

MA1. Are you currently married or living together with a man as if married?

[] 1 Yes, currently married
[] 2 Yes, living with a man
[] 3 No, not in union (Go to MA5)

MA2. How old is your husband/partner?
Probe: how old was your husband/partner on his last birthday?
_ _ Age in years
[] 98 DK

MA3. Besides yourself, does your husband/partner have any other wives or partners or does he live with other women as if married?

[] 1 Yes
[] 2 No (Go to MA7)

MA4. How many other wives or partners does he have?

_ _ Number (Go to MA7)
[] 98 DK (Go to MA7)

MA5. Have you ever been married or lived together with a man as if married?

[] 1 Yes, formerly married
[] 2 Yes, formerly lived with a man
[] 3 No, not in union (Go to next module)

MA6. What is your marital status now: are you widowed, divorced or separated?

[] 1 Widowed
[] 2 Divorced
[] 3 Separated

MA7. Have you been married or lived with a man only once or more than once?

[] 1 Only once
[] 2 More than once

MA8. In what month and year did you first marry or start living with a man as if married?

Date of first marriage
_ _ Month
[] 98 DK month
_ _ _ _ Year (Go to next module)
[] 9998 DK year

MA9. How old were you when you started living with your first husband/partner?

Age in years _ _

Sexual behavior: SB

Check for the presence of others. Before continuing, ensure privacy.

SB1. Now I would like to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.
The information you supply will remain strictly confidential.
How old were you when you had sexual intercourse for the very first time?

[] 00 Never had intercourse (Go to next module)
_ _ Age in years
[] 95 First time when started living with (first) husband/partner

SB2. The first time you had sexual intercourse, was a condom used?

[] 1 Yes
[] 2 No
[] 8 DK/don't remember

SB3. When was the last time you had sexual intercourse?
Record answers in days, weeks or months if less than 12 months (one year). If more than 12 months (one year), answer must be recorded in years.
[] 1 Days ago _ _
[] 2 Weeks ago _ _
[] 3 Months ago _ _
[] 4 Years ago _ _ (Go to SB15)

SB4. The last time you had sexual intercourse, was a condom used?

[] 1 Yes
[] 2 No

SB5. What was your relationship to this person with whom you last had sexual intercourse?
Probe to ensure that the response refers to the relationship at the time of sexual intercourse.
If 'boyfriend', then ask: Were you living together as if married? If 'yes', circle '2'. If 'no', circle'3'.
[] 01 Spouse (Go to SB7)
[] 02 Cohabiting partner (Go to SB7)
[] 03 Ex-spouse
[] 04 Ex-cohabiting partner
[] 05 Boyfriend/fiancé
[] 06 Casual date or acquaintance
[] 07 Sex worker
[] 96 Other (specify) ____

SB6. How old is this person?
If response is DK, probe: About how old is this person?
_ _ Age of sexual partner
[] 98 DK

SB7. Have you had sexual intercourse with any other person in the last 12 months?

[] 1 Yes
[] 2 No (Go to SB13)

SB8. The last time you had sexual intercourse with this other person, was a condom used?

[] 1 Yes
[] 2 No

SB9. What was your relationship to this person?
Probe to ensure that the response refers to the relationship at the time of sexual intercourse
If 'boyfriend' then ask: Were you living together as if married? If 'yes', circle '2'. If 'no', circle '3'.
[] 01 Spouse (Go to SB11)
[] 02 Cohabiting partner (Go to SB11)
[] 03 Ex-spouse
[] 04 Ex-cohabiting partner
[] 05 Boyfriend/fiancé
[] 06 Casual date or acquaintance
[] 07 Sex worker
[] 96 Other (specify) ____

SB10. How old is this person?
If response is DK, probe: About how old is this person?
_ _ Age of sexual partner
[] 98 DK

SB11. Other than these two persons, have you had sexual intercourse with any other person in the last 12 months?

[] 1 Yes
[] 2 No (Go to SB13)

SB12. In total, with how many different people have you had sexual intercourse in the last 12 months?

_ _ Number of partners

SB13. In total, with how many different people have you had sexual intercourse in your lifetime?
If a non-numeric answer is given, probe to get an estimate. If number of partners is 95 or more, write '95'.
_ _ Number of lifetime partners
[] 98 DK

HIV/AIDS: HA

HA1. Now I would like to talk with you about something else.
Have you ever heard of an illness called AIDS?

[] 1 Yes
[] 2 No (Go to next module)

HA2. Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

[] 1 Yes
[] 2 No
[] 8 DK

HA3. Can people get the AIDS virus because of witchcraft or other supernatural means?

[] 1 Yes
[] 2 No
[] 8 DK

HA4. Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

[] 1 Yes
[] 2 No
[] 8 DK

HA5. Can people get the AIDS virus from mosquito bites?

[] 1 Yes
[] 2 No
[] 8 DK

HA6. Can people get the aids virus by sharing food with a person who has the AIDS virus?

[] 1 Yes
[] 2 No
[] 8 DK

HA7. Is it possible for a healthy-looking person to have the AIDS virus?

[] 1 Yes
[] 2 No
[] 8 DK

HA8. Can the virus that causes AIDS be transmitted from a mother to her baby:

[A] During pregnancy?

[] 1 Yes
[] 2 No
[] 8 DK

[B] During delivery?

[] 1 Yes
[] 2 No
[] 8 DK

[C] By breastfeeding?

[] 1 Yes
[] 2 No
[] 8 DK

HA9. In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in school?

[] 1 Yes
[] 2 No
[] 8 DK/not sure/depends

HA10. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

[] 1 Yes
[] 2 No
[] 8 DK/not sure/depends

HA11. If a member of your family got infected with the AIDS virus, would you want it to remain a secret?

[] 1 Yes
[] 2 No
[] 8 DK/not sure/depends

HA12. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

[] 1 Yes
[] 2 No
[] 8 DK/not sure/depends

HA13. Check CM13: Any live birth in last 2 years?
[] No live birth in last 2 years (CM13="No" or blank) (Go to HA24)
[] One or more live births in last 2 years (Continue with HA14)

HA14. Check MN1: Received antenatal care?
[] Received antenatal care (Continue with HA15)
[] Did not receive antenatal care (Go to HA24)

HA15. During any of the antenatal visits for your pregnancy with (name), did you receive information about AIDS or the AIDS virus?

[] 1 Yes
[] 2 No
[] 8 DK

HA16. I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

[] 1 Yes
[] 2 No (Go to HA19)
[] 8 DK (Go to HA19)

HA17. I don't want to know the results, but did you get the results of the test?

[] 1 Yes
[] 2 No (Go to HA22)
[] 8 DK (Go to HA22)

HA18. Regardless of the result, all women who are tested are supposed to receive counseling after getting the result. After you were tested, did you receive counselling?

[] 1 Yes (Go to HA22)
[] 2 No (Go to HA22)
[] 8 DK (Go to HA22)

HA19. Check MN17: Birth delivered by health professional (A, B or C)?
[] Yes, birth delivered by health professional (Continue with HA20)
[] No, birth not delivered by health professional (Go to HA24)

HA20. I don't want to know the results, but were you tested for the AIDS virus between the time you went for delivery but before the baby was born?

[] 1 Yes
[] 2 No (Go to HA24)

HA21. I don't want to know the results, but did you get the results of the test?

[] 1 Yes
[] 2 No

HA22. Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

[] 1 Yes
[] 2 No (Go to HA25)

HA23. When was the most recent time you were tested for the AIDS virus?

[] 1 Less than 12 months ago (Go to next module)
[] 2 12-23 months ago (Go to next module)
[] 3 2 or more years ago (Go to next module)

HA24. I don't want to know the results, but have you ever been tested to see if you have the AIDS virus?

[] 1 Yes
[] 2 No (Go to HA27)

HA25. When was the most recent time you were tested?

[] 1 Less than 12 months ago
[] 2 12-23 months ago
[] 3 2 or more years ago

HA26. I don't want to know the results, but did you get the results of the test?

[] 1 Yes (Go to next module)
[] 2 No (Go to next module)
[] 8 DK (Go to next module)

HA27. Do you know of a place where people can go to get tested for the AIDS virus?

[] 1 Yes
[] 2 No

WM11. Record the time.
_ _ : _ _ Hour and minutes

WM12. Check Household Listing Form, column HL9.
Is the respondent the mother or caretaker of any child age 0-4 living in this household?
[] Yes (Go to questionnaire for children under five for that child and start the interview with this respondent.)
[] No (End the interview with this respondent by thanking her for her cooperation. Check for the presence of any other eligible woman, man or child under-5 in the household.)

Interviewer's observations

Field editor's observations

Supervisor's observations