Surveypoint

Q01

Name of District

Q02

Name of Block

Q03

Rural/ Urban

Rural

Urban

Q04

Name of Village

Q05

Designation of Service Provider

Doctor

Nurse

ANM

Family Planning Counsellor

Q06

Address of Service Provider with land mark

Q07

FIELD CONTROL INFORMATION

Q07_1

VISIT DATE

Q07_2

SUPV.CODE

Q07_3

INV.CODE

Q07_4

CHECKED CODE

Q07_5

START TIME

Q07_6

END TIME

A01

Did the provider greet you?

Yes

No

A02

Did the provider show respect (received well in the facility and providers were polite)?

Yes

No

A03

Did the provider help you to feel at ease (given opportunity to establish a dialogue)?

Yes

No

A04

Were you counseled in a place where visual privacy was guaranteed?

Yes

No

A05

Were you counseled in a place where auditory privacy was guaranteed?

Yes

No

A06

Did the provider assure you that your information would be kept confidential??

Yes

No

A07

Did the provider ask the reason for visiting?

Yes

No

A08

Did the provider listen to your concerns carefully?

Yes

No

A09

Did the provider ask about your age?

Yes

No

A10

Did the provider counsel you along with your spouse?

Yes

No

A11

Did the provider counsel both of you separately?

Yes

No

A12

Did the provider counsel only wife?

Yes

No

A13

Did the provider counsel only husband?

Yes

No

A14

Did the provider encourage you to make a mutual decision?

Yes

No

A15

Did the provider ascertain your occupation?

Yes

No

A16

Did the provider ask about your fertility intentions (whether you want more children and if so, when)?

Yes

No

A17

Did the provider talk with you about the benefits of healthy timing and spacing of pregnancies?

Yes

No

A18

Did the provider try to explore your and (or) your spouse’s knowledge on family planning?

Yes

No

A19

Did the provider try to determine the usage of any types of family planning methods by you or your spouse?

Yes

No

A20

Did the provider inform you about any method of contraception?

Yes

No

A21

What all methods were you informed about?

Condoms

IUD

OCP

Injectables

A22

Did the provider tell you about condoms?

Yes

No

A23

Did the provider give a brief description on condoms

Yes

No

A24

Did the provider tell you about the benefits of using a condom

Yes

No

A25

Did the provider talk with you about dual method use (using a condom to protect against HIV/STIs and unintended pregnancy as well as a second highly effective contraceptive method for better protection against unintended pregnancy)?

Yes

No

A26

Did the provider tell you from where you can buy/get condoms

Yes

No

A27

Did the provider tell you about Intra-Uterine Device or IUD

Yes

No

A28

Did the provider give a brief description on IUD?

Yes

No

A29

Did the provider tell you about the types of IUD?

Yes

No

A30

Did the provider tell you about the mode of action of IUD?

Yes

No

A31

Did the provider tell you about when to get an IUD inserted

Yes

No

A32

Did the provider tell you from where you can get an IUD inserted

Yes

No

A33

Did the provider tell you about the benefits of using IUD

Yes

No

A34

Did the provider tell you about the side-effects of using IUD

Yes

No

A35

Did the provider tell you about the contradictions of using IUD?

Yes

No

A36

Did the provider tell you about Oral Contraceptive pills?

Yes

No

A37

Did the provider give description on Oral contraceptive pills?

Yes

No

A38

Did the provider tell you about the mode of action of OCPs?

Yes

No

A39

Did the provider tell you about the types of OCP?

Yes

No

A40

Did the provider explain when to start taking the pills?

Yes

No

A41

Did the provider tell you what to do in case a woman misses one dose

Yes

No

A42

Did the provider tell you the time of taking pills

Yes

No

A43

Did the provider tell you about the benefits of using OCP

Yes

No

A44

Did the provider tell you about the side-effects of using OCP

Yes

No

A45

Did the provider tell you about the contradictions of using

Yes

No

A46

Did the provider tell you from where you can get OCPs

Yes

No

A47

Did the provider tell you about Injectable Contraceptives by the name of DMPA?

Yes

No

A48

Did the provider give description on Injectable contraceptive?

Yes

No

A49

Did the provider tell you about the mode of action of injectable contraceptive?

Yes

No

A50

Did the provider tell you about the duration of effectiveness of injection/did he tell you when you should make a follow-up visit?

Yes

No

A51

Did the provider tell you about the side-effects of Injectable contraceptive?

Yes

No

A52

Did the provider counsel you to refer a doctor in case of danger signs such as excessive or prolonged bleeding, severe abdominal cramps, severe headaches etc?

Yes

No

A53

Did the provider tell you about the benefit of Injectable contraceptive?

Yes

No

A54

Did the provider tell you from where you can get injectable contraceptive?

Yes

No

A55

Did the provider clarify all your doubts and questions?

Yes

No

A56

Did the provider give enough information to you to make a decision on the choice of best contraceptive method?

Yes

No

A57

Did the provider offer help in future regarding provision of a contraceptive method?

Yes

No

A58

Did the provider tell about toll free careline services for contraceptives including injectables?

Yes

No

A59

Did the service provider use any reference material while counselling? If so, what materials? (brochure, poster, etc)

Yes

No

A60

Did the provider give you an opportunity to ask questions?

Yes

No

B01

During this interaction, did the Service Provider (doctor/nurse) treat you with courtesy and respect?

Very respectfully

Somewhat respectfully

Somewhat dis-respectfully

Very dis-respectfully

B02

Did the Service Provider (doctor/nurse) listen carefully to you?

Always – spent a lot of time in understanding everything I said

Usually – ignored some points that I expressed

Sometimes – ignored most of the points that I expressed

Never – was in great hurry

B03

Did the Service Provider (doctor/nurse) explain things in a way you could understand?

Explained everything very patiently

Most of the things were explained well

Very little

Not at all

B04

Would you recommend this Service Provider (doctor/nurse) to your friends and family?

Definitely yes

Probably yes

Probably not

Definitely not

B05

Using any number from 1 to 10, where 1 is the worst Service Provider possible and 10 is the best Service Provider (doctor/nurse) possible, what number would you use to rate this Service Provider (doctor/nurse) during your interaction?

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