Please Wait...

Ipv Template -Form Fill

Village Information
Q01

District
Q02

Block
Q03

Village
Q04

ASHA Area
Q05

Structure No.
Q06

HH No.
Q07

UID
Q08

Name

Q09

Code

Q10

Total eligible women in the household
Q11

Woman ID
Respondent Information
A01

Name of the head of the household
A02

Address

A03

Important Landmark nearest to the HH
A04

Phone Number

A05

Respondent category

A06

Name of the Mother of the Child
A07

Age of the woman
A08

Name of the Child
A09

Date of Birth of the Child

A10

Age of the Child (in completed months)
Survey Information
B01

Name of the respondent

B02

First Visit

B02_1

Interviewer name

B02_2

Interviewer code

B02_3

Date of the interview
B02_4

Result of the interview

B03

Second Visit
B03_1

Interviewer name

B03_2

Interviewer code

B03_3

Date of the interview
B03_4

Result of the interview

B04

Third Visit
B04_1

Interviewer name

B04_2

Interviewer code

B04_3

Date of the interview
B04_4

Result of the interview

B04_5

RECORD TIME WHEN YOU START THE INTERVIEW.
BACKGROUND CHARACTERISTICS
C01

What is your religion?

C02

Do you belong to a scheduled caste, scheduled tribe, other backward class or general class?
C03

How old is your husband?
C04

Do you know how to read and write?
C05

Have you ever attended school?
C06

What is the highest standard or class you completed?

C07

Apart from housework, have you worked in any job for which you were paid in cash or kind in the last 12 months?

C08

What kinds of work did/do you do?
C09

Did your husband ever attend school?

C10

What is the highest standard or class your husband completed?
C11

In the past 12 months, has your husband been employed?
C12

What is your husband’s occupation?

C13

Do/did you and your husband both earn the same amount of money?
DECISION MAKING, SELF-EFFICACY AND WOMEN EMPOWERMENT
D01

Who in your household usually has the final say regarding the health of women in the family? Would you say yourself, your partner or both equally or any other?
D02

Who in your household usually has the final say about decisions involving your children (their schooling, their activities)? Would you say yourself, your partner or both equally or any other?
D03

Who has the final say about decisions involving how your family spends money on food and clothing? Would you say yourself, your partner or both equally or any other?
D04

Who has the final say about decisions involving how your family spends money on large investments such as buying a car, or a house or a household appliance? Would you say yourself, your partner or both equally or any other?
D05

Not including any help you receive from others, how do you and your husband divide the following tasks:
D05A

Preparing food
D05B

Cleaning the house
D05C

Washing clothes
D05D

Taking care of the children
D06

Has your husband ever talked to you about what to use or do to prevent or stop a pregnancy?
D07

Are (were) you afraid of your (last) husband: most of the time, sometimes or never?
D08

Does (did) your husband drink alcohol?
D09

 How often does (did) he get drunk: often, only sometimes, or never?
D10

Does/did your husband ever use drugs?
D11

How likely do you think it is that your husband is having sex with someone else?
D12

Have you ever had sex with a man because he:
D12A

Provided you with food, cosmetics, clothes, cell phone, transportation, drugs or anything else you could not afford by yourself
D12B

Provided you with somewhere to stay
D12C

Gave items or did something for your children or family
D12D

Gave you cash or money to pay your bills or school fees
D13

How often did this happen during the last 12 months: often, only sometimes, or not at all?
D14

Please let me know if you think that wife beating is justified if:
D14A

She burns food
D14B

She neglects children
D14C

She argues with husband
D14D

She talks to other men
D14E

She wastes husband’s money
D14F

She goes out without telling husband
D14G

She refuses to have sex with husband
D15

I WOULD NOW LIKE TO READ OUT SOME STATEMENTS AND I WOULD LIKE YOU TO THINK ABOUT YOUR RELATIONSHIP WITH YOUR HUSBAND, AND FOR EACH STATEMENT TO TELL ME IF YOU STRONGLY AGREE, AGREE, DISAGREE OR STRONGLY DISAGREE.
D15A

When my husband/ partner wants sex he expects me to agree
D15B

If I ask my husband/ partner to use a condom, he gets angry.
D15C

My husband/partner won’t let me wear certain things
D15D

My husband/ partner has more to say than I do about important decisions that affect us.
D15E

My husband/ partner tells me who I can spend time with.
D15F

When I wear things that make me look beautiful my husband/ partner thinks I may be trying to attract other men
D15G

My husband/ partner always wants to know where I am.
D15H

My partner lets me know I am not the only partner he could have
D15I

My husband/ partner ask for my approval before taking any big decision
D16

Has your husband ever prohibited you from getting a job, going to work, trading, earning money or participating in income generation projects?
D16A

How often did this happen during the last 12 months: often, only sometimes, or not at all?
D17

Has your husband ever taken your earnings from you?
D17A

How often did this happen during the last 12 months: often, only sometimes, or not at all?
D18

Has your husband ever thrown you or your children out of the house where you were living?
D18A

How often did this happen during the last 12 months: often, only sometimes, or not at all?
D19

Has your husband ever refused to give you money you needed for household expenses even when he has money for other things?
D19A

How often did this happen during the last 12 months: often, only sometimes, or not at all?
VIOLENCE AGAINST WOMEN
E01

First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband.

E01A

He (does/did) not permit you to meet your female friends.
E01B

He (tries/tried) to limit your contact with your family
E01C

He (does/did) not trust you with any money.
E01D

He (insists/insisted) on knowing where you (are/were) at all times.
E01E

He frequently (accuses/accused) you of being unfaithful.
E01F

He (is/was) jealous or angry if you (talk/talked) to other men.
E01G

He (ignores/ignored) you or (treats/treated) you indifferently
E01H

He (expects/expected) you to seek permission before seeking health care for herself
E02

(Does/did) your (last) husband ever:
E02A

Say or do something to humiliate/insult you in front of others?
E02B

Threaten to hurt or harm you or someone close to you?
E02C

Insult you or make you feel bad about yourself?
E02D

Scare or intimidate you on purpose for example, by the way he looks at you, by yelling or smashing things?
E02E

Hurt people you care about as a way of hurting you or damaging things of importance to you?
E03

How often did this happen during the last 12 months: often, only sometimes, or not at all?
E04

(Does/did) your (last) husband ever do any of the following things to you:
E04A

Slap you?
E04B

Twist your arm or pull your hair?
E04C

Push you, shake you or throw something at you?
E04D

Kick you, drag you or beat you up?
E04E

Try to choke you or burn you on purpose?
E04F

Punch you with his fist or with something that could hurt you?
E04G

Threaten or attack you with a knife, gun or any other weapon?
E04H

Physically force you to have sexual intercourse with him even when you did not want to?
E04I

Physically force you to perform any other sexual acts you did not want to?
E04J

Force you with threats or in any other way to perform sexual acts you did not want to?
E04K

Had sexual intercourse when you did not want to because you were afraid of what your husband might do?
E04L

Force you to do something sexual that you found degrading or humiliating?
E05

How often did this happen during the last 12 months: often, only sometimes, or not at all?
E06

How long after you first got married to your (last) husband did (this/any of these things) first happen?
E07

Did the following ever happen as a result of what your (last) husband did to you?
E07A

You had cuts, bruises or aches?
E07B

You had severe burns?
E07C

You had eye injuries, sprains, dislocations or minor burns?
E07D

You had deep wounds, broken bones, broken teeth or other serious injury?
E08

So far we have been talking about the behaviour of your(current/last) husband. Now I want to ask you about thebehaviour of any previous husband.
E08A

Did any previous husband ever hit, slap, kick, or do anything else to hurt you physically?
E08B

Did any previous husband physically forceyou to have intercourse or perform any other sexual acts against your will?
E09

How long ago did this happen?
E10

From the time you were 15 years old has anyone (other than your husband) ever hit you, slapped you, kicked you, or done anything else to hurt you physically?
E11

Who has hurt you in this way?
E12

In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?
E13

Has anyone ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?
E14

Who has done any of these things to physically hurt you while you were pregnant?
E15

At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?
E16

Who was the person who was forcing you the very first time thishappened?
E17

In the last 12 months, has anyoneother than (your/any) husbandphysically forced you to havesexual intercourse when you didnot want to?
E18

How old were you the firsttime you were forced to time you were forced tohave sexual intercourse or perform any other sexual acts by anyone, including (your/any)husband?
E19

Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) husband at times when he was not already beating or hurting you?
E20

In the last 12 months, how often have you done this to your (last) husband? Often, only sometimes or not at all?
SEEKING HELP ON DOMESTIC VIOLENCE
F01

Have you ever tried to seek help to stop your husband/other household members from doing this to you?
F02

From whom have you sought help to stop this?
F03

Did this violence stop because of the intervention of the concerned person whom you had approached for help?

F04

Were you discouraged to voice against violence by your family or other community members?
F05

Who do you think you can approach to seek help for addressing the situation of violence against you?
F06

Are there any groups or activists in your village who support women suffering from violence?
F07

Please tell me what these groups are.
F08

What should a woman do if she is facing violence within the family?
AGE OF MARRIAGE
G01

What is the legal age of marriage for girls in our country?

G02

According to you, at what age a girl should get married?

G03

In your household, who decides the age of marriage of girls?
G04

Ideally, who should decide the age of marriage of girls?
G05

What are the main reasons due to which girls should marry early?
G06

What are the main reasons due to which girls should marry late?
G07

What should a girl do if her parents want to get her married at a younger age?
G08

How old were you when you got married for the first time?

G09

Did you wanted to get married at that age?
G10

Why did you get married against your wish?
MIGRATION
H01

Has your husband migrated outside the village in the last 1 year?
H02

How many times did your husband migrate in the last 1 year?
H03

What was the longest duration of migration of your husband in the last year?
H04

For how many days did your husband migrate last time?
H05

What is the reason for migration for your husband?